Obstacles in the optimization of bone health outcomes in the female athlete triad

Differences of Bone Mineral Density by Characteristics of Sports in Amenorrheic Athletes

Hypothalamic amenorrhea leads to a hypoestrogenic state, causing decreased bone mineral density (BMD), while strong impact loading on bone has been shown to increase BMD. The purpose of this study is to compare BMD in female athletes based on menstrual status and their sports/events by impact loading characteristics. BMD at the lumbar spine was measured by dual-energy X-ray absorptiometry and hormone level. The subjects were classified into four groups and BMD and hormone levels were compared among the four groups, which were divided into amenorrheic athletes (AAs) and eumenorrheic athletes (EAs). This study recruited 410 female athletes (164 in the AAs and 246 in the EAs), 55 athletes in non-impact sports, 123 in low-impact sports, 141 in multidirectional sports, and 91 in high-impact sports. In the AAs group, BMD Z-score was lowest in low-impact sports (Z-score: -1.53 [-1.76, -1.30]), and was highest in high-impact sports (Z-score: 0.02 [-0.34, 0.38]). In multidirectional and high-impact sports, BMD Z-score in the AAs group did not show results lower than the average for non-athletes. When screening female athletes for low BMD, it is important to evaluate the risk of low BMD based on the impact loading characteristics of their sports/events, in addition to the menstrual state.

One Season in Professional Cycling Is Enough to Negatively Affect Bone Health

Cycling is a very popular sport worldwide, and several studies have already indicated that cycling at various levels has a negative impact on bone health. This is of concern to both performance and health managers of many cycling teams at different levels because of its economic and social impact. Based on the scientific literature, we hypothesize that a single season at the professional level can negatively affect bone health status. The aim of this study was to assess how professional cycling affects bone health markers after one season. Densitometry was used to measure the bone mineral density (BMD), bone mineral content (BMC), bone area (BA), fat mass (FM), fat-free mass (FFM), T-score and Z-score in professional cyclists after one season. After one season at the professional level, cyclists' BMD decreased significantly in the legs, trunk, ribs and pelvis (p ≤ 0.05). BMC decreased in the arms and spine (p ≤ 0.05). BA decreased significantly in the arms and spine (p ≤ 0.05). In addition, a significant decrease in Z-score (p ≤ 0.05) and a decreasing trend in T-score and total BMD (p = 0.06) were observed. One season of professional cycling is enough to negatively affect bone health status.

Oral Contraceptives and Female Rowers' Skeletal Health

ABSTRACT

Redinger, AL and Baker, BS. Oral contraceptives and female rowers' skeletal health. J Strength Cond Res 37(3): 669-677, 2023-Previous studies suggest that women using oral contraceptives (OC) experience fewer skeletal benefits from exercise compared with non-OC users. These findings may be especially important for athletes competing in weight-supported sports with a high prevalence of low bone mineral density and fracture, such as rowing. The purpose of this study was to examine skeletal health and bone injuries in collegiate female rowers. Forty-nine National Collegiate Athletic Association Division I female rowers completed general health, menstrual history, and bone physical activity questionnaire (BPAQ) surveys. Dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT) scans were used to assess bone content, density, and geometry. Contraceptive (OC users n = 14, non-OC users n = 35) and self-reported stress fracture (SFx n = 11, None n = 38) groups were analyzed using analysis of covariance and independent t -tests. Additionally, effect sizes ( d ) were calculated and significance was set at p ≤ 0.05. Oral contraceptive users had reduced lumbar spine areal bone mineral density after adjustment for Total BPAQ ( d = 0.58; p = 0.041) compared with non-OC users, but all other total body and site-specific DXA measures of bone mineral content and density were similar between contraceptive and injury groups. When comparing bone geometry of the 4, 38, and 66% tibiae using pQCT, no significant differences were found after adjustment for either contraceptive or injury group (all p > 0.060). Our findings suggest that OC usage was not associated with reduced skeletal health in competitive female rowers as evidenced by all Z-scores being above -2.0 and similar bone indices of mineralized content, density, geometry, and estimated strength between the groups.

The effect of underweight on female and male reproduction

Chronic energy deficiency can impair the hypothalamic-pituitary-gonadal (HPG) axis and lead to hypothalamic anovulation in underweight women. This review presents the syndromes related to underweight status that are associated with infertility, summarizes the underlying mechanisms, and reviews the available treatment options. Eating disorders, such as anorexia nervosa (AN), constitute the most common cause of infertility in underweight women, who, in addition, experience miscarriages, and sexual dysfunction. The relative energy deficiency in sports (RED-S; former terminology: athlete's triad) involves menstrual dysfunction due to low energy availability, which results in anovulation. Moreover, lipodystrophies, malnutrition, starvation, systematic illnesses (malignancies, endocrinopathies, infectious diseases, advanced chronic diseases, neurologic illnesses), and the utilization of drugs can cause excessive weight loss. They may result in fertility problems due to the loss of adipose tissue and the subsequent hormonal disturbances. Each of these conditions requires multidisciplinary management. Nutritional counseling should target the restoration of energy balance by increasing intake and reducing output. Medical treatment, recommended only for patients who did not respond to standard treatment, may include antipsychotics, antidepressants, or leptin administration. Finally, psychiatric treatment is considered an integral part of the standard treatment.

Low Bone Mineral Density in Elite Female Athletes With a History of Secondary Amenorrhea in Their Teens

OBJECTIVE

To determine whether secondary amenorrhea during teenage years influences bone mineral density (BMD) in female athletes in their 20s.

DESIGN

Original research.

SETTING

Japan Institute of Sports Sciences.

PARTICIPANTS

Two hundred ten elite female athletes older than 20 years were included in the study.

MAIN OUTCOME MEASURES

Information on the participants' past (ie, during their teenage years) and current menstrual cycle, training time, history of stress fractures, and blood tests for hormones received was obtained. Bone mineral density of the lumbar spine was evaluated by dual-energy x-ray absorptiometry; low BMD was defined as a Z-score ≤-1. We investigated the correlation factors for low BMD in athletes in their 20s by univariable and multivariable logistic regression analysis.

RESULTS

A total of 39 (18.6%) female athletes had low BMD. Secondary amenorrhea in their teens [odds ratio (OR), 7.11, 95% confidence interval (CI), 2.38-21.24; P < 0.001] and present body mass index (BMI) (OR, 0.56, 95% CI, 0.42-0.73; P < 0.001) were independent correlation factors for low BMD in the multivariable logistic regression analysis. The average Z-score for those with secondary amenorrhea in their teens and 20s, secondary amenorrhea in their 20s only, and regular menstruation was -1.56 ± 1.00, -0.45 ± 1.21, and 0.82 ± 1.11 g/cm, respectively.

CONCLUSIONS

Secondary amenorrhea for at least 1 year during teenage years in female athletes and BMI at present was strongly associated with low BMD in their 20s.

Primary Ovarian Insufficiency in the Prepubertal Adolescent: A Case Report

Although there are many etiologies for delayed puberty in adolescent-aged girls, the pediatric provider should consider primary ovarian insufficiency if estradiol remains undetectable despite elevated levels of gonadotropins. Adolescent girls with this diagnosis will need holistic care from their primary care provider, focusing on both their medical and psychosocial needs. The following case study describes a 14-year-old girl who was referred to pediatric endocrinology for delayed puberty, in the setting of increased gonadotropins and undetectable estradiol. The differential diagnosis, evaluation, and management of primary ovarian insufficiency are reviewed as well as potential long-term health considerations.

Effect of transdermal estradiol therapy on bone mineral density of amenorrheic female athletes

BACKGROUND

The effects of transdermal estradiol treatment (HT) in amenorrheic athletes (AA) with low body weight (BW) and low bone mineral density (BMD) are unknown.

PURPOSE

To investigate whether HT increases BMD in AA with low BW and to compare the results with levels in AA who have recovered spontaneous menstruation (SM).

METHODS

Female athletes (n = 151) were recruited at the Japan Institute of Sports Sciences and the University of Tokyo. All participants were divided into four groups: an AA group (untreated group) (n = 36), a HT group (n = 55), a SM group (n = 21), and an eumenorrheic athletes (EA) group (n = 39). Height, body weight, blood tests, and dual-energy X-ray absorptiometry were measured at baseline and after 12 months. The HT group was treated daily for 12 months with transdermal estrogen therapy. In addition, participants received oral progestin for 7 days once every 3 months.

RESULTS

After 12 months, BMD in the AA group was significantly lower than at baseline; however, BMD in the other three groups was significantly higher than at baseline. The ratio of the change in BMD values before and after 12 months was -1.6 ± 3.2% for the AA group, 5.3 ± 8.7% for the HT group, 11.1 ± 8.9% for the SM group, and 2.3 ± 5.7% for the EA group. The rate of change in BMD values in the SM group was greater than that in the HT group.

CONCLUSION

HT increased BMD in AA with low BW, and the increase in those with SM was greater than that in those treated with HT.

Total Hip Arthroplasty for Bilateral Femoral Neck Stress Fracture: A Case Report and Review of the Literature

Femoral neck stress fractures (FNSFs) can be treated conservatively or surgically, depending on initial displacement and patient condition. Surgical treatment options include internal fixation, with or without valgus osteotomy or hip arthroplasty, either hemi or total. The latter is mainly considered when initial treatment fails. A review of the literature shows that total hip arthroplasty (THA) is only considered as primary treatment in displaced fractures (type 3) in low-demand patients. We present a case of successive bilateral FNSF in a young active patient, where a THA was performed on one side, after failed internal fixation, and where it was chosen as primary treatment on the other side after failed conservative treatment.

Low Energy Availability, Plasma Lipids, and Hormonal Profiles of Recreational Athletes

Black, K, Slater, J, Brown, RC, and Cooke, R. Low energy availability, plasma lipids, and hormonal profiles of recreational athletes. J Strength Cond Res 32(10): 2816-2824, 2018-It has been postulated that low energy availability (LEA) impacts bone health, hormonal concentrations, and cardiovascular function. This study describes the lipid levels, hormonal profiles, and nutrient intakes of recreationally active adults at risk of LEA compared with those not at risk. Thirty-eight women who meet or exceed the New Zealand guidelines for physical activity participated. Each participant completed an online questionnaire including the Low Energy Availability in Females questionnaire (LEAF-Q), demographic questions, and daily exercise to determine energy expenditure. Participants also provided a weighed 3-day diet record, a blood sample analyzed for total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, and cortisol, and a saliva sample analyzed for testosterone. Body composition was assessed using bioelectrical impedance. Those classed as at risk of LEA according to the LEAF-Q showed very likely lower energy availability (at risk: mean, 36.3 [95% confidence interval, 30.8-41.7] kcal·kg·FFMd vs. not at risk: mean, 47.5 [95% CI, 39.5-55.4] kcal·kg·FFMd) and lower calcium intakes (mean, 847 [95% CI, 695-998] mg, vs. mean, 1488 [95% CI, 690-2,286] mg). Those at risk also had a likely small lower T3 concentration of 1.78 (SD: 0.36) nmol·L compared with 2.01 (SD: 0.53) nmol·L for those not at risk. These data suggest that recreationally active female subjects classed as at risk of LEA according to the LEAF-Q also have lower energy availability as determined by diet records and exercise diaries. The results also suggests that those at risk of LEA have reductions in T3, and their low energy intake, in addition to a low calcium intake, could put them at an increased risk of poor bone health.

Combined Oral Contraceptives Increase High-Sensitivity C-Reactive Protein but Not Haptoglobin in Female Athletes

BACKGROUND

No studies have examined the effects of oral hormonal contraception on chronic low-grade inflammation as assessed by stratified levels of high-sensitivity C-reactive protein (hsCRP) in athletes. We explored the impact of combined oral contraceptives (OCs) on serum hsCRP, haptoglobin, triglycerides and cholesterol in white female athletes.

METHODS

Italian sportswomen (n = 205; mean age 24 ± 5.3 years; body mass index 21 ± 2.2 kg m^-2; sport activity 8.7 ± 3.65 h week^-1) were analyzed according to OC use.

RESULTS

Progressive hsCRP levels were evaluated in OC users (n = 53) compared to non-OC users (n = 152). Levels of hsCRP from 3.0 to <10.0 mg L^-1 (at high risk of future cardiovascular events) were found in 26.4 % (14/53) of OC users and only in 2.6 % (4/153) of non-OC users (OR = 13.3, 95 % CI 4.14-42.6, P < 0.001). Risky hsCRP levels ≥1.0 mg L^-1 were found in 62.3 % of OC users versus 13.2 % non-OC users (OR = 10.9, 95 % CI 5.26-22.5, P < 0.001). Protective hsCRP levels (<0.5 mg L^-1) were found in 17.0 % of OC users and in 64.5 % of non-OC users (OR = 0.11, 95 % CI 0.05-0.25, P < 0.001). OC use increased serum triglycerides (P < 0.001), total cholesterol (P = 0.027) and HDL cholesterol (P = 0.018), whereas haptoglobin was unaffected. Hours of exercise week^-1 had a mild inverse association with hsCRP (P = 0.048) in non-OC users only.

CONCLUSIONS

OC use markedly elevated chronic low-grade inflammation in athletes, which could predispose to a higher inflammatory response to physical stress and elevate cardiovascular risk. Physical activity without OC use seemed to favor low hsCRP. Further research is needed to extend our results and to elucidate the potential effects on athletic performance of chronically elevated hsCRP. Our findings would be useful for sport physicians interpreting blood tests in athletes.

Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones

Low energy availability, defined as low caloric intake relative to exercise energy expenditure, has been linked to endocrine alterations frequently observed in chronically energy-deficient exercising women. Our goal was to determine the endocrine effects of low energy availability in exercising men. Six exercising men (VO2peak: 49.3 ± 2.4 ml · kg(-1) · min(-1)) underwent two conditions of low energy availability (15 kcal · kg(-1) fat-free mass [FFM] · day(-1)) and two energy-balanced conditions (40 kcal · kg(-1) FFM · day(-1)) in randomised order. During one low energy availability and one balanced condition, participants exercised to expend 15 kcal · kg(-1) FFM · day(-1); no exercise was conducted during the other two conditions. Metabolic hormones were assessed before and after each 4-day period. Following both low energy availability conditions, leptin (-53% to -56%) and insulin (-34% to -38%) were reduced (P < 0.05). Reductions in leptin and insulin were independent of whether low energy availability was attained with or without exercise (P > 0.80). Low energy availability did not significantly impact ghrelin, triiodothyronine, testosterone and IGF-1 (all P > 0.05). The observed reductions in leptin and insulin were in the same magnitude as changes previously reported in sedentary women. Further research is needed to understand why other metabolic hormones are more robust against low energy availability in exercising men than those in sedentary and exercising women.

Diets High in Fiber and Vegetable Protein Are Associated with Low Lumbar Bone Mineral Density in Young Athletes with Oligoamenorrhea

BACKGROUND

Associations of bone mineral density (BMD) with specific food components, including dietary fiber and isoflavones (that have a negative association with serum estrogen), are unclear and need to be determined, particularly in populations more likely to consume large amounts of these nutrients (such as young athletes).

OBJECTIVE

To determine dietary intake of specific food components in athletes with oligoamenorrhea (OA) compared to athletes with eumenorrhea (EA) and nonathletes (NA), and associations of the dietary intake of these nutrients with lumbar spine BMD.

DESIGN AND SUBJECTS

This cross-sectional study evaluated 68 OA, 24 EA, and 26 NA individuals aged 14 to 23 years. Measurements included 4-day food records, a dual x-ray absorptiometry scan evaluating lumbar spine BMD and body composition, and hormone levels. Multivariate analysis was used to estimate associations of nutrients with lumbar spine BMD.

RESULTS

Compared with EA and NA, OA had higher intake of fiber, phytic acid, and vegetable protein (all P values <0.0001). Intake of isoflavones, genistein, and daidzein was higher in OA than NA (P=0.003 and P=0.0002, respectively). OA had lower consumption of energy from saturated fatty acids than NA (P=0.002). After controlling for confounders such as body weight, menstrual status (indicative of estrogen status), calcium intake, and serum vitamin D (known BMD determinants), lumbar spine BMD z scores were inversely associated with dietary fiber (β=-.30; P=0.01), vegetable protein (β= -.28; P=0.02), phytic acid (β=-.27; P=0.02), genistein (β=-.25; P=0.01), and daidzein (β=-.24; P=0.01), and positively associated with percent energy from fatty acids (β=.32; P=0.0006).

CONCLUSIONS

Compared with EA and NA, OA had a higher dietary intake of fiber, vegetable protein, and phytic acid, which were inversely associated with lumbar spine BMD z scores. Further studies are needed to assess dietary recommendations for OA to optimize bone accrual.

Female Athlete Triad Awareness Among Multispecialty Physicians

Background

The female athlete triad (Triad) is a serious condition with lifelong consequences seen in physically active females. Prior studies assessing Triad knowledge among coaches/athletic trainers reported surprisingly low awareness results. Our aims were to (1) determine the percentage of physicians across multiple specialties who had heard of the phrase “female athlete triad” and (2) determine the percentage who can properly diagnose or have a high comfort level appropriately referring these patients.

Methods

Via electronic survey, we recruited medical staff, residents, and fellows at three large academic institutions across specialties to answer an eight-item test on Triad awareness and knowledge.

Results

A total of 931 physician participants were recorded. Of the total responders (40 % male and 60 % female), 23 % were residents, 12 % were fellows, and 65 % were attending physicians. Overall, 37 % had heard of the Triad. Of these respondents, an average of 2.1 ± 1.1 of the three components were properly identified with an overall average score on the Triad awareness test of 71 ± 18 % out of a possible 100 %. Fifty-one percent reported feeling either comfortable treating or referring a patient with the Triad.

When assessing awareness among specialties, the awareness rates were highest among orthopedic surgery (80 %), followed by obstetrics and gynecology (55 %) and physical medicine and rehabilitation/rheumatology (52 %). The three with the lowest awareness were anesthesia (9 %), radiology (10 %), and psychiatry (11 %).

Conclusions

Our findings suggest that approximately one third of the physicians surveyed have heard of the Triad. Approximately one half of physicians were comfortable treating or referring a patient with the Triad. Increased awareness through education to properly identify and manage the Triad is essential for all physicians.

Female Athlete Triad: Past, Present, and Future

After the passage of Title IX in 1972, female sports participation skyrocketed. In 1992, the female athlete triad was first defined; diagnosis required the presence of an eating disorder, amenorrhea, and osteoporosis. However, many athletes remained undiagnosed because they did not meet all three of these criteria. In 2007, the definition was modified to a spectrum disorder involving low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density. With the new definition, all three components need not be present for a diagnosis of female athlete triad. Studies using the 1992 definition of the disorder demonstrated a prevalence of 1% to 4% in athletes. However, in certain sports, many female athletes may meet at least one of these criteria. The actual prevalence of athletes who fall under the "umbrella" diagnosis of the female athlete triad remains unknown.

20 years of leptin: role of leptin in human reproductive disorders

Leptin, as a key hormone in energy homeostasis, regulates neuroendocrine function, including reproduction. It has a permissive role in the initiation of puberty and maintenance of the hypothalamic-pituitary-gonadal axis. This is notable in patients with either congenital or acquired leptin deficiency from a state of chronic energy insufficiency. Hypothalamic amenorrhea is the best-studied, with clinical trials confirming a causative role of leptin in hypogonadotropic hypogonadism. Implications of leptin deficiency have also emerged in the pathophysiology of hypogonadism in type 1 diabetes. At the other end of the spectrum, hyperleptinemia may play a role in hypogonadism associated with obesity, polycystic ovarian syndrome, and type 2 diabetes. In these conditions of energy excess, mechanisms of reproductive dysfunction include central leptin resistance as well as direct effects at the gonadal level. Thus, reproductive dysfunction due to energy imbalance at both ends can be linked to leptin.

Current perspectives on the etiology and manifestation of the "silent" component of the Female Athlete Triad

The Female Athlete Triad (Triad) represents a syndrome of three interrelated conditions that originate from chronically inadequate energy intake to compensate for energy expenditure; this environment results in insufficient stored energy to maintain physiological processes, a condition known as low energy availability. The physiological adaptations associated with low energy availability, in turn, contribute to menstrual cycle disturbances. The downstream effects of both low energy availability and suppressed estrogen concentrations synergistically impair bone health, leading to low bone mineral density, compromised bone structure and microarchitecture, and ultimately, a decrease in bone strength. Unlike the other components of the Triad, poor bone health often does not have overt symptoms, and therefore develops silently, unbeknownst to the athlete. Compromised bone health among female athletes increases the risk of fracture throughout the lifespan, highlighting the long-term health consequences of the Triad. The purpose of this review is to examine the current state of Triad research related to the third component of the Triad, ie, poor bone health, in an effort to summarize what we know, what we are learning, and what remains unknown.

Female athlete triad and its components: toward improved screening and management

As female athletic participation has increased, the positive effects of exercise on health have become evident. However, with this growth in sports activity, a set of health problems unique to the female athlete has emerged. The female athlete triad as first described in 1992 by the American College of Sports Medicine consisted of disordered eating, amenorrhea, and osteoporosis; the definition was updated in 2007 to include a spectrum of dysfunction related to energy availability, menstrual function, and bone mineral density. For this review, a comprehensive search of databases-MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Scopus, from earliest inclusive dates to January 2013-was conducted by an experienced librarian with input from the authors. Controlled vocabulary supplemented with keywords such as female athlete triad, amenorrhea, oligomenorrhea, fracture, osteopenia, osteoporosis, bone disease, anorexia, bulimia, disordered eating, low energy availability was used to search for articles on female athlete triad. Articles addressing the prevalence, screening, and management of the female athlete triad were selected for inclusion in the review. This article reviews the current definitions of the triad components, epidemiology, pathophysiology, and recommended screening and management guidelines. The lack of efficacy of current screening of athletes is highlighted. Low energy availablity, from either dietary restriction or increased expenditure, plays a pivotal role in development of the triad. Athletes involved in "lean sports" (those that emphasize weight categories or aesthetics, such as ballet, gymnastics, or endurance running) are at highest risk. Treatment is centered on restoring energy availability to reverse adverse changes in the metabolic milieu. Prevention and early recognition of triad disorders are crucial to ensure timely intervention. Caregivers and physicians of female athletes must remain vigilant in education, recognition, and treatment of athletes at risk.

Stress fractures

Stress fractures are common injuries in military recruits and athletes, particularly long-distance runners. A high index of suspicion coupled with a thorough history and correct imaging are vital in the diagnosis. A delay in their diagnosis or undertreatment can result in extended recovery times that are particularly damaging to sportspeople where these injuries can be career-ending. In most cases, treatment includes reducing the causative activity to a pain-free level. “High-risk” fractures which typically include the femoral neck, anterior tibia, proximal fifth metatarsal and tarsal navicular may however require surgical fixation. Stress fractures carry a high risk of recurrence and prevention involves reducing modifiable risk factors through training and diet adjustments. All members involved in an athlete or military recruit’s training should therefore be aware of the presence of eating disorders, the effects of overtraining and the importance of rest in order to reduce the incidence of these injuries.

Update on stress fractures in female athletes: epidemiology, treatment, and prevention

Stress fractures are a common type of overuse injury in athletes. Females have unique risk factors such as the female athlete triad that contribute to stress fracture injuries. We review the current literature on risk factors for stress fractures, including the role of sports participation and nutrition factors. Discussion of the management of stress fractures is focused on radiographic criteria and anatomic location and how these contribute to return to play guidelines. We outline the current recommendations for evaluating and treatment of female athlete triad. Technologies that may aid in recovery from a stress fracture including use of anti-gravity treadmills are discussed. Prevention strategies may include early screening of female athlete triad, promoting early participation in activities that improve bone health, nutritional strategies, gait modification, and orthotics.

Update on the female athlete triad

Updated prevalence estimates of all 3 components of the Female Athlete Triad, a syndrome characterized by low energy availability, functional hypothalamic amenorrhea, and osteoporosis, is low (0 %-16 %), however, estimates of 1 or 2 concurrent components approach 50 %-60 % among certain athlete groups. Recent research identifies components of the Triad among female adolescent athletes, particularly those participating in leanness sports, such as endurance running. This is alarming, as adolescents require adequate nutrition and normal hormone function to optimize bone mineral gains during this critical developmental period. Current literature highlights new assessments, such as measurements of bone microarchitecture and hormone levels to better evaluate bone strength and the hormonal and metabolic profile of athletes with and at risk for the Triad. Recent data also provides support for additional potential consequences of the Triad, such as endothelial dysfunction and related cardiovascular effects, stress fractures, and musculoskeletal injuries. Additional prospective research is needed to evaluate long-term indicators and consequences of the Triad and identify effective behavioral treatment strategies.

Female Athlete Triad

The passage of Title IX in 1972 resulted in a tremendous increase in the number of females participating in high school and collegiate athletics. This rise in female athletes sparked new focus areas of research in sports medicine related to woman with an important area emerging in 1980, the female athlete triad. This triad consisting of low energy availability, menstrual irregularities, and bone health disruption spans a spectrum of severity and has evolved both in diagnosis and in management throughout the years. Many health questions arise for female athletes and their health care providers, often concerning the most effective management and treatment strategies for this triad. This review examines the research and latest advancements in recognizing and understanding the female athlete triad and explores the most current recommendations for treatment and prevention.

Association between the stress fracture and bone metabolism/quality markers in lacrosse players

Background

Overuse injury including stress fracture is a serious problem for athletes. Recently, the importance of bone metabolism and quality as factors preventing overuse injury has been increasingly recognized. Hence, we hypothesized that markers of bone metabolism and quality are related to overuse injuries.

Methods

The subjects, which were elite university lacrosse players (male, n = 35; age, 19.8 ± 1.1; female, n = 49; age, 20.0 ± 1.0), were divided into a stress fracture group and a control group. We measured the subjects’ physical characteristics (height, weight, body mass index, and body fat) and bone architecture was evaluated using quantitative ultrasound. Bone alkaline phosphatase, N-telopeptide cross-link of type I collagen, tartrate-resistant acid phosphatase 5b (TRAP-5b), homocysteine, and pentosidine were measured from blood samples obtained from all subjects.

Results

No significant difference was observed between groups with respect to height, weight, body mass index, and body fat, as well as quantitative ultrasound. Further, there were no significant differences in the levels of bone alkaline phosphatase, N-telopeptide cross-link of type I collagen, or TRAP-5b between stress fracture and control groups in all subjects and in male subjects. However, a significant increase in TRAP-5b level was observed in the stress fracture group compared with the control in the female subjects (409.9 ± 209.3 and 318.6 ± 81.6 mU/dL, respectively; P < 0.05). Homocysteine and pentosidine did not differ between groups.

Conclusion

These results suggest that osteoclast activity of female athletes with stress fractures may be enhanced by TRAP-5b.