What is the Female Athlete Triad?

Patient Presentation
A 19-year-old female came to clinic when she was home from college over Thanksgiving break. She complained of several months duration of bilateral shin pain. She denied acute injury
She was a dance performance major and said the pain persisted for several hours after rehearsal with occasional pain in the morning.
The past medical history reveals depression and she was currently taking anti-depressive medication.
The pertinent physical exam revealed a well-appearing female. She was 5 foot 6 inches tall, and weighed123 pounds (body mass index = 20.0). HEENT and skin were normal. She had full range of motion in hips, knees and ankles. There was significant tenderness to palpation along the entire medial aspect of both tibiae.
There was less discomfort over the anterior tibiae with normal strength with ankle dorsiflexion and plantar flexion. Lumbosacral spine was normal and there was normal sensation in the lower extremities.
The radiologic evaluation revealed no abnormalities or fractures on bilateral anterio-posterior and oblique tibia-fibula radiographs.
Furthur history revealed that the patient has been being pressured from her instructors to lose weight. She described binge eating and using laxatives with a >15 pound weight gain since the beginning of the academic year. She has no vomiting behaviors.
She has dance classes several times/day with additional workouts.
She has been in counseling for her depression for 15 months but has not told her counselor about the pressure from her instructors, nor the disordered eating.
She has had amenorrhea for the past 6 months with a previous history of normal menses.
The physician suspected the diagnoses of medial tibial stress syndrome and female athlete triad. He recommended long-leg pneumatic splints, non-steroidal anti-inflammatory medication and limiting her activities (which she said she could not do because of immediate performance demands).
He also recommended continued counseling with her current therapist with disclosure of the disordered eating and feelings of pressure from instructors. He also recommended discussing these issues with her instructors.
Additionally, she was instructed to not restrict her diet, take a calcium supplement and was referred to a nutritionist. A bone mineral density test performed later confirmed mild osteoporosis.
Despite having some set backs and not being able to implement all of the plan initially, the patient’s clinical course at the end of 5 months showed her with minor medial tibial pain, ongoing therapy with her counselor and support from her instructors, no binging and purging episodes but some continued caloric restriction. Her menses had returned but were irregular.

Hopefully all children and adolescents live active lives, but activity may lead to injuries. Underconditioned or de-conditioned children are at increased risk of injury. In prepubertal children, the soft tissues are stronger than their muscular insertions or growth plates and therefore fractures are common. In skeletally mature adolescents, soft tissue injuries predominate.
Trauma often can be found in the history but a health care provider also needs to remember that a healthy child or adolescent can also have other disease processes like any child can.
For example, an ice skater could have hip pain from falling on the ice or Legg-Perthes disease.

Learning Point
Female athlete triad describes physically active girls and women who also have amenorrhea, osteoporosis, and disordered eating.

Girls and women benefit from sports participation just as males do. With the increasing number of girls and women participating in sports, the triad is being more frequently recognized.
Although anyone could have the triad, it is more common in sports involving endurance that emphasizes leaness (e.g. distance running, etc.), weight categories for participating (i.e. rowing, etc.), those emphasizing pre-pubertal body habitus (e.g. gymnastics, skating, etc.), those with body contour-revealing clothing (e.g. dance, weight lifting, swimming, etc.)

The disordered eating may present with any variation including preoccupation with food, exercise or body image, caloric restriction, fasting, binging, purging or combinations. The problems are not limited to strict anorexia nervosa or buliminia nervosa patterns.
The amenorrhea may range from oligomenorrhea to primary or secondary amenorrhea. Secondary amenorrhea occurs in 3-66% in female athletes compared to 2-5% of the general population.
Osteoporosis is caused by impaired bone formation, premature bone resorption or both. During adolescence, a normal female gains more than 50% of her adult skeletal mass and 15% of her adult height. Peak bone mass is between 18-25 years with bone mass being lost at a rate of 0.3-0.5% annually. With oligomenorrhea, the adolescent is actually at risk of losing 2% of bone mass annually when she should be gaining bone mass.

Treatment includes nutritional counseling for appropriate caloric ingestion. Adolescent athletes need extra calcium, protein and carbohydrates. Extra calcium (1500mg total/day) is recommended instead of the normal 1200 mg/day for non-athletes.
Use of estrogen-progesterone combination medications may also be used to increase bone mineral density but this is recommended for skeletally mature athletes only.
Increased nutrition and appropriate weight gain usually corrects the amenorrhea.

Prevention includes education of athletes, parents, coaches, trainers etc. about proper nutrition, training practices and warning signs of the triad.
Psychological pressure to conform to an ideal standard is counterproductive for an athlete to be in top performing condition.

Questions for Further Discussion
1. What are the indications for a bone mineral density scan?
2. Can female athlete triad be also found in male athletes?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MEDLINEplus for these topics: Eating Disorders, Osteoporosis, Menstruation and Sports Fitness
and at Pediatric Common Questions, Quick Answers for this topic: Compulsive Exercise and Eating Disorders.

To view current news articles on this topic check Google News.

Lerand SJ, Williams JF. The Female Athlete Triad. Pediatr Rev. 2006;27:e12-e13.

Mier RJ, Brower TD. Pediatric Orthopedics, A Guide for the Primary Care Physician. Plenum Medical Book Co. New York. 1996;226.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa
    Dr. D’Alessandro would also like to thank Dr. George Phillips, Assistant Professor of Clinical Pediatrics for his assistance with this case.

    April 3, 2006