Although exercise is essential for building and maintaining bone mass, in some cases, it can potentially take a negative toll on bone health.


J. Lindsay Quade, MD

“Young female athletes are at risk for Female Athlete Triad, or relative energy deficiency in sports syndrome (RED-S),” says
J. Lindsay Quade, MD , instructor in internal medicine and primary care physician specializing in sports medicine. “We need to watch for this syndrome in men too, but it is more commonly seen in women. Women who suffer from this aren’t having their menstrual periods and, therefore, they’re not getting the benefits of estrogen, which is important for bone health.”

Female Athlete Triad was first recognized in 1997 by the American College of Sports Medicine as a syndrome with three components: energy availability, menstruation and bone health (J Acad Nutr Diet 2016;116:74). Men also are susceptible to the effects of insufficient energy availability. In 2014, the International Olympic Committee introduced an alternative term, RED-S, to encompass symptoms related to energy deficiency that can occur in all athletes, including men. Women, however, have the compounded effects of abnormal menstruation.


Rebecca Northway, MD

“In female athletes who push themselves too much or who do not have sufficient caloric intake to match energy expenditure, there can be a lack of periods because of low body weight,” says Rebecca Northway, MD, instructor in internal medicine and primary care physician specializing in sports medicine. “Therefore, it’s really important to screen young female athletes to see if they’re at risk. In addition, we often think about bone health in older patients because there is an emphasis on osteoporosis in elderly women, but it’s also important to focus on bone health in younger women.”

Quade adds, “I make it a point to talk about exercise and bone health with all of my patients who come in for their annual visits, just as much as we talk about mammograms, Pap smears and colonoscopies.”

For young women in high school or college who are set to join an athletic team, pre-participation physical examinations and questionnaires can be used to screen for potential risk factors related to Female Athlete Triad.

“These tools look at menstrual periods and the history around them, such as the age when they started and how often they occur,” Northway says. The risk assessment also includes measuring the athlete’s body mass index and asking her whether she worries about her body image or weight.

Northway adds, “It’s also important to determine if these women have ever had or are dealing with an eating disorder, or if they have a medically necessary dietary restriction or an absorption problem, such as celiac disease or inflammatory bowel disease.”

cic_jointFinally, asking athletes about past or current stress fractures is an indicator of potential risk.

“Once we have identified an athlete at risk, we risk stratify to see if we need to have them on provisional clearance for sports, restrict them from a certain aspect of their sport, or—the worst-case scenario—prohibit them from participation in their sport entirely,” Northway says. “For any athlete—and I speak from personal experience as an athlete who has been injured—it’s very difficult to sit on the sidelines.”

Restricting physical activity or participation in sports in someone who does not have a physical injury can be even more challenging.

“We need to get buy-in from the athlete,” Northway says.

Quade and Northway have an array of multidisciplinary resources available to aid in the diagnosis and treatment of these patients. Nutritionists and behavioral health specialists are essential in managing the spectrum of symptoms, as well as the University of Michigan Fragility Fracture Clinic, part of the University of Michigan Comprehensive Musculoskeletal Center.


Karen Cummings, PA-C

The clinic helps patients with bone fractures that fracture from a low-energy or ground-level fall. If Quade and Northway feel a patient they are seeing may have bone fragility, they work with Karen Cummings, PA-C , physician assistant in orthopaedic surgery and fragility fracture program coordinator, and her team to have the patient seen in the clinic.

“Most female athletes scheduled in our clinic have had running-related stress fractures,” Cummings says. “Not all patients have a bone density deficit, eating problem or menstrual disruption. But, these issues need to be ruled out. Sometimes, the sheer amount of training and biomechanics of the individual may be contributors to a fracture.”

Quade and Northway explain helping patients with bone health requires time from both the patient and physician, but is a rewarding process.

“I see my role in helping patients maintain bone health as twofold,” Quade says. “One, as a primary care doctor, because of the importance of preventive health care, and also from a sports medicine perspective, in terms of being comfortable with making exercise recommendations.”

Even with the most supportive resources, treatment can be tough, but helping patients achieve and maintain optimum bone health is a fundamental part of their clinical practices.

“It’s not an easy, quick visit when you’re discussing these things,” Northway says. “It takes a lot of time and a good relationship between the patient and the physician.”



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