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Shi V, Morgan EF. Estrogen and estrogen receptors mediate the mechanobiology of bone disease and repair. Bone 2024; 188:117220. [PMID: 39106937 PMCID: PMC11392539 DOI: 10.1016/j.bone.2024.117220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 07/28/2024] [Accepted: 07/30/2024] [Indexed: 08/09/2024]
Abstract
It is well understood that the balance of bone formation and resorption is dependent on both mechanical and biochemical factors. In addition to cell-secreted cytokines and growth factors, sex hormones like estrogen are critical to maintaining bone health. Although the direct osteoprotective function of estrogen and estrogen receptors (ERs) has been reported extensively, evidence that estrogen signaling also has a role in mediating the effects of mechanical loading on maintenance of bone mass and healing of bone injuries has more recently emerged. Recent studies have underscored the role of estrogen and ERs in many pathways of bone mechanosensation and mechanotransduction. Estrogen and ERs have been shown to augment integrin-based mechanotransduction as well as canonical Wnt/b-catenin, RhoA/ROCK, and YAP/TAZ pathways. Estrogen and ERs also influence the mechanosensitivity of not only osteocytes but also osteoblasts, osteoclasts, and marrow stromal cells. The current review will highlight these roles of estrogen and ERs in cellular mechanisms underlying bone mechanobiology and discuss their implications for management of osteoporosis and bone fractures. A greater understanding of the mechanisms behind interactions between estrogen and mechanical loading may be crucial to addressing the shortcomings of current hormonal and pharmaceutical therapies. A combined therapy approach including high-impact exercise therapy may mitigate adverse side effects and allow an effective long-term solution for the prevention, treatment, and management of bone fragility in at-risk populations. Furthermore, future implications to novel local delivery mechanisms of hormonal therapy for osteoporosis treatment, as well as the effects on bone health of applications of sex hormone therapy outside of bone disease, will be discussed.
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Affiliation(s)
- Vivian Shi
- Boston University, Department of Biomedical Engineering, 44 Cummington St, Boston 02215, MA, USA; Center for Multiscale and Translational Mechanobiology, Boston University, 44 Cummington St, Boston 02215, MA, USA
| | - Elise F Morgan
- Boston University, Department of Biomedical Engineering, 44 Cummington St, Boston 02215, MA, USA; Center for Multiscale and Translational Mechanobiology, Boston University, 44 Cummington St, Boston 02215, MA, USA.
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2
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George ERM, Sheerin KR, Reid D. Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports Med 2024; 54:2247-2265. [PMID: 39141251 PMCID: PMC11393297 DOI: 10.1007/s40279-024-02051-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 08/15/2024]
Abstract
Tibial bone stress injuries (BSIs) are common among long-distance runners. They have a high recurrence rate, and complexity emerges in the wider management and successful return to running. Following a tibial BSI, a critical component of complete rehabilitation is the successful return to running, and there is a lack of consistency or strong evidence to guide this process. The objectives of this review were to outline the criteria used in clinical decision-making prior to resuming running, and to establish evidence-based guidelines for the return to running process following a tibial BSI. Electronic databases including MEDLINE, CINAHL, Scopus, SPORTDiscus and AMED were searched for studies that stated criteria or provided guidelines on the objectives above. Fifty studies met the inclusion criteria and were included. Thirty-nine were reviews or clinical commentaries, three were retrospective cohort studies, two were randomised controlled trials, two were pilot studies, one was a prospective observational study, and three were case studies. Therefore, the recommendations that have been surmised are based on level IV evidence. Decisions on when an athlete should return to running should be shared between clinicians, coaches and the athlete. There are five important components to address prior to introducing running, which are: the resolution of bony tenderness, pain-free walking, evidence of radiological healing in high-risk BSIs, strength, functional and loading tests, and the identification of contributing factors. Effective return to running planning should address the athlete's risk profile and manage the risk by balancing the athlete's interests and reinjury prevention. An individualised graduated return to running programme should be initiated, often starting with walk-run intervals, progressing running distance ahead of speed and intensity, with symptom provocation a key consideration. Contributing factors to the initial injury should be addressed throughout the return to run process.
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Affiliation(s)
- Esther R M George
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.
- InForm Physio, Silverstream, New Zealand.
| | - Kelly R Sheerin
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Duncan Reid
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
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Ihalainen JK, Mikkonen RS, Ackerman KE, Heikura IA, Mjøsund K, Valtonen M, Hackney AC. Beyond Menstrual Dysfunction: Does Altered Endocrine Function Caused by Problematic Low Energy Availability Impair Health and Sports Performance in Female Athletes? Sports Med 2024; 54:2267-2289. [PMID: 38995599 PMCID: PMC11393114 DOI: 10.1007/s40279-024-02065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/13/2024]
Abstract
Low energy availability, particularly when problematic (i.e., prolonged and/or severe), has numerous negative consequences for health and sports performance as characterized in relative energy deficiency in sport. These consequences may be driven by disturbances in endocrine function, although scientific evidence clearly linking endocrine dysfunction to decreased sports performance and blunted or diminished training adaptations is limited. We describe how low energy availability-induced changes in sex hormones manifest as menstrual dysfunction and accompanying hormonal dysfunction in other endocrine axes that lead to adverse health outcomes, including negative bone health, impaired metabolic activity, undesired outcomes for body composition, altered immune response, problematic cardiovascular outcomes, iron deficiency, as well as impaired endurance performance and force production, all of which ultimately may influence athlete health and performance. Where identifiable menstrual dysfunction indicates hypothalamic-pituitary-ovarian axis dysfunction, concomitant disturbances in other hormonal axes and their impact on the athlete's health and sports performance must be recognized as well. Given that the margin between podium positions and "losing" in competitive sports can be very small, several important questions regarding low energy availability, endocrinology, and the mechanisms behind impaired training adaptations and sports performance have yet to be explored.
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Affiliation(s)
- Johanna K Ihalainen
- Biology of Physical Activity, Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, 40014, Jyväskylä, Finland.
- Finnish Institute of High Performance Sport KIHU, Jyväskylä, Finland.
| | - Ritva S Mikkonen
- Biology of Physical Activity, Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, 40014, Jyväskylä, Finland
- Sports Technology Unit, Faculty of Sport and Health Sciences, University of Jyväskylä, Vuokatti, Finland
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ida A Heikura
- Canadian Sport Institute-Pacific, Victoria, BC, Canada
- Exercise Science, Physical and Health Education, University of Victoria, Victoria, BC, Canada
| | - Katja Mjøsund
- Paavo Nurmi Centre and Unit for Health and Physical Activity, University of Turku, Turku, Finland
- National Olympic Training Centre Helsinki, Helsinki, Finland
| | - Maarit Valtonen
- Finnish Institute of High Performance Sport KIHU, Jyväskylä, Finland
| | - Anthony C Hackney
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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4
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MacMillan C, Olivier B, Viljoen C, van Rensburg DCJ, Sewry N. The Association Between Menstrual Cycle Phase, Menstrual Irregularities, Contraceptive Use and Musculoskeletal Injury Among Female Athletes: A Scoping Review. Sports Med 2024:10.1007/s40279-024-02074-5. [PMID: 39215933 DOI: 10.1007/s40279-024-02074-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The influence of menstrual cycle phases (MCPs), menstrual irregularities (MI) and hormonal contraceptive (HC) use on injury among female athletes has been scrutinised. Existing systematic reviews investigating the effect of exposures affecting the endogenous reproductive hormone status on sporting injuries are limited in terms of the types of studies included and injuries investigated. OBJECTIVE This scoping review aims to summarise the coverage of the literature related to the extent, nature and characteristics of the influence of MCP, MI and HC use on musculoskeletal injuries among athletes. It also aims to summarise key concepts and definitions in the relevant literature. Observational and experimental studies investigating the effect of MCP, MI, and HC on musculoskeletal injuries among female individuals of reproductive age were included. Studies specifically stating pregnant women, perimenopausal/postmenopausal athletes, or those using medication (other than HC) that affects reproductive hormone profiles or the musculoskeletal system were excluded. METHODS This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping reviews and JBI scoping review guidelines. Published and unpublished studies were sourced from several databases and resources. Initial keywords used included terms related to "menstrual cycle", "hormonal contraception" and "injury." Titles and abstracts of identified citations were screened independently and assessed for eligibility by two independent reviewers. Data from the included studies were extracted using a standard data extraction form. RESULTS The search yielded 10,696 articles, of which 96 met the eligibility criteria. Most studies investigated MI (77%), and 49% included MCP as a contributing injury risk factor. Publications have increased over the last two decades. Collectively, only 16% of research has been conducted in Africa, Asia and Oceania. There were no studies from South America. Seventy-five percent of the studies investigated individual versus team (25%) sport athletes. Most studies only investigated elite or professional (n = 24; 25%) level athletes. The definitions of injury, eumenorrhea and MI differ vastly among studies. Regarding MI, most studies (69%) investigated secondary amenorrhea, followed by oligomenorrhea (51%) and primary amenorrhea (43%). Concerning HC, the influence of oral contraceptive pills was mainly investigated. CONCLUSIONS Research related to MCP, MI and HC as contributing musculoskeletal injury risk factors is increasing; however, several gaps have been identified, including research from countries other than North America and Europe, the study population being non-professional/elite level athletes, athletes participating in team sports and specific injuries related to MCP, MI and HC, respectively. Differences in methodology and terminology of injury, MCP and MI hinder comparative summative research, and future research should consider current published guidelines during the study design. Identifying barriers to following standard guidelines or research investigating the most practical yet accurate methods to investigate the influence of MCP on musculoskeletal health might yield valuable insights for future research designs. CLINICAL TRIAL REGISTRATION Scoping review registration number: Open Science Framework ( https://doi.org/10.17605/OSF.IO/5GWBV ).
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Affiliation(s)
- Candice MacMillan
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, South Street, Pretoria, 0083, Gauteng, South Africa.
- Sport, Exercise Medicine, and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
| | - Benita Olivier
- Centre for Healthy Living Research, Oxford Institute of Allied Health Research, Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK
- Wits Cricket Research Hub for Science, Medicine and Rehabilitation, Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carel Viljoen
- Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | | | - Nicola Sewry
- Sport, Exercise Medicine, and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- International Olympic Committee (IOC) Research Centre, Pretoria, South Africa
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Lodge MT, Ackerman KE, Garay J. Differences in Knowledge of Female Athlete Triad and Relative Energy Deficiency in Sport in Female Cross-Country Athletes. J Athl Train 2024; 59:836-844. [PMID: 38014797 PMCID: PMC11340665 DOI: 10.4085/1062-6050-0608.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND The female athlete triad (Triad) and relative energy deficiency in sport (REDs) describe potential health and performance consequences of low energy availability. OBJECTIVE We surveyed female cross-country athletes to assess differences in educational impact scores (EIS; knowledge score × confidence score factor) of Triad and REDs. Associations between EIS and participant characteristics (eg, mileage [current and peak], years of running experience, age, bone stress injury history, division level participation, academic area of study, Triad or REDs diagnoses, and Triad or REDs education) were explored. MAIN OUTCOME MEASURE(S) An evidence-based online survey was developed and administered via Qualtrics to female collegiate cross-country athletes (n = 275; age = 20 ± 1 years). RESULTS A weak correlation existed between peak career mileage and EIS (r = 0.195; P = .010). Educational impact scores significantly differed in athletes with a related academic area of study versus those without (21.91 ± 5.16 and 16.11 ± 5.54, respectively). Educational impact scores significantly differed in athletes with Triad and REDs diagnoses (21.69 ± 5.85 and 22.58 ± 6.82, respectively) versus those without (16.80 ± 6.54 and 17.20 ± 6.34, respectively). Educational impact scores were higher in those who had received Triad education versus those who had not (21.03 ± 6.86 and 18.12 ± 6.82, respectively). A significant interaction between peak career mileage and Triad diagnosis was found (P = .005). CONCLUSIONS Significant education-based and diagnosis differences suggest that Triad diagnoses correlate with peak career mileage. These findings support the facilitation of education to improve not only the treatment but also the prevention of Triad and REDs.
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Myers SJ, Knight RL, Wardle SL, Waldock KA, O'Leary TJ, Jones RK, Muckelt PE, Eisenhauer A, Tang JC, Fraser WD, Greeves JP. Effect of Menstrual Cycle and Hormonal Contraception on Musculoskeletal Health and Performance: Protocol for a Prospective Cohort Design and Cross-Sectional Comparison. JMIR Res Protoc 2024; 13:e50542. [PMID: 38990638 PMCID: PMC11273068 DOI: 10.2196/50542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 04/24/2024] [Accepted: 05/22/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Women of reproductive age experience cyclical variation in the female sex steroid hormones 17β-estradiol and progesterone during the menstrual cycle that is attenuated by some hormonal contraceptives. Estrogens perform a primary function in sexual development and reproduction but have nonreproductive effects on bone, muscle, and sinew tissues (ie, ligaments and tendons), which may influence injury risk and physical performance. OBJECTIVE The purpose of the study is to understand the effect of the menstrual cycle and hormonal contraceptive use on bone and calcium metabolism, and musculoskeletal health and performance. METHODS A total of 5 cohorts of physically active women (aged 18-40 years) will be recruited to participate: eumenorrheic, nonhormonal contraceptive users (n=20); combined oral contraceptive pill (COCP) users (n=20); hormonal implant users (n=20); hormonal intrauterine system users (n=20); and hormonal injection users (n=20). Participants must have been using the COCP and implant for at least 1 year and the intrauterine system and injection for at least 2 years. First-void urine samples and fasted blood samples will be collected for biochemical analysis of calcium and bone metabolism, hormones, and metabolic markers. Knee extensor and flexor strength will be measured using an isometric dynamometer, and lower limb tendon and stiffness, tone, and elasticity will be measured using a Myoton device. Functional movement will be assessed using a single-leg drop to assess the frontal plane projection angle and the qualitative assessment of single leg loading. Bone density and macro- and microstructure will be measured using ultrasound, dual-energy x-ray absorptiometry, and high-resolution peripheral quantitative computed tomography. Skeletal material properties will be estimated from reference point indentation, performed on the flat surface of the medial tibia diaphysis. Body composition will be assessed by dual-energy x-ray absorptiometry. The differences in outcome measures between the hormonal contraceptive groups will be analyzed in a one-way between-group analysis of covariance. Within the eumenorrheic group, the influence of the menstrual cycle on outcome measures will be assessed using a linear mixed effects model. Within the COCP group, differences across 2 time points will be analyzed using the paired-samples 2-tailed t test. RESULTS The research was funded in January 2020, and data collection started in January 2022, with a projected data collection completion date of August 2024. The number of participants who have consented at the point of manuscript submission is 66. It is expected that all data analysis will be completed and results published by the end of 2024. CONCLUSIONS Understanding the effects of the menstrual cycle and hormonal contraception on musculoskeletal health and performance will inform contraceptive choices for physically active women to manage injury risk. TRIAL REGISTRATION ClinicalTrials.gov NCT05587920; https://classic.clinicaltrials.gov/ct2/show/NCT05587920. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50542.
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Affiliation(s)
- Sarah J Myers
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Rebecca L Knight
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
- Division of Surgery & Interventional Science, University College London, London, United Kingdom
| | - Kirsty Am Waldock
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
- Division of Surgery & Interventional Science, University College London, London, United Kingdom
| | - Richard K Jones
- School of Health and Society, University of Salford, Salford, United Kingdom
| | - Paul E Muckelt
- School of Health Sciences, University of Southampton, Southampton, United Kingdom
- Southampton Biomedical Research Centre, National Institute for Health and Care Research, Southampton, United Kingdom
| | - Anton Eisenhauer
- GEOMAR Helmholtz-center for Ocean Research Kiel, Kiel, Germany
- Osteolabs, Kiel, Germany
| | - Jonathan Cy Tang
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
- Clinical Biochemistry, Department of Laboratory Medicine, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom
| | - William D Fraser
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
- Departments of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
- Division of Surgery & Interventional Science, University College London, London, United Kingdom
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Kuliczkowska-Płaksej J, Zdrojowy-Wełna A, Jawiarczyk-Przybyłowska A, Gojny Ł, Bolanowski M. Diagnosis and therapeutic approach to bone health in patients with hypopituitarism. Rev Endocr Metab Disord 2024; 25:513-539. [PMID: 38565758 DOI: 10.1007/s11154-024-09878-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
The results of many studies in recent years indicate a significant impact of pituitary function on bone health. The proper function of the pituitary gland has a significant impact on the growth of the skeleton and the appearance of sexual dimorphism. It is also responsible for achieving peak bone mass, which protects against the development of osteoporosis and fractures later in life. It is also liable for the proper remodeling of the skeleton, which is a physiological mechanism managing the proper mechanical resistance of bones and the possibility of its regeneration after injuries. Pituitary diseases causing hypofunction and deficiency of tropic hormones, and thus deficiency of key hormones of effector organs, have a negative impact on the skeleton, resulting in reduced bone mass and susceptibility to pathological fractures. The early appearance of pituitary dysfunction, i.e. in the pre-pubertal period, is responsible for failure to achieve peak bone mass, and thus the risk of developing osteoporosis in later years. This argues for the need for a thorough assessment of patients with hypopituitarism, not only in terms of metabolic disorders, but also in terms of bone disorders. Early and properly performed treatment may prevent patients from developing the bone complications that are so common in this pathology. The aim of this review is to discuss the physiological, pathophysiological, and clinical insights of bone involvement in pituitary disease.
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Affiliation(s)
- Justyna Kuliczkowska-Płaksej
- Department and Clinic of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże Pasteura 4, Wrocław, 50-367, Poland
| | - Aleksandra Zdrojowy-Wełna
- Department and Clinic of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże Pasteura 4, Wrocław, 50-367, Poland
| | - Aleksandra Jawiarczyk-Przybyłowska
- Department and Clinic of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże Pasteura 4, Wrocław, 50-367, Poland.
| | - Łukasz Gojny
- Department and Clinic of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże Pasteura 4, Wrocław, 50-367, Poland
| | - Marek Bolanowski
- Department and Clinic of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże Pasteura 4, Wrocław, 50-367, Poland
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Passoni P, Inzoli A, De Ponti E, Polizzi S, Ceccherelli A, Fantauzzi M, Procaccianti C, Cattoni A, Villa S, Riva A, Righetti S, Landoni F, Fruscio R. Association between Physical Activity and Menstrual Cycle Disorders in Young Athletes. Int J Sports Med 2024; 45:543-548. [PMID: 38417813 PMCID: PMC11216807 DOI: 10.1055/a-2278-3253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/17/2024] [Indexed: 03/01/2024]
Abstract
Our study aims to evaluate clinical predictors of menstrual cycle disorders in female athletes who compete in running disciplines. This is a prospective observational study. Women were recruited between January and May 2022. Fifty-three patients were enrolled and completed a questionnaire about menstrual cycle, physical activity, and food habit characteristics. Of the women in our population, 39.6% had menstrual irregularities and reported a significantly higher number of kilometers run per week (67 vs. 35, p:0.02). The number of kilometers run per week was associated with menstrual irregularities (for 10 km, OR 1.35; IC95% 1.05-1.73; p: 0.02) after adjusting for BMI, age, level of sport and caloric intake. The variable of "km run per week" appeared as a diagnostic indicator of irregular menstrual cycle with statistical significance (AUC ROC curve 0.71, IC95% 0.54-0.86, p-value=0.01) and the cut-off of 65 km run per week is a good indicator of the presence of irregular menstrual cycle (sensitivity (SE) and specificity (SP) of 55% and 81.48%). Menstrual cycle disorders are very frequent in female athletes, and the variable of km run per week may play a role in screening endurance athletes at high risk for these disorders.
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Affiliation(s)
- Paolo Passoni
- UO Gynecology, Fondazione IRCCS San Gerardo dei Tintori, Monza,
Italy
| | - Alessandra Inzoli
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
| | - Elena De Ponti
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
- Department of Physical Medicine, Fondazione IRCCS San Gerardo dei
Tintori, Monza, Italy
| | - Serena Polizzi
- UO Gynecology, Fondazione IRCCS San Gerardo dei Tintori, Monza,
Italy
| | - Anna Ceccherelli
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
| | - Martina Fantauzzi
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
| | - Chiara Procaccianti
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
| | - Alessandro Cattoni
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza,
Italy
| | - Silvia Villa
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
| | - Anna Riva
- Child and Adolescent Mental Health Department, Fondazione IRCCS San
Gerardo dei Tintori, Monza, Italy
| | - Stefano Righetti
- Interventional Cardiology Department, Fondazione IRCCS San Gerardo dei
Tintori, Monza, Italy
| | - Fabio Landoni
- UO Gynecology, Fondazione IRCCS San Gerardo dei Tintori, Monza,
Italy
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
| | - Robert Fruscio
- UO Gynecology, Fondazione IRCCS San Gerardo dei Tintori, Monza,
Italy
- Department of Medicine and Surgery, University of Milan-Bicocca,
Milano, Italy
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9
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Tenforde AS, Ackerman KE, Bouxsein ML, Gaudette L, McCall L, Rudolph SE, Gehman S, Garrahan M, Hughes JM, Outerleys J, Davis IS, Popp KL. Factors Associated With High-Risk and Low-Risk Bone Stress Injury in Female Runners: Implications for Risk Factor Stratification and Management. Orthop J Sports Med 2024; 12:23259671241246227. [PMID: 38779133 PMCID: PMC11110515 DOI: 10.1177/23259671241246227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/24/2023] [Indexed: 05/25/2024] Open
Abstract
Background Bone stress injury (BSI) is a common overuse injury in active women. BSIs can be classified as high-risk (pelvis, sacrum, and femoral neck) or low-risk (tibia, fibula, and metatarsals). Risk factors for BSI include low energy availability, menstrual dysfunction, and poor bone health. Higher vertical load rates during running have been observed in women with a history of BSI. Purpose/Hypothesis The purpose of this study was to characterize factors associated with BSI in a population of premenopausal women, comparing those with a history of high-risk or low-risk BSI with those with no history of BSI. It was hypothesized that women with a history of high-risk BSI would be more likely to exhibit lower bone mineral density (BMD) and related factors and less favorable bone microarchitecture compared with women with a history of low-risk BSI. In contrast, women with a history of low-risk BSI would have higher load rates. Study Design Cross-sectional study; Level of evidence, 3. Methods Enrolled were 15 women with a history of high-risk BSI, 15 with a history of low-risk BSI, and 15 with no history of BSI. BMD for the whole body, hip, and spine was standardized using z scores on dual-energy x-ray absorptiometry. High-resolution peripheral quantitative computed tomography was used to quantify bone microarchitecture at the radius and distal tibia. Participants completed surveys characterizing factors that influence bone health-including sleep, menstrual history, and eating behaviors-utilizing the Eating Disorder Examination Questionnaire (EDE-Q). Each participant completed a biomechanical assessment using an instrumented treadmill to measure load rates before and after a run to exertion. Results Women with a history of high-risk BSI had lower spine z scores than those with low-risk BSI (-1.04 ± 0.76 vs -0.01 ± 1.15; P < .05). Women with a history of high-risk BSI, compared with low-risk BSI and no BSI, had the highest EDE-Q subscores for Shape Concern (1.46 ± 1.28 vs 0.76 ± 0.78 and 0.43 ± 0.43) and Eating Concern (0.55 ± 0.75 vs 0.16 ± 0.38 and 0.11 ± 0.21), as well as the greatest difference between minimum and maximum weight at current height (11.3 ± 5.4 vs 7.7 ± 2.9 and 7.6 ± 3.3 kg) (P < .05 for all). Women with a history of high-risk BSI were more likely than those with no history of BSI to sleep <7 hours on average per night during the week (80% vs 33.3%; P < .05). The mean and instantaneous vertical load rates were not different between groups. Conclusion Women with a history of high-risk BSI were more likely to exhibit risk factors for poor bone health, including lower BMD, while load rates did not distinguish women with a history of BSI.
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Affiliation(s)
- Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Logan Gaudette
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Lauren McCall
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara E Rudolph
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Gehman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret Garrahan
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Jereme Outerleys
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Irene S Davis
- School of Physical Therapy Tampa, University of South Florida, Florida, USA
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- Oak Ridge Associated Universities, Oak Ridge, Tennessee, USA. A.S.T., K.E.A., and M.L.B. contributed equally to this study. I.S.D. and K.L.P. contributed equally to this study
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10
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Lu Y, Lu P, Lin L, Chen H, Zhang F, Li X. Characteristics of bone mineral density in patients with functional hypothalamic amenorrhoea and its association with reproductive hormones and body composition. Clin Endocrinol (Oxf) 2024; 100:358-365. [PMID: 38229276 DOI: 10.1111/cen.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/16/2023] [Accepted: 12/23/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Bone mineral density (BMD) is typically reduced in patients with female athlete triad (FAT) and anorexia nervosa (AN). However, bone health in most patients with functional hypothalamic amenorrhoea (FHA), who may not suffer from severe energy deficiency, has not received adequate attention in clinical practice. This study aimed to investigate BMD and its association with clinical and endocrine features in individuals with FHA and to provide clinical evidence for improving bone loss and preventing osteoporosis in FHA. DESIGN To assess the bone status of patients with FHA and investigate its association with various clinical and endocrinological characteristics. PATIENTS We retrospectively analysed 80 patients with FHA who attended the Obstetrics and Gynecology Hospital of Fudan University from January 2022 to March 2023. MEASUREMENTS The levels of reproductive hormones, including luteinising hormone (LH), follicle-stimulating hormone, oestradiol (E2 ) and total testosterone (TT), were examined at the time of initial diagnosis, and a body composition analyser was used to measure body fat percentage (BF%), lean body mass (LBM) and segmental muscle/fat. Dual-emission X-ray absorptiometry was used to measure lumbar spine BMD and femoral neck BMD in patients with FHA, and the Z score was calculated. RESULTS The study cohort consisted of 80 female patients with FHA. The average age of the patients was 24.64 ± 6.02 years, and their body mass index (BMI) was 19.47 ± 2.86 kg/m2 . The duration of weight loss was 12 (6, 24) months, while the duration of oligo/amenorrhoea was 12 (4.5, 24) months. The mean degree of weight loss was 18.39 ± 9.53%. Low BMD were present in 15% of patients with FHA at the lumbar spine and/or femoral neck; 12.5% and 10% had low bone mass at the lumbar spine and femoral neck, respectively. The low bone mass group experienced a longer period of weight loss than the normal group [24 (16.5, 60) vs. 12 (4.5, 24) months, p = .037]. In addition, the abnormal group had a lower BMR (basal metabolic rate, BMR) [1158 ± 85 vs. 1231 ± 91 kcal/day, p = .011] and lower bone mineral content [2.15 ± 0.26 vs. 2.43 ± 0.31 kg, p = .009] than the normal group. Both LBMD and femoral neck BMD (Fn BMD) were positively correlated with BMI, BF%, LBM, and regional muscle/fat mass (all p < .05). There was also a positive correlation between LBMD and basal LH levels (p = .009) and waist-to-hip ratio (p = .034), whereas Fn BMD was positively correlated with TT levels (p = .029). Multiple linear regression analysis showed that LBM was positively associated with LBMD (β = .007, 95% confidence interval [CI] = 0.004-0.009, p < .001), while trunk muscle mass was positively associated with Fn BMD (β = .046, 95% CI = 0.013-0.080, p = .008). CONCLUSION Fifteen percent of the patients with FHA exhibited low bone mass, a condition associated with prolonged weight loss. The basal LH and TT levels showed positive correlations with LBMD and Fn BMD, respectively. Meanwhile, BMR levels, BMI, BF%, and muscle mass were all positively correlated with LBMD and Fn BMD. Clinically, we should be attentive to suboptimal bone health in patients with FHA and take early screening, diagnosis and intervention measures, especially appropriate muscle mass gain, to prevent the onset of osteoporosis and fragility fractures in the long term.
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Affiliation(s)
- Ye Lu
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Ping Lu
- Department of Obstetrics and Gynecology, Maternity and Child Health Care Hospital of Sheyang County, Jiangsu, China
| | - Lixian Lin
- Department of Obstetrics and Gynecology, The First Hospital of Putian City, Fujian, China
| | - Hang Chen
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Feifei Zhang
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xin Li
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
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11
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Besor O, Redlich N, Constantini N, Weiler-Sagie M, Monsonego Ornan E, Lieberman S, Bentur L, Bar-Yoseph R. Assessment of Relative Energy Deficiency in Sport (REDs) Risk among Adolescent Acrobatic Gymnasts. J Pers Med 2024; 14:363. [PMID: 38672990 PMCID: PMC11051467 DOI: 10.3390/jpm14040363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Energy imbalance exposes athletes to relative energy deficiency in sports (REDs) syndrome. Data on energy consumption, REDs, and bone mineral density (BMD) in adolescent acrobatic gymnasts, especially in males, are scarce. Our aim was to examine the eating habits, energy balance, body composition, and BMD of these athletes. In this study, 18 healthy adolescents participating in competitive acrobatic gymnastics completed a questionnaire, underwent a dual-energy X-ray absorptiometry scan (DXA), received a food log, and had their activities monitored for 3 days. Eighteen acrobats were enrolled (mean age: 14.3 ± 1.2 years; males: 6/18). The mean total body BMD Z-score was 0.4 ± 1.0. Top-position acrobats (7/18) had significantly lower total body BMD Z-scores than base-positioned acrobats (-0.2 ± 0.3 vs. 0.8 ± 0.3, p = 0.032), though their forearms were not significantly different (0.2 ± 0.5 vs. 0.8 ± 0.7, p = 0.331). No sex differences were found for BMD Z-scores, BMI, or energy availability. The BMD parameters of the acrobats were within the normal range for a healthy pediatric population, although three had low BMDs (<-1 SD) for healthy athletes. Total body and LS BMD Z-scores were significantly lower in top-position athletes compared to base-position athletes. These findings suggest personalized (top vs. base) training programs (high-impact training) that may achieve better health outcomes.
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Affiliation(s)
- Omri Besor
- Department of Family Medicine, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
| | - Noam Redlich
- Heidi Rothberg Sports Medicine Center, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University, Jerusalem 9103102, Israel
- Institute of Biochemistry and Nutrition, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University, Rehovot 7610001, Israel
| | - Naama Constantini
- Heidi Rothberg Sports Medicine Center, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University, Jerusalem 9103102, Israel
| | - Michal Weiler-Sagie
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Efrat Monsonego Ornan
- Institute of Biochemistry and Nutrition, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University, Rehovot 7610001, Israel
| | - Shira Lieberman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
| | - Lea Bentur
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
- Ruth Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Ronen Bar-Yoseph
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
- Ruth Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
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12
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Burt LA, Wyatt PM, Morrison A, Boyd SK. Bone Quality in Competitive Athletes: A Systematic Review. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2023; 23:456-470. [PMID: 38037364 PMCID: PMC10696374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 12/02/2023]
Abstract
The study objective was to assess bone quality measured by high resolution peripheral quantitative computed tomography (HR-pQCT) in competitive athletes. Medline, EMBASE and Sport Discus were searched through May 2022. Prior to submission, a follow-up database search was performed (January 2023). Studies of competitive athletes using HR-pQCT to assess bone quality were included. Athletes were aged between 14 and 45 years. Data extraction included study design and location (country), skeletal imaging modality and site, bone variables and any additional musculoskeletal-related outcome. Information identifying sports and athletes were also extracted. This review included 14 manuscripts and a total of 928 individuals (male: n=75; female: n=853). Athletes comprised 78% (n=722) of the included individuals and 93% of athletes were female. Assessment scores indicate the studies were good to fair quality. The athletes included in this review can be categorized into three groups: 1) healthy athletes, 2) athletes with compromised menstrual function (e.g., amenorrhoea), and 3) athletes with compromised bone health (e.g., bone stress injuries). When assessing bone quality using HR-pQCT, healthy competitive athletes had denser, stronger and larger bones with better microarchitecture, compared with controls. However, the same cannot be said for athletes with amenorrhoea or bone stress injuries.
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Affiliation(s)
- Lauren A. Burt
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Paige M. Wyatt
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Canadian Sports Institute, Calgary, Canada
| | - Alida Morrison
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Steven K. Boyd
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
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13
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Ekenros L, Fridén C, von Rosen P. Does injury risk increase when youth athletes start to study at a sports high school? BMJ Open Sport Exerc Med 2023; 9:e001686. [PMID: 37937308 PMCID: PMC10626774 DOI: 10.1136/bmjsem-2023-001686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/09/2023] Open
Abstract
Background/aim The injury risk is high in adolescent elite athletes. However, little is known about how the injury risk changes when young talented athletes start studying at a sports high school. The primary aim was therefore to explore the risk of injury when the athlete starts to study at a sports high school. A secondary aim was to identify risk factors for injury. Methods A total of 489 athletes (age 15-16 years) were followed for 20 weeks, including 10 weeks before and 10 weeks after the athlete had started to study at a sports high school. Substantial injury was monitored in adolescent elite athletes using the Oslo Sports Trauma Research Centre Questionnaire. Results The results showed that the mean difference (md) in injury prevalence was significantly (p=0.001) higher across the 10 weeks after school had started (md 3.6; 95% CI 1.5 to 5.8), compared with the 10 weeks before. Female athletes had significantly (p<0.001) higher injury prevalence (md 6.4%; 95% CI 3.0 to 9.8) across the 10 weeks after school had started, whereas male athletes (md 0.9%; 95% CI -1.8 to 3.6) had not (p=0.530). Three significant (p<0.05) risk factors were identified; previous injury within the past 12 months (OR 3.23), higher training volume (OR 0.97) and lower well-being (OR 0.71). Conclusions Our results provide supporting evidence for increased injury risk in female adolescent elite athletes after the athletes had started to study at a sports high school.
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Affiliation(s)
- Linda Ekenros
- Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Huddinge, Sweden
| | - Cecilia Fridén
- Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Huddinge, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- School of Health, Care and Social Welfare, Physiotherapy, Mälardalen University, Mälardalen, Västerås, Sweden
| | - Philip von Rosen
- Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Huddinge, Sweden
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14
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Kawashima I, Hiraiwa H, Ishizuka S, Oba H, Sakaguchi T, Idota M, Kawai R, Tsukahara T, Imagama S. Displaced tibial and fibular stress fractures in a female elite pole-vaulter with menstrual dysfunction, vitamin D deficiency, and high serum pentosidine. J Orthop Sci 2023; 28:1513-1517. [PMID: 34794859 DOI: 10.1016/j.jos.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/31/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Itaru Kawashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Hideki Hiraiwa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Shinya Ishizuka
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takefumi Sakaguchi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masaru Idota
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Ryosuke Kawai
- Department of Orthopaedic Surgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu, Gifu, 500-8523, Japan
| | - Takashi Tsukahara
- Department of Orthopaedic Surgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu, Gifu, 500-8523, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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15
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Stellingwerff T, Mountjoy M, McCluskey WT, Ackerman KE, Verhagen E, Heikura IA. Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)-by a subgroup of the IOC consensus on REDs. Br J Sports Med 2023; 57:1109-1118. [PMID: 37752002 DOI: 10.1136/bjsports-2023-106914] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/28/2023]
Abstract
Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one's environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee's REDs Clinical Assessment Tool-V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and 'weighted' in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs.
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Affiliation(s)
- Trent Stellingwerff
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Margo Mountjoy
- Association for Summer Olympic International Federations (ASOIF), Lausanne, Switzerland
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Evert Verhagen
- Amsterdam Collaboration on Health and Safety in Sports and Department of Public and Occupational Health, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Ida A Heikura
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
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16
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Eastman K, O’Leary TJ, Carswell A, Walsh N, Izard R, Fraser W, Greeves J. Distal Tibial Bone Properties and Bone Stress Injury Risk in Young Men Undergoing Arduous Physical Training. Calcif Tissue Int 2023; 113:317-328. [PMID: 37481657 PMCID: PMC10449708 DOI: 10.1007/s00223-023-01111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/22/2023] [Indexed: 07/24/2023]
Abstract
Trabecular microarchitecture contributes to bone strength, but its role in bone stress injury (BSI) risk in young healthy adults is unclear. Tibial volumetric BMD (vBMD), geometry, and microarchitecture, whole-body areal BMD, lean and fat mass, biochemical markers of bone metabolism, aerobic fitness, and muscle strength and power were measured in 201 British Army male infantry recruits (age 20.7 [4.3] years, BMI 24.0 ± 2.7 kg·m2) in week one of basic training. Tibial scans were performed at the ultra-distal site, 22.5 mm from the distal endplate of the non-dominant leg using High Resolution Peripheral Quantitative Computed Tomography (XtremeCT, Scanco Medical AG, Switzerland). Binary logistic regression analysis was performed to identify associations with lower body BSI confirmed by MRI. 20 recruits (10.0%) were diagnosed with a lower body BSI. Pre-injured participants had lower cortical area, stiffness and estimated failure load (p = 0.029, 0.012 and 0.011 respectively) but tibial vBMD, geometry, and microarchitecture were not associated with BSI incidence when controlling for age, total body mass, lean body mass, height, total 25(OH)D, 2.4-km run time, peak power output and maximum dynamic lift strength. Infantry Regiment (OR 9.3 [95%CI, 2.6, 33.4]) Parachute versus Line Infantry, (p ≤ 0.001) and 2.4-km best effort run time (1.06 [95%CI, 1.02, 1.10], p < 0.033) were significant predictors. Intrinsic risk factors, including ultradistal tibial density, geometry, and microarchitecture, were not associated with lower body BSI during arduous infantry training. The ninefold increased risk of BSI in the Parachute Regiment compared with Line Infantry suggests that injury propensity is primarily a function of training load and risk factors are population-specific.
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Affiliation(s)
- Katharine Eastman
- Norwich Medical School, University of East Anglia, Norwich, UK
- Army Health and Performance Research, Army Headquarters, Andover, UK
- HQ DPHC, Coltman House, DMS Whittington, Lichfield, WS14 9PY UK
| | - Thomas J. O’Leary
- Army Health and Performance Research, Army Headquarters, Andover, UK
- Division of Surgery and Interventional Science, UCL, London, UK
| | | | - Neil Walsh
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Rachel Izard
- Science and Technology Commissioning, Defence Science and Technology, Porton Down, Salisbury, UK
| | - William Fraser
- Norwich Medical School, University of East Anglia, Norwich, UK
- Departments of Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Julie Greeves
- Norwich Medical School, University of East Anglia, Norwich, UK
- Army Health and Performance Research, Army Headquarters, Andover, UK
- Division of Surgery and Interventional Science, UCL, London, UK
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17
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Burke LM, Ackerman KE, Heikura IA, Hackney AC, Stellingwerff T. Mapping the complexities of Relative Energy Deficiency in Sport (REDs): development of a physiological model by a subgroup of the International Olympic Committee (IOC) Consensus on REDs. Br J Sports Med 2023; 57:1098-1108. [PMID: 37752007 DOI: 10.1136/bjsports-2023-107335] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
The 2023 International Olympic Committee (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) notes that exposure to low energy availability (LEA) exists on a continuum between adaptable and problematic LEA, with a range of potential effects on both health and performance. However, there is variability in the outcomes of LEA exposure between and among individuals as well as the specific manifestations of REDs. We outline a framework for a 'systems biology' examination of the effect of LEA on individual body systems, with the eventual goal of creating an integrated map of body system interactions. We provide a template that systematically identifies characteristics of LEA exposure (eg, magnitude, duration, origin) and a variety of moderating factors (eg, medical history, diet and training characteristics) that could exacerbate or attenuate the type and severity of impairments to health and performance faced by an individual athlete. The REDs Physiological Model may assist the diagnosis of underlying causes of problems associated with LEA, with a personalised and nuanced treatment plan promoting compliance and treatment efficacy. It could also be used in the strategic prevention of REDs by drawing attention to scenarios of LEA in which impairments of health and performance are most likely, based on knowledge of the characteristics of the LEA exposure or moderating factors that may increase the risk of harmful outcomes. We challenge researchers and practitioners to create a unifying and dynamic physiological model for each body system that can be continuously updated and mapped as knowledge is gained.
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Affiliation(s)
- Louise M Burke
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ida A Heikura
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anthony C Hackney
- Department of Exercise & Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Trent Stellingwerff
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
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18
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Hutson MJ, O'Donnell E, Brooke-Wavell K, James LJ, Raleigh CJ, Carson BP, Sale C, Blagrove RC. High-impact jumping mitigates the short-term effects of low energy availability on bone resorption but not formation in regularly menstruating females: A randomized control trial. Scand J Med Sci Sports 2023; 33:1690-1702. [PMID: 37365858 DOI: 10.1111/sms.14437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Low energy availability (LEA) is prevalent in active individuals and negatively impacts bone turnover in young females. High-impact exercise can promote bone health in an energy efficient manner and may benefit bone during periods of LEA. Nineteen regularly menstruating females (aged 18-31 years) participated in two three-day conditions providing 15 (LEA) and 45 kcals kg fat-free mass-1 day-1 (BAL) of energy availability, each beginning 3 ± 1 days following the self-reported onset of menses. Participants either did (LEA+J, n = 10) or did not (LEA, n = 9) perform 20 high-impact jumps twice per day during LEA, with P1NP, β-CTx (circulating biomarkers of bone formation and resorption, respectively) and other markers of LEA measured pre and post in a resting and fasted state. Data are presented as estimated marginal mean ± 95% CI. P1NP was significantly reduced in LEA (71.8 ± 6.1-60.4 ± 6.2 ng mL-1 , p < 0.001, d = 2.36) and LEA+J (93.9 ± 13.4-85.2 ± 12.3 ng mL-1 , p < 0.001, d = 1.66), and these effects were not significantly different (time by condition interaction: p = 0.269). β-CTx was significantly increased in LEA (0.39 ± 0.09-0.46 ± 0.10 ng mL-1 , p = 0.002, d = 1.11) but not in LEA+J (0.65 ± 0.08-0.65 ± 0.08 ng mL-1 , p > 0.999, d = 0.19), and these effects were significantly different (time by condition interaction: p = 0.007). Morning basal bone formation rate is reduced following 3 days LEA, induced via dietary restriction, with or without high-impact jumping in regularly menstruating young females. However, high-impact jumping can prevent an increase in morning basal bone resorption rate and may benefit long-term bone health in individuals repeatedly exposed to such bouts.
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Affiliation(s)
- Mark J Hutson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- School of Sport, Faculty of Life and Health Sciences, Ulster University, Coleraine, UK
| | - Emma O'Donnell
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | | | - Lewis J James
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Conor J Raleigh
- Department of Physical Education & Sport Sciences, University of Limerick, Limerick, Ireland
| | - Brian P Carson
- Department of Physical Education & Sport Sciences, University of Limerick, Limerick, Ireland
| | - Craig Sale
- Department of Sport and Exercise Sciences, Institute of Sport, Manchester Metropolitan University, Manchester, UK
| | - Richard C Blagrove
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Ackerman KE, Rogers MA, Heikura IA, Burke LM, Stellingwerff T, Hackney AC, Verhagen E, Schley S, Saville GH, Mountjoy M, Holtzman B. Methodology for studying Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the International Olympic Committee (IOC) consensus on REDs. Br J Sports Med 2023; 57:1136-1147. [PMID: 37752010 DOI: 10.1136/bjsports-2023-107359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/28/2023]
Abstract
In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research.This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred, Used and Recommended or Potential Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care.
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Affiliation(s)
- Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margot Anne Rogers
- Australian Institute of Sport, Bruce, South Australia, Australia
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, Australian Capital Territory, Australia
| | - Ida A Heikura
- Canadian Sport Institute-Pacific, Victoria, British Columbia, Canada
- Department of Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Louise M Burke
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Trent Stellingwerff
- Canadian Sport Institute-Pacific, Victoria, British Columbia, Canada
- Department of Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anthony C Hackney
- Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Evert Verhagen
- Amsterdam Collaboration on Health and Safety in Sports and Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Stacey Schley
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace H Saville
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
- Games Group, International Olympic Committee, Lausanne, Switzerland
| | - Bryan Holtzman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts, USA
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20
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O'Leary TJ, Coombs CV, Perrett C, Double RL, Keay N, Wardle SL, Greeves JP. Menstrual Function, Eating Disorders, Low Energy Availability, and Musculoskeletal Injuries in British Servicewomen. Med Sci Sports Exerc 2023; 55:1307-1316. [PMID: 36893306 DOI: 10.1249/mss.0000000000003154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
PURPOSE This study aimed to investigate associations between menstrual function, eating disorders, and risk of low energy availability with musculoskeletal injuries in British servicewomen. METHODS All women younger than 45 yr in the UK Armed Forces were invited to complete a survey about menstrual function, eating behaviors, exercise behaviors, and injury history. RESULTS A total of 3022 women participated; 2% had a bone stress injury in the last 12 months, 20% had ever had a bone stress injury, 40% had a time-loss musculoskeletal injury in the last 12 months, and 11% were medically downgraded for a musculoskeletal injury. Menstrual disturbances (oligomenorrhea/amenorrhea, history of amenorrhea, and delayed menarche) were not associated with injury. Women at high risk of disordered eating (Female Athlete Screening Tool score >94) were at higher risk of history of a bone stress injury (odds ratio (OR; 95% confidence interval (CI)), 2.29 (1.67-3.14); P < 0.001) and time-loss injury in the last 12 months (OR (95% CI), 1.56 (1.21-2.03); P < 0.001) than women at low risk of disordered eating. Women at high risk of low energy availability (Low Energy Availability in Females Questionnaire score ≥8) were at higher risk of bone stress injury in the last 12 months (OR (95% CI), 3.62 (2.07-6.49); P < 0.001), history of a bone stress injury (OR (95% CI), 2.08 (1.66-2.59); P < 0.001), a time-loss injury in the last 12 months (OR (95% CI), 9.69 (7.90-11.9); P < 0.001), and being medically downgraded with an injury (OR (95% CI), 3.78 (2.84-5.04); P < 0.001) than women at low risk of low energy availability. CONCLUSIONS Eating disorders and risk of low energy availability provide targets for protecting against musculoskeletal injuries in servicewomen.
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Affiliation(s)
| | - Charlotte V Coombs
- Army Health and Performance Research, Army Headquarters, Andover, UNITED KINGDOM
| | - Caitlin Perrett
- Division of Surgery and Interventional Science, UCL, London, UNITED KINGDOM
| | - Rebecca L Double
- Army Health and Performance Research, Army Headquarters, Andover, UNITED KINGDOM
| | - Nicky Keay
- Division of Medicine, UCL, London, UNITED KINGDOM
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21
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Greeves JP, Beck B, Nindl BC, O'Leary TJ. Current risks factors and emerging biomarkers for bone stress injuries in military personnel. J Sci Med Sport 2023:S1440-2440(23)00075-0. [PMID: 37188615 DOI: 10.1016/j.jsams.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 04/01/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Bone stress injuries (BSIs) have plagued the military for over 150 years; they afflict around 5 to 10% of military recruits, more so in women, and continue to place a medical and financial burden on defence. While the tibia generally adapts to the rigours of basic military training, the putative mechanisms for bone maladaptation are still unclear. METHODS This paper provides a review of the published literature on current risk factors and emerging biomarkers for BSIs in military personnel; the potential for biochemical markers of bone metabolism to monitor the response to military training; and, the association of novel biochemical 'exerkines' with bone health. RESULTS The primary risk factor for BSI in military (and athletic) populations is too much training, too soon. Appropriate physical preparation before training will likely be most protective, but routine biomarkers will not yet identify those at risk. Nutritional interventions will support a bone anabolic response to training, but exposure to stress, sleep loss, and medication is likely harmful to bone. Monitoring physiology using wearables-ovulation, sleep and stress-offer potential to inform prevention strategies. CONCLUSIONS The risk factors for BSIs are well described, but their aetiology is very complex particularly in the multi-stressor military environment. Our understanding of the skeletal responses to military training is improving as technology advances, and potential biomarkers are constantly emerging, but sophisticated and integrated approaches to prevention of BSI are warranted.
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Affiliation(s)
- Julie P Greeves
- Army Health and Performance Research, Army HQ, Andover, United Kingdom; Norwich Medical School, University of East Anglia, United Kingdom; Division of Surgery and Interventional Science, UCL, United Kingdom.
| | - Belinda Beck
- School of Health Sciences and Social Work, Griffith University, Australia; The Bone Clinic, Australia.
| | - Bradley C Nindl
- School of Health and Rehabilitation Sciences, University of Pittsburgh, United States.
| | - Thomas J O'Leary
- Army Health and Performance Research, Army HQ, Andover, United Kingdom; Division of Surgery and Interventional Science, UCL, United Kingdom.
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22
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Ito E, Sato Y, Kobayashi T, Soma T, Matsumoto T, Kimura A, Miyamoto K, Matsumoto H, Matsumoto M, Nakamura M, Sato K, Miyamoto T. Low energy availability reduces bone mass and gonadal function in male mice. J Bone Miner Metab 2023; 41:182-192. [PMID: 36914793 DOI: 10.1007/s00774-023-01413-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/17/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION In women, the female athlete triad, marked by low energy availability, functional hypothalamic amenorrhea and osteoporosis, is a recognized risk for stress fractures. Stress injuries also occur in men, but by contrast risks and mechanisms underlying them are less characterized. MATERIALS AND METHODS 5 week-old wild-type male mice were fed ad libitum (ad) or subjected to 60% food restriction (FR) for five weeks. In both groups, some mice were allowed access to an exercise wheel in cages to allow voluntary wheel running (ex) and/or treated with active vitamin D analogues. Mice were sacrificed and analyzed at 10 weeks of age. RESULT Male FR mice exhibited significantly reduced testicle weight, serum testosterone levels and bone mass. Such bone losses in FR male mice were enhanced by exercise. Histological analysis revealed that both bone-resorbing and -forming activities were significantly reduced in FR or FR plus exercise (FR + ex) mice, mimicking a state of low bone turnover. Significantly reduced bone mass in FR or FR + ex male mice was significantly rescued by treatment with active vitamin D analogues, with significant restoration of osteoblastic activities. Serum levels of insulin-like growth factor I (IGF-I), which is critical for bone remodeling, were significantly lower in FR versus control male mice. CONCLUSIONS Low energy availability puts men at risk for stress injuries as well, and low energy availability is upstream of gonadal dysfunction and osteoporosis in males. Active vitamin D analogues could serve as therapeutic or preventive options for stress injuries in men.
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Affiliation(s)
- Eri Ito
- Institute for Integrated Sports Medicine, Keio University School of Medicine, 35 Shinano-Machi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yuiko Sato
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
- Department of Advanced Therapy for Musculoskeletal Disorders II, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
- Department of Musculoskeletal Reconstruction and Regeneration Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tami Kobayashi
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
- Department of Advanced Therapy for Musculoskeletal Disorders II, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
- Department of Musculoskeletal Reconstruction and Regeneration Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tomoya Soma
- Division of Oral and Maxillofacial Surgery, Department of Dentistry and Oral Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tatsuaki Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Atushi Kimura
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kana Miyamoto
- Department of Orthopedic Surgery, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hideo Matsumoto
- Institute for Integrated Sports Medicine, Keio University School of Medicine, 35 Shinano-Machi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of Medicine, 35 Shinano-Machi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Takeshi Miyamoto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.
- Department of Advanced Therapy for Musculoskeletal Disorders II, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.
- Department of Musculoskeletal Reconstruction and Regeneration Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.
- Department of Orthopedic Surgery, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
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23
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Costa TMDRL, Borba VZC, Correa RGP, Moreira CA. Stress fractures. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:765-773. [PMID: 36382766 PMCID: PMC10118812 DOI: 10.20945/2359-3997000000562] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Stress fractures (SF) represent 10%-20% of all injuries in sport medicine. An SF occurs when abnormal and repetitive loading is applied on normal bone: The body cannot adapt quickly enough, leading to microdamage and fracture. The etiology is multifactorial with numerous risk factors involved. Diagnosis of SF can be achieved by identifying intrinsic and extrinsic factors, obtaining a good history, performing a physical exam, and ordering laboratory and imaging studies (magnetic resonance imaging is the current gold standard). Relative energy deficiency in sport (RED-S) is a known risk factor. In addition, for women, it is very important know the menstrual status to identify long periods of amenorrhea in the past and the present. Early detection is important to improve the chance of symptom resolution with conservative treatment. Common presentation involves complaints of localized pain, with or without swelling, and tenderness on palpation of bony structures that begins earlier in training and progressively worsens with activity over a 2- to 3-week period. Appropriate classification of SF based on type, location, grading, and low or high risk is critical in guiding treatment strategies and influencing the time to return to sport. Stress injuries at low-risk sites are typically managed conservatively. Studies have suggested that calcium and vitamin D supplementation might be helpful. Moreover, other treatment regimens are not well established. Understanding better the pathophysiology of SFs and the potential utility of current and future bone-active therapeutics may well yield approaches that could treat SFs more effectively.
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Stürznickel J, Hinz N, Delsmann MM, Hoenig T, Rolvien T. Impaired Bone Microarchitecture at Distal Radial and Tibial Reference Locations Is Not Related to Injury Site in Athletes With Bone Stress Injury. Am J Sports Med 2022; 50:3381-3389. [PMID: 36053067 PMCID: PMC9527365 DOI: 10.1177/03635465221120385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone stress injuries (BSIs) are common sports injuries that occur because of an imbalance between microdamage accumulation and removal through bone remodeling. The underlying bone phenotype has been assumed to be a contributing factor. However, the bone microarchitecture of athletes with BSI is not well characterized, and no study has investigated whether impaired bone microarchitecture is associated with bone composition or anatomic site of injury. PURPOSE/HYPOTHESIS This cross-sectional study characterizes the bone microarchitecture at distal radial and tibial reference locations in athletes with BSI. Based on previous dual-energy X-ray absorptiometry (DXA) findings, the aim was to compare anatomic injury sites, hypothesizing that athletes with BSIs in bones with greater trabecular composition show impaired bone microarchitecture parameters compared with those with BSIs in bones with greater cortical composition. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Athletes who had presented to our outpatient clinic because of a high-grade BSI (ie, stress fracture) were retrospectively included. Blood and urine samples were collected. Areal bone mineral density (aBMD) was assessed by DXA at the lumbar spine and both hips. Bone microarchitecture was analyzed by high-resolution peripheral quantitative computed tomography (HR-pQCT) at the distal radius and tibia. HR-pQCT parameters were expressed in relation to available sex-, age-, and device-adjusted reference values and compared with a cohort of 53 age- and sex-matched controls. RESULTS In total, 53 athletes had a BSI of the foot (n = 20), tibia/fibula (n = 18), pelvis (n = 9), femur (n = 5), or sternum (n = 1). Based on DXA measurements, a Z-score of -1.0 or lower was found in 32 of 53 (60.4%) of the athletes, of whom 16 of 53 (30.2%) had a Z score -2.0 or lower. While an impairment of cortical area (P = .034 and P = .001) and thickness (P = .029 and P < .001) was detected at the distal radius and tibia in the BSI cohort compared with controls, no differences in BMD or bone microarchitecture were observed between anatomic injury sites. Furthermore, no difference was revealed when BSIs were grouped into cortical- and trabecular-rich sites. CONCLUSION Reduced aBMD and impaired cortical bone microarchitecture were present in a considerable number of athletes with BSI. Neither aBMD nor bone microarchitecture was related to the injury site, highlighting the multifactorial etiology of BSI.
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Affiliation(s)
- Julian Stürznickel
- Department of Osteology and
Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Julian Stürznickel, MD,
Department of Osteology and Biomechanics, University Medical Center
Hamburg-Eppendorf, Lottestraße 59, 22529 Hamburg, Germany (
); or Tim Rolvien, MD, PhD, MBA,
Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery,
University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg,
Germany ()
| | - Nico Hinz
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Department of Trauma Surgery,
Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Maximilian M. Delsmann
- Department of Osteology and
Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Hoenig
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Julian Stürznickel, MD,
Department of Osteology and Biomechanics, University Medical Center
Hamburg-Eppendorf, Lottestraße 59, 22529 Hamburg, Germany (
); or Tim Rolvien, MD, PhD, MBA,
Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery,
University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg,
Germany ()
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Tenforde AS, Katz NB, Sainani KL, Carlson JL, Golden NH, Fredericson M. Female Athlete Triad Risk Factors Are More Strongly Associated With Trabecular-Rich Versus Cortical-Rich Bone Stress Injuries in Collegiate Athletes. Orthop J Sports Med 2022; 10:23259671221123588. [PMID: 36157087 PMCID: PMC9502250 DOI: 10.1177/23259671221123588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Bone stress injuries (BSIs) are common in athletes. Risk factors for BSI may differ by skeletal anatomy and relative contribution of trabecular-rich and cortical-rich bone. Hypothesis: We hypothesized that Female Athlete Triad (Triad) risk factors would be more strongly associated with BSIs sustained at trabecular-rich versus cortical-rich skeletal sites. Study Design: Cohort study; Level of evidence, 2. Methods: The study population comprised 321 female National Collegiate Athletic Association Division I athletes participating in 16 sports from 2008 to 2014. Triad risk factors and a Triad cumulative risk score were assessed using responses to preparticipation examination and dual energy x-ray absorptiometry to measure lumbar spine and whole-body bone mineral density (BMD). Sports-related BSIs were diagnosed by a physician and confirmed radiologically. Athletes were grouped into those sustaining a subsequent trabecular-rich BSI, a subsequent cortical-rich BSI, and those without a BSI. Data were analyzed with multinomial logistic regression adjusted for participation in cross-country running versus other sports. Results: A total of 19 participants sustained a cortical-rich BSI (6%) and 10 sustained a trabecular-rich BSI (3%) over the course of collegiate sports participation. The Triad cumulative risk score was significantly related to both trabecular-rich and cortical-rich BSI. However, lower BMD and weight were associated with significantly greater risk for trabecular-rich than cortical-rich BSIs. For every value lower than 1 SD, the odds ratios (95% CIs) for trabecular-rich versus cortical-rich BSI were 3.08 (1.25-7.56) for spine BMD; 2.38 (1.22-4.64) for whole-body BMD; and 5.26 (1.48-18.70) for weight. Taller height was a significantly better predictor of cortical-rich than trabecular-rich BSI. Conclusion: The Triad cumulative risk score was significantly associated with both trabecular-rich and cortical-rich BSI, but Triad-related risk factors appeared more strongly related to trabecular-rich BSI. In particular, low BMD and low weight were associated with significantly higher increases in the risk of trabecular-rich BSI than cortical-rich BSI. These findings suggest Triad risk factors are more common in athletes sustaining BSI in trabecular-rich than cortical-rich locations.
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Affiliation(s)
- Adam S Tenforde
- Spaulding Rehabilitation Hospital, Spaulding National Running Center, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Nicole B Katz
- Spaulding Rehabilitation Hospital, Spaulding National Running Center, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Kristin L Sainani
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Jennifer L Carlson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Michael Fredericson
- Boswell Human Performance Laboratory, Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA.,Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
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Fleischer SH, Freire AK, Brown K, Creer A, Eggett DL, Fullmer S. Association of Short-Term Changes in Menstrual Frequency, Medication Use, Weight and Exercise on Bone Mineral Density in College-Aged Women. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10363. [PMID: 36011999 PMCID: PMC9408413 DOI: 10.3390/ijerph191610363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
To evaluate if experiencing a short-term exposure (18-months) to factors such as menstrual irregularities, dieting, changes in exercise or body weight, and medication usage is associated with bone mineral density (BMD) in college-aged females. A retrospective survey assessing health behaviors during a recent 18-month time period and a DXA scan were completed in 641 females. A total of 45.5% of participants reported amenorrhea during the 18-month time period. Those who experienced amenorrhea had lower femoral neck BMD (p = 0.018), trochanter (p = 0.018) and spine BMD (p = 0.022) compared to eumenorrheic women. Lifetime oral contraceptive usage longer than six months was negatively associated with BMD at femoral neck (p = 0.018) and total hip (p = 0.021). Women who lost weight trended towards having the lowest BMD at all sites compared to women who gained weight. Following a very-low calorie diet during the time period was negatively correlated with spine BMD (p = 0.001). Time spent in vigorous and very vigorous activity was weakly correlated with some hip BMD sites but time spent in extremely vigorous activity was not. In conclusion, females who experienced weight loss, amenorrhea, or a very low-calorie diet within an 18-month period of time in young adulthood had lower BMD. Additionally, oral contraceptive usage for longer than six months during their lifetime was associated with lower BMD.
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Affiliation(s)
- Stacie H. Fleischer
- Department of Nutrition, Dietetics and Food Science, College of Life Sciences, Brigham Young University, Provo, UT 84602, USA
| | - Annalisa K. Freire
- Department of Nutrition, Dietetics and Food Science, College of Life Sciences, Brigham Young University, Provo, UT 84602, USA
| | - Katie Brown
- Department of Nutrition, Dietetics & Food Sciences, College of Agriculture and Applied Sciences, Utah State University, Logan, UT 84322, USA
| | - Andrew Creer
- Department of Statistics, College of Physical and Mathematical Sciences, Brigham Young University, Provo, UT 84602, USA
| | - Dennis L. Eggett
- Department of Exercise Science & Outdoor Recreation, College of Science, Utah Valley University, Orem, UT 84058, USA
| | - Susan Fullmer
- Department of Nutrition, Dietetics and Food Science, College of Life Sciences, Brigham Young University, Provo, UT 84602, USA
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Emmet D, Roberts J, Yao KV. Update on Preventing Overuse Injuries in Youth Athletes. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2022. [DOI: 10.1007/s40141-022-00362-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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28
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Moreno TRP, Araujo MPD, Benayon PC, Faroni RP, Barsottini CGN, Sartori MGF. BRAZILIAN OLYMPIC FEMALE ATHLETES’ MULTIDISCIPLINARY CARE: AN OBSERVATIONAL STUDY. REV BRAS MED ESPORTE 2022. [DOI: 10.1590/1517-8692202228042021_0306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Introduction: Female participation in sports had reached a milestone in 1972 when a constitutional amendment was implemented to ensure equal opportunities for men and women. Since then, the percentage of participants in competitive sports has grown. In 1992, an association was made between three disorders related to female athletes called the “Female Athlete Triad”. After that, much has been studied about this and other particularities of female athletes. Objective: To identify the professionals who follow-up Brazilian female Olympic athletes and the association between a multidisciplinary approach and athletes’ knowledge about gynecological issues related to the practice of sport, i.e., female athlete triad, urinary incontinence, and weight control concerns. Methods: This observational study was conducted in Rio de Janeiro, Brazil, in 2016, during the Olympic Games. It included 120 female members of the Brazilian teams. A self-applied questionnaire, validated and adapted from the pre-participation gynecological evaluation of female athletes, was used to evaluate their multidisciplinary follow-ups, weight control concerns, and knowledge about the Female Athlete Triad and urinary incontinence. Results: The athletes practiced 28 different sports. For 66%, it was their first participation in Olympic Games; 56% were unaware of the female athlete triad, 77% indicated weight concerns, and 52% were on a diet. The use of diuretics or laxatives or vomiting was reported by 11%; 67.5% were aware that sports are a risk factor for urinary incontinence, and 40% had already experienced urine loss. Decreased sportive performance was mentioned by 31%. Several athletes presented multidisciplinary follow-ups psychological (83%), nutritional (96%), and gynecological (83%). Conclusion: Brazilian Olympic athletes sought multidisciplinary follow-ups during the Olympic cycle; however, participants’ knowledge of sports-related issues remains limited. An orientation program regarding the above conditions is needed for female athletes and the professionals working with them to improve health and performance. Evidence Level IV; Cross-sectional observational study.
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Abstract
Relative Energy Deficiency in Sport (RED-S) refers to a condition in which energy imbalance leads to impaired physiological function of multiple organ systems and expands on the diagnosis previously known as the Female Athlete Triad. Researchers attribute the medical complications of RED-S to low energy availability, in which energy availability is defined as dietary energy intake minus exercise energy expenditure divided by fat-free mass. This article reviews the history of this diagnosis, the changing terminology, and the reasons for the expansion. Accepted definitions of each part of the energy availability equation are considered and the difficulties that exist using these equations in practice or comparatively in the literature are assessed. The review analyzes the broad spectrum of health consequences of RED-S, especially as it relates to hypoestrogenemia and menstrual function, gives guidance to those caring for athletes on the identification and management of RED-S, and sheds lights on the important role of coaches, athletic trainers, and families in recognizing this diagnosis and in helping getting patients to care.
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Polonine S, de Santa Rosa RG, Farias MLF, Garcia MI, Gomes CP, Gottlieb I, Madeira M. Hyperphosphatemia is associated with cardiac valve calcification in chronic hypoparathyroidism. J Endocrinol Invest 2022; 45:1359-1366. [PMID: 35235195 DOI: 10.1007/s40618-022-01770-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/16/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the association between metabolic abnormalities and cardiovascular risk factors in patients with chronic hypoparathyroidism (HPP). PATIENTS AND METHODS Patients 18 years and older, glomerular filtration > 30 mL/min/1.73 m2 and no documented coronary artery disease were selected. Serum calcium, phosphorus, glucose, lipids, PTH, 25(OH)D and FGF23 were measured. Cardiovascular risk was estimated by the European Society of Cardiology (ESC) calculator. Transthoracic echocardiogram and carotid ultrasound were performed to detect carotid plaques (CP), carotid intima-media thickness (IMT), cardiac valve calcification (CVC), and left ventricular hypertrophy (LVH). RESULTS Thirty-seven patients (94.6% female), aged 56.0 ± 13.5 years and HPP duration 7.0 (4.0; 11.3) years, were included. Fifteen were classified as low cardiovascular risk, 9 as intermediate risk, 9 as high risk and none as very high risk. The prevalence of CP, CVC and LVH was 24.3%, 24.3% and 13.5%, respectively. IMT values were within normal ranges in all cohort. FGF23 were not associated with CP, IMT, CVC or LVH. After logistic regression, phosphorus was the only significant metabolic variable impacting CVC in univariate analysis (OR 2.795; 95% CI 1.132-6.905; p = 0.026), as well as in the multivariate analysis (OR 3.572; 95% CI 1.094-11.665; p = 0.035). Analysis by ROC curve showed serum phosphorus > 5.05 mg/dL (AUC 0.748; CI 0.584-0.877; p = 0.05) as the best cutoff point associated with valve heart calcification (sensitivity 78%; negative predictive value 91.3%). CONCLUSION Hyperphosphatemia was associated with CVC in HPP patients. Further studies are needed to investigate whether the control of hyperphosphatemia may reduce cardiovascular risk in this population.
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Affiliation(s)
- S Polonine
- Division of Endocrinology, Clementino Fraga Filho Hospital, UFRJ, Avenida Professor Rodolpho Paulo Rocco 255, Rio de Janeiro, RJ, 21941-913, Brazil.
| | - R G de Santa Rosa
- Division of Nephrology, Clementino Fraga Filho Hospital, UFRJ, Avenida Professor Rodolpho Paulo Rocco 255, Rio de Janeiro, RJ, 21941-913, Brazil
| | - M L F Farias
- Division of Endocrinology, Clementino Fraga Filho Hospital, UFRJ, Avenida Professor Rodolpho Paulo Rocco 255, Rio de Janeiro, RJ, 21941-913, Brazil
| | - M I Garcia
- Division of Cardiology, Clementino Fraga Filho Hospital, UFRJ, Avenida Professor Rodolpho Paulo Rocco 255, Rio de Janeiro, RJ, 21941-913, Brazil
| | - C P Gomes
- Division of Nephrology, Clementino Fraga Filho Hospital, UFRJ, Avenida Professor Rodolpho Paulo Rocco 255, Rio de Janeiro, RJ, 21941-913, Brazil
| | - I Gottlieb
- Casa de Saúde São José, Rua Macedo Sobrinho 21, Rio de Janeiro, RJ, 22271-080, Brazil
| | - M Madeira
- Division of Endocrinology, Clementino Fraga Filho Hospital, UFRJ, Avenida Professor Rodolpho Paulo Rocco 255, Rio de Janeiro, RJ, 21941-913, Brazil
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Behary P, Comninos AN. Bone Perspectives in Functional Hypothalamic Amenorrhoea: An Update and Future Avenues. Front Endocrinol (Lausanne) 2022; 13:923791. [PMID: 35795153 PMCID: PMC9251506 DOI: 10.3389/fendo.2022.923791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/11/2022] [Indexed: 01/22/2023] Open
Abstract
One of the most important and potentially long-lasting detrimental consequences of Functional Hypothalamic Amenorrhoea (FHA) is on skeletal homeostasis. Beyond oestrogen deficiency, FHA is associated with a cascade of additional neuro-endocrine and metabolic alterations, some adaptive, but which combine to disrupt skeletal homeostasis. Ultimately, this leads to a two-fold increased risk of fractures in women with FHA compared to healthy eumenorrhoeic women. Although the cornerstone of management of FHA-related bone loss remains recovery of menses via restoration of metabolic/psychological balance, there is rapidly developing evidence for hormonal manipulations (with a particular emphasis on route of administration) and other pharmacological treatments that can protect or improve skeletal homeostasis in FHA. In this mini-review, we provide an update on the pathophysiology, clinical management and future avenues in the field from a bone perspective.
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Affiliation(s)
- Preeshila Behary
- Endocrine Bone Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alexander N. Comninos
- Endocrine Bone Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
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Freire Ribeiro AB, Bruininks BD, Street GM, Smock AJ, Scibora LM. Comparison of Tibial Geometry, Density, and Strength in College-Aged Female Eumenorrheic Dancers, Gymnasts, and Runners: A Peripheral Quantitative Computed Tomography Study. J Dance Med Sci 2022; 26:165-172. [PMID: 35697494 DOI: 10.12678/1089-313x.091522c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Weightbearing activities such as gymnastics, soccer, weightlifting, and running have often been used as benchmarks in skeletal research since they have been shown to promote densitometric and geometric benefits. In comparison with other sports, there is a paucity of information in relation to dance and its osteogenic potential. OBJECTIVE This study aimed to compare tibial geometry, density, and strength in college-aged dancers versus gymnasts and runners. METHODS A total of 60 trained eumenorrheic collegiate-aged female dancers (n = 11), gymnasts (n = 11), runners (n = 19), and sedentary controls (n = 19) were included in the study. Bone measurements, including total area (ToA), volumetric (total vBMD) and cortical density (CoD), compressive bone strength (BSI), and polar strength stress index (SSIp) of the dominant limb, were assessed using peripheral quantitative computed tomography (pQCT) at the distal and proximal tibia (4% and 66% of limb length). RESULTS No significant differences in ToA, CoD, CoA, and total vBMD were found between dancers and the comparison athletes at the measured sites. In addition, strength indices (BSI and SSIp) at the distal and proximal sites were similar between the dancing and both athlete groups. CONCLUSION Results suggest dance elicits similar structural adaptations at the tibia compared to benchmark high-impact and repetitive impact sports; thus, indicating dance, in its various forms, can have a positive effect on important bone variables that influence density and strength. These adaptations may potentially delay or prevent bone fragility later in life. Future studies should compare individual styles of dance separately, longitudinally, and include other important lower (e.g., hip) and upper body (e.g., radius) sites to further identify which forms provide the greatest osteogenic benefits.
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De Souza MJ, Ricker EA, Mallinson RJ, Allaway HCM, Koltun KJ, Strock NCA, Gibbs JC, Kuruppumullage Don P, Williams NI. Bone mineral density in response to increased energy intake in exercising women with oligomenorrhea/amenorrhea: the REFUEL randomized controlled trial. Am J Clin Nutr 2022; 115:1457-1472. [PMID: 35170727 PMCID: PMC9170471 DOI: 10.1093/ajcn/nqac044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 02/10/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Energy deficiency can result in menstrual disturbances and compromised bone health in women, a condition known as the Female Athlete Triad. OBJECTIVES The REFUEL randomized controlled trial assessed the impact of increased energy intake on bone health and menstrual function in exercising women with menstrual disturbances. METHODS Exercising women with oligomenorrhea/amenorrhea (Oligo/Amen) were randomly assigned to an intervention group (Oligo/Amen + Cal, n = 40, mean ± SEM age: 21.3 ± 0.5 y; weight: 55.0 ± 1.0 kg; BMI: 20.4 ± 0.3 kg/m2) who increased energy intake 20%-40% above baseline energy needs for 12 mo or a control group (Oligo/Amen Control, n = 36; mean ± SEM age: 20.7 ± 0.5 y; weight: 59.1 ± 1.3 kg; BMI: 21.3 ± 0.4 kg/m2). Energy intake and expenditure, metabolic and reproductive hormones, body composition, and areal bone mineral density (aBMD) were assessed. RESULTS Oligo/Amen + Cal improved energy status [increased body mass (2.6 ± 0.4 kg), BMI (0.9 ± 0.2 kg/m2), fat mass (2.0 ± 0.3 kg), body fat percentage (2.7% ± 0.4%), and insulin-like growth factor 1 (37.4 ± 14.6 ng/mL)] compared with Oligo/Amen Control and experienced a greater likelihood of menses (P < 0.05). Total body and spine aBMD remained unchanged (P > 0.05). Both groups demonstrated decreased femoral neck aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.0002 g/cm2 ; time main effect P = 0.043) and month 12 (-0.011 g/cm2; 95% CI: -0.021, -0.001 g/cm2; time main effect P = 0.023). Both groups demonstrated a decrease in total hip aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.002 g/cm2; time main effect P = 0.004). CONCLUSIONS Although higher dietary energy intake increased weight, body fat, and menstrual frequency, bone mineral density was not improved, compared with the control group. The 12-mo intervention may have been too short and the increase in energy intake (∼352 kcal/d), although sufficient to increase menstrual frequency, was insufficient to increase estrogen or improve aBMD. Future research should refine the optimal nutritional and/or pharmacological interventions for the recovery of bone health in athletes and exercising women with Oligo/Amen.This trial was registered at clinicaltrials.gov as NCT00392873.
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Affiliation(s)
- Mary Jane De Souza
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Emily A Ricker
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Rebecca J Mallinson
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Heather C M Allaway
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Kristen J Koltun
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Nicole C A Strock
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Jenna C Gibbs
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | | | - Nancy I Williams
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
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Restrictive Eating and Prior Low-Energy Fractures Are Associated With History of Multiple Bone Stress Injuries. Int J Sport Nutr Exerc Metab 2022; 32:325-333. [PMID: 35523419 DOI: 10.1123/ijsnem.2021-0323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 11/18/2022]
Abstract
Bone stress injuries (BSIs) are common among athletes and have high rates of recurrence. However, risk factors for multiple or recurrent BSIs remain understudied. Thus, we aimed to explore whether energy availability, menstrual function, measures of bone health, and a modified Female Athlete Triad Cumulative Risk Assessment (CRA) tool are associated with a history of multiple BSIs. We enrolled 51 female runners (ages 18-36 years) with history of ≤1 BSI (controls; n = 31) or ≥3 BSIs (multiBSI; n = 20) in this cross-sectional study. We measured lumbar spine, total hip, and femoral neck areal bone mineral density by dual-energy X-ray absorptiometry, bone material strength index using impact microindentation, and volumetric bone mineral density, microarchitecture, and estimated strength by high-resolution peripheral quantitative computed tomography. Participants completed questionnaires regarding medical history, low-energy fracture history, and disordered eating attitudes. Compared with controls, multiBSI had greater incidence of prior low-energy fractures (55% vs. 16%, p = .005) and higher modified Triad CRA scores (2.90 ± 2.05 vs. 1.84 ± 1.59, p = .04). Those with multiBSI had higher Eating Disorder Examination Questionnaire (0.92 ± 1.03 vs. 0.46 ± 0.49, p = .04) scores and a greater percentage difference between lowest and highest body mass at their current height (15.5% ± 6.5% vs. 11.5% ± 4.9% p = .02). These preliminary findings indicate that women with a history of multiple BSIs suffered more prior low-energy fractures and have greater historical and current estimates of energy deficit compared with controls. Our results provide strong rationale for future studies to examine whether subclinical indicators of energy deficit contribute to risk for multiple BSIs in female runners.
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Holtzman B, Popp KL, Tenforde AS, Parziale AL, Taylor K, Ackerman KE. Low energy availability surrogates associated with lower bone mineral density and bone stress injury site. PM R 2022; 14:587-596. [PMID: 35460534 DOI: 10.1002/pmrj.12821] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Exercise is an osteogenic stimulus that should increase bone mineral density (BMD) and protect against injury. However, some female athletes have lower BMD and increased bone stress injury (BSI) risk. Impaired bone health seen in athletes may be explained by low energy availability as described by concepts of Relative Energy Deficiency in Sport (RED-S) and Female Athlete Triad (Triad). OBJECTIVE To elucidate the relationship between RED-S/Triad risk factors and BSI to high-risk (femoral neck, sacrum) and low-risk (other) bones. DESIGN Cross-sectional survey and retrospective chart review. SETTING Tertiary care academic center. PATIENTS Female athletes aged 15-30 years participating in ≥4 h/week of exercise presenting to sports medicine/orthopedics clinic who had a self-reported BSI and available dual-energy x-ray absorptiometry (DXA) measurement of BMD. INTERVENTIONS Not applicable. MAIN OUTCOME MEASUREMENTS Location of BSI. RESULTS In 127 athletes, high-risk BSI was associated with surrogates of low energy availability (p = .032) and having a DXA Z-score < -1 (p = .035) but not a current/past history of menstrual dysfunction (p = .348). Accumulating RED-S/Triad risk factors increase the odds of incurring a high-risk BSI (p = .048). CONCLUSIONS Adolescent/young female athletes who sustain BSI at high-risk sites (femoral neck, sacrum) may have underlying risk factors (eg, low energy availability, poor overall bone health) that should prompt further workup and referral to optimize health in these athletes.
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Affiliation(s)
- Bryan Holtzman
- Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, United States.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kristin L Popp
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA, United States.,Endocrine Division, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Adam S Tenforde
- Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States
| | - Allyson L Parziale
- Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, University of Virginia Health System, Charlottesville, VA, United States
| | - Kathryn Taylor
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA, United States
| | - Kathryn E Ackerman
- Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, United States.,Endocrine Division, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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Popp KL, Cooke LM, Bouxsein ML, Hughes JM. Impact of Low Energy Availability on Skeletal Health in Physically Active Adults. Calcif Tissue Int 2022; 110:605-614. [PMID: 35171303 DOI: 10.1007/s00223-022-00957-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/04/2022] [Indexed: 12/13/2022]
Abstract
For decades researchers reported that pre-menopausal women who engage in extensive endurance exercise and have menstrual dysfunction can develop low bone mineral density (BMD) or osteoporosis. More recently, low energy availability has been recognized as the initiating factor for low BMD in these women. Furthermore, the relationship between low energy availability and poor skeletal health is not exclusive to women engaging in endurance exercise. Rather, both males and females commonly experience endocrine dysfunction resulting from low energy availability and high exercise levels that degrades skeletal health. Consequences to skeletal health can range from short-term changes in bone metabolism and increased risk of bone stress injuries to long-term consequences of low BMD, such as osteoporosis and related fragility fractures. The degree to which low energy availability degrades skeletal health may be dependent on the length and extent of the energy deficit. However, the complex relationships between under-fueling, short- and long-term skeletal consequences and the factors that mediate these relationships are not well described. In this review, we discuss the consequences of low energy availability on sex hormones and skeletal health in two highly-active populations-athletes and military trainees-and provide a summary of existing knowledge gaps for future study.
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Affiliation(s)
- Kristin L Popp
- United States Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA.
- Massachusetts General Hospital, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, 02215, USA.
| | - Laura M Cooke
- Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Mary L Bouxsein
- United States Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA
- Massachusetts General Hospital, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, 02215, USA
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Julie M Hughes
- United States Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA
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Alway P, Wedatilake T, Peirce N, Warren A, King M, Brooke-Wavell K. Bone health and asymmetry in elite female cricketers. Eur J Sport Sci 2022; 23:667-675. [PMID: 35414351 DOI: 10.1080/17461391.2022.2065929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The aim of this study is to determine if bone mineral density (BMD) and bone asymmetry differs between female cricket fast bowlers, spin bowlers and batters. BMD was determined at the total body, lumbar spine, and proximal femurs in 12 fast bowlers, 13 batters and 11 spin bowlers from pre-season DXA scans. High Z-scores at the total body, lumbar spine, and proximal femur were observed in all cricketers (mean Z-scores: +1.4 to +3.3) compared with a general age matched reference population. Fast bowlers had significantly greater BMD on the contralateral side of the lumbar spine compared with the ipsilateral side (p = 0.001, 5.9 - 12.1%). No asymmetry was found between hips in all groups. All cricket positions demonstrated high BMD at all measured sites. The lumbar spine of fast bowlers is asymmetric, with significantly greater BMD on the contralateral side of the spine, particularly at L4, possibly in response to the asymmetric lumbar loading patterns observed in bowling.HIGHLIGHTS Elite female cricketers demonstrate high BMD at total body, lumbar spine and proximal femur sites, regardless of playing position compared with a general age and ethnic group matched reference populationFast bowlers have greater BMD on the contralateral (opposite bowling arm) side of the lumbar spine compared with the ipsilateral side, while a symmetrical pattern was observed in spin bowlers and batters.No asymmetry in BMD or section modulus between hips was observed at any proximal femur site for any cricket position.
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Affiliation(s)
- Peter Alway
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom.,Department of Science and Medicine, National Cricket Performance Centre, England and Wales Cricket Board, Loughborough, United Kingdom
| | - Thamindu Wedatilake
- Department of Science and Medicine, National Cricket Performance Centre, England and Wales Cricket Board, Loughborough, United Kingdom
| | - Nicholas Peirce
- Department of Science and Medicine, National Cricket Performance Centre, England and Wales Cricket Board, Loughborough, United Kingdom
| | - Anna Warren
- Department of Science and Medicine, National Cricket Performance Centre, England and Wales Cricket Board, Loughborough, United Kingdom
| | - Mark King
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Katherine Brooke-Wavell
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
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Whitney KE, Sugimoto D, d'Hemecourt CA, d'Hemecourt DA, d'Hemecourt PA. Running gait biomechanics in female runners with sacroiliac joint pain. J Phys Ther Sci 2022; 34:327-334. [PMID: 35400840 PMCID: PMC8989488 DOI: 10.1589/jpts.34.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/25/2022] [Indexed: 11/26/2022] Open
Abstract
[Purpose] To identify running gait biomechanics associated with sacroiliac (SI) joint
pain in female runners compared to healthy controls. [Participants and Methods] In this
case-control study, treadmill running gait biomechanics of female runners diagnosed SI
joint pain, (by ultrasound-guided diagnostic SI joint injection and/or ≥2 positive SI
physical exam maneuvers) were compared with age, height, mass, and BMI matched healthy
female runners. Sagittal and coronal plane treadmill running video angles were measured
and compared. [Results] Eighteen female runners with SI pain, and 63 matched controls,
were analyzed. There was no difference in age, height, mass, or BMI between groups. At the
point of initial contact, runners with SI joint pain demonstrated less knee flexion,
greater tibial overstride, and greater ankle dorsiflexion, compared to controls. In
midstance, runners with SI pain had greater contralateral pelvic drop compared to
controls. For unilateral SI joint pain cases (N=15), greater contralateral pelvic drop was
observed when loading their affected side compared to the unaffected side. [Conclusion]
Female runners with SI joint pain demonstrated greater contralateral pelvic drop during
midstance phase; along with less knee flexion, greater “tibial overstride”, and greater
ankle dorsiflexion at initial contact compared to controls.
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Affiliation(s)
- Kristin E Whitney
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital: 319 Longwood Ave, Ste 6, Boston, MA 02115, USA.,The Micheli Center for Sports Injury Prevention, USA.,Harvard Medical School, USA
| | - Dai Sugimoto
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital: 319 Longwood Ave, Ste 6, Boston, MA 02115, USA.,The Micheli Center for Sports Injury Prevention, USA.,Harvard Medical School, USA
| | - Charles A d'Hemecourt
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital: 319 Longwood Ave, Ste 6, Boston, MA 02115, USA.,The Micheli Center for Sports Injury Prevention, USA
| | - Duncan A d'Hemecourt
- The Micheli Center for Sports Injury Prevention, USA.,George Washington University, USA
| | - Pierre A d'Hemecourt
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital: 319 Longwood Ave, Ste 6, Boston, MA 02115, USA.,The Micheli Center for Sports Injury Prevention, USA.,Harvard Medical School, USA
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39
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Gama E, Kasuki L, Paranhos-Neto FP, Madeira M, Mendonça L, Schtscherbyna A, Farias M. Low Energy Availability Interferes With Exercise-Associated Bone Effects in Female Long-Distance Triathletes as Detected by HR-pQCT. J Clin Densitom 2022; 25:160-167. [PMID: 33608221 DOI: 10.1016/j.jocd.2021.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 12/27/2022]
Abstract
Female Athlete Triad, initially described as the association of disordered eating, amenorrhea and osteoporosis, was further redefined to focus on low energy availability (EA), which has a central role in development of hypoestrogenism and low bone mineral density (BMD). However, the contribution of each variable, that is, low EA and hypoestrogenism, for bone derangements is still an open question. To evaluate body composition and bone status in long-distance triathletes without hypoestrogenism, as compared to non-athletes, using DXA and HR-pQCT, and the influence of EA. Population comprised 23 triathletes who had completed at least one long-distance race in the previous year, and 17 non-athletic healthy controls. The athletes denied previous oligo-amenorrhea and had spontaneous regular menses or were on hormonal contraceptives. Control patients also had regular menses. Energy deficiency (low EA) was defined as energy intake below the recommended level for athletes, that is, 45 kcal/kg free fat mass/day. Only femoral neck BMD Z-score measured by DXA trended higher in athletes (p = 0.05), whereas high-resolution peripheral quantitative computed tomography detected significantly higher values of entire bone and trabecular bone area, cortical perimeter, trabecular vBMD and trabecular bone volume/tissue volume, and lower trabecular separation and trabecular inhomogeneity in athletes. No difference was found between athletes with spontaneous menses and those on hormone contraceptives in respect to all parameters. The effects of exercise on bone were not so pronounced in athletes with low EA, although they still had better bone parameters than controls. Stress fractures were reported by 4:12 athletes with low EA and by 2:11 athletes with adequate EA. Long-distance female triathletes without hypoestrogenism show higher values of cortical perimeter, bone area, volumetric density and trabecular microstructure, but low EA interferes with exercise-associated bone effects. These innovative findings reinforce the importance of adequate EA in female athletes to guarantee skeletal health.
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Affiliation(s)
- Emf Gama
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil.
| | - L Kasuki
- Neuroendocrinology Research Center, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - F P Paranhos-Neto
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - M Madeira
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - Lmc Mendonça
- Division of Rheumatology of Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - A Schtscherbyna
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - Mlf Farias
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
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Abstract
PURPOSE OF REVIEW Adolescence and young adulthood are a critical period in the life of women for optimizing long-term bone health. Young athletes lead a demanding lifestyle with increased dietary requirements to meet the robust demands of energy expenditure to maintain a state of energy balance. During a time of fast paced changes and unpredictable societal demands on young athletes, it is important to review the severe consequences of energy deficiency and options for adequate management. RECENT FINDINGS This review focuses on hormonal adaptations that occur in energy deficient female athletes that lead to menstrual irregularities and impaired bone health, increasing the risk for stress and other fractures. We also describe management strategies to mitigate the consequences of limited energy availability on bone and other outcomes. SUMMARY These strategies should help guide the management of young female athletes to prevent irreversible changes to their bone health. Identifying current knowledge should help increase awareness among medical providers, which can then be communicated to the sports community, parents, and athletes.
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Affiliation(s)
- Jacqueline Maya
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Pedreira CC, Maya J, Misra M. Functional hypothalamic amenorrhea: Impact on bone and neuropsychiatric outcomes. Front Endocrinol (Lausanne) 2022; 13:953180. [PMID: 35937789 PMCID: PMC9355702 DOI: 10.3389/fendo.2022.953180] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/29/2022] [Indexed: 12/01/2022] Open
Abstract
Functional hypothalamic amenorrhea is a state of reversible hypogonadism common in adolescents and young women that can be triggered by energy deficit or emotional stress or a combination of these factors. Energy deficit may be a consequence of (i) reduced caloric intake, as seen in patients with eating disorders, such as anorexia nervosa, or (ii) excessive exercise, when caloric intake is insufficient to meet the needs of energy expenditure. In these conditions of energy deficit, suppression of the hypothalamic secretion of gonadotrophin-releasing hormone (with resulting hypoestrogenism) as well as other changes in hypothalamic-pituitary function may occur as an adaptive response to limited energy availability. Many of these adaptive changes, however, are deleterious to reproductive, skeletal, and neuropsychiatric health. Particularly, normoestrogenemia is critical for normal bone accrual during adolescence, and hypoestrogenemia during this time may lead to deficits in peak bone mass acquisition with longstanding effects on skeletal health. The adolescent years are also a time of neurological changes that impact cognitive function, and anxiety and depression present more frequently during this time. Normal estrogen status is essential for optimal cognitive function (particularly verbal memory and executive function) and may impact emotion and mood. Early recognition of women at high risk of developing hypothalamic amenorrhea and its timely management with a multidisciplinary team are crucial to prevent the severe and long-term effects of this condition.
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Affiliation(s)
- Clarissa Carvalho Pedreira
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Neuroendocrine Unit, Center for Endocrinology and Diabetes of Bahia State, Salvador, Brazil
- *Correspondence: Clarissa Carvalho Pedreira,
| | - Jacqueline Maya
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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Indirli R, Lanzi V, Mantovani G, Arosio M, Ferrante E. Bone health in functional hypothalamic amenorrhea: What the endocrinologist needs to know. Front Endocrinol (Lausanne) 2022; 13:946695. [PMID: 36303862 PMCID: PMC9592968 DOI: 10.3389/fendo.2022.946695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
In the original definition by Klinefelter, Albright and Griswold, the expression "hypothalamic hypoestrogenism" was used to describe functional hypothalamic amenorrhoea (FHA). Given the well-known effects of estrogens on bone, the physiopathology of skeletal fragility in this condition may appear self-explanatory. Actually, a growing body of evidence has clarified that estrogens are only part of the story. FHA occurs in eating disorders, overtraining, and during psychological or physical stress. Despite some specific characteristics which differentiate these conditions, relative energy deficiency is a common trigger that initiates the metabolic and endocrine derangements contributing to bone loss. Conversely, data on the impact of amenorrhoea on bone density or microarchitecture are controversial, and reduced bone mass is observed even in patients with preserved menstrual cycle. Consistently, oral estrogen-progestin combinations have not proven beneficial on bone density of amenorrheic women. Low bone density is a highly prevalent finding in these patients and entails an increased risk of stress or fragility fractures, and failure to achieve peak bone mass and target height in young girls. Pharmacological treatments have been studied, including androgens, insulin-like growth factor-1, bisphosphonates, denosumab, teriparatide, leptin, but none of them is currently approved for use in FHA. A timely screening for bone complications and a multidisciplinary, customized approach aiming to restore energy balance, ensure adequate protein, calcium and vitamin D intake, and reverse the detrimental metabolic-endocrine changes typical of this condition, should be the preferred approach until further studies are available.
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Affiliation(s)
- Rita Indirli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- *Correspondence: Rita Indirli,
| | - Valeria Lanzi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Cheng J, Santiago KA, Abutalib Z, Temme KE, Hulme A, Goolsby MA, Esopenko CL, Casey EK. Menstrual Irregularity, Hormonal Contraceptive Use, and Bone Stress Injuries in Collegiate Female Athletes in the United States. PM R 2021; 13:1207-1215. [PMID: 33340255 PMCID: PMC8262270 DOI: 10.1002/pmrj.12539] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/02/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Menstrual irregularity (MI) is common in female athletes and is a component of the Female Athlete Triad (Triad). Many athletes with the Triad are started on hormonal contraceptives (HC) for MI, but this interferes with the ability to monitor menstrual cycle regularity and can mask other causes of MI. There are limited studies investigating the relationship between MI, HC use, and injury in female collegiate athletes. OBJECTIVE To examine the prevalence of and relationship between HC use, MI, and bone stress injuries in female collegiate athletes in the United States. DESIGN Cross-sectional study. SETTING Online survey. PARTICIPANTS 1020 U.S. female collegiate athletes (age ≥ 18 years). METHODS OR INTERVENTIONS Assessment of risk factors for menstrual irregularity and bone stress injuries was conducted via a one-time survey. MAIN OUTCOME MEASURES HC use, MI, history of stress fractures. RESULTS Current HC use prevalence was 65% (95% confidence interval [CI], 61.9%, 67.8%). Of all athletes, 47% reported past MI. Of the athletes who were not currently using HCs, 32% had current MI. Compared with athletes without past MI, more athletes with past MI reported current HC use (73% vs. 57%) and indicated menstrual cycle consistency as the primary reason for use (24% vs. 4%) (P < .001). Additionally, 25% of athletes reported a history of stress fractures, which was associated with lean/aesthetic sports participation (odds ratio [95% CI]: 1.9 [1.4, 2.5]; P < .001) and less oral contraceptive pill (OCP) use (0.7 [0.5, 1.0]; P = .043). Compared with OCPs, injectable HCs were associated with greater odds of a history of stress fractures (4.5[1.6, 12.3]; P = .004). CONCLUSIONS HC use was prevalent among this cohort of female collegiate athletes, and almost half of the athletes reported past MI. A goal of menstrual cycle regularity was cited by 24% of athletes as a primary reason to use HCs, which shows that more athlete education is needed to avoid masking MI and the Triad with HCs. Further studies elucidating the relationship between HC use, MI, and sports-related injury are warranted.
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Affiliation(s)
- Jennifer Cheng
- Department of Physiatry, Hospital for Special Surgery, New York, NY
| | | | - Zafir Abutalib
- Biostatistics Core, Hospital for Special Surgery, New York, NY
| | - Kate E. Temme
- Department of Physical Medicine and Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ann Hulme
- Department of Physical Medicine and Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Marci A. Goolsby
- Department of Primary Care Sports Medicine, Hospital for Special Surgery, New York, NY
| | - Carrie L. Esopenko
- Department of Rehabilitation and Movement Sciences, Rutgers Biomedical Health Sciences, Newark, NJ
| | - Ellen K. Casey
- Department of Physiatry, Hospital for Special Surgery, New York, NY
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Holtzman B, Ackerman KE. Recommendations and Nutritional Considerations for Female Athletes: Health and Performance. Sports Med 2021; 51:43-57. [PMID: 34515972 PMCID: PMC8566643 DOI: 10.1007/s40279-021-01508-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
Optimal nutrition is an important aspect of an athlete’s preparation to achieve optimal health and performance. While general concepts about micro- and macronutrients and timing of food and fluids are addressed in sports science, rarely are the specific effects of women’s physiology on energy and fluid needs highly considered in research or clinical practice. Women differ from men not only in size, but in body composition and hormonal milieu, and also differ from one another. Their monthly hormonal cycles, with fluctuations in estrogen and progesterone, have varying effects on metabolism and fluid retention. Such cycles can change from month to month, can be suppressed with exogenous hormones, and may even be manipulated to capitalize on ideal timing for performance. But before such physiology can be manipulated, its relationship with nutrition and performance must be understood. This review will address general concepts regarding substrate metabolism in women versus men, common menstrual patterns of female athletes, nutrient and hydration needs during different phases of the menstrual cycle, and health and performance issues related to menstrual cycle disruption. We will discuss up-to-date recommendations for fueling female athletes, describe areas that require further exploration, and address methodological considerations to inform future work in this important area.
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Affiliation(s)
- Bryan Holtzman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Kathryn E Ackerman
- Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA. .,Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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MIYAMOTO-MIKAMI ERI, KUMAGAI HIROSHI, TANISAWA KUMPEI, TAGA YUKI, HIRATA KOSUKE, KIKUCHI NAOKI, KAMIYA NOBUHIRO, KAWAKAMI RYOKO, MIDORIKAWA TAISHI, KAWAMURA TAKUJI, KAKIGI RYO, NATSUME TOSHIHARU, ZEMPO HIROFUMI, SUZUKI KOYA, KOHMURA YOSHIMITSU, MIZUNO KAZUNORI, TORII SUGURU, SAKAMOTO SHIZUO, OKA KOICHIRO, HIGUCHI MITSURU, NAITO HISASHI, MIYAMOTO NAOKAZU, FUKU NORIYUKI. Female Athletes Genetically Susceptible to Fatigue Fracture Are Resistant to Muscle Injury: Potential Role of COL1A1 Variant. Med Sci Sports Exerc 2021; 53:1855-1864. [PMID: 33731655 PMCID: PMC8360671 DOI: 10.1249/mss.0000000000002658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE We aimed to investigate the hypothesis that type I collagen plays a role in increasing bone mineral density (BMD) and muscle stiffness, leading to low and high risks of fatigue fracture and muscle injury, respectively, in athletes. As a potential mechanism, we focused on the effect of the type I collagen alpha 1 chain gene (COL1A1) variant associated with transcriptional activity on bone and skeletal muscle properties. METHODS The association between COL1A1 rs1107946 and fatigue fracture/muscle injury was evaluated in Japanese athletes. Effects of the polymorphism on tissue properties (BMD and muscle stiffness) and type I collagen α1/α2 chain ratios in muscles were examined in Japanese nonathletes. RESULTS The C-allele carrier frequency was greater in female athletes with fatigue fracture than in those without (odds ratio = 2.44, 95% confidence interval [CI] = 1.17-5.77) and lower in female athletes with muscle injury than in those without (odds ratio = 0.46, 95% CI = 0.24-0.91). Prospective validation analysis confirmed that in female athletes, muscle injury was less frequent in C-allele carriers than in AA genotype carriers (multivariable-adjusted hazard ratio = 0.27, 95% CI = 0.08-0.96). Among female nonathletes, the C-allele of rs1107946 was associated with lower BMD and lower muscle stiffness. Muscle biopsy revealed that C-allele carriers tended to have a larger type I collagen α1/α2 chain ratio than AA genotype carriers (2.24 vs 2.05, P = 0.056), suggesting a higher proportion of type I collagen α1 homotrimers. CONCLUSION The COL1A1 rs1107946 polymorphism exerts antagonistic effects on fatigue fracture and muscle injury among female athletes by altering the properties of these tissues, potentially owing to increased levels of type I collagen α1 chain homotrimers.
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Affiliation(s)
- ERI MIYAMOTO-MIKAMI
- Institute of Health and Sports Science and Medicine, Juntendo University, Chiba, JAPAN
- Juntendo Advanced Research Institute for Health Science, Juntendo University, Tokyo, JAPAN
- Graduate School of Health and Sports Science, Juntendo University, Chiba, JAPAN
| | - HIROSHI KUMAGAI
- Institute of Health and Sports Science and Medicine, Juntendo University, Chiba, JAPAN
- Juntendo Advanced Research Institute for Health Science, Juntendo University, Tokyo, JAPAN
| | - KUMPEI TANISAWA
- Faculty of Sport Sciences, Waseda University, Saitama, JAPAN
| | - YUKI TAGA
- Nippi Research Institute of Biomatrix, Ibaraki, JAPAN
| | - KOSUKE HIRATA
- Research Fellow of Japanese Society for the Promotion of Science, Tokyo, JAPAN
- Graduate School of Engineering and Science, Shibaura Institute of Technology, Saitama, JAPAN
| | - NAOKI KIKUCHI
- Department of Training Science, Nippon Sport Science University, Tokyo, JAPAN
| | - NOBUHIRO KAMIYA
- Faculty of Budo and Sport Studies, Tenri University, Nara, JAPAN
| | - RYOKO KAWAKAMI
- Faculty of Sport Sciences, Waseda University, Saitama, JAPAN
| | - TAISHI MIDORIKAWA
- College of Health and Welfare, J. F. Oberlin University, Tokyo, JAPAN
| | - TAKUJI KAWAMURA
- Faculty of Sport Sciences, Waseda University, Saitama, JAPAN
| | - RYO KAKIGI
- Faculty of Management and Information Science, Josai International University, Chiba, JAPAN
| | - TOSHIHARU NATSUME
- Institute of Health and Sports Science and Medicine, Juntendo University, Chiba, JAPAN
| | - HIROFUMI ZEMPO
- Faculty of Health and Nutrition, Tokyo Seiei College, Tokyo, JAPAN
| | - KOYA SUZUKI
- Institute of Health and Sports Science and Medicine, Juntendo University, Chiba, JAPAN
- Juntendo Advanced Research Institute for Health Science, Juntendo University, Tokyo, JAPAN
- Graduate School of Health and Sports Science, Juntendo University, Chiba, JAPAN
| | - YOSHIMITSU KOHMURA
- Graduate School of Health and Sports Science, Juntendo University, Chiba, JAPAN
| | | | - SUGURU TORII
- Faculty of Sport Sciences, Waseda University, Saitama, JAPAN
| | - SHIZUO SAKAMOTO
- Faculty of Sport Sciences, Waseda University, Saitama, JAPAN
| | - KOICHIRO OKA
- Faculty of Sport Sciences, Waseda University, Saitama, JAPAN
| | - MITSURU HIGUCHI
- Faculty of Sport Sciences, Waseda University, Saitama, JAPAN
| | - HISASHI NAITO
- Institute of Health and Sports Science and Medicine, Juntendo University, Chiba, JAPAN
- Juntendo Advanced Research Institute for Health Science, Juntendo University, Tokyo, JAPAN
- Graduate School of Health and Sports Science, Juntendo University, Chiba, JAPAN
| | - NAOKAZU MIYAMOTO
- Graduate School of Health and Sports Science, Juntendo University, Chiba, JAPAN
| | - NORIYUKI FUKU
- Institute of Health and Sports Science and Medicine, Juntendo University, Chiba, JAPAN
- Juntendo Advanced Research Institute for Health Science, Juntendo University, Tokyo, JAPAN
- Graduate School of Health and Sports Science, Juntendo University, Chiba, JAPAN
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46
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Wardle SL, O'Leary TJ, McClung JP, Pasiakos SM, Greeves JP. Feeding female soldiers: Consideration of sex-specific nutrition recommendations to optimise the health and performance of military personnel. J Sci Med Sport 2021; 24:995-1001. [PMID: 34452842 DOI: 10.1016/j.jsams.2021.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 06/25/2021] [Accepted: 08/11/2021] [Indexed: 12/25/2022]
Abstract
Appropriate nutrition recommendations are required to optimise the health and performance of military personnel, yet limited data are available on whether male and female military personnel have different nutrition requirements. OBJECTIVES To consider the evidence for sex-specific nutrition requirements to optimise the health and performance of military personnel. DESIGN Narrative review. METHODS Published literature was reviewed, with a focus on sex-specific requirements, in the following areas: nutrition for optimising muscle mass and function, nutrition during energy deficit, and nutrition for reproductive and bone health. RESULTS There are limited data on sex differences in protein requirements but extant data suggest that, despite less muscle mass, on average, in women, sex-specific protein feeding strategies are not required to optimise muscle mass in military-aged individuals. Similarly, despite sex differences in metabolic and endocrine responses to energy deficit, current data do not suggest a requirement for sex-specific feeding strategies during energy deficit. Energy deficit impairs health and performance, most notably bone and reproductive health and these impairments are greater for women. Vitamin D, iron and calcium are important nutrients to protect the bone health of female military personnel due to increased risk of stress fracture. CONCLUSIONS Women have an increased incidence of bone injuries, less muscle mass and are more susceptible to the negative effects of energy deficit, including compromised reproductive health. However, there are limited data on sex differences in response to various nutrition strategies designed to improve these elements of health and performance. Future studies should evaluate whether sex-specific feeding recommendations are required.
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Affiliation(s)
- Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, United Kingdom; Division of Surgery and Interventional Science, University College London, United Kingdom.
| | - Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, United Kingdom; Division of Surgery and Interventional Science, University College London, United Kingdom
| | - James P McClung
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, United States of America
| | - Stefan M Pasiakos
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, United States of America
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, United Kingdom; Division of Surgery and Interventional Science, University College London, United Kingdom; Norwich Medical School, University of East Anglia, United Kingdom
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47
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Kimber ML, Meyer S, McHugh TL, Thornton J, Khurana R, Sivak A, Davenport MH. Health Outcomes after Pregnancy in Elite Athletes: A Systematic Review and Meta-analysis. Med Sci Sports Exerc 2021; 53:1739-1747. [PMID: 33560776 DOI: 10.1249/mss.0000000000002617] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE This study aimed to evaluate postpartum maternal health and training outcomes of females who were competing or training as elite athletes before or during pregnancy. METHODS Online databases were searched up to August 26, 2020. Studies of any design and language were eligible if they contained information on the relevant population (postpartum athletes [any period after pregnancy]), exposure (engaged in the highest level of sport immediately before or during pregnancy), comparators (sedentary/active controls), and outcomes: maternal (breastfeeding initiation and duration, postpartum weight retention or loss, bone mineral density, low back or pelvic girdle pain, incontinence [prevalence or severity of stress, urge or mixed urinary incontinence, fecal incontinence], injury, anemia, diastasis recti, breast pain, depression, anxiety) and training (<6 wk time to resume activity, training volume or intensity, performance level). RESULTS Eleven studies (n = 482 females, including 372 elite athletes) were included. We identified "very low" certainty evidence demonstrating a higher rate of return to sport before 6 wk postpartum among elite athletes compared with nonelite athletes (n = 145, odds ratio = 6.93, 95% confidence interval = 2.73-17.63, I2 = 11). "Very low" certainty evidence from three studies (n = 179) indicated 14 elite athletes obtained injuries postpartum (7 stress fractures, 9 "running injuries"). "Very low" certainty evidence from five studies (n = 262) reported that 101 (40.5%) elite athletes experienced improved performance postpartum. CONCLUSION Compared with controls, "very low" quality evidence suggests that elite athletes return to physical activity early in the postpartum period and may have an increased risk of injury. Additional high-quality evidence is needed to safely guide return to sport of elite athletes in the postpartum period.
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Affiliation(s)
- Miranda L Kimber
- Program for Pregnancy and Postpartum Health, Faculty of Kinesiology, Sports and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, CANADA
| | - Sarah Meyer
- Program for Pregnancy and Postpartum Health, Faculty of Kinesiology, Sports and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, CANADA
| | - Tara-Leigh McHugh
- Faculty of Kinesiology, Sports, and Recreation, University of Alberta, Edmonton, AB, CANADA
| | - Jane Thornton
- Department of Family Medicine, Fowler Kennedy Sports Medicine Clinic, and Department of Epidemiology, and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, CANADA
| | - Rshmi Khurana
- Departments of Medicine and Obstetrics and Gynecology, Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, CANADA
| | - Allison Sivak
- University of Alberta Libraries, University of Alberta, Edmonton, AB, CANADA
| | - Margie H Davenport
- Program for Pregnancy and Postpartum Health, Faculty of Kinesiology, Sports and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, CANADA
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48
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Hutson MJ, O'Donnell E, Petherick E, Brooke-Wavell K, Blagrove RC. Incidence of bone stress injury is greater in competitive female distance runners with menstrual disturbances independent of participation in plyometric training. J Sports Sci 2021; 39:2558-2566. [PMID: 34269142 DOI: 10.1080/02640414.2021.1945184] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Bone stress injury (BSI) is prevalent in female distance runners. Menstrual disturbances are associated with impaired bone health in endurance athletes. This study aimed to investigate the association between menstrual function and BSI and explore whether plyometric training may protect against BSI in individuals with menstrual disturbances. Competitive female distance runners (n = 183) aged 18-40 years were surveyed for training habits, menstrual function, and BSI, during the previous 12 months. Oligo/amenorrhoea during the previous 12 months (<9 menses) was deemed to indicate menstrual disturbance; hormonal contraceptive users and those previously diagnosed with a pathology that impacted menstrual function were excluded. BSI incidence rate was 2.25 (p = 0.02, 95% CI: 1.14-4.41) times greater in oligo/amenorrhoeic than eumenorrhoeic runners. BSI incidence rate was similar in oligo/amenorrhoeic and eumenorrhoeic runners that did plyometric training, but 3.78 (p = 0.001, 95% CI: 1.68-8.5) times greater in oligo/amenorrhoeic versus eumenorrhoeic runners that did not. However, the effect of plyometrics was non-significant (menstrual function × plyometric training interaction, p = 0.06; main effect, p = 0.89). Conventional plyometric training may not reduce BSI incidence in female distance runners, but menstrual disturbances and prolonged periods of low energy availability should be avoided.
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Affiliation(s)
- Mark J Hutson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Emma O'Donnell
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Emily Petherick
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | | | - Richard C Blagrove
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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49
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Hughes JM, O'Leary TJ, Koltun KJ, Greeves JP. Promoting adaptive bone formation to prevent stress fractures in military personnel. Eur J Sport Sci 2021; 22:4-15. [PMID: 34269162 DOI: 10.1080/17461391.2021.1949637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Mechanical loading leads to adaptive bone formation - the formation of new bone on existing skeletal surfaces - which increases bone strength and fatigue resistance. The same mechanical loading can also cause microdamage to bone and development of a stress fracture through targeted remodelling. Stress fractures are common in military recruits and cause significant morbidity, lost training time, and discharge from military service. This narrative review proposes strategies to promote adaptive bone formation as a novel approach to mitigate the risk of stress fracture injuries during arduous military training. Exercise that is unaccustomed, dynamic, high-impact, multidirectional, intermittent, and includes extended rest periods to restore bone mechanosensitivity, is most osteogenic. New bone formation can take up to one year to mineralize, and so new exercise training programmes should be initiated well in advance of military activities with high risk of stress fracture. Bone mechanosensitivity is highest in adolescence, before puberty, and so increasing physical activity in youth is likely to protect skeletal health in later life, including for those in the military. Recent data show that adaptive bone formation takes place during initial military training. Adaptive bone formation can also be supported with adequate sleep, vitamin D, calcium, and energy availability. Further evidence on how strategies to promote adaptive bone formation affect stress fracture risk are required. Adaptive bone formation can be optimized with a range of training and nutritional strategies to help create a resilient skeleton, which may protect against stress fracture throughout military service.
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Affiliation(s)
- Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Kristen J Koltun
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, PN, USA
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London, London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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O'Leary TJ, Wardle SL, Gifford RM, Double RL, Reynolds RM, Woods DR, Greeves JP. Tibial Macrostructure and Microarchitecture Adaptations in Women During 44 Weeks of Arduous Military Training. J Bone Miner Res 2021; 36:1300-1315. [PMID: 33856703 DOI: 10.1002/jbmr.4290] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/01/2021] [Accepted: 03/12/2021] [Indexed: 12/14/2022]
Abstract
Bone adapts to unaccustomed, high-impact loading but loses mechanosensitivity quickly. Short periods of military training (≤12 weeks) increase the density and size of the tibia in women. The effect of longer periods of military training, where the incidence of stress fracture is high, on tibial macrostructure and microarchitecture in women is unknown. This observational study recruited 51 women (age 19 to 30 years) at the start of 44 weeks of British Army Officer training. Tibial volumetric bone mineral density (vBMD), geometry, and microarchitecture were measured by high-resolution peripheral quantitative computed tomography (HRpQCT). Scans of the right tibial metaphysis (4% site) and diaphysis (30% site) were performed at weeks 1, 14, 28, and 44. Measures of whole-body areal bone mineral density (aBMD) were obtained using dual-energy X-ray absorptiometry (DXA). Blood samples were taken at weeks 1, 28, and 44, and were analyzed for markers of bone formation and resorption. Trabecular vBMD increased from week 1 to 44 at the 4% site (3.0%, p < .001). Cortical vBMD decreased from week 1 to 14 at the 30% site (-0.3%, p < .001). Trabecular area decreased at the 4% site (-0.4%); trabecular bone volume fraction (3.5%), cortical area (4.8%), and cortical thickness (4.0%) increased at the 4% site; and, cortical perimeter increased at the 30% site (0.5%) from week 1 to 44 (p ≤ .005). Trabecular number (3.5%) and thickness (2.1%) increased, and trabecular separation decreased (-3.1%), at the 4% site from week 1 to 44 (p < .001). Training increased failure load at the 30% site from week 1 to 44 (2.5%, p < .001). Training had no effect on aBMD or markers of bone formation or resorption. Tibial macrostructure and microarchitecture continued to adapt across 44 weeks of military training in young women. Temporal decreases in cortical density support a role of intracortical remodeling in the pathogenesis of stress fracture. © 2021 Crown copyright. Journal of Bone and Mineral Research © 2021 American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Robert M Gifford
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK
| | - Rebecca L Double
- Army Health and Performance Research, Army Headquarters, Andover, UK
| | - Rebecca M Reynolds
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - David R Woods
- Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK.,Research Institute for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK.,Northumbria and Newcastle National Health Service (NHS) Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, UK.,University of Newcastle, Newcastle, UK
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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