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ObjectiveBone stress injuries (BSIs) are classified in clinical practice as being at low- or high-risk for complication based on the injury location. However, this dichotomous approach has not been sufficiently validated. The purpose of this systematic review was to examine the prognostic role of injury location on return-to-sport (RTS) and treatment complications after BSI of the lower extremity and pelvis.DesignSystematic review and meta-analysis.Data sourcesPubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021.Eligibility criteria for selecting studiesPeer-reviewed studies that reported site-specific RTS of BSIs in athletes.ResultsSeventy-six studies reporting on 2974 BSIs were included. Sixteen studies compared multiple injury sites, and most of these studies (n=11) described the anatomical site of injury as being prognostic for RTS or the rate of treatment complication. Pooled data revealed the longest time to RTS for BSIs of the tarsal navicular (127 days; 95% CI 102 to 151 days) and femoral neck (107 days; 95% CI 79 to 135 days) and shortest duration of time for BSIs of the posteromedial tibial shaft (44 days, 95% CI 27 to 61 days) and fibula (56 days; 95% CI 13 to 100 days). Overall, more than 90% of athletes successfully returned to sport. Treatment complication rate was highest in BSIs of the femoral neck, tarsal navicular, anterior tibial shaft and fifth metatarsal; and lowest in the fibula, pubic bone and posteromedial tibial shaft.ConclusionThis systematic review supports that the anatomical site of BSIs influences RTS timelines and the risk of complication. BSIs of the femoral neck, anterior tibial shaft and tarsal navicular are associated with increased rates of complications and more challenging RTS.PROSPERO registration numberCRD42021232351.

The aim of this audit was to assess the representation of female athletes, dietary control methods, and gold standard female methodology that underpins the current guidelines for chronic carbohydrate (CHO) intake strategies for athlete daily training diets. Using a standardized audit, 281 studies were identified that examined high versus moderate CHO, periodized CHO availability, and/or low CHO, high fat diets. There were 3,735 total participants across these studies with only ∼16% of participants being women. Few studies utilized a design that specifically considered females, with only 16 studies (∼6%) including a female-only cohort and six studies (∼2%) with a sex-based comparison in their statistical procedure, in comparison to the 217 studies (∼77%) including a male-only cohort. Most studies (∼72%) did not provide sufficient information to define the menstrual status of participants, and of the 18 studies that did, optimal methodology for control of ovarian hormones was only noted in one study. While ∼40% of male-only studies provided all food and beverages to participants, only ∼20% of studies with a female-specific design used this approach for dietary control. Most studies did not implement strategies to ensure compliance to dietary interventions and/or control energy intake during dietary interventions. The literature that has contributed to the current guidelines for daily CHO intake is lacking in research that is specific to, or adequately addresses, the female athlete. Redressing this imbalance is of high priority to ensure that the female athlete receives evidence-based recommendations that consider her specific needs.

While an acute exercise session typically increases bone turnover markers (BTM), the impact of subsequent sessions and the interaction with pre-exercise calcium intake remains unclear despite the application to the 'real life' training of many competitive athletes.Using a randomized crossover design, elite male rowers (n = 16) completed two trials, a week apart, consisting of two 90-minute rowing ergometer sessions (Ex1, Ex2) separated by 150 minutes. Prior to each trial, participants consumed a high (CAL: ~1000 mg) or isocaloric low (CON:10 mg) calcium meal. Biochemical markers including parathyroid hormone: PTH; serum ionised calcium (iCa) and bone turnover markers (C-terminal telopeptide of type I collagen: β-CTX-I; osteocalcin: OC) were monitored from baseline to 3 hours post Ex2.While each session caused perturbances of serum iCa, CAL maintained calcium concentrations above those of CON for most time points, 4.5 and 2.4% higher post EX1 and EX2 respectively. The decrease in iCa in CON was associated with an elevation of blood PTH (p0.05) and β-CTX-I (p0.0001) over this period of repeated training sessions and their recovery, particularly during and after Ex2. Pre-exercise intake of calcium-rich foods lowered BTM over the course of a day with several training sessions.Pre-exercise intake of a calcium-rich meal prior to training sessions undertaken within the same day had a cumulative and prolonged effect on the stabilisation of blood iCa during exercise. In turn, this reduced the post-exercise PTH response, potentially attenuating the increase in markers of bone resorption. Such practical strategies may be integrated into the athlete's overall sports nutrition plan, with the potential to safeguard long term bone health and reduce the risk of bone stress injuries.

Context Female athletes, particularly runners, with insufficient caloric intake for their energy expenditure [low energy availability (EA) or relative energy deficiency] are at risk for impaired skeletal integrity. Data are lacking in male runners. Objective To determine whether male runners at risk for energy deficit have impaired bone mineral density (BMD), microarchitecture, and estimated strength. Design Cross-sectional. Setting Clinical research center. Participants 39 men (20 runners, 19 controls), ages 16–30 years. Main Outcome Measures Areal BMD (dual-energy x-ray absorptiometry); tibia and radius volumetric BMD and microarchitecture (high-resolution peripheral quantitative computed tomography); failure load (microfinite element analysis); serum testosterone, estradiol, leptin; energy availability. Results Mean age (24.5 ± 3.8 y), lean mass, testosterone, and estradiol levels were similar; body mass index, percent fat mass, leptin, and lumbar spine BMD Z-score (−1.4 ± 0.8 vs −0.8 ± 0.8) lower (P < .05); and calcium intake and running mileage higher (P ≤ .01) in runners vs controls. Runners with EA Conclusions Despite weight-bearing activity, skeletal integrity is impaired in male runners with lower caloric intake relative to exercise energy expenditure, which may increase bone stress injury risk. Lower estradiol and lean mass are associated with lower tibial strength in runners.

Exercise is an osteogenic stimulus that should increase bone mineral density (BMD) and protect against injury. However, some female athletes have lower BMD and increased bone stress injury (BSI) risk. Impaired bone health seen in athletes may be explained by low energy availability as described by concepts of Relative Energy Deficiency in Sport (RED-S) and Female Athlete Triad (Triad).To elucidate the relationship between RED-S/Triad risk factors and BSI to high-risk (femoral neck, sacrum) and low-risk (other) bones.Cross-sectional survey and retrospective chart review.Tertiary care academic center.Female athletes aged 15-30 years participating in ≥4 h/week of exercise presenting to sports medicine/orthopedics clinic who had a self-reported BSI and available dual-energy x-ray absorptiometry (DXA) measurement of BMD.Not applicable.Location of BSI.In 127 athletes, high-risk BSI was associated with surrogates of low energy availability (p = .032) and having a DXA Z-score -1 (p = .035) but not a current/past history of menstrual dysfunction (p = .348). Accumulating RED-S/Triad risk factors increase the odds of incurring a high-risk BSI (p = .048).Adolescent/young female athletes who sustain BSI at high-risk sites (femoral neck, sacrum) may have underlying risk factors (eg, low energy availability, poor overall bone health) that should prompt further workup and referral to optimize health in these athletes.

BACKGROUND Bone stress injury (BSI) in youth runners is clinically important during times of skeletal growth and is not well studied. OBJECTIVE To evaluate the prevalence, anatomical distribution, and factors associated with running-related BSI in boy and girl middle school runners. DESIGN Retrospective cross-sectional study. SETTING Online survey distributed to middle school runners. METHODS Survey evaluated BSI history, age, grade, height, weight, eating behaviors, menstrual function, exercise training, and other health characteristics. MAIN OUTCOME MEASUREMENTS Prevalence and characteristics associated with history of BSI, stratified by cortical-rich (eg, tibia) and trabecular-rich (pelvis and femoral neck) locations. PARTICIPANTS 2107 runners (n = 1250 boys, n = 857 girls), age 13.2 ± 0.9 years. RESULTS One hundred five (4.7%) runners reported a history of 132 BSIs, with higher prevalence in girls than boys (6.7% vs 3.8%, p = .004). The most common location was the tibia (n = 51). Most trabecular-rich BSIs (n = 16, 94% total) were sustained by girls (pelvis: n = 6; femoral neck: n = 6; sacrum: n = 4). In girls, consuming

Optimal nutrition is an important aspect of an athlete’s preparation to achieve optimal health and performance. While general concepts about micro- and macronutrients and timing of food and fluids are addressed in sports science, rarely are the specific effects of women’s physiology on energy and fluid needs highly considered in research or clinical practice. Women differ from men not only in size, but in body composition and hormonal milieu, and also differ from one another. Their monthly hormonal cycles, with fluctuations in estrogen and progesterone, have varying effects on metabolism and fluid retention. Such cycles can change from month to month, can be suppressed with exogenous hormones, and may even be manipulated to capitalize on ideal timing for performance. But before such physiology can be manipulated, its relationship with nutrition and performance must be understood. This review will address general concepts regarding substrate metabolism in women versus men, common menstrual patterns of female athletes, nutrient and hydration needs during different phases of the menstrual cycle, and health and performance issues related to menstrual cycle disruption. We will discuss up-to-date recommendations for fueling female athletes, describe areas that require further exploration, and address methodological considerations to inform future work in this important area.

The aim of this audit was to assess the representation of female athletes within the literature that has led to current guidelines for carbohydrate (CHO) intake in the acute periods surrounding exercise and the quality of this research.A standardized audit was conducted of research assessing CHO loading protocols, CHO mouth rinse, and CHO intake before, during and after exercise.A total of 937 studies was identified in this audit. There was a total of 11,202 participants across these studies with only ~11% being women. Most studies involved male only cohorts (~79%), with a mere 38 studies (~4%) involving female only cohorts and 14 studies (~2%) including a methodological design for comparison of sex-based responses. The frequent use of incorrect terminology surrounding menstrual status and the failure of most studies (~69%) to provide sufficient information on the menstrual status of participants suggests incomplete understanding and concern for female-specific considerations among researchers. Of the 197 studies that included women, only 13 (~7%) provided evidence of acceptable methodological control of ovarian hormones and no study met all best practice recommendations. Of these 13 studies, only half also provided sufficient information regarding the athletic caliber of participants. The topics that received such scrutiny were CHO loading protocols and CHO intake during exercise.The literature that underpins the current guidelines for CHO intake in the acute periods around exercise is lacking in high-quality research that can contribute knowledge specific to the female athlete and sex-based differences. New research that considers ovarian hormones and sex-based differences is needed to ensure that the recommendations for acute CHO fuelling provided to female athletes is evidence-based.

Understanding the prevalence and factors associated with running-related injuries in middle school runners may guide injury prevention.To determine the prevalence of running-related injuries and describe factors related to a history of injury.Retrospective cross-sectional study.Survey distributed online to middle school runners.Participants completed a web-based survey regarding prior running-related injuries, training, sleep, diet, and sport participation.Prevalence and characteristics differentiating girls and boys with and without running-related injury history adjusted for age.Youth runners (total: 2113, average age, 13.2 years; boys: n = 1255, girls: n = 858).Running-related injuries were more prevalent in girls (56% vs. 50%, p = .01). Ankle sprain was the most common injury (girls: 22.5%, boys: 21.6%), followed by patellofemoral pain (20.4% vs. 7.8%) and shin splints (13.6% vs. 5.9%); both were more prevalent in girls (p .001). Boys more frequently reported plantar fasciitis (5.6% vs. 3.3%, p = .01), iliotibial band syndrome (4.1% vs. 1.4%, p = .001) and Osgood-Schlatter disease (3.8% vs. 1.2%, p = .001). Runners with history of running-related injuries were older, ran greater average weekly mileage, ran faster, had fewer average hours of sleep on weekends, skipped more meals, missed breakfast, and consumed less milk (all p .05). Girls with history of running-related injuries reported higher dietary restraint scores, later age of menarche, more menstrual cycle disturbances, and higher likelihood of following vegetarian diets and an eating disorder diagnosis (all p .05). Runners with no history of running-related injuries were more likely to have participated in ≥2 years of soccer or basketball (p .001).Most middle school runners reported a history of running-related injuries and certain injuries differing by gender. Modifiable factors with the greatest association with running-related injuries included training volume, dietary restraint, skipping meals, and less sleep. Sport sampling, including participation in ball sports, may reduce running-related injury risk in this population.

Bone stress injuries are common in athletes, resulting in time lost from training and competition. Diets that are low in energy availability have been associated with increased circulating bone resorption and reduced bone formation markers, particularly in response to prolonged exercise. However, studies have not separated the effects of low energy availability per se from the associated reduction in carbohydrate availability. The current study aimed to compare the effects of these two restricted states directly. In a parallel group design, 28 elite racewalkers completed two 6-day phases. In the Baseline phase, all athletes adhered to a high carbohydrate/high energy availability diet (CON). During the Adaptation phase, athletes were allocated to one of three dietary groups: CON, low carbohydrate/high fat with high energy availability (LCHF), or low energy availability (LEA). At the end of each phase, a 25-km racewalk was completed, with venous blood taken fasted, pre-exercise, and 0, 1, 3 hours postexercise to measure carboxyterminal telopeptide (CTX), procollagen-1 N-terminal peptide (P1NP), and osteocalcin (carboxylated, gla-OC; undercarboxylated, glu-OC). Following Adaptation, LCHF showed decreased fasted P1NP (~26%; p < 0.0001, d = 3.6), gla-OC (~22%; p = 0.01, d = 1.8), and glu-OC (~41%; p = 0.004, d = 2.1), which were all significantly different from CON (p < 0.01), whereas LEA demonstrated significant, but smaller, reductions in fasted P1NP (~14%; p = 0.02, d = 1.7) and glu-OC (~24%; p = 0.049, d = 1.4). Both LCHF (p = 0.008, d = 1.9) and LEA (p = 0.01, d = 1.7) had significantly higher CTX pre-exercise to 3 hours post-exercise but only LCHF showed lower P1NP concentrations (p < 0.0001, d = 3.2). All markers remained unchanged from Baseline in CON. Short-term carbohydrate restriction appears to result in reduced bone formation markers at rest and during exercise with further exercise-related increases in a marker of bone resorption. Bone formation markers during exercise seem to be maintained with LEA although resorption increased. In contrast, nutritional support with adequate energy and carbohydrate appears to reduce unfavorable bone turnover responses to exercise in elite endurance athletes. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Bone stress injuries (BSIs) occur in up to 20% of runners and military recruits and those with a history of BSI have a 5-fold higher risk for a subsequent BSI. Yet, little is known about prior training, menstrual status and bone structure in runners who experience multiple BSIs. PURPOSE: To determine differences in health and physical activity history, bone density, microarchitecture, and strength among female athletes with a history of multiple BSI, athletes with ≤1 BSI, and non-athletes. METHODS: We enrolled 101 women (ages 18–32 years) for this cross-sectional study: non-athlete controls (n=17) and athletes with a history of ≥ 3 BSIs (n=21) or ≤1 BSI (n=63). We collected subjects’ health and training history and measured bone microarchitecture of the distal tibia via high-resolution peripheral quantitative computed tomography (HR-pQCT) and areal bone mineral density (aBMD) of the hip and spine by dual-energy X-ray absorptiometry (DXA). RESULTS: Groups did not differ according to age, BMI, age at menarche, aBMD, or tibial bone microarchitecture. Women with multiple BSIs had a higher prevalence of primary and secondary amenorrhea (p

Background To determine if following specific diets was associated with reporting behaviors that are consistent with disordered eating compared to non-diet-adherent athletes. We hypothesized that athletes adhering to specific diets were more likely to report disordered eating than those not following a diet. Methods One thousand female athletes (15–30 years) completed a comprehensive survey about athletic health and wellness. Athletes were asked to specify their diet and completed 3 eating disorder screening tools: the Brief Eating Disorder in Athletes Questionnaire, the Eating Disorder Screen for Primary Care, and self-reported current or past history of eating disorder or disordered eating. Descriptive statistics were calculated for all study measures and chi-squared tests assessed relationships between athletes’ dietary practices and their responses to eating disorder screening tools. Statistical significance was defined as p, Plain English summary Female athletes may follow special diets for various reasons including sociocultural practices, environmental concerns, or health and weight-management benefits. These practices may put them at risk for developing eating disorders, which peak during adolescence, and are more common among athletes. Eating disorders or disordered eating in athletes may lead to inadequate fueling or low energy availability and its subsequent health and performance-related complications, also known as Relative Energy Deficiency in Sport (RED-S). It may be difficult to detect eating disorders among athletes due to the secretive nature behind these behaviors. In addition, objective information such as low weight or body mass index (BMI) may not be reliable due to their increased muscle mass. The results of this study revealed that female athletes who reported practicing special diets, especially those who follow a low-carbohydrate diet may be associated with developing eating disorders compared to female athletes who did not report any dietary restrictions. These findings should prompt healthcare providers to evaluate these individuals further in order to enhance their nutritional knowledge and help treat and prevent consequences linked to eating disorders or disordered eating.

PurposeTo synthesise evidence on low back pain (LBP) in adult rowers and to create a consensus statement to inform clinical practice.MethodsThere were four synthesis steps that informed the consensus statement. In step one, seven expert clinicians and researchers established the scope of the consensus statement and conducted a survey of experienced and expert clinicians to explore current practice. In step two, working groups examined current evidence relating to key scope questions and summarised key issues. In step three, we synthesised evidence for each group and used a modified Delphi process to aid in the creation of the overall consensus statements. Finally, in step four, we combined information from step three with the findings of the clinician survey (and with athlete and coach input) to produce recommendations for clinical practice.ResultsThe scope of the consensus statement included epidemiology; biomechanics; management; the athlete’s voice and clinical expertise. Prevention and management of LBP in rowers should include education on risk factors, rowing biomechanics and training load. If treatment is needed, non-invasive management, including early unloading from aggravating activities, effective pain control and exercise therapy should be considered. Fitness should be maintained with load management and progression to full training and competition. The role of surgery is unclear. Management should be athlete focused and a culture of openness within the team encouraged.ConclusionRecommendations are based on current evidence and consensus and aligned with international LBP guidelines in non-athletic populations, but with advice aimed specifically at rowers. We recommend that research in relation to all aspects of prevention and management of LBP in rowers be intensified.

The National Collegiate Athletic Association (NCAA) Summit on Gender Identity and Student–Athlete Participation was convened to identify institutional/athletic department strategies that may support the well-being of trans and gender nonconforming (TGNC) collegiate student–athletes in the USA. The Summit’s purview did not include policy-level changes to eligibility rules. A modified Delphi consensus process was used to identify strategies for supporting collegiate TGNC student–athlete well-being. Key steps included an exploration phase (learning, generating ideas), and an evaluation phase (rating ideas in terms of their utility and feasibility). Summit participants (n=60) included individuals meeting at least one of the following criteria: current or former TGNC athlete, academic or healthcare professional with topical expertise, collegiate athletics stakeholder who would be involved in implementing potential strategies, representative from leading sports medicine organisation, or representative from relevant NCAA membership committee. Summit participants identified strategies in the following domains: healthcare practices (patient-centred care and culturally sensitive care); education for all stakeholders involved in athletics; and administration (inclusive language, quality improvement processes). Summit participants also proposed ways that the NCAA, through its existing committee and governance structures, could help support the well-being of TGNC athletes. NCAA-focused concepts were in the following domains: policy making processes; eligibility and transfer processes; resource development and dissemination; and visibility and support for TGNC athletes. The strategies developed represent important and relevant approaches that member institutions, athletic departments, NCAA committees, governance bodies and other stakeholders might consider in their efforts to support TGNC student–athlete well-being.

A 16.5-year-old, distance runner, female gender-assigned at birth, who identifies as male, presented with menstrual dysfunction and impaired athletic performance. The cause of the menstrual dysfunction and decreased athletic performance was identified as inadequate energy availability, largely motivated by a desired avoidance of menstruation and further development of secondary sex characteristics. The patient achieved significant weight gain (4.75 kg) in the year after presentation and resumed normal menses. When evaluating and treating transgender athletes for menstrual dysfunction and inadequate energy availability, psychological motivators related to the complex interplay between gender identity, disordered eating, and athletic performance must be addressed.

Female athletes are participating in collision sports in greater numbers than previously. The overall incidence of concussion is known to be higher in female athletes than in male athletes participating in similar sports. Evidence suggests anatomic, biomechanical, and biochemical etiologies behind this sex disparity. Future research on female athletes is needed for further guidance on prevention and management of concussion in girls and women.

As medical professionals, we outline the science underlying disorders or differences of sexual development (DSD), discuss the nuances of sex and gender and how terminology can differ based on medical vs. non-medical context, briefly review the evidence of the ergogenic effects of hyperandrogenism, and discuss the medical complications with the hormonal contraceptive use currently dictated by World Athletics to allow DSD athletes to compete in the female category.

Background: Bone stress injuries (BSIs) occur in up to 20% of runners and military personnel. Typically, after a period of unloading and gradual return to weightbearing activities, athletes return to unrestricted sports participation or military duty approximately 4 to 14 weeks after a BSI diagnosis, depending on the injury location and severity. However, the time course of the recovery of the bone’s mechanical competence is not well-characterized, and reinjury rates are high. Purpose: To assess the bone microarchitecture and volumetric bone mineral density (vBMD) over 12 months after a tibial BSI diagnosis. Study Design: Case-control study; Level of evidence, 3. Methods: We enrolled 30 female athletes from the local community (aged 18-35 years) with a tibial BSI (grade ≥2 of 4 on magnetic resonance imaging) for this prospective observational study. Participants completed a baseline visit within 3 weeks of the diagnosis. At baseline and 6, 12, 24, and 52 weeks after the BSI diagnosis, we collected high-resolution peripheral quantitative computed tomography scans of the ultradistal tibia (4% of tibial length) of the injured and uninjured legs as well as pain and physical activity assessment findings. Results: From baseline to 12 weeks after the diagnosis, total, trabecular, and cortical vBMD declined by 0.58% to 0.94% ( P < .05 for all) in the injured leg. Total and trabecular vBMD also declined by 0.61% and 0.67%, respectively, in the uninjured leg ( P < .05 for both). At 24 weeks, mean values for all bone parameters were nearly equivalent to baseline values, and by 52 weeks, several mean values had surpassed baseline values. Of the 30 participants, 10 incurred a subsequent BSI during the course of the study, and 1 of these 10 incurred 2 subsequent BSIs. Participants who suffered an additional BSI were younger and had a later age of menarche, a greater incidence of previous fractures, and lower serum parathyroid hormone levels ( P < .05 for all). Conclusion: Bone density declined in both the injured and the uninjured legs and, on average, did not return to baseline for 3 to 6 months after a tibial BSI diagnosis. The observed time to the recovery of baseline vBMD, coupled with the high rate of recurrent BSIs, suggests that improved return-to-sports and military duty guidelines may be in order.

Despite the worldwide popularity of running as a sport for children, relatively little is known about its impact on injury and illness. Available studies have focused on adolescent athletes, but these findings may not be applicable to preadolescent and pubescent athletes. To date, there are no evidence or consensus-based guidelines identifying risk factors for injury and illness in youth runners, and current recommendations regarding suitable running distances for youth runners at different ages are opinion based. The International Committee Consensus Work Group convened to evaluate the current science, identify knowledge gaps, categorise risk factors for injury/illness and provide recommendations regarding training, nutrition and participation for youth runners.

As medical professionals, we outline the science underlying disorders or differences of sexual development (DSD), discuss the nuances of sex and gender and how terminology can differ based on medical vs. non-medical context, briefly review the evidence of the ergogenic effects of hyperandrogenism, and discuss the medical complications with the hormonal contraceptive use currently dictated by World Athletics to allow DSD athletes to compete in the female category.

For many female athletes, serious pursuit of athletics occurs nearly at the same age as menarche and activation of the hypothalamic–pituitary–gonadal (HPG) axis. For much of their athletic careers, these athletes are exposed to normal physiologic changes that accompany their menstrual cycles — which can affect their comfort during training and competition — and the regular underlying hormonal shifts throughout the menstrual cycle. Different hormone levels between women and men have been hypothesized to play a role in injury risk, particularly anterior cruciate ligament (ACL) tears. This review serves as a primer on the HPG axis for athletes, coaches, caretakers, and physicians to understand basic physiology of the HPG axis, injuries affected by the HPG axis, purposeful manipulation of the HPG axis, and identification of improper function of the HPG axis.

Low energy availability (EA), caused by insufficient caloric intake for daily energy expenditure, is detrimental to an athlete's performance and long-term health. Male and female athletes are at considerable risk for low EA and relative energy deficiency in sport because of intense training regimens, potential lack of nutrition education, and pressures associated with “ideal” body type for performance. This review summarizes the endocrine and metabolic changes observed in athletes with low EA with an emphasis on the most recent research findings. While awareness of relative energy deficiency in sport has significantly increased, further investigation is needed in the advancement of a sensitive diagnostic tool across populations.

Bone stress injuries (BSIs) are common among athletes and have high rates of recurrence. However, risk factors for multiple or recurrent BSIs remain understudied. Thus, we aimed to explore whether energy availability, menstrual function, measures of bone health, and a modified Female Athlete Triad Cumulative Risk Assessment (CRA) tool are associated with a history of multiple BSIs. We enrolled 51 female runners (ages 18–36 years) with history of ≤1 BSI (controls; n = 31) or ≥3 BSIs (multiBSI; n = 20) in this cross-sectional study. We measured lumbar spine, total hip, and femoral neck areal bone mineral density by dual-energy X-ray absorptiometry, bone material strength index using impact microindentation, and volumetric bone mineral density, microarchitecture, and estimated strength by high-resolution peripheral quantitative computed tomography. Participants completed questionnaires regarding medical history, low-energy fracture history, and disordered eating attitudes. Compared with controls, multiBSI had greater incidence of prior low-energy fractures (55% vs. 16%, p = .005) and higher modified Triad CRA scores (2.90 ± 2.05 vs. 1.84 ± 1.59, p = .04). Those with multiBSI had higher Eating Disorder Examination Questionnaire (0.92 ± 1.03 vs. 0.46 ± 0.49, p = .04) scores and a greater percentage difference between lowest and highest body mass at their current height (15.5% ± 6.5% vs. 11.5% ± 4.9% p = .02). These preliminary findings indicate that women with a history of multiple BSIs suffered more prior low-energy fractures and have greater historical and current estimates of energy deficit compared with controls. Our results provide strong rationale for future studies to examine whether subclinical indicators of energy deficit contribute to risk for multiple BSIs in female runners.

A 16.5-year-old, distance runner, female gender-assigned at birth, who identifies as male, presented with menstrual dysfunction and impaired athletic performance. The cause of the menstrual dysfunction and decreased athletic performance was identified as inadequate energy availability, largely motivated by a desired avoidance of menstruation and further development of secondary sex characteristics. The patient achieved significant weight gain (4.75 kg) in the year after presentation and resumed normal menses. When evaluating and treating transgender athletes for menstrual dysfunction and inadequate energy availability, psychological motivators related to the complex interplay between gender identity, disordered eating, and athletic performance must be addressed.

Bone stress injury (BSI) of the tibia, a spectrum of impairments that include conditions commonly referred to as medial tibial stress syndrome (MTSS), tibial stress reaction, and tibial stress fracture, is relatively common in athletes of various ages and levels of competition. While simple rest from the offending activities remains the primary method of treatment, identification of nutritional, hormonal, and biomechanical risk factors is crucial to prevent persistent or recurrent injury. Perhaps the most basic and important mechanical risk factor, especially in those with chronic or recurrent injury, may be abnormalities in gait and ankle flexibility, which can range from subtle to severe. While magnetic resonance imaging-based (MRI) injury grading can provide a framework for expected healing time, treatment must be individualized and evolution of a patient’s symptoms should guide the progression to return to sport after a prescribed period of rest. The vast majority of tibial BSIs can be managed nonoperatively and surgery is largely reserved for those who have undergone exhaustive conservative management without success, those with multiple recurrences, or high-level competitive athletes with the most severe grades of injury. The current review aims to highlight current concepts in the treatment of tibial BSI, with a particular focus on the high-risk population of adolescent athletes.

Bone stress injuries (BSIs) are common in female runners, and recurrent BSI rates are high. Previous work suggests an association between higher impact loading during running and tibial BSI. However, it is unknown whether impact loading and fatigue-related loading changes discriminate women with a history of multiple BSIs. This study compared impact variables at the beginning of a treadmill run to exertion and the changes in those variables with exertion among female runners with no history of BSI as well as among those with a history of 1 or multiple BSIs.We enrolled 45 female runners (aged 18-40 years) for this cross-sectional study: having no history of diagnosed lower extremity BSI (N-BSI, n = 14), a history of 1 lower extremity BSI (1-BSI, n = 16), diagnosed by imaging, or a history of multiple (≥3) lower extremity BSIs (M-BSI, n = 15). Participants completed a 5-km race speed run on an instrumented treadmill while wearing an Inertial Measurement Unit. The vertical average loading rate (VALR), vertical instantaneous loading rate (VILR), vertical stiffness during impact via instrumented treadmill, and tibial shock determined as the peak positive tibial acceleration via Inertial Measurement Unit were measured at the beginning and end of the run.There were no differences between groups in VALR, VILR, vertical stiffness, or tibial shock in a fresh or exerted condition. However, compared to N-BSI, women with M-BSI had greater increase with exertion in VALR (-1.8% vs. 6.1%, p = 0.01) and VILR (1.5% vs. 4.8%, p = 0.03). Similarly, compared to N-BSI, vertical stiffness increased more with exertion among women with M-BSI (-0.9% vs. 7.3%, p = 0.006) and 1-BSI (-0.9% vs. 1.8%, p = 0.05). Finally, compared to N-BSI, the increase in tibial shock from fresh to exerted condition was greater among women with M-BSI (0.9% vs. 5.5%, p = 0.03) and 1-BSI (0.9% vs. 11.2%, p = 0.02).Women with 1-BSI or M-BSIs experience greater exertion-related increases in impact loading than women with N-BSI. These observations imply that exertion-related changes in gait biomechanics may contribute to risk of BSI.

Female endurance athletes exhibit an increased risk of Female Athlete Triad (Triad) and Relative Energy Deficiency in Sport (RED-S). Triad and RED-S are conditions that explore the health and performance consequences of low energy availability (LEA). Few studies to date have assessed the knowledge that athletes, coaches, and athletic trainers (ATs) have regarding Triad/RED-S. Proper education has been shown to be effective in increasing knowledge of sports medicine concerns for athletes. Yet, there are no known continuing education programs for Triad/RED-S at collegiate institutions.The primary purpose of this study was to assess the knowledge, confidence, and impact of identifying, screening, treating, and preventing Triad/RED-S.Cross-sectional study.An evidence-based online survey was developed and administered via QualtricsTM.Female collegiate cross-country athletes (n = 275; 20 ± 1 yrs.), collegiate cross-country coaches (n = 55, 34 ± 9 yrs.), and ATs working with cross-country teams (n = 30, 36 ± 11 yrs.).Knowledge, confidence, and impact scores were assessed between groups using ANOVA. Independent t-tests were used to determine differences in impact scores between people who had or had not received education.Female cross-country athletes' total knowledge, confidence, and impact scores (mean scores of 25.00 ± 5.27, 95.42 ± 28.83, 18.81 ± 7.05 respectively) were significantly different from scores of coaches (mean scores of 26.92 ± 5.02, 111.35 ± 24.14 and 22.41 ± 6.33) and ATs (mean scores of 28.66 ± 4.02, 117.67 ± 22.53, and 23.93 ± 5.69) (p0.05).Knowledge, confidence, and impact scores of Triad/RED-S were lowest in female cross-country athletes and highest in ATs. These findings support the call for education, which should be regarded as the primary tool to increase knowledge to improve the prevention and treatment of Triad/RED-S.

Context Female endurance athletes exhibit an increased risk of the female athlete triad (Triad) and relative energy deficiency in sport (RED-S). The triad and RED-S are conditions that involve the health and performance consequences of low energy availability. Few authors of studies to date have assessed the knowledge that athletes, coaches, and athletic trainers (ATs) have regarding the Triad or RED-S. Proper education has been shown to be effective in increasing knowledge of sports medicine concerns for athletes, yet no known continuing education programs for the Triad or RED-S exist at collegiate institutions. Objective To assess the knowledge, confidence, and educational impact of identifying, screening, treating, and preventing the Triad or RED-S. Design Cross-sectional study. Setting An evidence-based online survey was developed and administered via Qualtrics. Patients or Other Participants Female collegiate cross-country athletes (n = 275, age = 20 ± 1 years), collegiate cross-country coaches (n = 55, age = 34 ± 9 years), and ATs working with cross-country teams (n = 30, age = 36 ± 11 years). Main Outcome Measure(s) Knowledge, confidence, and educational impact scores were assessed among groups using analysis of variance. Independent t tests were calculated to determine differences in impact scores between people who had or had not received education on the topic. Results Female cross-country athletes' total knowledge, confidence, and educational impact scores (mean scores = 25.00 ± 5.27, 95.42 ± 28.83, and 18.81 ± 7.05, respectively) were different from those of coaches (mean scores = 26.92 ± 5.02, 111.35 ± 24.14, and 22.41 ± 6.33, respectively) and ATs (mean scores = 28.66 ± 4.02, 117.67 ± 22.53, and 23.93 ± 5.69, respectively; P < .05). Conclusions Knowledge, confidence, and educational impact scores regarding Triad or RED-S were lowest in female cross-country athletes and highest in ATs. These findings support the call for education, which should be regarded as the primary tool for increasing knowledge, to improve the prevention and treatment of the Triad or RED-S.

OBJECTIVES: To determine whether serum 25-hydroxy vitamin D (25-OH D) levels are associated with bone microarchitecture and strength in a multi-racial cohort of young adults. We also determined if race and calcium intake modified these associations. METHODS: This cross-sectional study included 176 young adults who identified as Asian, Black, or White (50% women). High-resolution peripheral quantitative computed tomography (HR-pQCT, 2nd generation) scans of the distal radius and tibia were used to assess bone microarchitecture and strength by micro-finite element analysis. We measured 25-OH D levels (ng/mL, immunoassay), dietary intake (Block's Food Frequency Questionnaire), and physical activity (questionnaire). We used linear regression to estimate the association between 25-OH D and standardized bone measures, adjusting for race, sex, age, weight, height, calcium intake, and physical activity. The interactions of 25-OH D with race and calcium intake (mg/d) were tested and models were stratified for significant interactions (P

ObjectiveTo summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement.Data sourcesFive databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS).ResultsAmong 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments.ConclusionsWhile several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

BACKGROUND: Despite their higher areal bone mineral density (aBMD), adolescents with obesity (OB) have an increase in fracture risk, particularly of the extremities, compared with normal-weight controls. Whereas bone parameters that increase fracture risk are well characterized in anorexia nervosa (AN), the other end of nutritional spectrum, these data are lacking in adolescents with obesity. OBJECTIVE: Our objective was to compare bone parameters in adolescent girls across the nutritional spectrum, to determine whether suboptimal bone adaptation to increased body weight may explain the increased fracture risk in OB. METHODS: We assessed bone endpoints in 153 adolescent girls 14-21 years old: 50 OB, 48 controls and 55 AN. We used (i) DXA to assess aBMD at the lumbar spine, proximal femur and whole body, and body composition, (ii) high resolution peripheral quantitative CT (HRpQCT) to assess bone geometry, microarchitecture and volumetric BMD (vBMD), and (iii) finite element analysis to assess failure load (a strength estimate) at the distal radius and tibia. All aBMD, microarchitecture and FEA analyses were controlled for age and race. RESULTS: Groups did not differ for age or height. Areal BMD Z-scores at all sites were highest in OB, intermediate in controls and lowest in AN (p