Females at Elevated Triad Risk Need More Care

A multicenter study has taken up the issue of the female athlete triad and risk assessment. According to femaleathletetriad.org, “The Female Athlete Triad is a syndrome of three interrelated conditions that exist on a continuum of severity, including, Energy Deficiency with or without Disordered Eating, Menstrual Disturbances/Amenorrhea, Bone Loss/Osteoporosis.”

The study, published in the February 2017 edition of The American Journal of Sports Medicine, was entitled, “Association of the Female Athlete Triad Risk Assessment Stratification to the Development of Bone Stress Injuries in Collegiate Athletes.”

The authors write, “A total of 323 athletes completed both electronic pre-participation physical examination and dual-energy x-ray absorptiometry scans. Of these, 239 athletes with known oligomenorrhea/amenorrhea status were assigned to a low-, moderate-, or high-risk category. Chart review was used to identify athletes who sustained a subsequent BSI [bone stress injury] during collegiate sports participation; the injury required a physician diagnosis and imaging confirmation.”

Michael Fredericson, M.D. is professor of Orthopaedic Surgery and program director for the Primary Care Sports Medicine Fellowship at the Stanford University School of Medicine. Dr. Fredericson, a co-author on the study, told OTW, “In 2014, the Female Athlete Triad Coalition published a consensus statement on treatment and return to play of the female athlete triad (De Souza et al. British J Sports Med). Athlete Triad Cumulative Risk Assessment includes the following 6 items scored on a scale from 0 to 2: low energy availability (EA) with or without disordered eating/eating disorder, body mass index (BMI), delayed menarche, oligomenorrhea (6-9 periods in 12 months) or amenorrhea (6 periods over 12 months), low BMD [bone mineral density], and prior stress reaction/fracture. The resulting risk assessment score is used to classify an athlete into 1 of 3 categories: low risk (0-1 points), moderate risk (2-5 points), or high risk (6 points). Ours was the first published study to determine the prevalence of athletes within each risk category based on sport and evaluate the association of risk category to subsequent development of bone stress injuries (BSIs).”

“We found that 29% of female collegiate athletes in this study were classified into moderate- or high-risk categories using the Female Athlete Triad Cumulative Risk Assessment Score. Moderate- and high-risk athletes were more likely to subsequently sustain a BSI. We did not anticipate that there would be such a broad spectrum of athletes from different sports found to be at moderate to high risk.”

“The cumulative risk assessment score is a valuable and easy to use scoring system that can be incorporated into the routine pre-participation exam that allows a better gauge of triad risk factors and prediction of risk for future bone stress injuries. Our findings support guideline recommendations that athletes with elevated triad risk categories should receive active medical treatment, including a nutrition evaluation to determine adequate energy availability and a workup for menstrual dysfunction. The goal of screening for and actively managing triad risk factors may help reduce the risk for adverse health consequences, including subsequently developing a BSI.”