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Energy status plays a key role in the health of athletes and exercising individuals. Energy deficiency/low energy availability (EA), referring to a state in which insufficient energy intake and/or excessive exercise energy expenditure has resulted in compensatory metabolic adaptations to conserve fuel, can affect numerous physiological systems in women and men. The Female Athlete Triad, Male Athlete Triad, and Relative Energy Deficiency in Sport (RED-S) models conceptualize the effects of energy deficiency in athletes, and each model has strengths and limitations. For instance, the Female Athlete Triad model depicts relationships between low EA, reproductive, and bone health, underpinning decades of experimental evidence, but may be perceived as limited in scope, while the more recent RED-S model proposes a wider range of potential health effects of low EA, though many model components require more robust scientific justification. This critical review summarizes current evidence regarding the effects of energy deficiency on athlete health by addressing the quality of the underlying science, the strengths and limitations of each model, and highlighting areas where future research is needed to advance the field. With the health and wellness of athletes and exercising individuals as the overarching priority, we conclude with specific steps that will help focus future research on the Female and Male Athlete Triad and RED-S, and encourage all researchers, clinicians, and practitioners to collaborate to support the common goal of promoting the highest quality science and evidence-based medicine in pursuit of the advancement of athletes’ health, well-being, and performance.

Athletes are vulnerable to sexual violence. Perpetrators of sexual violence may be a trusted coach, a member of the health care team, or a peer. The consequences of sexual violence are wide ranging, resulting in immediate and long-term physical and mental health outcomes that require recognition and comprehensive, multidisciplinary care. Sports medicine providers need to have specific knowledge and skill to care for athletes who experience sexual violence. Several sports organizations (e.g., International Olympic Committee, United States Olympic and Paralympic Committee, the National Collegiate Athletic Association, and the National Athletic Trainers' Association) have developed policies and procedures to prevent sexual violence and help sports medicine specialists provide care and services for athletes affected by sexual violence. Nevertheless, there remains a need for clinical guidelines, screening tools, and education, as well as clinical best practices to address sexual violence in sports medicine.

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 Female Athlete Triad (Triad) is a disorder observed in women and girls composed of three related components: low energy availability (EA), menstrual dysfunction, and low bone mineral density (BMD). The purpose of this review is to define the components of the Triad, review risk factors and complications, and review the diagnosis and management of the effects of the Triad. Recent research has defined guidelines for return to play for athlete with the Triad, which are summarized here. In addition, there has been recent vigorous debate and research in an attempt to define a related disorder in men. The Female Athlete Triad is a complex disorder involving many physiological systems and is intertwined with mental health. Early intervention by an experienced team of healthcare providers allows for optimal treatment of the patient.

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a position statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the task force used an iterative process and expert consensus to finalize the position statement. The objective of this position statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport.

Eating disorders, such as anorexia nervosa and bulimia nervosa, can have devastating effects on both the health and performance of athletes. Compared to non-athletes, both female and male athletes are at higher risk of developing an eating disorder. This is especially true for athletes participating in sports where low body weight or leanness confers a competitive advantage. Screening for disordered eating behaviours, eating disorders and for related health consequences should be a standard component of preparticipation examinations, and team physicians should be knowledgeable of the updated diagnostic criteria for eating disorders in the Diagnostic and Statistical Manual-V. Athletes with eating disorders should undergo thorough evaluation and treatment by an experienced multidisciplinary team. Team physicians play a critical role in decision-making on clearance for participation and return to play. Using evidence-based guidelines for clearance and return to play encourages transparency and accountability between the sports medicine care team and the athlete. Efforts to prevent eating disorders should be aimed at athletes, coaches, parents and athletic administrators, and focused on expanding knowledge of healthy nutrition in support of sport performance and health.

The U.S. population is plagued by physical inactivity, lack of cardiorespiratory fitness, and sedentary lifestyles, all of which are strongly associated with the emerging epidemic of chronic disease. The time is right to incorporate physical activity assessment and promotion into health care in a manner that engages clinicians and patients. In April 2015, the American College of Sports Medicine and Kaiser Permanente convened a joint consensus meeting of subject matter experts from stakeholder organizations to discuss the development and implementation of a physical activity vital sign (PAVS) to be obtained and recorded at every medical visit for every patient. This statement represents a summary of the discussion, recommendations, and next steps developed during the consensus meeting. Foremost, it is a "call to action" for current and future clinicians and the health care community to implement a PAVS in daily practice with every patient.

The Female Athlete Triad (Triad) was first defined by a group of clinical and scientific experts in 1992 (28). Since then, two American College of Sports Medicine (ACSM) Position Stands have been published (1997, 2007) (21,22), and more recently, the Female Athlete Triad Coalition Consensus on Clear

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chronic disease increases with age, both older patients and providers need to be aware of disease and medication-specific risks relative to wilderness sport and activity participation. Disabled and special needs athletes benefit from careful pre-event planning for the potential medical issues and equipment modifications that may affect their health in wilderness environments. Issues that demand special consideration for female adventurers include pregnancy, contraceptive use, menses, and ferritin levels at altitude. A careful preparticipation evaluation that factors in unique, population- specific risks will help special populations stay healthy and safe on wilderness adventures. The PubMed and SportDiscus databases were searched in 2014 using both MeSH terms and text words and include peer-reviewed English language articles from 1977 to 2014. Additional information was accessed from Web-based sources to produce this narrative review on preparticipation evaluation for special populations undertaking wilderness adventures. Key words include children, adolescent, pediatric, seniors, elderly, disabled, special needs, female, athlete, preparticipiation examination, wilderness medicine, and sports.

A majority of women do not meet the recommended levels of physical activity before and during pregnancy. Physically active women experience fewer complications of pregnancy such as gestational diabetes, hypertensive disorders of pregnancy, and low back pain, to name only a few. Exercise is Medicine encourages adults to achieve a minimum of 150 min·wk of moderate-intensity physical activity, and the same is true for women having uncomplicated pregnancies. Prenatal care is an opportune time to counsel women on how to achieve an active lifestyle to support their own health and the health of their developing fetus.

An IOC consensus group has recently introduced a new umbrella term, that is, ‘Relative Energy Deficiency in Sport’ (RED-S) to describe the physiological and pathophysiological effects of energy deficiency in male and female athletes.1 The authors assert that “new terminology is required to more accurately describe the clinical syndrome originally known as the Female Athlete Triad” that is a “more comprehensive, broader term for the overall syndrome, which includes what has so far been called the ‘Female Athlete Triad’.”1 This new terminology (RED-S) is insufficiently supported by scientific research to warrant adoption at this time. The Female Athlete Triad has more than 30 years of published evidence to support its existence in the scientific literature with strong evidence for its clinical sequelae and should remain a focus of scientific inquiry and translation.2–6 Moreover, several major concerns and errors with the IOC consensus statement should give researchers and practitioners great pause before adopting the IOC's new terminology, its theoretical construct and its proposed recommendations for screening and return to play. As stated by the IOC authors, the science of energy deficiency in the male athlete and in other groups is still in its ‘infancy’.1 In contrast, research on the Triad has been published since the early 1990s4 and, in fact, even earlier. Reports of menstrual and other problems in athletes were becoming prevalent in the literature as early as the 1960s, but particularly in the 1970s and 1980s.7–10 The first symposium related to the topic at the American College of Sports Medicine (ACSM) Annual Meeting was organised by Barbara Drinkwater in 1981 and was entitled ‘Menstrual Irregularities in Female Athletes’. The term ‘Female Athlete Triad’ was introduced at a workshop in 1992.4 The first position stand from the ACSM was published in 1997,2 and …

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.

As a family and sports physician, I care for many young women affected by the female athlete triad. Typically, they present with low body mass index (BMI), oligomenorrhea or amenorrhea, and, oftentimes, low bone mineral density or stress fractures. Sometimes, the low BMI stems from intentional restriction of dietary intake; other times, it is a consequence of an unintentional mismatch of caloric intake relative to high calorie expenditure related to training and/ or sport participation. Menstrual dysfunction may take the form of delayed menarche, short infrequent menses (oligomenorrhea), or complete absence of menstruation (amenorrhea). In this setting, bone health alterations are thought to be related to changes in one’s hormonal milieu, in addition to nutritional deficiencies. The mainstay of clinical management for patients affected by the female athlete triad is to correct the negative energy balance or low energy availability that leads to menstrual dysfunction and alterations in bone health. However, as many clinicians know, this can be challenging. Competitive female athletes often are resistant to recommendations to increase dietary intake and body weight and/or reduce their exercise or training. A common practice has been to place amenorrheic women, especially athletes, on oral contraceptives (OCP) in an effort to provide estrogen replacement, in hopes of protecting against bone loss and/or stress fracture. However, there is emerging evidence that this practice is not beneficial and may even lead to harm. The amenorrhea that occurs within the spectrum of the female athlete triad is referred to as functional hypothalamic amenorrhea. It is an adaptive mechanism that reduces a woman’s fertility when the body perceives that there is inadequate energy to support the substrate, let alone a fetus (2). While this may seem beneficial to many athletes, as they may not be seeking pregnancy, the adverse effects of this hormonal disruption is manifest in negative impacts on bone health, 1) in the form of inadequate bone mineral acquisition, 2) in the loss of existing bone mineral density, or 3) in increased risk of stress fracture, even in the setting of normal BMD. Combined OCP, consisting of estrogen and progesterone, have been recommended for use in treating women affected by the female athlete triad (1). However, the evidence supporting a role for OCP in treatment is inconclusive at best (5). This likely is related to the fact that combined OCP containing only estrogen and progesterone cannot overcome the alterations in hormone levels associated with low energy availability, including decreased total triiodothyronine, leptin, insulin, insulin-like growth factors, glucose, luteinizing hormone pulsatility, and follicle-stimulating hormone, as well as an increase in growth hormone and cortisol (5). Not only are OCP unable to counter the impact these hormone alterations have on bone health; they may contribute, in fact, to worsening bone health. Exogenous estrogen replacement in young athletes may lead to premature closure of physes (growth plate) (4), and early OCP use has been associated with lower BMD in the spine and femoral neck among female distance runners (6). So what is a clinician to do when faced with the challenge of treating an athlete with the female athlete triad? The first step is to perform a comprehensive history and physical examination to confirm the diagnoses. Second, engage a multidisciplinary team, which often includes a physician, sports dietician, and mental health professional, to guide and support the athlete’s recovery. The cornerstone of treatment is to reverse the situation of low energy availability, which is typically a consequence of both inadequate stored energy (low BMI) and low energy intake relative to expenditure. The goal is to increase caloric intake above 30-kcalIkg fat-free mass (FFM); some would recommend upward of 45-kcalIkg FFM to produce changes in bone mineral density (3,7). What this translates into practically is approximately 1,912 cal for a 110-lb female distance runner with 15% body fat (110 lb 0.85 = 93.5-lb FFM Y 42.5-kg FFM 45-kcalIkg FFM = 1,912 kcal). Assuming she was continuing to train throughout this recovery period, adding additional calories to cover exercise-related expenditures would be required to replace the deficit (~100 kcalImile). The role of the sports dietician is to help the athlete consume the required amount of calories while minimizing INVITED COMMENTARY

Context: Methicillin-resistant Staphylococcus aureus (MRSA) infections are increasingly common in athletic settings. The MRSA knowledge and infection-control practices of certified athletic trainers (ATs) and the cleanliness of the athletic training room are important factors in preventing MRSA infections. Objective: To assess knowledge of MRSA and the use of common disinfectants among ATs and to explore their infection-control practices. Design: Cross-sectional study. Setting: High school and collegiate athletic training rooms. Patients or Other Participants: A total of 163 ATs from National Collegiate Athletic Association Divisions I, II, and III and high schools, representing all 10 National Athletic Trainers' Association districts. Main Outcome Measure(s): Frequencies, analyses of variance, and χ2 tests were used to assess current practices and opinions and relationships between factors. Results: Methicillin-resistant Staphylococcus aureus was perceived as a national problem by 92% of respondents; 57% perceived MRSA as a problem in their practice setting. Most respondents had treated general infections (88%), staphylococcal infections (75%), and MRSA infections (57%). Male sex was associated with treating all 3 types of infections (χ2 test, P < .05). Noncurriculum education was associated with a lack of recognition of environmental issues as risk factors and with the use of isopropyl alcohol for disinfection (χ2 test, P < .05). For example, 10% of respondents did not recognize that contaminated whirlpools can be a source of MRSA infection. Respondents also incorrectly identified effective cleaning solutions. Thirty percent of respondents cleaned their hands frequently or sometimes before treating each athlete and 35% cleaned their hands sometimes, occasionally, or never after seeing each athlete. Conclusions: The majority of ATs were informed about MRSA and made correct disinfection choices. However, improvements are still needed, and not all ATs were using proper disinfection practices.

Athletic opportunities for females have come a long way since the passage of Title IX in the USA in 1972, and the first Olympic women's marathon in 1984. More than three million girls participate in high-school sports each year in the USA; there have been consecutive increases in participation in the past 24 years. With a steady rise in participation, come the positives and negatives. The positives range from improved academic performance in school age individuals to enhanced well-being in older athletes, in addition to many other benefits that extend across the lifespan. Negative consequences are inevitable, but are largely preventable. In this issue, several articles highlight the impact of sports and exercise on the health of female athletes. Dr De Souza and colleagues1 review the existing literature and present guidelines on clearance …

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhoea and osteoporosis. This consensus statement represents a set of recommendations developed following the 1st (San Francisco, California, USA) and 2nd (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team and implementation of treatment contracts. This consensus paper has been endorsed by the Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians and other healthcare professionals, the American College of Sports Medicine and the American Medical Society for Sports Medicine.