Female Athlete Triad Risk Factors Are More Strongly Associated With Trabecular-Rich Versus Cortical-Rich Bone Stress Injuries in Collegiate Athletes

BACKGROUND: Bone stress injuries (BSIs) are common in athletes.

Risk factors for BSI may differ by skeletal anatomy and relative contribution of trabecular-rich and cortical-rich bone.

HYPOTHESIS: We hypothesized that Female Athlete Triad (Triad) risk factors would be more strongly associated with BSIs sustained at trabecular-rich versus cortical-rich skeletal sites.

STUDY DESIGN: Cohort study; Level of evidence, 2.

METHODS: The study population comprised 321 female National Collegiate Athletic Association Division I athletes participating in 16 sports from 2008 to 2014.

Triad risk factors and a Triad cumulative risk score were assessed using responses to preparticipation examination and dual energy x-ray absorptiometry to measure lumbar spine and whole-body bone mineral density (BMD).

Sports-related BSIs were diagnosed by a physician and confirmed radiologically.

Athletes were grouped into those sustaining a subsequent trabecular-rich BSI, a subsequent cortical-rich BSI, and those without a BSI.

Data were analyzed with multinomial logistic regression adjusted for participation in cross-country running versus other sports.

RESULTS: A total of 19 participants sustained a cortical-rich BSI (6%) and 10 sustained a trabecular-rich BSI (3%) over the course of collegiate sports participation.

The Triad cumulative risk score was significantly related to both trabecular-rich and cortical-rich BSI.

However, lower BMD and weight were associated with significantly greater risk for trabecular-rich than cortical-rich BSIs.

For every value lower than 1 SD, the odds ratios (95% CIs) for trabecular-rich versus cortical-rich BSI were 3.08 (1.25-7.56) for spine BMD; 2.38 (1.22-4.64) for whole-body BMD; and 5.26 (1.48-18.70) for weight.

Taller height was a significantly better predictor of cortical-rich than trabecular-rich BSI.

CONCLUSION: The Triad cumulative risk score was significantly associated with both trabecular-rich and cortical-rich BSI, but Triad-related risk factors appeared more strongly related to trabecular-rich BSI.

In particular, low BMD and low weight were associated with significantly higher increases in the risk of trabecular-rich BSI than cortical-rich BSI.

These findings suggest Triad risk factors are more common in athletes sustaining BSI in trabecular-rich than cortical-rich locations.