Menstrual irregularity and musculoskeletal injury in female high school athletes

Association between Physical Activity and Menstrual Cycle Disorders in Young Athletes

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.

Age and menstrual cycle may be important in establishing pregnancy in female athletes after retirement from competition

BACKGROUND

Although it has been shown that amenorrhea associated with low energy availability or relative energy deficiency in sport affects body physiology in female athletes, the association between menstrual dysfunction during active sports careers and reproductive function after retirement is not clear.

OBJECTIVE

To investigate the association between menstrual dysfunction during their active sports career and post-retirement infertility in female athletes.

METHODS

A voluntary web-based survey was aimed at former female athletes who had become pregnant and gave birth to their first child after retirement. Nine multiple-choice questions were included, on maternal age, competition levels and menstrual cycles during active sports careers, time from retirement to pregnancy, the time of resumption of spontaneous menstruation after retirement, conception method, and mode of delivery, etc. Regarding cases of primary and secondary amenorrhea among the abnormal menstrual cycle group, only those whose spontaneous menstruation had not recovered from retirement to the time of pregnancy were included in the study. The association between the presence of abnormal menstrual cycles from active sports careers to post-retirement pregnancy and the implementation of infertility treatment was evaluated.

RESULTS

The study population included 613 female athletes who became pregnant and gave birth to their first child after retiring from competitive sports. Of the 613 former athletes, the infertility treatment rate was 11.9%. The rate of infertility treatment was significantly higher in athletes with abnormal than normal menstrual cycles (17.1% vs. 10.2%, p = 0.0225). Multivariable logistic regression analysis showed that maternal age (adjusted odds ratio [OR] 1.194; 95% confidence interval [CI] 1.129, 1.262) and abnormal menstrual cycles (OR and 1.903; adjusted OR 1.105, 3.278) were the relevant factors for infertility treatment.

CONCLUSION

It was suggested that menstrual dysfunction that persist from active sports careers to post-retirement may be a factor in infertility when trying to conceive after retirement.

Higher Eccentric Hamstring Muscle Fatigue After Participation in a Soccer Match in Young Female Athletes

BACKGROUND

Hamstring (HS) strength deficits and imbalances have been identified as risk factors for sustaining anterior cruciate ligament (ACL) injuries and muscular strains, with HS injuries being the most prevalent muscle injuries in soccer athletes. The aim of this study was to investigate HS eccentric strength before and after a soccer match in both male and female soccer athletes.

HYPOTHESIS

Soccer athletes have changes in eccentric HS strength after a soccer game.

STUDY DESIGN

Cohort observational study.

LEVEL OF EVIDENCE

Level 3.

METHODS

HS eccentric strength (mean and absolute peak torque and total work) was measured in 64 healthy male and female competitive football athletes (14-25 years) with an automatic device during the execution of the Nordic hamstring exercise (NHE) test before and after a 90-minute soccer match. The anterior-knee laxity (AKL) was quantified with an arthrometer.

RESULTS

Mean and absolute eccentric HS peak torque decreased by 24.5 N.m (-12.34%; P < 0.01) and 21.9 N.m (-10.08%; P < 0.01) in female athletes, whereas their male peers improved by 19.9 N.m (+9.01%; P = 0.01) and by 20.9 N.m (+8.51%; P = 0.02), respectively. HS total work in female athletes decreased by 831.1 J (P < 0.01) compared with the male athlete reduction of 235.3 J. Both the pre- versus postmatch intersex mean and absolute eccentric HS peak torque changes were significant (P < 0.01), as were the changes in HS total work (P < 0.01). The pre- versus postmatch AKL difference and the dominant versus nondominant limb comparison of the strength parameters were not significantly different. Younger female athletes (14-19 years old) presented a greater decrease in mean and absolute peak HS eccentric strength compared with those in older female athletes and men.

CONCLUSION

HS eccentric strength and work differ based on athlete sex, as measured by the NHE test. Mean peak, absolute peak, and total work showed greater reductions in female athletes than those in their male peers. The subgroup of 14- to 19-year-old female athletes experienced the highest reduction in strength parameters.

Free-living competitive racewalkers and runners with energy availability estimates of <35 kcal·kg fat-free mass-1·day-1 exhibit peak serum progesterone concentrations indicative of ovulatory disturbances: a pilot study

Introduction

The release of luteinising hormone (LH) before ovulation is disrupted during a state of low energy availability (EA). However, it remains unknown whether a threshold EA exists in athletic populations to trigger ovulatory disturbances (anovulation and luteal phase deficiency) as indicated by peak/mid-luteal serum progesterone concentration (Pk-PRG) during the menstrual cycle.

Methods

We assessed EA and Pk-PRG in 15 menstrual cycles to investigate the relationship between EA and Pk-PRG in free-living, competitive (trained-elite) Guatemalan racewalkers (n = 8) and runners (n = 7) [aged: 20 (14-41) years; post-menarche: 5 (2-26) years; height: 1.53 ± 0.09 m; mass: 49 ± 6 kg (41 ± 5 kg fat-free mass "FFM")]. EA was estimated over 7 consecutive days within the follicular phase using food, training, and physical activity diaries. A fasted blood sample was collected during the Pk-PRG period, 6-8 days after the LH peak, but before the final 2 days of each cycle. Serum progesterone concentration was quantified using electrochemiluminescence immunoassay.

Results

Participants that reported an EA of <35 kcal·kg FFM-1·day-1 (n = 7) exhibited ovulatory disturbances (Pk-PRG ≤9.40 ng·mL-1). Athletes with EA ≥36 kcal·kg FFM-1·day-1 (n = 8) recorded "normal"/"potentially fertile" cycles (Pk-PRG >9.40 ng·mL-1), except for a single racewalker with the lowest reported protein intake (1.1 g·kg body mass-1·day-1). EA was positively associated with Pk-PRG [r(9) = 0.79, 95% confidence interval (CI): 0.37-0.94; p = 0.003; 1 - β = 0.99] after excluding participants (n = 4) that likely under-reported/reduced their dietary intake.

Conclusions

The result from the linear regression analysis suggests that an EA ≥ 36 kcal·kg FFM-1·day-1 is required to achieve "normal ovulation." The threshold EA associated with ovulatory disturbances in athletes and non-invasive means of monitoring the ovulatory status warrant further research.

Previous Injury and Lower Well-being Increase Injury Risk in Female Adolescent Athletes

Several risk factors for injury have been suggested in female elite athletes. However, there is a lack of prospective studies in young female athletes where multiple risk factors have been studied. The aim of this study was to identify risk factors for injury in female adolescent elite athletes. Substantial injuries were monitored in 222 athletes using the validated Oslo Sports Trauma Research Centre Questionnaire over 20 weeks. Over 20 potential risk factors were explored. Based on a binomial generalized linear mixed model, two significant (p<0.05) risk factors for injury were identified; previous injury within the last 12 months (OR 2.55) and well-being (OR 0.97). An athlete with a previous injury had twice as high a risk of injury (13% vs. 6%) compared to an athlete with no previous injury. Higher perceived well-being was associated with a decreased risk of injury. Based on a prospective design with a large sample of female adolescent elite athletes, investigating over 20 potential risk factors for injury, our results suggest that a previous injury and well-being are risk factors for injury.

Symptoms of eating disorders and low energy availability in recreational active female runners

Objectives

This retrospective, cross-sectional study aimed to investigate symptoms of eating disorders (EDs) and low energy availability (LEA) among recreational female runners.

Methods

Females (18-39 years) (n=89) participating in running group sessions organised by running clubs and companies were recruited via social media and completed an anonymous online survey compromising the Eating Disorder Examination Questionnaire (EDE-Q) and Low Energy Availability in Females Questionnaire (LEAF-Q). An EDE-Q global score ≥2.3 and a LEAF-Q total score ≥8 (in combination with an injury score≥2 and/or menstruation dysfunction score≥4) were used to categorise subjects as having symptoms of EDs and LEA, respectively.

Results

Among the subjects fulfilling the age criteria (n=85), 18% (n=15) had symptoms of EDs and 19% (n=16) had symptoms of LEA. Of those with symptoms of EDs, 13% (n=2) had concomitant symptoms of LEA. The higher the EDE-Q dietary restraint score, the higher the gastrointestinal problem score (r=0.23, p=0.04), otherwise no other associations were found between EDE-Q global or subscale scores and LEAF-Q scores.

Conclusion

Our results indicate that symptoms of EDs and LEA are frequent among adult females at all athletic levels, including the recreational level. Hence, to prevent the negative health consequences of EDs and LEA, preventative initiatives are also needed in recreational running communities.

The impact of the menstrual cycle on orthopaedic sports injuries in female athletes

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.

Link Between the Female Athlete Triad and Gymnastics-Related Injury in Retired Collegiate Gymnasts

OBJECTIVES

To compare gymnastics-related injuries between former collegiate gymnasts who did and did not report components of the female athlete triad (Triad) during college, including disordered eating or menstrual irregularity. We hypothesized that athletes reporting these 2 triad symptoms would have higher rates of time loss injury and injuries requiring surgery.

DESIGN

Retrospective case-control.

SETTING

Online survey.

PATIENTS

Four hundred seventy former collegiate gymnasts.

INTERVENTIONS

Athletes completed online survey distributed through social media.

MAIN OUTCOME MEASURES

Participants were grouped based on self-reported menstrual irregularity and disordered eating during college. We compared time loss injuries, injuries resulting in surgery, and injury locations between the groups using χ2 analyses.

RESULTS

Seventy percent (n = 328) of participants in this study reported a time loss college injury without surgery, and 42% (n = 199) reported an injury during college that required surgical treatment. A significantly greater proportion of gymnasts with only disordered eating reported a time loss gymnastics injury (without surgery) compared with those who reported only menstrual irregularity during college (79% vs 64%; P =0 .03). A significantly greater proportion of the disordered eating-only group reported a spine injury compared with the menstrual irregularity-only group (P = 0.007) and the group who reported neither menstrual irregularity nor disordered eating (P = 0.006).

CONCLUSIONS

College gymnasts who experienced disordered eating were more likely to experience a nonsurgical time loss injury while in college, as well as spine injury compared with those with menstrual irregularity. Sports medicine providers should be aware of the association between injuries and individual components of Triad in gymnasts beyond bone stress injuries.

Association Between Reproductive Health Factors and Musculoskeletal Injuries in Female Canadian Armed Forces Members

Background: Musculoskeletal injuries (MSKi) play a role in member retention in the military. In general, female military members have higher rates of MSKi than males and female reproductive health characteristics may be contributing to these disparities. This study seeks to characterize reproductive health factors in female Canadian Armed Forces (CAF) members and their relationship with MSKi. Materials and Methods: An electronic survey (SurveyMonkey^®) was made available to present and former CAF members 18-65 years of age. Responses were collected between September 2020 and February 2021. Seven female reproductive characteristics were assessed: age of menarche, menstrual cycle regularity, birth control use, having given birth while serving, endometriosis, early menopause, and secondary oligomenorrhea/amenorrhea. Binary logistic regressions were used to analyze associations between reproductive characteristics with repetitive strain (RSI) and acute injuries. Results: A total of 2,001 participants consented to the survey with 855 respondents being female. Females reporting menstrual cycles as never regular, irregular for a few months, who never had a period, and whose periods stopped while serving presented a greater likelihood of reporting RSI compared to their peers who reported regular menstrual cycles (adjusted odds ratio [aOR]: 1.898, confidence interval [CI]: 1.138-3.166). Participants who have experienced endometriosis presented a higher likelihood of reporting acute injuries than those who did not (aOR: 2.426, CI: 1.030-5.709). Conclusion: This examination of females within the CAF suggests that irregular menstrual cycles or absent periods increase the likelihood of experiencing MSKi, namely those categorized as RSI injuries and reporting endometriosis were associated with greater rates of acute injuries.

(Low) Energy Availability and Its Association with Injury Occurrence in Competitive Dance: Cross-Sectional Analysis in Female Dancers

Background and objectives: The risk of low energy availability is related to various health problems in sports. This cross-sectional study aimed to identify a possible association between various dance factors, anthropometrics/body build, and energy availability with injury occurrence in contemporary dancers. Materials and Methods: The participants were 50 female competitive dancers (19.8 ± 4.1 years of age). The independent variables included age, dance factors (amount of training and competitions per week–exposure time, experience in dance), anthropometrics/body composition (body height, mass, BMI, body fat percentage (BF%), and fat-free mass (FFM)), and energy availability score (EAS; evaluated by accelerometer-based measurement of energy expenditure and Dance Energy Availability Questionnaires). The dependent variables were the occurrence of (i) soft-tissue injuries and (ii) bone injuries. The measurements were obtained by experienced technicians during the pre-competition period for each specific dance discipline. Univariate and multivariate logistic regressions were calculated to identify the associations between independent variables and injury prevalence. Results: The results showed that EAS (OR = 0.81, 95% CI:0.65–0.91), age (OR = 1.65, 95% CI: 1.1–2.46), higher BF% (OR = 1.23, 95% CI: 1.04–1.46) and BMI (OR = 1.61, 95% CI: 1.05–2.47) were correlated with soft-tissue injuries. Dancers who suffered from bone injuries reported higher exposure time (OR = 1.21, 95% CI: 1.05–1.37) and had lower values of FFM (OR = 0.73, 95% CI: 0.56–0.98). Multivariate regression analyses evidenced a higher likelihood of soft-tissue injuries in older dancers (OR = 1.75, 95% CI: 1.21–2.95) and the ones who had lower EAS (OR = 0.84, 95% CI: 0.71–0.95) while the exposure time was associated with a higher likelihood of bone injuries (OR = 1.21, 95% CI: 1.05–1.39). Conclusions: In order to decrease the injury prevalence among dancers, special attention should be paid to maintaining adequate nutrition that will provide optimal available energy for the demands of training and performing. Additionally, the control of training volume should be considered in order to reduce traumatic bone injuries.

Irisin: circulating levels in serum and its relation to gonadal axis

Irisin is an exercise-induced myokine/adipokine in mice and humans that plays an important role in 'browning' of white adipose tissue and has shown great potential as a treatment for some metabolic diseases, such as obesity, insulin resistance, and inflammation. The circulating irisin level is reported to be associated with exercise, obesity, diet, diseases, and exposure to different pharmacological agents. Several studies have attempted to characterize the role of irisin in PCOS and other reproductive diseases, but contradictory results have been reported. Our previous study showed that irisin may serve further functions in folliculogenesis and fertility. In this review, we present the current knowledge on the physiology of irisin and its role in gonadal axis. Firstly, we describe irisin circulating levels and speculate on the potential mechanisms involved in irisin secretion and regulation. Then, we focus on the irisin levels in PCOS, and explore the relationships between, BMI, insulin resistance, and hyperandrogenism. Finally, we present the results from animal interventional studies and in vitro experiments to investigate the relationship between irisin and gonadal axis, indicating its novel effects on reproduction and fertility.

Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature

Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.

Improving the Diagnosis of Menstrual Dysfunction through Quality Improvement

Introduction:

Prevalence of menstrual dysfunction (MD) in high school athletes ranges from 7% to 54%. Early recognition and intervention are crucial to prevent future consequences. The purpose of this Quality Improvement project was to optimize the institution’s Epic Best Practice Advisory (BPA) screening tool and synthesize new patient questionnaires to diagnose MD in athletes greater than 12 years of age presenting to a pediatric sports medicine clinic.

Methods:

Using Quality Improvement methodology, we evaluated clinic flow, the Epic BPA tool, and actions by the physician following the appropriate triggering of the BPA. Diagnoses targeted were primary amenorrhea, oligomenorrhea, or irregular menstruation unspecified. Areas for intervention were global staff education, patient education, and provider alert fatigue. Our team implemented interventions using monthly Plan-Do-Study-Act cycles to address our key drivers. Proper implementation of questionnaire data and restructuring of the Epic BPA promoted identification and diagnosis of MD. The clinician discussed the diagnosis with the patient and family and provided an educational handout on MD.

Results:

The rate of appropriate diagnosis of MD in athletes greater than 12 years of age seen at a pediatric sports medicine clinic increased from a baseline of 2.1% to 30% over ten months. Identification of three key drivers ultimately drove the success and achievement of our aim.

Conclusions:

Using Quality Improvement methodology, we optimized the EPIC BPA and subsequently increased the rate of appropriate diagnosis of MD. Identification of the proper diagnosis improves our patient education. Ultimately, this project provided the framework for applicable discussion, interventions, and work-up for at-risk athletes.

Menstrual Irregularity, Hormonal Contraceptive Use, and Bone Stress Injuries in Collegiate Female Athletes in the United States

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.

Menstrual dysfunction and body weight dissatisfaction among Finnish young athletes and non-athletes

To determine the prevalence of menstrual dysfunction (MD; ie, oligomenorrhea or amenorrhea) and attitudes toward body weight among athletes and non-athletes, we studied a cohort of athletes and non-athletes, in adolescence (14-16 years) and subsequently in young adulthood (18-20 years). We further studied the differences between athletes reporting MD and eumenorrheic athletes at both time periods and identified physical and behavioral characteristics that might predict MD in young adulthood. Data were collected using questionnaires, accelerometers, and a pre-participation screening. In adolescence, the athletes reported current primary amenorrhea more often than the non-athletes (4.7% vs 0%, P = .03). In young adulthood, athletes reported MD more frequently than non-athletes (38.7% vs 5.6%, P < .001). Athletes had less desire than non-athletes to lose weight at both time points, and in adolescence, athletes were more satisfied with their weight. However, about one fifth of the athletes and about 40% of the non-athletes experienced body weight dissatisfaction at both time points. In adolescence, athletes reporting MD had lower BMI than eumenorrheic athletes. In young adulthood, athletes with MD were more physically active than eumenorrheic athletes. The only longitudinal predictor of MD in young adulthood was MD in adolescence. Our findings indicate that MD is relatively frequent among young Finnish athletes. However, athletes appear to have a smaller tendency to experience body weight dissatisfaction than their non-athletic peers. MD seems to track from adolescence to adulthood, suggesting that there is a need to focus on possible causes at the earliest feasible phase of an athlete's career.

Validation of an Age-Appropriate Screening Tool for Female Athlete Triad and Relative Energy Deficiency in Sport in Young Athletes

Background

The purpose of this study was to determine the concurrent validity of a newly created relative energy deficiency in sport (RED-S) specific screening tool (RST) by comparing scores with the validated pre-participation gynecological examination (PPGE). We hypothesized that the investigators would observe no significant difference between the means of the RST and the PPGE survey.

Methods

This was a crossover study of 39 female subjects who completed both the RST and the PPGE. The survey order was randomized.

Results

The RST was validated compared with the PPGE (Pearson’s r = 0.697, p < 0.001).

Conclusion

The administration of an RST to middle- and high-school female athletes was validated compared with the PPGE. Formatting limitations of the screening tool were highlighted, leading to changes that improved the accuracy of the screening tool prior to application in a clinical setting. The RST is an age-appropriate screening tool that can be used by coaches, athletic trainers, physical therapists, and other healthcare practitioners to detect RED-S risk and allow for earlier intervention.  

The risk of injuries and physiological benefits of pole dancing

BACKGROUND

This study aimed to evaluate the positive and negative aspects of pole dance training.

METHODS

We included 30 women trained in pole dancing and 30 untrained young women. We measured maximal hand strength, lower back and hamstring muscle flexibility, and body composition. Participants also completed an anonymous questionnaire, which mainly asked about injuries.

RESULTS

The pole dancers possessed significantly greater muscle strength and lower back and hamstring muscle flexibility compared to untrained controls. Pole dancers had significantly less body fat and significantly more muscle mass in the upper limbs compared to untrained controls. During two years of pole dance training, 36.7% of the dancers had sustained acute injuries (mainly muscle, shoulder joint, and wrist injuries) and 80% of the dancers had sustained a chronic injury. Most injuries occurred during handsprings, twines, and carousel performances. Moreover, pole dancers experienced more menstrual irregularities than the controls.

CONCLUSIONS

Pole dancing had many positive physiological effects, but pole dancers should be aware that pole dancing and behavior associated with training significantly increased the risk of injury. The most important factors which can protect pole dancers by acute injuries are well performed warm-up and balanced diet. Results indicate that many attempts at weight loss are connected with high risk of acute injury.

The Female Athlete Triad: A Comparison of Knowledge and Risk in Adolescent and Young Adult Figure Skaters, Dancers, and Runners

STUDY OBJECTIVE

The female athlete triad is often found in sports that value leanness and aesthetics and can lead to adverse health effects. We aimed to compare knowledge and risk of the triad among adolescent figure skaters, dancers, and runners.

DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES

We advertised our survey on social media platforms: sports-specific forums; Facebook; and Instagram. We received 928 responses. We included female figure skaters, dancers, and runners aged 25 years or younger (N = 712). We asked participants to name the triad components and dichotomized knowledge scores as high or low. We developed a 6-question triad risk scale and defined "at risk" if participants endorsed 3 or more questions.

RESULTS

Of 712 participants: 60% were figure skaters; 28% dancers; 12% runners; 78% were adolescents (≤17 years of age); 22% young adults (18-25 years); 12% had heard of the triad. A higher proportion of runners than figure skaters and dancers had high knowledge of the triad (16% vs 6% vs 5%, P < .01). Overall 60% of athletes were "at risk" of the triad, 25% skipped a period for 3 or more months, and 34% had a history of stress fractures or shin splints. Young adults vs adolescents and dancers vs figure skaters and runners had nearly twice the odds of triad risk.

CONCLUSION

Most athletes were at risk of the triad but few knew about it. Dancers were at higher risk compared with figure skaters and runners. Efforts should be made to raise awareness of the triad among athletes, parents, and coaches, with special attention paid to the dance community.

Menstrual irregularity and use of oral contraceptives in female adolescent athletes in Swedish National Sports High Schools

Objective Female adolescent athletes seem to use oral contraceptives (OCs) in the same proportion as the general population. In athletes not using OCs, menstrual irregularity (MI) is reported to be common but there are few studies of MI in adolescent athletes. The aim of the study was to survey menarche, menstrual irregularity and use of OCs in adolescent athletes in the National Sports High Schools in Sweden. A further aim was to study the associations between current sport injury and menstrual irregularity as well as use of OCs. Subjects Two hundred and ninety-eight female adolescent athletes at Swedish National Sports High Schools. Methods A web-based questionnaire containing questions related to menstrual status, contraception and current injury. Results One third (32.6%) of the athletes used OCs and of the remaining athletes 31.8% had MI. The group of athletes with MI had a significantly (p = 0.038; Cohen's d, 0.32) lower BMI and consisted of a significantly (p = 0.043) higher proportion of endurance athletes. OC users were less likely to participate in endurance sports compared to non-OC users (p = 0.024). Current injury was equally distributed in the OC and the non-OC group but athletes with MI had fewer sports injuries compared to eumenorrheic women. Conclusion OCs are frequently used among athletes at Swedish National Sports High Schools. OC users were less likely to participate in endurance sports compared to non-OC users. MI was common and athletes with MI had lower BMI compared to eumenorrheic athletes. Sports injuries were not associated with use of OC and eumenorrheic athletes had a higher proportion of current injury.

Association of Concussion With Abnormal Menstrual Patterns in Adolescent and Young Women

IMPORTANCE

Brain injury may interrupt menstrual patterns by altering hypothalamic-pituitary-ovarian axis function. Investigators have yet to evaluate the association of concussion with menstrual patterns in young women.

OBJECTIVE

To compare abnormal menstrual patterns in adolescent and young women after a sport-related concussion with those after sport-related orthopedic injuries to areas other than the head (nonhead).

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study of adolescent and young women with a sport-related concussion (n = 68) or a nonhead sport-related orthopedic injury (n = 61) followed up participants for 120 days after injury. Patients aged 12 to 21 years who presented within 30 days after a sport-related injury to a concussion or sports medicine clinic at a single academic center were eligible. Menstrual patterns were assessed using a weekly text message link to an online survey inquiring about bleeding episodes each week. The first patient was enrolled on October 14, 2014, and follow-up was completed on January 24, 2016. Inclusion criteria required participants to be at least 2 years postmenarche, to report regular menses in the previous year, and to report no use of hormonal contraception.

EXPOSURES

Sport-related concussion or nonhead sport-related orthopedic injury.

MAIN OUTCOMES AND MEASURES

Abnormal menstrual patterns were defined by an intermenstrual interval of less than 21 days (short) or more than 35 days (long) or a bleeding duration of less than 3 days or more than 7 days.

RESULTS

A total of 1784 survey responses were completed of the 1888 text messages received by patients, yielding 487 menstrual patterns in 128 patients (mean [SD] age, 16.2 [2.0] years). Of the 68 patients who had a concussion, 16 (23.5%) experienced 2 or more abnormal menstrual patterns during the study period compared with 3 of 60 patients (5%) who had an orthopedic injury. Despite similar gynecologic age, body mass index, and type of sports participation between groups, the risk of 2 or more abnormal menstrual bleeding patterns after injury was significantly higher among patients with concussion than among those with an orthopedic injury (odds ratio, 5.85; 95% CI, 1.61-21.22).

CONCLUSIONS AND RELEVANCE

Adolescent and young women may have increased risk of multiple abnormal menstrual patterns after concussion. Because abnormal menstrual patterns can have important health implications, monitoring menstrual patterns after concussion may be warranted in this population. Additional research is needed to elucidate the relationship between long-term consequences of concussion and the function of the hypothalamic-pituitary-ovarian axis.

The Female Athlete Triad

The number of girls participating in sports has increased significantly since the introduction of Title XI in 1972. As a result, more girls have been able to experience the social, educational, and health-related benefits of sports participation. However, there are risks associated with sports participation, including the female athlete triad. The triad was originally recognized as the interrelationship of amenorrhea, osteoporosis, and disordered eating, but our understanding has evolved to recognize that each of the components of the triad exists on a spectrum from optimal health to disease. The triad occurs when energy intake does not adequately compensate for exercise-related energy expenditure, leading to adverse effects on reproductive, bone, and cardiovascular health. Athletes can present with a single component or any combination of the components. The triad can have a more significant effect on the health of adolescent athletes than on adults because adolescence is a critical time for bone mass accumulation. This report outlines the current state of knowledge on the epidemiology, diagnosis, and treatment of the triad conditions.

Epidemiology of Injuries in United States High School Track and Field: 2008-2009 Through 2013-2014

BACKGROUND

Track and field is one of the most popular high school sports among boys and girls, but epidemiological research on the sport and its individual events has been limited.

PURPOSE

To describe injury rates and patterns in boys' and girls' high school track and field.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

A retrospective epidemiological analysis of injury and exposure data from a longitudinal national high school sports injury surveillance system was conducted.

RESULTS

From 2008-2009 through 2013-2014, 2485 track and field injuries occurred during 2,962,308 athlete exposures (0.84 injuries per 1000 athlete exposures). Injury rates were higher in competition versus practice for both sexes. Girls had higher injury rates than boys overall (rate ratio, 1.37; 95% CI, 1.27-1.48) and in practice (rate ratio, 1.60; 95% CI, 1.46-1.76), but competition injury rates did not differ. Overuse/chronic injuries accounted for 27.5% and 36.2% of boys' and girls' track and field injuries, respectively. The majority of injuries were to the lower extremity. Sprints, distance running, and jumps accounted for over 65% of all track injuries. Boys sustained a greater proportion of injuries in relay events (injury proportion ratio, 2.02; 95% CI, 1.69-2.36) but fewer in hurdle events (injury proportion ratio, 0.51; 95% CI, 0.23-0.78).

CONCLUSION

Injury rates varied by event, sex, and competition versus practice exposure. To increase effectiveness, targeted strategies for injury prevention should be driven by an understanding of such differences. Because many track and field injuries are overuse/chronic across sexes and for both competitions and practices, coaches and athletic trainers should be adept at recognizing early injury symptoms, intervene to treat minor injuries in order to prevent severe injuries, and ensure the prompt diagnosis and management of all injuries.

Amenorrhea in the Female Athlete: What to Do and When to Worry

Functional hypothalamic amenorrhea is a diagnosis of exclusion that is common in female athletes, particularly those participating in aesthetic sports (ballet, other dance genres, figure skating, and gymnastics) and endurance sports (cross-country running). Although common, it should be considered abnormal even in the high-level elite athlete. Amenorrhea in combination with low energy availability and low bone density is labeled "the Female Athlete Triad." Studies have demonstrated numerous long-term consequences of athletes suffering from all or a portion of this triad, including increased rate of musculoskeletal injuries, stress fractures, abnormal lipid profiles, endothelial dysfunction, potential irreversible bone loss, depression, anxiety, low self- esteem, and increased mortality. This article provides the clinician with the tools to evaluate an athlete with secondary amenorrhea, reviews the recommended treatment options for affected athletes, and discusses when to return to the activity in an effort to facilitate "healthy" participation.

Skeletal complications of eating disorders

Anorexia nervosa (AN) is a psychiatric illness with profound medical consequences. Among the many adverse physical sequelae of AN, bone health is impacted by starvation and can be permanently impaired over the course of the illness. In this review of skeletal complications associated with eating disorders, we discuss the epidemiology, neuroendocrine changes, adolescent vs. adult skeletal considerations, orthopedic concerns, assessment of bone health, and treatment options for individuals with AN. The focus of the review is the skeletal sequelae associated with anorexia nervosa, but we also briefly consider other eating disorders that may afflict adolescents and young adults. The review presents updates to the field of bone health in AN, and also suggests knowledge gaps and areas for future investigation.

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.

Common overuse injuries in the young athlete

Pediatric overuse injury is a common complaint presenting to pediatricians. Overuse injury can affect the soft tissues or bone, and results from an imbalance between training and load to the tissues and recovery time. In the skeletally immature athlete, physeal and apophyseal tissue is particularly vulnerable to overuse resulting in different patterns of injury compared to adults. Awareness of age-dependent patterns of overuse is necessary for proper recognition, treatment, and prevention of injury. This article reviews the most common pediatric overuse injuries with emphasis on risk factors, diagnosis, and treatment. Guidelines for prevention are included, as this is the key component for successful management of overuse injury in pediatric athletes.

Athletic activity and hormone concentrations in high school female athletes

CONTEXT

Physical activity may affect the concentrations of circulating endogenous hormones in female athletes. Understanding the relationship between athletic and physical activity and circulating female hormone concentrations is critical.

OBJECTIVE

To test the hypotheses that (1) the estradiol-progesterone profile of high school adolescent girls participating in training, conditioning, and competition would differ from that of physically inactive, age-matched adolescent girls throughout a 3-month period; and (2) athletic training and conditioning would alter body composition (muscle, bone), leading to an increasingly greater lean-body-mass to fat-body-mass ratio with accompanying hormonal changes.

DESIGN

Cohort study.

SETTINGS

Laboratory and participants' homes.

PATIENTS OR OTHER PARTICIPANTS

A total of 106 adolescent girls, ages 14-18 years, who had experienced at least 3 menstrual cycles in their lifetime.

MAIN OUTCOME MEASURE(S)

Participants were prospectively monitored throughout a 13-week period, with weekly physical activity assessments and 15 urine samples for estrogen, luteinizing hormone, creatinine, and progesterone concentrations. Each girl underwent body-composition measurements before and after the study period.

RESULTS

Seventy-four of the 98 girls (76%) who completed the study classified themselves as athletes. Body mass index, body mass, and fat measures remained stable, and 17 teenagers had no complete menstrual cycle during the observation period. Mean concentrations of log(estrogen/creatinine) were slightly greater in nonathletes who had cycles of <24 or >35 days. Mean log(progesterone/creatinine) concentrations in nonathletes were less in the first half and greater in the second half of the cycle, but the differences were not statistically significant.

CONCLUSIONS

A moderate level of athletic or physical activity did not influence urine concentrations of estrogen, progesterone, or luteinizing hormones. However, none of the participants achieved high levels of physical activity. A significant number (17%) of girls in both activity groups were amenorrheic during the 3-month study period.

Knowledge of the female athlete triad, and prevalence of triad risk factors among female high school athletes and their coaches

STUDY OBJECTIVE

This study aimed to determine awareness/knowledge of the Triad and its health implications among female high school athletes and their coaches, and to evaluate coaches' Triad screening/intervention practices.

DESIGN

Cross-sectional survey.

SETTING

Two high schools in the western United States.

PARTICIPANTS

Female athletes from a variety of sports (N = 240) ages 14-18 years and their coaches (N = 10).

INTERVENTION

Participants completed surveys that assessed Triad knowledge and athlete Triad risk factors.

MAIN OUTCOME MEASURES

Frequency of responses to Triad knowledge, Triad risk factor, and Triad education/screening procedures questions; athlete summative knowledge score.

RESULTS

Half (N = 120) of participants reported menstrual irregularity, and 42% (N = 101) had 2 or more Triad risk factors: past amenorrhea (N = 39), past stress fracture (N = 41), self-reported not eating enough (N = 53), underweight (BMI-for-age < 5(th) percentile) (N = 10), pressure to be a certain weight (N = 143), and wanting to lose >10 pounds when self-reported weight was in a healthy range (N = 34). Average athlete Triad knowledge score was 2.97 ± 1.61 out of 8. Coach Triad knowledge was limited; however, most (9/10) were comfortable discussing menstruation with their athletes. Barriers to Triad screening/education were coaches' insufficient time, knowledge, and educational resources.

CONCLUSION

Triad risk factors were prevalent among athletes and coach and athlete Triad knowledge was low. Providing coaches with Triad screening/education training may increase Triad knowledge and decrease Triad risk among high school athletes.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad

BACKGROUND

Low energy availability (EA) in female athletes with or without an eating disorder (ED) increases the risk of oligomenorrhoea/functional hypothalamic amenorrhoea and impaired bone health, a syndrome called the female athlete triad (Triad). There are validated psychometric instruments developed to detect disordered eating behaviour (DE), but no validated screening tool to detect persistent low EA and Triad conditions, with or without DE/ED, is available.

AIM

The aim of this observational study was to develop and test a screening tool designed to identify female athletes at risk for the Triad.

METHODS

Female athletes (n=84) with 18-39 years of age and training ≥5 times/week filled out the Low Energy Availability in Females Questionnaire (LEAF-Q), which comprised questions regarding injuries and gastrointestinal and reproductive function. Reliability and internal consistency were evaluated in a subsample of female dancers and endurance athletes (n=37). Discriminant as well as concurrent validity was evaluated by testing self-reported data against measured current EA, menstrual function and bone health in endurance athletes from sports such as long distance running and triathlon (n=45).

RESULTS

The 25-item LEAF-Q produced an acceptable sensitivity (78%) and specificity (90%) in order to correctly classify current EA and/or reproductive function and/or bone health.

CONCLUSIONS

The LEAF-Q is brief and easy to administer, and relevant as a complement to existing validated DE screening instruments, when screening female athletes at risk for the Triad, in order to enable early detection and intervention.

Female athlete triad for the primary care pediatrician

PURPOSE OF REVIEW

Female participation in athletics has increased significantly over the past several decades. For most young women, participation in sport fosters self-confidence, positive relationships with peers, and good physical health. However, with growing female representation in athletics, the sport community has become increasingly aware of the syndrome known as 'female athlete triad,' which describes the interplay between low energy availability (LEA), menstrual disturbances, and decreased bone mineral density (BMD). This review aims to discuss the definition and prevalence of the triad and prevention, detection, and treatment strategies.

RECENT FINDINGS

Current research has elucidated the importance of identifying and treating the triad in young athletes, as adolescence is a critical time for bone development and failure to intervene can lead to long-term problems. First defined in 1992, full characterization of the triad in adolescents has been elusive because of difficulties in diagnosing low BMD in this population and reliance on self-report for menstrual disturbances and LEA. A 2007 reformulation of the triad incorporated research demonstrating that the full deleterious triad is rare and emphasized that its components exist on a spectrum. Removal of the stigma from the triad has the potential to allow earlier detection and treatment, thereby improving outcomes.

SUMMARY

The female athlete triad is a problem with important long-term consequences. Education should be geared toward athletes as well as coaches, athletic trainers, school nurses, primary care providers, and others involved in female athletics to allow early identification and intervention.

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.