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Astur DC, Zanatta F, Arliani GG, Moraes ER, Pochini ADC, Ejnisman B. Fraturas por estresse: definição, diagnóstico e tratamento. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Astur DC, Zanatta F, Arliani GG, Moraes ER, Pochini ADC, Ejnisman B. Stress fractures: definition, diagnosis and treatment. Rev Bras Ortop 2016; 51:3-10. [PMID: 26962487 PMCID: PMC4767832 DOI: 10.1016/j.rboe.2015.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 02/05/2015] [Indexed: 12/13/2022] Open
Abstract
Stress fractures were first described in Prussian soldiers by Breithaupt in 1855. They occur as the result of repeatedly making the same movement in a specific region, which can lead to fatigue and imbalance between osteoblast and osteoclast activity, thus favoring bone breakage. In addition, when a particular region of the body is used in the wrong way, a stress fracture can occur even without the occurrence of an excessive number of functional cycles. The objective of this study was to review the most relevant literature of recent years in order to add key information regarding this pathological condition, as an updating article on this topic.
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Amorim T, Wyon M, Maia J, Machado JC, Marques F, Metsios GS, Flouris AD, Koutedakis Y. Prevalence of low bone mineral density in female dancers. Sports Med 2015; 45:257-68. [PMID: 25281333 DOI: 10.1007/s40279-014-0268-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVE While some authors report that dancers have reduced bone mineral density (BMD) and increased risk of osteoporosis, others have stressed the positive effects of dance training on developing healthy BMD. Given the existing controversy, the aim of this systematic review was to examine the best evidence-based information available in relation to female dancers. METHODS Four databases (Web of Science, PubMed, EBSCO, Scopus) and two dance science journals (Journal of Dance Medicine and Science and Medical Problems of Performing Artists) were searched for relevant material using the keywords "dance", "ballet", "BMD", "bone density", "osteoporosis" and "female athlete triad syndrome". A total of 257 abstracts were screened using selected inclusion (studies involving bone measurements in dancers) and exclusion (editorials, opinion papers, chapters in books, narrative reviews and non-English language papers) criteria according to PRISMA guidelines. Following the above screening, a total of 108 abstracts were identified as potentially relevant. After the exclusion of conference proceedings, review papers, studies focusing only in male dancers and studies in which dancers' information were combined with other athletes, the eligible papers were subsequently assessed using the GRADE system and grouped according to: (1) prevalence of low BMD and associated factors, (2) incidence of low BMD and risk factors, (3) prevention/treatment of low BMD in dancers, and (4) other studies. RESULTS Of the 257 abstracts that were initially screened, only 35 studies were finally considered. Only one of these 35 was of high quality, while the remaining 34 were of relatively low quality. Seven studies reported prevalence of low BMD and associated factors, 10 reported associated factors with no prevalence data, while one reported prevalence with no associated factors data. One study cited risk factors, while another one elaborated on the treatment of low BMD in dancers. The remaining 15 studies were classified as "other studies". CONCLUSIONS It remains unclear whether low BMD is prevalent in female dancers. The present review highlights the need for high-quality BMD research in this area.
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Affiliation(s)
- Tânia Amorim
- Centre of Research, Education, Innovation and Intervention in Sport, Faculty of Sports, University of Porto, Rua Dr. Plácido Costa 91, 4200-450, Porto, Portugal,
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Davey T, Lanham-New SA, Shaw AM, Cobley R, Allsopp AJ, Hajjawi MOR, Arnett TR, Taylor P, Cooper C, Fallowfield JL. Fundamental differences in axial and appendicular bone density in stress fractured and uninjured Royal Marine recruits--a matched case-control study. Bone 2015; 73:120-6. [PMID: 25543013 DOI: 10.1016/j.bone.2014.12.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 12/09/2014] [Accepted: 12/18/2014] [Indexed: 11/20/2022]
Abstract
Stress fracture is a common overuse injury within military training, resulting in significant economic losses to the military worldwide. Studies to date have failed to fully identify the bone density and bone structural differences between stress fractured personnel and controls due to inadequate adjustment for key confounding factors; namely age, body size and physical fitness; and poor sample size. The aim of this study was to investigate bone differences between male Royal Marine recruits who suffered a stress fracture during the 32 weeks of training and uninjured control recruits, matched for age, body weight, height and aerobic fitness. A total of 1090 recruits were followed through training and 78 recruits suffered at least one stress fracture. Bone mineral density (BMD) was measured at the lumbar spine (LS), femoral neck (FN) and whole body (WB) using Dual X-ray Absorptiometry in 62 matched pairs; tibial bone parameters were measured using peripheral Quantitative Computer Tomography in 51 matched pairs. Serum C-terminal peptide concentration was measured as a marker of bone resorption at baseline, week-15 and week-32. ANCOVA was used to determine differences between stress fractured recruits and controls. BMD at the LS, WB and FN sites was consistently lower in the stress fracture group (P<0.001). Structural differences between the stress fracture recruits and controls were evident in all slices of the tibia, with the most prominent differences seen at the 38% tibial slice. There was a negative correlation between the bone cross-sectional area and BMD at the 38% tibial slice. There was no difference in serum CTx concentration between stress fracture recruits and matched controls at any stage of training. These results show evidence of fundamental differences in bone mass and structure in stress fracture recruits, and provide useful data on bone risk factor profiles for stress fracture within a healthy military population.
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Affiliation(s)
- Trish Davey
- Institute of Naval Medicine, Alverstoke, Gosport PO12 2DL, UK.
| | - Susan A Lanham-New
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | | | - Rosalyn Cobley
- Institute of Naval Medicine, Alverstoke, Gosport PO12 2DL, UK
| | | | - Mark O R Hajjawi
- Bone Biology Laboratory, University College London, London WC1E 6BT, UK
| | - Timothy R Arnett
- Bone Biology Laboratory, University College London, London WC1E 6BT, UK
| | - Pat Taylor
- The Osteoporosis Centre, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
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56
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Kahanov L, Eberman LE, Games KE, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med 2015; 6:87-95. [PMID: 25848327 PMCID: PMC4384749 DOI: 10.2147/oajsm.s39512] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Stress fractures account for between 1% and 20% of athletic injuries, with 80% of stress fractures in the lower extremity. Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. Accurate diagnosis for stress fractures is dependent on the anatomical area. Anatomical regions such as the pelvis, sacrum, and metatarsals offer challenges due to difficulty differentiating pathologies with common symptoms. Special tests and treatment regimes, however, are similar among most stress fractures with resolution between 4 weeks to a year. The most difficult aspect of stress fracture treatment entails mitigating internal and external risk factors. Practitioners should address ongoing risk factors to minimize recurrence.
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Affiliation(s)
- Leamor Kahanov
- College of Health Science, Misericordia University, Dallas, PA, USA
| | - Lindsey E Eberman
- Department of Applied Medicine and Rehabilitation, Indiana State University, Terre Haute, IN, USA
| | - Kenneth E Games
- Department of Applied Medicine and Rehabilitation, Indiana State University, Terre Haute, IN, USA
| | - Mitch Wasik
- Department of Applied Medicine and Rehabilitation, Indiana State University, Terre Haute, IN, USA
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57
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Abstract
Context: Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings. Evidence Acquisition: Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete. Study Design: Clinical review. Level of Evidence: Level 5. Results: Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving. Conclusion: A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient.
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Pegrum J, Dixit V, Padhiar N, Nugent I. The pathophysiology, diagnosis, and management of foot stress fractures. PHYSICIAN SPORTSMED 2014; 42:87-99. [PMID: 25419892 DOI: 10.3810/psm.2014.11.2095] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION There is an increasing prevalence of osteoporosis, and with it a rise in the diagnosis of stress fractures. Postmenopausal women are particularly at risk of stress fractures. This review article describes the pathophysiology of foot stress fractures and the latest diagnostic and treatment strategies for these common injuries. DISCUSSION There are numerous risk factors for stress fractures that have been identified in the literature. Reduced bone mineral density is an independent risk factor for delayed union. Prevention of stress fractures with training periodization and nutritional assessment is essential, especially in females. Diagnosis of stress fractures of the foot is based on history and diagnostic imaging, which include radiographs, ultrasound, therapeutic ultrasound, computed tomography, and bone scans; however, magnetic resonance imaging is still the gold standard. Treatment depends on the bone involved and the risk of nonunion, with high-risk fractures requiring immobilization or surgical intervention. Patients presenting with underlying bone mineral deficiency treated without surgery require a longer period of activity modification. Training rehabilitation protocols are described for those with low-risk stress fractures. RESULTS A useful algorithm is presented to guide the clinician in the diagnosis and management of such injuries.
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Affiliation(s)
- James Pegrum
- Oxford John Radcliffe Hospitals Orthopaedic Trauma Rotation, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, England.
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59
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Summer training factors and risk of musculoskeletal injury among high school cross-country runners. J Orthop Sports Phys Ther 2014; 44:793-804. [PMID: 25193436 DOI: 10.2519/jospt.2014.5378] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Prospective cohort. OBJECTIVES To examine the relationship between summer training practices and risk of injury during the first month of a high school interscholastic cross-country season. BACKGROUND Several prospective studies have reported a high incidence of injury in adolescent cross-country runners. However, limited reports exist on the role of summer training practices and risk of injury among these runners. METHODS Four hundred twenty-one athletes (186 girls, 235 boys) who competed in interscholastic cross-country were followed during a cross-country season. At the start of the season, all participants completed a questionnaire regarding summer training routines. Time-loss, running-related injuries were tracked during the subsequent season. Logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of initial injury during the first month of the season associated with summer training variables. RESULTS Sixty-seven runners (15.9%) had a confirmed injury during the first month of the season, with a higher percent among girls (19.4%) than boys (13.2%) (P = .06). Overall, 60.1% of the participants ran during the summer prior to the season, with a significantly higher percent among girls (71.5%) than boys (51.1%) (P<.0001). Overall, no significant association (OR = 0.9; 95% CI: 0.5, 1.5; P = .90) was found between not running sometime during the preceding summer and increased risk of initial injury during the first month of the season. Among only the runners who ran during the summer, after adjusting for sex and prior injury, first-month injuries were more common among those who did not frequently alternate short and long mileage on different days (OR = 3.0; 95% CI: 1.4, 6.4; P = .005), and/or who ran 8 weeks or fewer (OR = 2.7; 95% CI: 1.2, 5.8; P = .01) during their summer training. Running 8 weeks or fewer (P = .03), not frequently alternating mileage on different days (P = .01), and running a higher percentage of time on predominantly hill (P = .001) and irregular terrains (P = .004) were associated with increased risk of injury for girls. CONCLUSION These findings suggest that injuries during the first month of the high school cross-country season may be reduced if runners who participate in summer training activities run a greater number of weeks and frequently vary their daily running mileage during the summer. For girls, training programs that reduce mileage on hills and irregular terrains may help to minimize the occurrence of running-related injury. LEVEL OF EVIDENCE Prognosis, level 1b-.
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Weidauer LA, Binkley T, Vukovich M, Specker B. Greater Polar Moment of Inertia at the Tibia in Athletes Who Develop Stress Fractures. Orthop J Sports Med 2014; 2:2325967114541411. [PMID: 26535343 PMCID: PMC4588523 DOI: 10.1177/2325967114541411] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Several previous investigations have determined potential risk factors for stress fractures in athletes and military personnel. Purpose: To determine factors associated with the development of stress fractures in female athletes. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 88 female athletes (cross-country, n = 29; soccer, n = 15; swimming, n = 9; track and field, n = 14; volleyball, n = 12; and basketball, n = 9) aged 18 to 24 years were recruited to participate in a longitudinal bone study and had their left distal tibia at the 4%, 20%, and 66% sites scanned by peripheral quantitative computed tomography (pQCT). Patients included 23 athletes who developed stress fractures during the following year (cases). Whole body, hip, and spine scans were obtained using dual-energy x-ray absorptiometry (DXA). Analysis of covariance was used to determine differences in bone parameters between cases and controls after adjusting for height, lower leg length, lean mass, fat mass, and sport. Results: No differences were observed between cases and controls in any of the DXA measurements. Cases had significantly greater unadjusted trabecular bone mineral content (BMC), greater polar moment of inertia (PMI) at the 20% site, and greater cortical BMC at the 66% site; however, after adjusting for covariates, the differences became nonsignificant. When analyses were repeated using all individuals who had ever had a stress fracture as cases (n = 31) and after controlling for covariates, periosteal circumference was greater in the cases than the controls (71.1 ± 0.7 vs 69.4 ± 0.5 mm, respectively; P = .04). Conclusion: A history of stress fractures is associated with larger bones. These findings are important because larger bones were previously reported to be protective against fractures and stress fractures, but study findings indicate that may not always be true. One explanation could be that individuals who sustain stress fractures have greater loading that results in greater periosteal circumference but also results in the development of stress fractures.
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Affiliation(s)
- Lee A Weidauer
- Ethel Austin Martin Program in Human Nutrition, South Dakota State University, Brookings, South Dakota, USA. ; Health and Nutritional Sciences Department, South Dakota State University, Brookings, South Dakota, USA
| | - Teresa Binkley
- Ethel Austin Martin Program in Human Nutrition, South Dakota State University, Brookings, South Dakota, USA
| | - Matt Vukovich
- Health and Nutritional Sciences Department, South Dakota State University, Brookings, South Dakota, USA
| | - Bonny Specker
- Ethel Austin Martin Program in Human Nutrition, South Dakota State University, Brookings, South Dakota, USA
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Thein-Nissenbaum JM, Carr KE, Hetzel S, Dennison E. Disordered eating, menstrual irregularity, and musculoskeletal injury in high school athletes: a comparison of oral contraceptive pill users and nonusers. Sports Health 2014; 6:313-20. [PMID: 24982703 PMCID: PMC4065553 DOI: 10.1177/1941738113498852] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The female athlete triad is the interrelatedness of energy availability, menstrual function, and bone density. Currently, limited information about triad components and their relationship to musculoskeletal injury in the high school population exists. In addition, no study has specifically examined triad components and injury rate in high school oral contraceptive pill (OCP) users. HYPOTHESIS To compare the prevalence of disordered eating (DE), menstrual irregularity (MI), and musculoskeletal injury (INJ) among high school female athletes in OCP users and non-OCP users. STUDY DESIGN Retrospective cohort study. LEVEL OF EVIDENCE Level 2. METHODS The subject sample completed the Eating Disorder Examination-Questionnaire (EDE-Q) and Healthy Wisconsin High School Female Athletes Survey (HWHSFAS). Athletes were classified by OCP use and sport type. RESULTS Of the participants, 14.8% reported OCP use. There was no difference in MI and INJ among groups. The prevalence of DE was significantly higher among OCP users as compared with non-OCP users; OCP users were twice as likely to meet the criteria for DE (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.20-5.09). OCP users were over 5 times more likely to have a global score that met criteria for DE as compared with non-OCP users (OR, 5.36; 95% CI, 1.92-14.89). CONCLUSION Although MI and INJ rates are similar among groups, there is a higher prevalence of DE among high school female athletes using OCPs as compared with non-OCP users. CLINICAL RELEVANCE Because OCP users may be menstruating, clinicians may fail to recognize the other triad components. However, DE exists in the menstruating OCP user. As such, clinicians should be vigilant when screening for triad components in high school OCP users, particularly DE.
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Affiliation(s)
- Jill M Thein-Nissenbaum
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kathleen E Carr
- Departments of Family Medicine and Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Emily Dennison
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Weidauer L, Minett M, Negus C, Binkley T, Vukovich M, Wey H, Specker B. Odd-impact loading results in increased cortical area and moments of inertia in collegiate athletes. Eur J Appl Physiol 2014; 114:1429-38. [PMID: 24664495 DOI: 10.1007/s00421-014-2870-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 03/04/2014] [Indexed: 01/18/2023]
Abstract
PURPOSE The purpose of this study was to investigate tibial changes in volumetric bone mineral density and geometry that take place in athletes from pre- to post-season. METHODS Female college athletes (n = 36) and ten controls recruited from the student population were included in the study. Participants had their left tibia scanned by pQCT at 4, 20, and 66 % of the overall length from the distal end before and after their competitive seasons. Subjects were divided into four groups: non-athlete (controls, n = 10), moderate-impact (cross-country runners, n = 13), high-impact (volleyball and basketball, n = 11), and odd-impact (soccer, n = 12). RESULTS Anterior-posterior and medial-lateral diameter increased at the 4 % site in control subjects. In the moderate-impact group, medial-lateral moment of inertia (MOI) increased by 1.2 ± 1.8 (mean ± SD) percent at the 20 % site. In high-impact group, anterior-posterior MOI increased by 1.6 ± 2.0 percent at the 66 % site. In odd-impact group, cortical area (1.4 ± 2.3 %) and cortical thickness (1.8 ± 2.8 %) increased at the 20 % site increased, as did the polar MOI (1.8 ± 2.2 %) at the 66 % site. CONCLUSIONS Load-specific changes resulting in improved measures of bone strength take place in athletes during a competitive season. These changes may result in improved resistance to fractures and stress fractures.
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Affiliation(s)
- Lee Weidauer
- Ethel Austin Martin Program in Human Nutrition, South Dakota State University, Box 506, Brookings, SD, 57007, USA,
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63
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Abstract
Stress fractures, were first described in military recruits but in recent years have increasingly been described in runners. In most surveys they comprise between 10 and 20% of all running injuries. The tibia is the most common site of all stress fractures although recent studies involving track and field athletes show an increased incidence of navicular stress fractures. The diagnosis is based on the clinical findings of a history of exercise-related bone pain with local bony tenderness on examination. The diagnosis is often confirmed by a typical appearance on an isotope bone scan or plain radiograph. In general, treatment consists of relative rest from the aggravating activity until symptom-free and then graduated resumption of activity. Attention also needs to be paid to correction of possible causative factors. These include excessive training, low bone density, low calcium intake, menstrual abnormalities in females and biomechanical features such as excessive sub-talar pronation. Certain stress fractures, such as those in the navicular, require specific management, e.g. six weeks non-weight bearing cast immobilization.
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Affiliation(s)
- P D Brukner
- Olympic Park Sports Medicine Centre, Swan Street, Melbourne, Australia
| | - K L Bennell
- Department of Human Biosciences, La Trobe University, Melbourne, Australia
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64
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Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clin J Sport Med 2014; 24:3-20. [PMID: 24366013 DOI: 10.1097/jsm.0000000000000060] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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65
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Abstract
Stress fractures are common injuries in military recruits and athletes, particularly long-distance runners. A high index of suspicion coupled with a thorough history and correct imaging are vital in the diagnosis. A delay in their diagnosis or undertreatment can result in extended recovery times that are particularly damaging to sportspeople where these injuries can be career-ending. In most cases, treatment includes reducing the causative activity to a pain-free level. “High-risk” fractures which typically include the femoral neck, anterior tibia, proximal fifth metatarsal and tarsal navicular may however require surgical fixation. Stress fractures carry a high risk of recurrence and prevention involves reducing modifiable risk factors through training and diet adjustments. All members involved in an athlete or military recruit’s training should therefore be aware of the presence of eating disorders, the effects of overtraining and the importance of rest in order to reduce the incidence of these injuries.
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Affiliation(s)
| | - Osama Aweid
- Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Samed Talibi
- Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Keith Porter
- Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
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66
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Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, McGuigan FEA, Lindsay R, Nieves J. Determinants of stress fracture risk in United States Military Academy cadets. Bone 2013; 55:359-66. [PMID: 23624291 DOI: 10.1016/j.bone.2013.04.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 03/26/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Prior studies have identified some risk factors for stress fracture in athletes and military recruits. OBJECTIVE To determine whether historical factors, physical measures, biochemical variables of skeletal metabolism, genetic factors, bone density (BMD) and bone size could predict risk of stress fracture over 4 years in physically fit cadets at the US Military Academy (USMA). METHODS Baseline surveys, assessments of height, weight, scores on the Army Physical Fitness Test, and peripheral BMD were obtained in all cadets (755 men, 136 women), and central BMD in a subset. Blood samples were analyzed for variables of calcium homeostasis, bone turnover, and selected hormones and genetic factors. Stress fractures were adjudicated by review of orthopedic notes and imaging reports. RESULTS 5.7% of male and 19.1% of female cadets had at least 1 stress fracture (58% metatarsal and 29% tibial), most within 3 months of entry to USMA. In males, risk of stress fracture was higher in those who exercised <7 h per week during the prior year (RR 2.31; CI 1.29,4.12), and in those with smaller tibial cortical area (RR 1.12; CI 1.03,1.23), lower tibial bone mineral content (RR 1.11; CI 1.03,1.20) and smaller femoral neck diameter (RR 1.35, CI 1.01, 1.81). In women, higher stress fracture risk was seen in those with shorter time since menarche (RR 1.44 per year; CI 1.19, 1.73) and smaller femoral neck diameter (RR 1.16; CI 1.01, 1.33.). CONCLUSION Although prior physical training in men, length of prior estrogen exposure in women and leg bone dimensions in both genders played a role, the maximum variance explained by all of these factors was below 10%. We conclude these factors play a minor role in the development of stress fractures in physically fit USMA cadets.
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67
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Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes: a review. Sports Health 2013; 5:165-74. [PMID: 24427386 PMCID: PMC3658382 DOI: 10.1177/1941738112467423] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
CONTEXT Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time. EVIDENCE ACQUISITION PubMed articles published from 1974 to January 2012. RESULTS Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis. CONCLUSIONS These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports.
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Affiliation(s)
- Steve B. Behrens
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew E. Deren
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andrew Matson
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul D. Fadale
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Keith O. Monchik
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Thein-Nissenbaum JM, Rauh MJ, Carr KE, Loud KJ, McGuine TA. Menstrual irregularity and musculoskeletal injury in female high school athletes. J Athl Train 2013; 47:74-82. [PMID: 22488233 DOI: 10.4085/1062-6050-47.1.74] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT The female athlete triad describes the interrelatedness of energy availability, menstrual function, and bone density. Although associations between triad components and musculoskeletal injury (INJ) have been reported in collegiate athletes, limited information exists about menstrual irregularity (MI) and INJ in the high school population. OBJECTIVE To determine the prevalence of and relationship between MI and INJ in high school athletes. DESIGN Cross-sectional study. SETTING High schools. PATIENTS OR OTHER PARTICIPANTS The sample consisted of 249 female athletes from 3 high schools who competed in 33 interscholastic, school-sponsored sport teams, dance teams, and cheerleading or pom-pon squad during the 2006-2007 school year. Each athlete remained on the roster throughout the season. MAIN OUTCOME MEASURE(S) Participants completed a survey regarding injury type, number of days of sport participation missed, and menstrual history in the past year. RESULTS The prevalences of M I and INJ were 19.7% and 63.1 %, respectively. Athletes who reported MI sustained a higher percentage of severe injuries (missing ≥ 22 days of practice or competition) than did athletes who reported normal menses. Although the trend was not significant, athletes with MI were almost 3 times more likely to sustain an injury resulting in 7 or more days of time lost from sport (odds ratio = 2.7, 95% confidence interval = 0.8, 8.8) than those who sustained an injury resulting in 7 or fewer days of time lost. CONCLUSIONS The incidences of MI and INJ in this high school population during the study period were high. Athletes who reported MI sustained a higher percentage of severe injuries than did athletes who reported normal menses. Education programs to increase knowledge and improve management of MI and its potential effects on injury in female high school athletes are warranted.
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Affiliation(s)
- Jill M Thein-Nissenbaum
- Graduate Program in Orthopaedic and Sports Science, Rocky Mountain University of Health Professions, Provo, UT, USA.
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69
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Goolsby MA, Barrack MT, Nattiv A. A displaced femoral neck stress fracture in an amenorrheic adolescent female runner. Sports Health 2012; 4:352-6. [PMID: 23016107 PMCID: PMC3435922 DOI: 10.1177/1941738111429929] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
This case demonstrates the potential serious consequences of the female athlete triad and its effects on bone. Displaced femoral neck stress fractures cause significant morbidity, and this case highlights the preventable nature of this injury. The treatment was focused on improving low energy availability, and, although challenging, improvements were made. This injury could have been prevented if the signs and symptoms of her injury had been addressed and there had been better knowledge of her risk factors. This case highlights the need for further education in the sports and health communities.
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70
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Abstract
Context: The female athlete triad (the triad) is an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density; it is relatively common among young women participating in sports. Diagnosis and treatment of this potentially serious condition is complicated and often requires an interdisciplinary team. Evidence Acquisition: Articles from 1981 to present found on PubMed were selected for review of major components of the female athlete triad as well as strategies for diagnosis and treatment of the conditions. Results: The main goal in treatment of young female athletes with the triad is a natural return of menses as well as enhancement of bone mineral density. While no specific drug intervention has been shown to consistently improve bone mineral density in this patient population, maximizing energy availability and optimizing vitamin D and calcium intake are recommended. Conclusions: Treatment requires a multidisciplinary approach involving health care professionals as well as coaches and family members. Prevention of this condition is important to minimize complications of the female athlete triad.
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Affiliation(s)
| | - Kathryn E. Ackerman
- Division of Sports Medicine, Children’s Hospital Boston and Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
- Address correspondence to Kathryn E. Ackerman, MD MPH Division of Sports Medicine Children’s Hospital Boston 319 Longwood Avenue, Boston, MA 02115 (e-mail: )
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71
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Abstract
Nutrition, in sufficient amount and substance, is crucial for healthy growth and development of the skeleton and surrounding tissues, especially in physically active populations. Inadequate nutrition has been linked to maladies such as the female athlete triad, as well as poor training or competitive performance and increased risk of injury. Dietary choices favoring items high in quality protein of animal or plant origin, polyunsaturated fatty acids, fruits and vegetables high in potassium and fiber, and dairy products or other beverages fortified with calcium and vitamin D are essential to athletes to ensure adequate vitamin and mineral availability to the skeleton, which in turn can affect peak physical performance.
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Affiliation(s)
- Caeley Lorincz
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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72
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Pegrum J, Crisp T, Padhiar N, Flynn J. The pathophysiology, diagnosis, and management of stress fractures in postmenopausal women. PHYSICIAN SPORTSMED 2012; 40:32-42. [PMID: 23528619 DOI: 10.3810/psm.2012.09.1978] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Increasing numbers of elderly individuals are now participating in marathons. With increased participation in running, there has been an increase in the diagnosis of stress fractures in the elderly population. Postmenopausal women are particularly at risk due to osteoporosis. DISCUSSION There are numerous risk factors for stress fractures in the literature that need to be addressed to reduce the risk of injury and recurrence in postmenopausal women. Diagnostic tests include plain radiograph, ultrasound, therapeutic ultrasound, computed tomography scan, and isotope bone scans; however, magnetic resonance imaging remains the gold standard. Treatment is based on risk stratification, with high-risk fractures managed aggressively with either non-weightbearing or surgical intervention. Although exercise is prescribed as a well-recognized treatment modality of poor bone density, balance is essential to avoid precipitating stress fractures. CONCLUSION Optimal exercise programs should balance the beneficial effect of increasing bone mineral density through exercise with the detrimental effect of stress fractures. A useful algorithm is presented in this article to guide the clinician in the diagnosis and management of appropriate investigations and management of such injuries. This review article describes the pathophysiology and provides a review of the literature to determine the latest diagnostic and treatment strategies for this unique population.
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Affiliation(s)
- James Pegrum
- Trauma Registrar, Oxford John Radcliffe Hospitals rotation, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, Buckinghamshire, United Kingdom; Honorary Research Associate, Centre for Sport and Exercise Medicine, Queen Mary, University of London, London, United Kingdom.
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73
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Abstract
Many runners in the United States are at risk for stress-related injuries, which are largely preventable. Severity and recovery vary, and can range from uneventful to surgical intervention. This article explores risks, pathophysiology, diagnostic considerations, and rehabilitation. Prevention strategies are also outlined.
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74
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Yanovich R, Merkel D, Israeli E, Evans RK, Erlich T, Moran DS. Anemia, iron deficiency, and stress fractures in female combatants during 16 months. J Strength Cond Res 2012; 25:3412-21. [PMID: 22080308 DOI: 10.1519/jsc.0b013e318215f779] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Yanovich, R, Merkel, D, Israeli, E, Evans, RK, Erlich, T, and Moran, DS. Anemia, iron deficiency, and stress fractures in female combatants during 16 months. J Strength Cond Res 25(12): 3412-3421, 2011-The purpose of this study is to evaluate the hematological profile of military recruits in different settings and training programs and to investigate the link between anemia and iron deficiency with stress fracture (SF) occurrence. We surveyed 3 groups of recruits for 16 months: 221 women (F) and 78 men (M) from 3 different platoons of a gender-integrated combat battalion and a control group (CF) of 121 female soldiers from a noncombat unit. Data were fully collected upon induction and at 4 and 16 months from 48F, 21M, and 31CF. Blood tests, anthropometry, physical aerobic fitness, and SF occurrence were evaluated. On induction day, 18.0 and 19.0% of F and CF were found to be anemic, and 61.4 and 50.9%, respectively, were found to have iron deficiency, whereas 7.7% of M were found to be anemic and 10.2% iron deficient. During the 4 months of army basic training (ABT), anemia and iron deficiency prevalence did not change significantly in any group. After 16-months, anemia prevalence decreased by 8% among F and CF and abated in M. Iron deficiency was prevalent in 50.0, 59.4, and 18.8% of F, CF, and M, respectively. Stress fractures were diagnosed in 14 F during ABT, and they had a significantly higher prevalence (p < 0.05) of anemia and iron deficiency anemia compared to F without SFs. The observed link between anemia and iron deficiency on recruitment day and SFs suggests the importance of screening female combat recruits for these deficiencies. To minimize the health impact of army service on female soldiers, preventative measures related to anemia and iron deficiency should be administered. Further research is needed for evaluating the influence of low iron in kosher meat as a possible explanation for the high prevalence of iron deficiency among young Israeli recruits.
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Affiliation(s)
- Ran Yanovich
- Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer, Israel
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75
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Schnackenburg KE, Macdonald HM, Ferber R, Wiley JP, Boyd SK. Bone quality and muscle strength in female athletes with lower limb stress fractures. Med Sci Sports Exerc 2012; 43:2110-9. [PMID: 21552163 DOI: 10.1249/mss.0b013e31821f8634] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Lower limb stress fractures (SF) have a high prevalence in female athletes of running-related sports. The purpose of this study was to investigate bone quality, including bone microarchitecture and strength, and muscle strength in athletes diagnosed with SF. METHODS Female athletes with lower limb SF (SF subjects, n = 19, 18-45 yr, premenopausal) and healthy female athletes (NSF subjects, n = 19) matched according to age, sport, and weekly training volume were recruited. Bone microarchitecture of all participants was assessed using high-resolution peripheral quantitative computed tomography at two skeletal sites along the distal tibia of the dominant leg. Bone strength and load distribution between cortical and trabecular bone was estimated by finite element analysis. Using dual-energy x-ray absorptiometry, areal bone mineral density (aBMD) at the hip, femoral neck, and spine was measured. Muscle torque (knee extension, plantarflexion, eversion/inversion) was assessed (Biodex dynamometer) as a measure of lower leg muscle strength. RESULTS SF subjects, after adjusting for body weight, had thinner tibia compared with NSF subjects as indicated by a lower tibial cross-sectional area (-7.8%, P = 0.02) and higher load carried by the cortex as indicated by finite element analysis (4.1%, P = 0.02). Further site-specific regional analysis revealed that, in the posterior region of the tibia, SF subjects had lower trabecular BMD (-19.8%, P = 0.02) and less cortical area (-5.2%, P = 0.02). The SF group exhibited reduced knee extension strength (-18.3%, P = 0.03) compared with NSF subjects. CONCLUSIONS These data suggest an association of impaired bone quality, particularly in the posterior region of the distal tibia, and decreased muscle strength with lower limb SF in female athletes.
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76
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Micklesfield LK, Gray J, Taliep MS. Bone mineral density and body composition of South African cricketers. J Bone Miner Metab 2012; 30:232-7. [PMID: 21947734 DOI: 10.1007/s00774-011-0310-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 08/11/2011] [Indexed: 11/24/2022]
Abstract
Mechanical loading associated with weight-bearing physical activity has been positively associated with bone mineral density in athletes participating in various sports. The aim of this study was to compare the body composition and bone mineral density of South African male cricketers to controls. Whole body (WB), femoral neck (FN), proximal femur (PF) and lumbar spine (LS) BMD, as well as whole body fat mass (WBFM) and lean mass (WBLM) were measured, using dual-energy X-ray absorptiometry (DXA), on 34 high-performance (senior provincial and national level) cricketers and 23 physically active controls between the ages of 16 and 34 years. Cricketers were significantly younger, taller, and had greater WBLM and WBBMC compared to the controls. LS, PF and FN BMD were higher in the cricketers and controls before and after adjusting for age and height. WBBMD was significantly lower in the spin bowlers compared to the batsmen and fast bowlers, after adjusting for age and height; however, there were no differences at the BMD sites between the groups. Bone mineral density at the lumbar spine and hip sites was significantly greater in the cricketers compared to the controls, suggesting that the mechanical loading associated with cricket is beneficial for bone mineral density.
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Affiliation(s)
- Lisa K Micklesfield
- UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Private Bag, Rondebosch, 7700, South Africa.
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Duckham RL, Peirce N, Meyer C, Summers GD, Cameron N, Brooke-Wavell K. Risk factors for stress fracture in female endurance athletes: a cross-sectional study. BMJ Open 2012; 2:bmjopen-2012-001920. [PMID: 23166136 PMCID: PMC3533057 DOI: 10.1136/bmjopen-2012-001920] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To identify psychological and physiological correlates of stress fracture in female endurance athletes. DESIGN A cross-sectional design was used with a history of stress fractures and potential risk factors assessed at one visit. METHODS Female-endurance athletes (58 runners and 12 triathletes) aged 26.0±7.4 years completed questionnaires on stress fracture history, menstrual history, athletic training, eating psychopathology and exercise cognitions. Bone mineral density, body fat content and lower leg lean tissue mass (LLLTM) were assessed using dual-x-ray absorptiometry. Variables were compared between athletes with a history of stress fracture (SF) and those without (controls; C) using χ², analysis of variance and Mann-Whitney U tests. RESULTS Nineteen (27%) athletes had previously been clinically diagnosed with SFs. The prevalence of current a/oligomenorrhoea and past amenorrhoea was higher in SF than C (p=0.008 and p=0.035, respectively). SF recorded higher global scores on the eating disorder examination questionnaire (p=0.049) and compulsive exercise test (p=0.006) and had higher LLLTM (p=0.029) compared to C. These findings persisted with weight and height as covariates. In multivariate logistic regression, compulsive exercise, amenorrhoea and LLLTM were significant independent predictors of SF history (p=0.006, 0.009 and 0.035, respectively). CONCLUSIONS Eating psychopathology was associated with increased risk of SF in endurance athletes, but this may be mediated by menstrual dysfunction and compulsive exercise. Compulsive exercise, as well as amenorrhoea, is independently related to SF risk.
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Affiliation(s)
- Rachel L Duckham
- Centre for Global Health and Human Development, Loughborough University, SSEHS, Loughborough, Leicestershire, UK
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78
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Becker CB, McDaniel L, Bull S, Powell M, McIntyre K. Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigation of two peer-led interventions. Body Image 2012; 9:31-42. [PMID: 22019502 PMCID: PMC3246101 DOI: 10.1016/j.bodyim.2011.09.005] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 08/26/2011] [Accepted: 09/19/2011] [Indexed: 11/28/2022]
Abstract
Female athletes are at least as at risk as other women for eating disorders (EDs) and at risk for the female athlete triad (i.e., inadequate energy availability, menstrual disorders, and osteoporosis). This study investigated whether two evidence-based programs appear promising for future study if modified to address the unique needs of female athletes. Athletes were randomly assigned to athlete-modified dissonance prevention or healthy weight intervention (AM-HWI). ED risk factors were assessed pre/post-treatment, and 6-week and 1-year follow-up. Results (analyzed sample, N=157) indicated that both interventions reduced thin-ideal internalization, dietary restraint, bulimic pathology, shape and weight concern, and negative affect at 6 weeks, and bulimic pathology, shape concern, and negative affect at 1 year. Unexpectedly we observed an increase in students spontaneously seeking medical consultation for the triad. Qualitative results suggested that AM-HWI may be more preferred by athletes.
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Affiliation(s)
- Carolyn Black Becker
- Department of Psychology, Trinity University, San Antonio, TX 78212-7200, United States.
| | - Leda McDaniel
- Department of Psychology, Trinity University, San Antonio, TX
| | - Stephanie Bull
- Department of Psychology, Trinity University, San Antonio, TX
| | - Marc Powell
- Department of Athletics, Trinity University, San Antonio, TX
| | - Kevin McIntyre
- Department of Psychology, Trinity University, San Antonio, TX
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Ducher G, Turner AI, Kukuljan S, Pantano KJ, Carlson JL, Williams NI, De Souza MJ. Obstacles in the optimization of bone health outcomes in the female athlete triad. Sports Med 2011; 41:587-607. [PMID: 21688870 DOI: 10.2165/11588770-000000000-00000] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Maintaining low body weight for the sake of performance and aesthetic purposes is a common feature among young girls and women who exercise on a regular basis, including elite, college and high-school athletes, members of fitness centres, and recreational exercisers. High energy expenditure without adequate compensation in energy intake leads to an energy deficiency, which may ultimately affect reproductive function and bone health. The combination of low energy availability, menstrual disturbances and low bone mineral density is referred to as the 'female athlete triad'. Not all athletes seek medical assistance in response to the absence of menstruation for 3 or more months as some believe that long-term amenorrhoea is not harmful. Indeed, many women may not seek medical attention until they sustain a stress fracture. This review investigates current issues, controversies and strategies in the clinical management of bone health concerns related to the female athlete triad. Current recommendations focus on either increasing energy intake or decreasing energy expenditure, as this approach remains the most efficient strategy to prevent further bone health complications. However, convincing the athlete to increase energy availability can be extremely challenging. Oral contraceptive therapy seems to be a common strategy chosen by many physicians to address bone health issues in young women with amenorrhoea, although there is little evidence that this strategy improves bone mineral density in this population. Assessment of bone health itself is difficult due to the limitations of dual-energy X-ray absorptiometry (DXA) to estimate bone strength. Understanding how bone strength is affected by low energy availability, weight gain and resumption of menses requires further investigations using 3-dimensional bone imaging techniques in order to improve the clinical management of the female athlete triad.
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Affiliation(s)
- Gaele Ducher
- Centre for Physical Activity and Nutrition Research, School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia.
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80
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Powers S, Nelson WB, Larson-Meyer E. Antioxidant and Vitamin D supplements for athletes: sense or nonsense? J Sports Sci 2011; 29 Suppl 1:S47-55. [PMID: 21830999 DOI: 10.1080/02640414.2011.602098] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The idea that dietary supplements can improve athletic performance is popular among athletes. The use of antioxidant supplements is widespread among endurance athletes because of evidence that free radicals contribute to muscle fatigue during prolonged exercise. Furthermore, interest in vitamin D supplementation is increasing in response to studies indicating that vitamin D deficiency exists in athletic populations. This review explores the rationale for supplementation with both antioxidants and vitamin D and discusses the evidence to support and deny the benefits of these dietary supplements. The issue of whether athletes should use antioxidant supplements remains highly controversial. Nonetheless, at present there is limited scientific evidence to recommend antioxidant supplements to athletes or other physically active individuals. Therefore, athletes should consult with their health care professional and/or nutritionist when considering antioxidant supplementation. The issue of whether athletes should supplement with vitamin D is also controversial. While arguments for and against vitamin D supplementation exist, additional research is required to determine whether vitamin D supplementation is beneficial to athletes. Nevertheless, based upon the growing evidence that many athletic populations are vitamin D deficient or insufficient, it is recommended that athletes monitor their serum vitamin D concentration and consult with their health care professional and/or nutritionist to determine if they would derive health benefits from vitamin D supplementation.
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Affiliation(s)
- Scott Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida 32611-8208, USA.
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81
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Female athlete triad syndrome in the high school athlete. Phys Ther Sport 2011; 12:108-16. [PMID: 21802036 DOI: 10.1016/j.ptsp.2011.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 02/04/2011] [Accepted: 04/20/2011] [Indexed: 02/04/2023]
Abstract
Female sports participation at the high school level has significantly increased since the 1970s. Physical activity in females has numerous positive benefits, including improved body image and overall health. Unfortunately, a select population of exercising females may experience symptoms related to the "female athlete triad," which refers to the interrelationships among energy availability, menstrual function, and bone mineral density. Clinically, these conditions can manifest as disordered eating behaviors, menstrual irregularity, and stress fractures. Athletes with conditions related to the triad are distributed along a spectrum between optimal health and disease and may not experience all conditions simultaneously. Previous research related to the triad has primarily focused on collegiate and elite athletes. However, mounting evidence demonstrates that the triad is present in the high school population. High school athletes should be assessed for triad components at preparticipation physicals. In addition, parents, coaches, and health care professionals should be educated and informed about the female athlete triad syndrome. In the presence of triad symptoms, further evaluation and treatment by a multidisciplinary team is strongly recommended for the athlete.
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82
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Abstract
The number of females participating in sports continues to increase. Adolescent and preadolescent females are at a risk injury to both their open growth plates as well as their joints. The purpose of this article is to review the common injuries seen with the most popular sports with females. Mt Sinai J Med 77:307-314, 2010. (c) 2010 Mount Sinai School of Medicine.
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83
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Abstract
Absolute and relative components of body mass are a primary focus in studies of body composition. Components change with growth and maturation, requiring care in selecting methods of assessment in children and adolescents. Although sex differences are apparent in fat-free mass (FFM), fat mass (FM), and relative fatness (% Fat) during childhood, they are more clearly defined during adolescence and adulthood. Body composition is one of many determinants of sport performance, but % Fat tends to be the primary focus of discussion in young athletes. The influence of training for sport on bone mineral has received more attention in recent years because of methodological advances in assessment and concern for potential negative effects of altered menstrual function on bone. Relative fatness of young athletes in several sports is summarized, and issues related to sport training and body composition in young athletes are considered. Suggestions for dealing with body composition in young athletes are provided.
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Affiliation(s)
- Robert M. Malina
- Department of Kinesiology and Health Education, University of Texas at Austin, Texas, Department of Kinesiology, Tarleton State University, Stephenville, Texas,
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84
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Rauh MJ, Nichols JF, Barrack MT. Relationships among injury and disordered eating, menstrual dysfunction, and low bone mineral density in high school athletes: a prospective study. J Athl Train 2011; 45:243-52. [PMID: 20446837 DOI: 10.4085/1062-6050-45.3.243] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Prior authors have reported associations among increased risk of injury and factors of the female athlete triad, as defined before the 2007 American College of Sports Medicine position stand, in collegiate and adult club sport populations. Little is known about this relationship in an adolescent competitive sports population. OBJECTIVE To examine the relationship among disordered eating, menstrual dysfunction, and low bone mineral density (BMD) and musculoskeletal injury among girls in high school sports. DESIGN Prospective cohort study. SETTING The sample consisted of 163 female athletes competing in 8 interscholastic sports in southern California during the 2003-2004 school year. Each participant was followed throughout her respective sport season for occurrence of musculoskeletal injuries. MAIN OUTCOME MEASURE(S) Data collected included daily injury reports, the Eating Disorder Examination Questionnaire that assessed disordered eating attitudes and behaviors, a dual-energy x-ray absorptiometry scan that measured BMD and lean tissue mass, anthropometric measurements, and a questionnaire on menstrual history and demographic characteristics. RESULTS Sixty-one athletes (37.4%) incurred 90 musculoskeletal injuries. In our BMD z score model of <or=-1 SD, a history of oligomenorrhea/amenorrhea during the past year and low BMD (z score <or=-1 SD) were associated with the occurrence of musculoskeletal injury during the interscholastic sport season. In our BMD z score model of <or=-2 SDs, disordered eating (Eating Disorder Examination Questionnaire score >or=4.0), a history of oligomenorrhea/amenorrhea during the past year, and a low BMD (z score <or=-2 SDs) were associated with musculoskeletal injury occurrence. CONCLUSIONS These findings indicate that disordered eating, oligomenorrhea/amenorrhea, and low BMD were associated with musculoskeletal injuries in these female high school athletes. Programs designed to identify and prevent disordered eating and menstrual dysfunction and to increase bone mass in athletes may help to reduce musculoskeletal injuries.
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Affiliation(s)
- Mitchell J Rauh
- School of Exercise & Nutritional Sciences, San Diego State University, CA, USA.
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85
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Toraishi M, Uenishi K. Relationship between Bone Health and Vitamin K Nutritional Status in University Student Male Long-distance Runners. ACTA ACUST UNITED AC 2011. [DOI: 10.5264/eiyogakuzashi.69.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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86
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Finch CF, Ullah S, McIntosh AS. Combining Epidemiology and Biomechanics in Sports Injury Prevention Research. Sports Med 2011; 41:59-72. [DOI: 10.2165/11537260-000000000-00000] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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87
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Nieves JW, Melsop K, Curtis M, Kelsey JL, Bachrach LK, Greendale G, Sowers MF, Sainani KL. Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners. PM R 2010; 2:740-50; quiz 794. [PMID: 20709302 DOI: 10.1016/j.pmrj.2010.04.020] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 04/16/2010] [Accepted: 04/22/2010] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify nutrients, foods, and dietary patterns associated with stress fracture risk and changes in bone density among young female distance runners. DESIGN AND SETTING Two-year, prospective cohort study. Observational data were collected in the course of a multicenter randomized trial of the effect of oral contraceptives on bone health. PARTICIPANTS One hundred and twenty-five female competitive distance runners ages 18-26 years. ASSESSMENT OF RISK FACTORS Dietary variables were assessed with a food frequency questionnaire. MAIN OUTCOME MEASUREMENTS Bone mineral density and content (BMD/BMC) of the spine, hip, and total body were measured annually by dual x-ray absorptiometry (DEXA). Stress fractures were recorded on monthly calendars, and had to be confirmed by radiograph, bone scan, or magnetic resonance imaging. RESULTS Seventeen participants had at least one stress fracture during follow-up. Higher intakes of calcium, skim milk, and dairy products were associated with lower rates of stress fracture. Each additional cup of skim milk consumed per day was associated with a 62% reduction in stress fracture incidence (P < .05); and a dietary pattern of high dairy and low fat intake was associated with a 68% reduction (P < .05). Higher intakes of skim milk, dairy foods, calcium, animal protein, and potassium were associated with significant (P < .05) gains in whole-body BMD and BMC. Higher intakes of calcium, vitamin D, skim milk, dairy foods, potassium, and a dietary pattern of high dairy and low fat were associated with significant gains in hip BMD. CONCLUSIONS In young female runners, low-fat dairy products and the major nutrients in milk (calcium, vitamin D, and protein) were associated with greater bone gains and a lower stress fracture rate. Potassium intake was also associated with greater gains in hip and whole-body BMD.
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Affiliation(s)
- Jeri W Nieves
- Clinical Research Center, Helen Hayes Hospital, Route 9W, West Haverstraw, NY 10993, USA.
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Frisbie DD, Mc Ilwraith CW, Arthur RM, Blea J, Baker VA, Billinghurst RC. Serum biomarker levels for musculoskeletal disease in two- and three-year-old racing Thoroughbred horses: A prospective study of 130 horses. Equine Vet J 2010; 42:643-51. [PMID: 20840580 DOI: 10.1111/j.2042-3306.2010.00123.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
REASON FOR PERFORMING STUDY Biomarkers have shown some in vivo promise for the detection of musculoskeletal injuries, but further study to assess biomarker levels in clinical orthopaedic disease is required. OBJECTIVE To assess 7 serum biomarkers for the detection of musculoskeletal injuries. METHODS Two- and 3-year-old racehorses were entered into the study (n = 238). Exit criteria were lack of training for >30 days, or completion of 10 study months. Data from horses with solitary musculoskeletal injuries and completion of >2 months were analysed. Musculoskeletal injury was considered intra-articular fragmentation (IAF), tendon or ligamentous injury (TL), stress fractures (SF) and dorsal metacarpal disease (DMD). Monthly lameness examination and serum collection were performed. Serum was analysed for glycosaminoglycan (GAG), type I and II collagen degradation (C1, 2C), type II collagen synthesis (CPII), type II collagen degradation (Col CEQ), aggrecan synthesis (CS846), osteocalcin (OC) as a marker of bone formation and (C-terminal telopeptide of type I collagen) CTX as a marker of bone degradation. RESULTS Of the 238 horses 59 injured and 71 uninjured control horses met the analysis criteria. Based on injury no significant differences in the proportions were observed for age, gender or lesion type, although a higher proportion of injuries occurred at the beginning of the study. Of injured horses, 16 (27%) sustained an IAF, 17 (29%) a TL injury, 7 (12%) SF and 19 (32%) were diagnosed with DMD. There were significant changes seen in biomarkers based on the injury incurred when longitudinal samples were assessed. Furthermore, based on the serum biomarkers collected prior to injury, horses could be correctly classified as injured or uninjured 73.8% of the time. CONCLUSIONS A unique biomarker pattern occurred before each injury and this was beneficial in classifying horses as injured or uninjured. POTENTIAL RELEVANCE Biomarkers have the potential to be used as a screening aid prior to musculoskeletal injury.
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Affiliation(s)
- D D Frisbie
- Gail Holmes Equine Orthopaedic Research Center, Colorado State University, USA.
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89
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Tenforde AS, Sayres LC, Sainani KL, Fredericson M. Evaluating the Relationship of Calcium and Vitamin D in the Prevention of Stress Fracture Injuries in the Young Athlete: A Review of the Literature. PM R 2010; 2:945-9. [DOI: 10.1016/j.pmrj.2010.05.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 04/28/2010] [Accepted: 05/08/2010] [Indexed: 12/12/2022]
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Polacek M, Småbrekke A. Displaced stress fracture of the femoral neck in young active adults. BMJ Case Rep 2010; 2010:bcr0220102749. [PMID: 22778106 PMCID: PMC3029614 DOI: 10.1136/bcr.02.2010.2749] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Stress fractures of the femoral neck in healthy individuals are rare and most prevalent among long-distance runners and military recruits. Women seem to be at higher risk of developing stress fractures because of possible eating disorders and, thereby, following amenorrhoea and osteoporosis. The majority of fractures of the femoral neck are undisplaced. However, they might progress into displaced fractures with avascular necrosis of the femoral head and following development of osteoarthritis as a probable consequence even when treated properly. Early diagnosis with MRI or radionuclide scanning in patients with a history of pain in the groin region during training might be crucial in detecting the fractures at early stages; thereby preventing possible complications following surgical treatment of displaced fractures. The authors present a report of two young adults who developed displaced fractures of the femoral neck and were treated with closed reduction and internal fixation.
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Affiliation(s)
- Martin Polacek
- Orthopaedic Department, University Hospital in North Norway, Tromsø, Norway.
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91
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Upper extremity stress fractures and spondylolysis in an adolescent baseball pitcher with an associated endocrine abnormality: a case report. J Pediatr Orthop 2010; 30:339-43. [PMID: 20502233 DOI: 10.1097/bpo.0b013e3181dac0c1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Lower extremity stress fractures are relatively common among competitive athletes. Stress fractures of the upper extremity, however, are rare and most have been reported in the literature as case reports. We present a case of an adolescent baseball pitcher who had both proximal humeral and ulnar shaft stress fractures, as well as spondylolysis of the lumbar spine. This particular patient also had an underlying endocrine abnormality of secondary hyperparathyroidism with a deficiency in vitamin D. A bone mineral density panel demonstrated a high T score (+2.79 SD above the mean) and the patient's biologic bone age was noted to be 2 years ahead of his chronologic age. The patient was treated with a course of vitamin D and calcium supplementation. After treatment, both the vitamin D and parathyroid hormone returned to normal levels. The upper extremity stress fractures and spondylolysis were managed conservatively and he was able to return to full activity and baseball. For patients who present with multiple stress fractures not associated with consistent high levels of repeated stress, a bone mineral density panel should be considered. If vitamin D deficiency is present, a course of oral supplementation may be considered in the management. An endocrinology consult should also be considered in patients who present with multiple stress fractures. Conservative management of upper extremity stress fractures and spondylolysis was successful in returning this patient back to his previous activity level.
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92
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Abstract
Stress fracture represents an overuse injury of the bone resulting from excessive repetitive stress. Diagnosis in most cases is based on clinical evaluation. Plain radiographs may show characteristic changes 2 to 4 weeks from onset of symptoms. Increasingly, magnetic resonance imaging is recognized as the study of choice in the evaluation of stress injury of the bone. Most stress fractures at low-risk sites can be managed in the primary care setting with conservative measures. From a primary care perspective, orthopedic or sports medicine consultation is considered for stress fractures at high-risk sites. This article reviews general principles of diagnosis and management of stress fractures in adolescents.
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93
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Popp KL, Hughes JM, Smock AJ, Novotny SA, Stovitz SD, Koehler SM, Petit MA. Bone geometry, strength, and muscle size in runners with a history of stress fracture. Med Sci Sports Exerc 2010; 41:2145-50. [PMID: 19915505 DOI: 10.1249/mss.0b013e3181a9e772] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Our primary aim was to explore differences in estimates of tibial bone strength, in female runners with and without a history of stress fractures. Our secondary aim was to explore differences in bone geometry, volumetric density, and muscle size that may explain bone strength outcomes. METHODS A total of 39 competitive distance runners aged 18-35 yr, with (SFX, n = 19) or without (NSFX, n = 20) a history of stress fracture were recruited for this cross-sectional study. Peripheral quantitative computed tomography (XCT 3000; Orthometrix, White Plains, NY) was used to assess volumetric bone mineral density (vBMD, mg x mm(-3)), bone area (ToA, mm(2)), and estimated compressive bone strength (bone strength index (BSI) = ToA x total volumetric density (ToD(2))) at the distal tibia (4%). Total (ToA, mm(2)) and cortical (CoA, mm(2)) bone area, cortical vBMD, and estimated bending strength (strength-strain index (SSIp), mm(3)) were measured at the 15%, 25%, 33%, 45%, 50%, and 66% sites. Muscle cross-sectional area (MCSA) was measured at the 50% and 66% sites. RESULTS Participants in the SFX group had significantly smaller (7%-8%) CoA at the 45%, 50%, and 66% sites (P <or= 0.05 for all), significantly lower SSIp (9%-10%) at the 50% and 66% sites, and smaller MCSA (7%-8%) at the 66% site. The remaining bone parameters including vBMD were not significantly different between groups. After adjusting for MCSA, there were no differences between groups for any measured bone outcomes. CONCLUSIONS These findings suggest that cortical bone strength, cortical area, and MCSA are all lower in runners with a history of stress fracture. However, the lower strength was appropriate for the smaller muscle size, suggesting that interventions to reduce stress fracture risk might be aimed at improving muscle size and strength.
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Affiliation(s)
- Kristin L Popp
- School of Kinesiology, Laboratory of Musculoskeletal Health, University of Minnesota, Minneapolis, MN 55455, USA
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94
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Pantano KJ. Coaching Concerns in Physically Active Girls and Young Women-Part I: The Female Athlete Triad. Strength Cond J 2009. [DOI: 10.1519/ssc.0b013e3181c105dd] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Chatzipapas C, Boikos S, Drosos GI, Kazakos K, Tripsianis G, Serbis A, Stergiopoulos S, Tilkeridis C, Verettas DA, Stratakis CA. Polymorphisms of the vitamin D receptor gene and stress fractures. Horm Metab Res 2009; 41:635-40. [PMID: 19391078 PMCID: PMC3135021 DOI: 10.1055/s-0029-1216375] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Our aim was to evaluate the association between VDR polymorphisms and calcaneal Stiffness Index (SI) with stress fractures in a case control study including male military personnel. Thirty- two patients with stress fractures were matched with 32 uninjured healthy volunteers (controls), by gender, age, height, body weight, and level of physical activity. The two groups were genotyped for the FokI, BsmI, ApaI, and TaqI polymorphisms of the VDR gene with PCR-RFLP method. In addition, calcaneal SI was measured by heel quantitative ultrasound in both groups. Data were analyzed by chi-squared test and logistic regression analysis. The f allele was significantly more frequent in patients than in controls (p=0.013), while the B allele showed such a tendency without reaching statistical significance (p=0.052). Among the entire cohort, a 2.7-fold and a 2.0-fold increase in risk of stress fractures was associated with the f and B alleles (OR, 2.7, 95% CI, 1.2-5.9; p=0.014 and OR, 2.0, 95% CI, 1.0-4.1; p=0.053, respectively). No statistically significant association was found between the incidence of stress fractures and t or a alleles. Decreased T-scores were also associated with the presence of f and B alleles. Mean values of T-scores of SI were statistically significantly lower in patients than in controls (p=0.018). These results suggest that the FokI and BsmI polymorphisms of the VDR gene could be associated with increased risk of stress fractures among military personnel. Moreover, a low calcaneal SI could represent a measurable index of this increased risk.
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Affiliation(s)
- C Chatzipapas
- 1Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
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Manore MM, Kam LC, Loucks AB. The female athlete triad: components, nutrition issues, and health consequences. J Sports Sci 2009; 25 Suppl 1:S61-71. [PMID: 18049984 DOI: 10.1080/02640410701607320] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This paper, which was part of the International Association of Athletics Federations (IAAF) 2007 Nutritional Consensus Conference, briefly reviews the components of the female athlete triad (Triad): energy availability, menstrual status, and bone health. Each component of the Triad spans a continuum from health to disease, and female athletes can have symptoms related to each component of the Triad to different degrees. Low energy availability is the primary factor that impairs menstrual dysfunction and bone health in the Triad. We discuss nutritional issues associated with the Triad, focusing on intakes of macronutrients needed for good health, and stress fractures, the most common injury associated with the Triad. Finally, we briefly discuss screening and treatment for the Triad and the occurrence of the Triad in men.
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Affiliation(s)
- Melinda M Manore
- Department of Nutrition and Exercise Sciences, Oregon State University, Milam Hall 103, Corvallis, OR, USA.
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Schtscherbyna A, Soares EA, de Oliveira FP, Ribeiro BG. Female athlete triad in elite swimmers of the city of Rio de Janeiro, Brazil. Nutrition 2009; 25:634-9. [DOI: 10.1016/j.nut.2008.11.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 11/22/2008] [Accepted: 11/30/2008] [Indexed: 10/21/2022]
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Hagihara Y, Nakajima A, Fukuda S, Goto S, Iida H, Yamazaki M. Running Exercise for Short Duration Increases Bone Mineral Density of Loaded Long Bones in Young Growing Rats. TOHOKU J EXP MED 2009; 219:139-43. [DOI: 10.1620/tjem.219.139] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yoshinobu Hagihara
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine
| | - Satoshi Fukuda
- International Space Radiation Laboratory, National Institute of Radiological Sciences
| | - Sumio Goto
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine
| | - Haruzo Iida
- International Space Radiation Laboratory, National Institute of Radiological Sciences
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine
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EVANS RACHELK, NEGUS CHARLES, ANTCZAK AMANDAJ, YANOVICH RAN, ISRAELI ERAN, MORAN DANIELS. Sex Differences in Parameters of Bone Strength in New Recruits. Med Sci Sports Exerc 2008; 40:S645-53. [DOI: 10.1249/mss.0b013e3181893cb7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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