Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: A prospective multisite study of exercising girls and women

Michelle T. Barrack, Jenna C. Gibbs, Mary Jane De Souza, Nancy Williams, Jeanne F. Nichols, Mitchell J. Rauh, Aurelia Nattiv

Research output: Contribution to journalArticle

102 Citations (Scopus)

Abstract

Background: Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women. Purpose: To evaluate the effect of single or combined risk factors as defined by the female athlete triad-a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass-with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women. Study Design: Cohort study; Level of evidence, 3. Methods: At baseline, participants' (N = 259; mean age, 18.1 ± 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body composition. Participants were followed prospectively for the occurrence of injuries; those injuries confirmed by a physician were recorded. Results: Twenty-eight participants (10.8%) incurred a BSI. Forty-six percent of those who had ≥12 h/wk of purposeful exercise, a bone mineral density (BMD) Z score<-1.0, and who exhibited 3 to 4 of the following: BMI<21.0 kg/m2, oligo- or amenorrhea, elevated dietary restraint, and/or participation in a leanness sport exercise/activity at baseline, incurred a BSI during the prospective study period. Single factors significantly (P<.05) associated with the development of a BSI included ≥12 h/wk of purposeful exercise (14.7%), BMI<21.0 kg/m2 (15.3%), and low bone mass (BMD Z score<-1.0; 21.0%). The strongest 2- and 3-variable combined risk factors were low BMD (Z score<-1.0) 1 ≥12 h/wk of exercise, with 29.7% incurring a BSI (odds ratio [OR], 5.1; 95% CI, 2.2-12.1), and ≥12 h/wk of exercise 1 leanness sport/activity 1 dietary restraint, with 46.2% incurring a BSI (OR, 8.7; 95% CI, 2.7-28.3). Conclusion: In the sample, which included female adolescents and young adults participating in competitive or recreational exercise activities, the risk of BSIs increased from approximately 15% to 20% for significant single risk factors to 30% to 50% for significant combined female athlete triad-related risk factor variables. These data support the notion that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.

Original languageEnglish (US)
Pages (from-to)949-958
Number of pages10
JournalAmerican Journal of Sports Medicine
Volume42
Issue number4
DOIs
StatePublished - Jan 1 2014

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Female Athlete Triad Syndrome
Prospective Studies
Bone and Bones
Exercise
Incidence
Wounds and Injuries
Bone Density
Sports
Thinness
Odds Ratio
Oligomenorrhea
Stress Fractures
Behavior Control
Bone Development
Femur Neck
Amenorrhea
Feeding Behavior
Body Composition
Hip
Young Adult

All Science Journal Classification (ASJC) codes

  • Orthopedics and Sports Medicine
  • Physical Therapy, Sports Therapy and Rehabilitation

Cite this

@article{73298ee207704c4c94dbfbb7e52fc0ac,
title = "Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: A prospective multisite study of exercising girls and women",
abstract = "Background: Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women. Purpose: To evaluate the effect of single or combined risk factors as defined by the female athlete triad-a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass-with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women. Study Design: Cohort study; Level of evidence, 3. Methods: At baseline, participants' (N = 259; mean age, 18.1 ± 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body composition. Participants were followed prospectively for the occurrence of injuries; those injuries confirmed by a physician were recorded. Results: Twenty-eight participants (10.8{\%}) incurred a BSI. Forty-six percent of those who had ≥12 h/wk of purposeful exercise, a bone mineral density (BMD) Z score<-1.0, and who exhibited 3 to 4 of the following: BMI<21.0 kg/m2, oligo- or amenorrhea, elevated dietary restraint, and/or participation in a leanness sport exercise/activity at baseline, incurred a BSI during the prospective study period. Single factors significantly (P<.05) associated with the development of a BSI included ≥12 h/wk of purposeful exercise (14.7{\%}), BMI<21.0 kg/m2 (15.3{\%}), and low bone mass (BMD Z score<-1.0; 21.0{\%}). The strongest 2- and 3-variable combined risk factors were low BMD (Z score<-1.0) 1 ≥12 h/wk of exercise, with 29.7{\%} incurring a BSI (odds ratio [OR], 5.1; 95{\%} CI, 2.2-12.1), and ≥12 h/wk of exercise 1 leanness sport/activity 1 dietary restraint, with 46.2{\%} incurring a BSI (OR, 8.7; 95{\%} CI, 2.7-28.3). Conclusion: In the sample, which included female adolescents and young adults participating in competitive or recreational exercise activities, the risk of BSIs increased from approximately 15{\%} to 20{\%} for significant single risk factors to 30{\%} to 50{\%} for significant combined female athlete triad-related risk factor variables. These data support the notion that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.",
author = "Barrack, {Michelle T.} and Gibbs, {Jenna C.} and {De Souza}, {Mary Jane} and Nancy Williams and Nichols, {Jeanne F.} and Rauh, {Mitchell J.} and Aurelia Nattiv",
year = "2014",
month = "1",
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doi = "10.1177/0363546513520295",
language = "English (US)",
volume = "42",
pages = "949--958",
journal = "American Journal of Sports Medicine",
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Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors : A prospective multisite study of exercising girls and women. / Barrack, Michelle T.; Gibbs, Jenna C.; De Souza, Mary Jane; Williams, Nancy; Nichols, Jeanne F.; Rauh, Mitchell J.; Nattiv, Aurelia.

In: American Journal of Sports Medicine, Vol. 42, No. 4, 01.01.2014, p. 949-958.

Research output: Contribution to journalArticle

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T1 - Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors

T2 - A prospective multisite study of exercising girls and women

AU - Barrack, Michelle T.

AU - Gibbs, Jenna C.

AU - De Souza, Mary Jane

AU - Williams, Nancy

AU - Nichols, Jeanne F.

AU - Rauh, Mitchell J.

AU - Nattiv, Aurelia

PY - 2014/1/1

Y1 - 2014/1/1

N2 - Background: Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women. Purpose: To evaluate the effect of single or combined risk factors as defined by the female athlete triad-a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass-with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women. Study Design: Cohort study; Level of evidence, 3. Methods: At baseline, participants' (N = 259; mean age, 18.1 ± 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body composition. Participants were followed prospectively for the occurrence of injuries; those injuries confirmed by a physician were recorded. Results: Twenty-eight participants (10.8%) incurred a BSI. Forty-six percent of those who had ≥12 h/wk of purposeful exercise, a bone mineral density (BMD) Z score<-1.0, and who exhibited 3 to 4 of the following: BMI<21.0 kg/m2, oligo- or amenorrhea, elevated dietary restraint, and/or participation in a leanness sport exercise/activity at baseline, incurred a BSI during the prospective study period. Single factors significantly (P<.05) associated with the development of a BSI included ≥12 h/wk of purposeful exercise (14.7%), BMI<21.0 kg/m2 (15.3%), and low bone mass (BMD Z score<-1.0; 21.0%). The strongest 2- and 3-variable combined risk factors were low BMD (Z score<-1.0) 1 ≥12 h/wk of exercise, with 29.7% incurring a BSI (odds ratio [OR], 5.1; 95% CI, 2.2-12.1), and ≥12 h/wk of exercise 1 leanness sport/activity 1 dietary restraint, with 46.2% incurring a BSI (OR, 8.7; 95% CI, 2.7-28.3). Conclusion: In the sample, which included female adolescents and young adults participating in competitive or recreational exercise activities, the risk of BSIs increased from approximately 15% to 20% for significant single risk factors to 30% to 50% for significant combined female athlete triad-related risk factor variables. These data support the notion that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.

AB - Background: Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women. Purpose: To evaluate the effect of single or combined risk factors as defined by the female athlete triad-a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass-with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women. Study Design: Cohort study; Level of evidence, 3. Methods: At baseline, participants' (N = 259; mean age, 18.1 ± 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body composition. Participants were followed prospectively for the occurrence of injuries; those injuries confirmed by a physician were recorded. Results: Twenty-eight participants (10.8%) incurred a BSI. Forty-six percent of those who had ≥12 h/wk of purposeful exercise, a bone mineral density (BMD) Z score<-1.0, and who exhibited 3 to 4 of the following: BMI<21.0 kg/m2, oligo- or amenorrhea, elevated dietary restraint, and/or participation in a leanness sport exercise/activity at baseline, incurred a BSI during the prospective study period. Single factors significantly (P<.05) associated with the development of a BSI included ≥12 h/wk of purposeful exercise (14.7%), BMI<21.0 kg/m2 (15.3%), and low bone mass (BMD Z score<-1.0; 21.0%). The strongest 2- and 3-variable combined risk factors were low BMD (Z score<-1.0) 1 ≥12 h/wk of exercise, with 29.7% incurring a BSI (odds ratio [OR], 5.1; 95% CI, 2.2-12.1), and ≥12 h/wk of exercise 1 leanness sport/activity 1 dietary restraint, with 46.2% incurring a BSI (OR, 8.7; 95% CI, 2.7-28.3). Conclusion: In the sample, which included female adolescents and young adults participating in competitive or recreational exercise activities, the risk of BSIs increased from approximately 15% to 20% for significant single risk factors to 30% to 50% for significant combined female athlete triad-related risk factor variables. These data support the notion that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.

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