(Scientific Session) Female Athlete Triad and Risk of Non-Bone Stress Overuse Musculoskeletal Injuries in Collegiate Athletes

Background and/or Objectives: The association between the female athlete triad and non-bone stress overuse injuries is poorly understood. This study aimed to elucidate the relationship between the female athlete triad and overuse musculoskeletal injuries in female athletes.

Design: Retrospective cohort study

Setting: Single academic institution

Participants: National Collegiate Athletic Association Division I Female Athletes

Interventions: Not applicable

Main Outcome Measures: Overuse musculoskeletal injuries

Results: 235 athletes who completed pre-participation examinations and dual-energy x-ray absorptiometry scans were assigned female athlete triad risk scores. 57% of athletes (n=134) sustained at least one overuse musculoskeletal injury, including bone stress injuries (BSI), while 51% (n=119) sustained at least one overuse musculoskeletal injury excluding BSIs. Athletes with a higher triad score were more likely to sustain at least one overuse musculoskeletal injury (relative risk [RR] from Poisson regression model per 1-point higher risk score on a 0 to 12 scale: 1.11; 95% confidence interval [95% CI]: 1.05-1.18). However, this association was primarily related to the increased risk of BSIs (RR: 1.29; 95% CI: 1.18-4.0). After excluding BSIs, athletes with a higher triad score were not at an increased risk of overuse musculoskeletal injuries (RR: 1.03; 95% CI: 0.96-1.11). These associations were unchanged when adjusting for sport type: endurance (i.e. running, swimming, crew), other low energy availability (EA) risk sports including aesthetic and weight class sports (i.e. gymnastics, sailing) and sports with low risk of low EA (i.e. ball sports). When controlling for triad risk score, participants in aesthetic sports (n=30) had an increased risk of non-BSI overuse injuries (RR: 2.04; 95% CI: 1.41-2.96) compared to athletes in low EA risk sports (n=111).

Conclusions: Female athlete triad risk score is associated with increased risk of bone-stress injuries but not other overuse musculoskeletal injuries. Athletes in aesthetic sports had a higher risk of non-BSI overuse injuries than athletes in sports with low risk of low energy availability.