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“Female Athlete Triad”: a Cause of Bone Stress Injury and Fractures

Female Athlete Triad

According to a new study in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), women with symptoms known as the “female athlete triad” are at greater risk of bone stress injury and fractures.

The female athlete triad is a spectrum of symptoms that include low energy availability,menstrual cycle abnormalities, and low bone mineral density.
Low energy availability can be a result of taking in inadequate calories or expending more energy than the body is designed to do. It can result from poor nutrition or eating habits or any type of eating disorder. Any combination of these conditions can lead to premature bone loss in females.

Both athletes and nonathletes participating in any sports and exercise can develop symptoms of the female athlete triad. But the likelihood of female athletes sustaining a bone stress injury significantly increases as the number of symptoms they have increases. The increase is substantial—

Female athletes diagnosed with poor nutrition or low energy availability are two to four times more likely to sustain a sports-related injury. Female athletes who self-reported menstrual cycle abnormalities had a nearly three times greater risk of a bone and joint injury.


Dieting is a common entry point to female athlete triad. Additional factors for athletes include early start of sport-specific training , injury, and a sudden increase in training volume. Surveys show more negative eating attitude scores in athletic disciplines favoring leanness. Disordered eating behaviors are risk factors for eating disorders. Frequent weigh-ins, punitive consequences for weight gain, pressure to “win at all costs,” an overly controlling parent or coach, and social isolation caused by intensive involvement in sports may increase an athlete’s risk. Societal perpetuation of the ideal body image may intensify the endeavor for a thin physique.
Gymnastics, figure skating, ballet, diving, swimming, and long distance running are examples of sports which emphasize low body weight. The Triad is seen more often in aesthetic sports such as versus ball game sports. Women taking part in these sports may be at an increased risk for developing female athlete triad.

The optimal time to screen athletes for the female athlete triad is during the preparticipation sports physical examination. The physician might also screen for the triad during acute visits for fractures, weight change, disordered eating, amenorrhea, bradycardia, arrhythmia and depression, and also during visits for routine Papanicolaou smears (pap test).
Treatment Guidelines & Care

Proper nutrition and energy balance are key to staying healthy in athletes of all ages. Maximizing bone health when you are young is paramount to your bone health later in life. It is important for young females to maximize their bone density until about the age of 25. After age 25 we can only hope to maintain what we have. Athletes who weigh less than 80 percent of their ideal body weight should not be allowed to prticipate and reduce the amount of time they spend exercising by 10-12 percent.
Persons with female athlete triad should get treatment from a multi-disciplinary team that includes a physician, dietitian, and mental health counselor, and seek support from family, friends, and their coach. Involvement of the family is crucial to the success of treatment. Family members should be included in treatment plans from the beginning, particularly with adolescent patients. Although at first the physician’s intervention may appear to be detrimental to the child’s athletic career, education about the significance of the female athlete triad may motivate parents to participate in a treatment program.

A weight gain of 0.23 to 0.45 kg (0.5 to 1 lb) per week until the goal weight is achieved is a reasonable expectation. The patient should focus on optimal health and performance instead of weight. The patient need not stop exercising completely. Exercise activity should be decreased by 10 to 20 percent, and weight should be monitored closely for two to three months.

As one of the symptom of the female athlete triad is menstrual dysfunction, some physicians may recommend oral contraceptives because those pills will regulate the menstrual cycle.However, the underlying cause of the menstrual disorder is an energy imbalance, and using pills to regulate the menstrual cycle without changes in diet and behavior are likely to mask the food deficiency and delay appropriate treatment. A woman taking contraceptives to treat menstrual dysfunction without correcting this energy imbalance will continue to lose bone density.

As participation in sports by women and girls continues to increase and become more competitive, it is important to prevent, diagnose, and manage the components of the female athlete triad. Although the female athlete triad poses a great health risk, the benefits of participation in sports significantly outweigh the risks.

In one study, 5.4% of athletes with eating disorders reported suicide attempts. Although 83% of anorexia nervosa patients partially recover, the rate of sustained recovery of weight, menstrual function and eating behavior is only 33%.

By preventing premature bone loss in young female athletes, we can potentially prevent future fragility fractures.


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