Today's topic is on a lesser known topic that affects mainly younger athletes. Specifically, younger female athletes. The Female Athlete Triad is a common presentation of health issues that can arise in younger female athletes.
The Female Athlete Triad is categorised by three main types of health issues:
Low energy availability
Menstrual dysfunction
Poor bone health
Evidence among elite female athletes have suggested that the prevalence of clinical eating disorders ranges from 10-47%, compared to 10% in the non-athletic female population of the same age.
Common outward signs and symptoms include:
fatigue or chronic tiredness
frequent illnesses due to weakened immune function
Difficulty maintaing body weight despite regular eating
Increased irritability or mood swings
Poor athletic performance or a decline in endurance or strength
Irregular or absent periods
Delayed onset of menstruation
Lighter or less frequent menstrual cycles
Frequent stress fractures
Bone pain or tenderness
Early onset of osteoporosis or low bone mass
Difficulty healing from bone-related injuries
Low energy availability
Female athletes, particularly those participating in sports that emphasize leanness—such as ballet, gymnastics, figure skating, lightweight rowing, and running—are at an increased risk of developing eating disorders. This risk is often due to pressures to maintain a low body weight or inadequate nutritional guidance. In some cases, this can lead to a serious energy deficiency. However, understanding the difference between healthy and harmful dieting can help ensure athletes receive proper nutrition.
Healthy dieting involves a modest reduction in daily calorie intake, while harmful dieting, or disordered eating, includes restrictive behaviors like skipping meals, using laxatives, bingeing, and purging. Ideally, athletes should avoid dieting altogether and instead focus on maintaining a healthy body weight and the energy levels needed for optimal performance and function. Low energy availability can result from eating disorders or simply from not consuming enough calories to meet the high energy demands of their sport.
Menstrual dysfunction
When an athlete stops menstruating, it could be due to several factors, such as over-exercising, increased stress, or inadequate nutrition, all of which can lower estrogen and other hormone levels. However, other medical conditions, such as pregnancy, polycystic ovarian syndrome, and pituitary abnormalities, can also cause menstrual irregularities. Therefore, any menstrual dysfunction should be addressed by a doctor.
Common types of menstrual irregularities in female athletes:
• Primary amenorrhea: When a female has normal secondary sexual characteristics, such as breast development, but no period by age 15 or 16
• Secondary amenorrhea: The absence of menses for three or six months in a female who previously had menses
• Oligomenorrhea: Menstrual periods occurring at intervals greater than 35 days, with fewer than 9 periods in a year
• Functional hypothalamic amenorrhea: An absence of menses, commonly associated with exercise and stress (when other causes of absence of menses have been ruled out)
Poor bone health
Healthy athletes generally have higher bone mineral density compared to non-athletes, likely due to regular physical activity, particularly weight-bearing exercises that strengthen bones. However, athletes affected by the female athlete triad may experience reduced bone strength and density, leading to stress fractures or even early-onset osteoporosis.
Proper caloric intake helps maintain normal hormone levels, including estrogen, which is vital for building and maintaining bone density. Adolescence is a critical period for girls to receive adequate nutrition and maintain normal menstrual function, as 90% of a woman’s peak bone mass is achieved by age 18. If low bone mineral density is detected and treated early, it may be possible to regain bone mass. However, delayed treatment may result in permanently reduced bone density.
How does this relate to pain management and Physiotherapy?
In my practice, I have noticed that certain athletes taking longer than the usual timeframe for recovery. When this happens, I change up my treatment plan by finding out more about the context of the injury sustained. Often, over time and rapport formed with the patient, I will be able to determine more underlying causes that are most likely under-reported by the patient. Sometimes, these signs and symptoms will emerge during conversation organically, and it takes a keen ear to notice that these are signs and symptoms:
Signs and Symptoms to Look Out for in Patients with Female Athlete Triad:
Physical Signs:
Frequent stress fractures: Especially in weight-bearing bones like the shin, foot, or hip.
Recurrent injuries: Musculoskeletal injuries that take longer to heal than expected.
Reduced bone mineral density: May present as early osteoporosis or osteopenia (lower bone density than normal).
Muscle weakness: Decreased strength or endurance during exercises.
Chronic pain: Persistent pain in bones or joints, often without a clear cause.
Significant weight loss: Unintentional or rapid loss of weight.
Menstrual Changes:
Amenorrhea: Absence of menstruation for three months or more.
Oligomenorrhea: Irregular periods or cycles longer than 35 days.
Delayed menarche: Late onset of menstruation in adolescent athletes.
Nutritional Red Flags:
Restrictive eating behaviors: Avoiding certain food groups, skipping meals, or following extreme diets.
Obsessive focus on body weight: Preoccupation with weight, body shape, or food intake.
Fatigue or low energy levels: Complaints of chronic tiredness, especially during training.
Cold intolerance: Feeling cold frequently, which may indicate low energy availability.
Psychological Symptoms:
Mood changes: Increased irritability, anxiety, or depression.
Low self-esteem: Poor body image or dissatisfaction with appearance.
Increased stress: Pressure to perform in sport or achieve a certain body weight.
An injury for a highly competitive athlete can be a major setback, and this often can exacerbate the symptoms of the recent injury. Essentially, this creates a vicious cycle of injury and health issues from a need to perform at a high level:
Predisposition to injury from the pressure of having to 'look' or weigh a certain way
Sustaining an injury
Pushing through the injury
Injury then might develop as an acute-on-chronic injury
Worsening mental health with mounting pressure
Affected well-being, sleep and nutrition leading to poor injury recovery
There is a saying that 'it takes a village to raise a child', and the same principle applies for athletes wanting to perform at a high level. While Physiotherapists are able to manage injuries, physical biomechanical risk factors and perhaps even behavioural modifications, other medical issues facing athletes with this triad need support and attention from other healthcare providers. These providers include Psychologists, Orthopaedic doctors, Counsellors, and Chinese Physicians.
Role of Physiotherapy in Managing Female Athlete Triad:
Education and Awareness: Educating athletes about the importance of balanced nutrition, adequate energy intake, and recognizing early signs of the triad. This includes guidance on healthy eating habits, exercise moderation, and the potential risks of overtraining.
Exercise Modification: Creating a progressive exercise program that reduces the risk of injury and stress fractures while promoting bone health and overall well-being. This may involve reducing the intensity or volume of training, incorporating rest days, and focusing on weight-bearing exercises that support bone density.
Injury Prevention and Management: Identifying and addressing movement patterns or biomechanical issues that could contribute to injuries, such as stress fractures or muscle strains. Physiotherapists may provide specific exercises to improve strength, flexibility, and balance.
Rehabilitation: For athletes who have experienced stress fractures or other injuries, physiotherapy helps with rehabilitation, focusing on gradually restoring strength, range of motion, and function. A gradual return-to-sport plan is often necessary to avoid further complications.
Monitoring and Support: Physiotherapists can monitor the athlete’s progress, ensuring they maintain adequate energy levels and are not overtraining. Regular check-ins help to assess bone health, menstrual function, and overall well-being.
Key takeaways:
Menstrual dysfunction can lead to infertility
Younger female athletes may experience decreased immune function
Many athletes with low bone mineral density or menstrual irregularities suffer from stress fractures more frequently
Low energy availability can lead to nutritional deficiencies, impair the body’s ability to build bone, maintain muscle mass, and recover from injury.
A vicious cycle starting with injury, pushing through pain, resulting in worsening physical/mental state can arise
Muskuloskeletal injury risks increase exponentially if not addressed in a timely manner
References
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Bevers, K., Watts, L., Kishino, N. D., & Gatchel, R. J. (2016). The biopsychosocial model of the assessment, prevention, and treatment of chronic pain. touchREVIEWS in Neurology, 12(02), 98. https://doi.org/10.17925/usn.2016.12.02.98
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Di Lorito, C., Long, A., Byrne, A., Harwood, R. H., Gladman, J. R., Schneider, S., Logan, P., Bosco, A., & Van Der Wardt, V. (2021). Exercise interventions for older adults: A systematic review of meta-analyses. Journal of Sport and Health Science/Journal of Sport and Health Science, 10(1), 29–47. https://doi.org/10.1016/j.jshs.2020.06.003
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