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To present a synthesis of recent literature regarding the risk factors and management for MTSS. Risk factors include female sex, prior history of MTSS, less running experience, female athlete triad/RED-S, higher BMI, smoking, and biomechanical abnormalities. Management includes activity modification, gait retraining, orthotics, medications, and, very rarely, surgery. MTSS is an overuse injury commonly seen in runners. The pathophysiology remains disputed, and diagnosis is often determined from clinical presentation alone. For unclear reasons, women are at increased risk for development of MTSS. Other risk factors include increased BMI, prior history of MTSS, less running experience, smoking, presence of at least one component of the female athlete triad/RED-S, and biomechanical abnormalities. Treatment often includes cessation of high-impact activity, gait retraining, neuromuscular training, and orthotics. In rare circumstances, surgery may be considered. Identifying risk factors is important for prevention and individualized management.

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

The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

The health benefits of regular recreational physical activity are well known in reducing secondary health consequences of a sedentary lifestyle in the general population. However, individuals with physical disabilities participate less frequently in recreational activity compared with those without disabilities. Although evidence on the impact of recreational physical activity on quality of life in this population is in its infancy, regular recreational and sports activity participation has shown to have a positive association with improvements in quality of life, life satisfaction, community reintegration, mood, and employment in those with disabilities. Facilitators of participating in adaptive sports include a desire to improve social support, physical fitness, health, and fun. Unfortunately, those with disabilities face numerous barriers to participate in adaptive sports including accessibility, transportation, awareness, finances, and physical and cognitive impairments. Further studies are needed to investigate facilitators and barriers to participating in adaptive sports to capitalize on the physical and psychosocial benefits of regular recreational activity. The aim of this article is to review the available literature on the effects of adaptive sports participation on quality of life.

PURPOSE OF REVIEW: This review article seeks to highlight common youth athlete knee conditions due to overuse or trauma and elucidate differences from the adult populations. RECENT FINDINGS: Overuse conditions presented include apophysitis, osteochondritis dissecans plica syndrome, and discoid meniscus. Traumatic conditions presented include patellar instability, patellar sleeve fracture, and patellofemoral osteochondral fractures. SUMMARY: Knee injuries affect a significant proportion of youth athletes. These injuries place athletes at higher risk of chronic pain and potentially osteoarthritis. We have reviewed common overuse and traumatic knee injuries and differentiating factors between the adult population to improve and expedite the diagnosis, treatment, and prognosis for youth athletes with knee injuries.

OBJECTIVE To identify the prevalence of male and female athlete triad risk factors in ultramarathon runners and explore associations between sex hormones and bone mineral density (BMD). DESIGN Multiyear cross-sectional study. SETTING One hundred-mile ultramarathon. PARTICIPANTS Competing runners were recruited in 2018 and 2019. ASSESSMENT OF RISK FACTORS Participants completed a survey assessing eating behaviors, menstrual history, and injury history; dual-energy x-ray absorptiometry for BMD; and laboratory evaluation of sex hormones, vitamin D, and ferritin (2019 cohort only). MAIN OUTCOME MEASURE A Triad Cumulative Risk Assessment Score was calculated for each participant. RESULTS One hundred twenty-three runners participated (83 males and 40 females, mean age 46.2 and 41.8 years, respectively). 44.5% of men and 62.5% of women had elevated risk for disordered eating. 37.5% of women reported a history of bone stress injury (BSI) and 16.7% had BMD Z scores

Bone stress injuries (BSIs) of the pelvis and sacrum comprise only 1–7% of all BSIs and can be challenging to diagnose and manage. These BSIs are often missed since they are difficult to diagnose on plain radiographs, their presenting symptoms are often vague and can be easily mistaken for other diagnoses. For this reason, advanced imaging is often required for diagnosis. Pelvic BSIs are medium-risk, meaning that they have a low likelihood of progressing to complete fracture or non-union, but should still be treated with caution. These BSIs tend to require a much longer treatment period prior to return to full activity. This chapter focuses on BSIs in the pubic rami, ilium, acetabular roof, and sacrum, in addition to osteitis pubis, including epidemiology, common presentation, diagnosis, and management recommendations.

Barrack, MT, Fredericson, M, Dizon, F, Tenforde, AS, Kim, BY, Kraus, E, Kussman, A, Singh, S, and Nattiv, A. Dietary supplement use according to sex and Triad risk factors in collegiate endurance runners. J Strength Cond Res 35(2): 404-410, 2021-This cross-sectional study evaluated the prevalence in the use of dietary supplements among elite collegiate runners among 2 NCAA Division I cross-country teams. At the start of each season from 2015 to 2017, male and female endurance runners were recruited to complete baseline study measures; the final sample included 135 (male n = 65, female n = 70) runners. Runners completed a health survey, web-based nutrition survey, and Triad risk assessment. The prevalence of dietary supplement use and Triad risk factors, including disordered eating, low bone mass, amenorrhea (in women), low body mass index, and stress fracture history, was assessed. A total of 78.5% (n = 106) runners reported taking 1 or more supplements on ≥4 days per week over the past month, 48% (n = 65) reported use of ≥3 supplements. Products used with highest frequency included multivitamin/minerals 46.7% (n = 63), iron 46.7% (n = 63), vitamin D 34.1% (n = 46), and calcium 33.3% (n = 45). More women, compared with men, used iron (61.4 vs. 30.8%, p < 0.001) and calcium (41.4 vs. 24.6%, p = 0.04); men exhibited higher use of amino acids and beta-alanine (6.2 vs. 0%, p = 0.04). Runners with bone stress injury (BSI) history, vs. no previous BSI, reported more frequent use of ≥3 supplements (61.5 vs. 32.8%, p = 0.001), vitamin D (49.2 vs. 19.4%, p < 0.001), and calcium (47.7 vs. 19.4%, p = 0.001). Low bone mineral density was also associated with higher use of vitamin D and calcium. Most runners reported regular use of 1 or more supplements, with patterns of use varying based on sex, history of BSI, and bone mass.

Background: The female athlete triad (Triad) has been associated with increased risk of bone stress injury (BSI) in certain populations. Purpose: The purpose of this study is to evaluate the prevalence of Triad risk factors and identify hormonal and extrinsic factors that may influence Triad risk in high school (HS) distance runners. Methods: Thirty-nine female HS distance runners completed a questionnaire, which included disordered eating (DE)/eating disorder (ED), menstrual irregularities, BSI history, and height/weight. Serum labs were obtained, including ferritin, 25-hydroxyvitamin D, estradiol, insulin-like growth factor, and free T3. Runners completed dual-energy x-ray absorptiometry to measure bone mineral density (BMD) using Z-scores that are age, sex and ethnicity-matched. Body fat percentage was also obtained. A risk score was then calculated using energy availability (EA), body mass index (BMI), age of menarche, oligomenorrhea, BMD, and history of BSI. The statistical model used was Spearman correlation coefficient. P-values

Background: Increased neck strength may be a protective factor for reducing concussions in youth athletes. However, little research exists regarding validated neck strength training methods among this demographic. Purpose: To determine whether a 7-week neck strength training period is sufficient to achieve significant gains in neck strength and size amongst high school football players. Additionally, to assess if increased neck strength influences concussion outcomes. Methods: This study enrolled 54 male high school football players, ages 14-17, in a 7-week strength training protocol in which neck exercises were incorporated into preseason strength and conditioning workouts (figure 1). Pre- and post-neck strength was assessed in four directions: forward flexion (FF), extension (EXT), right lateral flexion (RLF) and left lateral flexion (LLF). Strength was measured as maximal isometric head pressure applied into a pre-inflated sphygmomanometer cuff (figure 2). Concussion totals from the subsequent 2018 season were compared with totals from the 2017 and 2016 seasons per data obtained from the team’s athletic trainer. Results: Fifty athletes in total were analyzed; 4/54 athletes did not complete final testing due to scheduling conflicts. A two sample t-test of neck circumferences revealed a statistically significant increase of 0.37 cm from pre- to post-neck strength training (p=0.0025, figure 3). Single sample strength t-test analysis (corrected for cuff pre-inflation) demonstrated a statistically significant post-test strength increase of 19.8% (FF), 11.0% (EX), 18.8% (RLF), and 18.0% (LLF) (pConclusion This study demonstrates that increases in neck size and strength can be achieved amongst high school athletes using easily implemented training methods during a 7-week preseason training period. The additional observation of reduced concussion outcomes is not conclusive, though these initial results are promising. Additional research is needed to investigate the potential of neck strengthening in modifying concussion risk. Funding provided by the Stanford Medical Scholars Fellowship Program [Figure: see text][Figure: see text][Figure: see text]

Bone stress injuries are common in military personnel and athletes. The delayed diagnosis of a bone stress injury can lead to a more severe injury that requires a longer period of treatment. The early detection of bone stress injuries is a central part of management. Currently, the reference standard for detecting bone stress injuries is magnetic resonance imaging. However, the expanding use of point-of-care ultrasonography (US) may enable the early detection of bone stress injuries in the clinical setting. In this article, we review the US detection of bone stress injuries, as well as discuss the rationale for the use of US in the diagnosis of these injuries.

Foot injuries account for 10% to 20% of all running injuries, and ankle injuries account for 15% of all sports injuries. In running, the foot serves as the link between the ground and the kinetic chain of the lower limb and trunk to enable forward propulsion. Excessive stress or abnormalities in biomechanical stress can predispose runners to overuse and traumatic injury. This chapter provides a framework for approaching the differential diagnosis of foot and ankle injuries in runners and outlines evidence-based medicine to prevent, evaluate, and manage injury. Within this framework, common running injuries are highlighted and grouped based on structure. We cover tendon, ligament/fascia, nerve, and bone disorders. A more comprehensive analysis is devoted to Achilles tendinopathy, plantar fasciopathy, and acute lateral ankle sprain due to their commonality in runners. Multidisciplinary and evidence-based clinical care can enable most runners to make a successful return to sport following conservative treatment.

Bone stress injuries (BSIs) occur when bone is no longer able to withstand repetitive, mechanical loading. BSIs are common in elite and recreational runners. The 1-year prospective incidence of BSI in competitive cross-country and track-and-field athletes is as high as 21%. Early identification and proper management of BSI may prevent progression of injury down the pathology continuum on magnetic resonance imaging. BSI may represent a systemic deficit in metabolic or hormonal status. Screening for the Female Athlete Triad and parallel male Triad can help prevent BSI or BSI recurrence. This chapter uses evidence-based medicine to highlight the pathophysiology, risk factors, clinical evaluation, and management of common BSIs in runners. Within this framework, BSIs are grouped by high-, moderate-, and low-risk anatomic sites based on healing properties. With evidence-based management and proper rehabilitation principles, most runners can return to play with conservative treatment.

Background: A multidisciplinary approach is an intrinsic part of the sports medicine management process as providers, therapists and athletic trainers frequently interact to deliver optimal care to athletes both in clinic and on the sideline. Establishing effective communication and engaging athletes in the decision making process as treatment plans are developed may help increase compliance and improve health outcomes. Gender preference of patients for their providers has been found to influence patient satisfaction and health outcomes but has not been studied in depth. Purpose: The purpose of this study was to systematically review the literature to identify and characterize young athletes’ gender preferences for their sports medicine providers. Methods: This review was conducted according to the Preferred Reporting Items for Systemic Reviews and Meta-Analyses Group (PRISMA) guidelines. Pubmed, Embase, CINAHL and PsycInfo databases were searched utilizing MeSH terms, with results limited to English-language publications from the year 1945 to present day. The investigators assessed study eligibility independently and limited to studies that had quantitative outcome measures related to gender preference and participants ≤ 22 years of age. The Appraisal Tool for Cross-Sectional Studies (AXIS) was utilized to assess studies for bias. Results: Six cross-sectional studies met the eligibility criteria. Across studies, there were a total of 2,159 participants with mean ages ranging from 14.7 to 21.0 years. Of the five studies that reported the gender of participants, 50.6% were female. Participants were more likely to have a preference for a gender-concordant sports medicine provider when their chief complaint was related to their genital region and/or their sexual health. Participants of both genders favored a female provider when the health issue pertained to behavioral and/or psychosocial health, such as depression. Female athletes preferred a female provider when the issue was related to body image and/or disordered eating. For strength and conditioning coaches, male athletes reported a strong preference for male providers, but female athletes did not express a gender preference. Two of the studies’ quality was categorized as “good” by the AXIS criteria and four were “fair”. Conclusions: Young athletes’ gender preference for their sports medicine providers is situation-dependent. However, there is a paucity of studies examining gender provider preferences in pediatric athletes. Further studies are necessary to address this void in the literature as this may impact health outcomes.

Background: Investigations of the female athlete triad (Triad) in high school athletes have found that 36% had low energy availability, 54% had menstrual abnormalities, and 16% had low bone mineral density (BMD). Limited data are available showing the prevalence of these risk factors in high school distance runners or regarding best practice on screening for the Triad in the adolescent population. Purpose: To (1) evaluate the prevalence of Triad risk factors and iron supplementation in high school distance runners and (2) pilot a screening tool for Triad risk score. Study Design: Descriptive epidemiology study. Methods: The study population included female high school athletes who participated in cross-country/track. Participants completed a survey including questions regarding dietary habits, menstrual history, and bone stress injury (BSI) history. They then underwent evaluation of 25-hydroxyvitamin D, free triiodothyronine (T3), and dual-energy x-ray absorptiometry scan to measure body fat and BMD through use of age-, sex-, and ethnicity-matched Z scores. Triad scores were calculated. Relationships were analyzed using Spearman correlation coefficient. Results: There were 38 study participants (mean age, 16.9 years). Average body mass index was 19.8 kg/m2. Disordered eating or eating disorders were reported in 76.3% of runners; in addition, 23.7% reported delayed menarche, 45.9% had a history of amenorrhea or oligomenorrhea, 42.1% had low BMD ( Z score < –1.0), and 15.8% reported prior BSI. Low free T3 was significantly associated with higher Triad risk scores ( r S = –0.36; P = .028). More than 42% of athletes were supplementing iron. Conclusion: The prevalence of Triad risk factors in high school distance runners was high. Free T3 was inversely associated with Triad score, which may serve as an indicator of low energy availability. Nearly half of the athletes were using iron supplementation.

ObjectivesBone stress injuries (BSI) are common in runners of both sexes. The purpose of this study was to determine if a modified Female Athlete Triad Cumulative Risk Assessment tool would predict BSI in male distance runners.Methods156 male runners at two collegiate programmes were studied using mixed retrospective and prospective design for a total of 7 years. Point values were assigned using risk assessment categories including low energy availability, low body mass index (BMI), low bone mineral density (BMD) and prior BSI. The outcome was subsequent development of BSI. Statistical models used a mixed effects Poisson regression model with pResults42/156 runners (27%) sustained 61 BSIs over an average 1.9 years of follow-up. In the baseline risk factor model, each 1 point increase in prior BSI score was associated with a 57% increased risk for prospective BSI (p=0.0042) and each 1 point increase in cumulative risk score was associated with a 37% increase in prospective BSI risk (p=0.0079). In the longitudinal model, each 1 point increase in cumulative risk score was associated with a 27% increase in prospective BSI risk (p=0.05). BMI (rate ratio (RR)=1.91, p=0.11) and BMD (RR=1.58, p=0.19) risk scores were not associated with BSI.ConclusionA modified cumulative risk assessment tool may help identify male runners at elevated risk for BSI. Identifying risk factors may guide treatment and prevention strategies.

Objective To determine whether endometriosis ultimately results in an increased risk of embryonic aneuploidy. Design Retrospective cohort. Setting Infertility clinic. Patient(s) Patients participating in an in vitro fertilization (IVF) cycle from 2009-2015 using preimplantation genetic screening (PGS) who had endometriosis identified by surgical diagnosis or by ultrasound findings consistent with a persistent space-occupying disease whose sonographic appearance was consistent with endometriosis. Intervention(s) None. Main outcome measure(s) Rate of aneuploidy in endometriosis patients undergoing IVF compared to controls without endometriosis undergoing IVF. Result(s) There were 305 patients with endometriosis who produced 1,880 blastocysts that met the criteria for inclusion in the endometriosis group. The mean age of the patients with endometriosis was 36.1 ± 3.9 years. When the aneuploidy rates in patients with endometriosis and aneuploidy rates in patients without endometriosis were stratified by Society for Assisted Reproductive Technology age groups and compared, there were no statistically significant differences in the rate of aneuploidy (odds ratio 0.85; 95% confidence interval, 0.84-0.85). Conclusion(s) Patients with endometriosis undergoing IVF have aneuploidy rates equivalent to their age-matched peers in IVF population who do not have endometriosis.

Background Student-run free clinics (SRFCs) have emerged as an important educational component of United States (U.S.) medical schools. Despite the prevalence of musculoskeletal (MSK) problems presenting to SRFCs, students and clinics are often unprepared to diagnose and to treat common MSK complaints. Objective We sought to determine the scope of diagnosis and treatment at a medical student−run free clinic specializing in musculoskeletal care using physical medicine and rehabilitation (PM&R) residents. Secondary goals included reviewing student satisfaction and determining the appropriateness of the clinic in medical education. Design Retrospective chart review, anonymous online survey. Setting Primary care, free student clinic affiliated with tertiary academic medical center. Participants A total of 20 medical student volunteers, 6 PM&R residents, and 91 community patients. Methods We established a musculoskeletal clinic as a specialty referral clinic for the 2 primary care SRFCs with institutional support from a partner medical school. We then reviewed clinical operations retrospectively using electronic medical records and student satisfaction based on an online survey. Main Outcome Measurements We analyzed patient demographics and chief complaints, referrals provided, and medical services rendered. We also used a 5-point Likert scale to assess student satisfaction. Results A monthly musculoskeletal referral clinic was established with the oversight of PM&R attendings and residents. The clinic received 91 referrals and managed 61 unique patients over a 2.5-year study period. The most common presentations to the clinic involved knee pain (n = 17, 27.9%) and back pain (n = 16, 26.2%). Pro bono relationships with community and institutional partners enabled all patients to receive medical examinations, physical therapy visits, plain film radiographs, and insurance consultations free of charge. Student satisfaction with teaching and patient care was high, with 19 of 20 students reporting their experience as "good" or "excellent." Conclusions SRFCs represent an underused opportunity to enhance MSK education among medical students by treating a variety of common MSK complaints in an underserved population. Level of Evidence Not applicable.

Fractures are common in childhood and adolescence, with an estimated 30% of this population experiencing at least 1 broken bone. The forearm is the most common fracture site.In the absence of major trauma, fractures of the femur and spine are suggestive of abnormal bone fragility; such cases warrant

Bone stress injuries (BSIs) are common running injuries and may occur at a rate of 20% annually. Both biological and biomechanical risk factors contribute to BSI. Evaluation of a runner with suspected BSI includes completing an appropriate history and physical examination. MRI grading classification for BSI has been proposed and may guide return to play. Management includes activity modification, optimizing nutrition, and addressing risk factors, including the female athlete triad. BSI prevention strategies include screening for risk factors during preparticipation evaluations, optimizing nutrition (including adequate caloric intake, calcium, and vitamin D), and promoting ball sports during childhood and adolescence.

A 68-year-old male long distance runner presented with low back and left buttock pain, which eventually progressed to severe and debilitating pain, intermittently radiating to the posterior thigh and foot. A comprehensive workup ruled out possible spine or hip causes of his symptoms. A pelvic magnetic resonance imaging neurogram with complex oblique planes through the piriformis demonstrated variant anatomy of the left sciatic nerve consistent with the clinical diagnosis of piriformis syndrome. The patient ultimately underwent neurolysis with release of the sciatic nerve and partial resection of the piriformis muscle. After surgery the patient reported significant pain reduction and resumed running 3 months later. Piriformis syndrome is uncommon but should be considered in the differential diagnosis for buttock pain. Advanced imaging was essential to guide management.

I was two months into my nursing training when I was diagnosed with type 2 diabetes at just 24 years of age.