Female Athlete Triad Physical Therapy
Female athlete triad involves three interrelated conditions: energy availability, bone mineral density, and the menstrual cycle. Energy availability is the cornerstone of the triad as low energy and nutrient deficiencies can lead to the development of low bone density and changes in the menstrual cycle in female athletes. Physical therapy can help to prevent or resolve female athlete triad, screening for triad risk as they treat female athletes, identify signs, address triad-related injuries, and educate athletes on proper health and fitness for their overall health and athletic training.
What is the Female Athlete Triad?
Female athlete triad involves three interrelated conditions: energy availability, bone mineral density, and the menstrual cycle. Energy availability is the cornerstone of the triad as low energy and nutrient deficiencies can lead to the development of low bone density and changes in the menstrual cycle. While female athlete triad can affect college and elite professional female athletes, it is most common among high school female athletes. Recent studies have shown that among female high school athletes, 36% had low energy availability, 54% had menstrual abnormalities, and 16% had low bone mineral density (BMD).
The three factors of the female athlete triad involve:
Energy Availability: Energy availability is the cornerstone of the triad as complications from low energy availability lead to the other two factors and has widespread physical and psychological impacts. Energy availability is defined as an individual’s dietary energy intake minus the energy expended during exercise. The remaining energy is used for other bodily functions. Low energy availability can be caused by a diagnosed eating disorder, temporary use of abnormal eating patterns to change the body’s appearance or lack of good nutrition during training. It can also occur inadvertently if the athlete’s energy demands are exceeding her caloric intake. Low energy availability can lead to a diminished ability to recover from injury, an inability to build or maintain muscle mass, impaired menstrual function or infertility, and an increased risk of cardiovascular disease.
Bone Mineral Density: Bone mineral density, or BMD, describes the quality and strength of an individual’s bones. If bones are overstressed by too much exercise or do not get the nutrients and hormonal support they need, abnormal changes can occur to the bone structure. When this occurs, the bones begin to lose density with can lead to osteopenia, or lower than normal BMD, and eventually osteoporosis if left untreated. This predisposes the female athlete to an increased risk of stress fractures as well as long-term bone mineral loss.
Menstrual Cycle: The menstrual cycle refers to the regularity of a woman’s period. Dysfunction refers to absent or abnormal menstrual periods. Amenorrhea is defined as the absence or cessation of menstrual flow and is reflected in a decrease in the number of menstrual cycles per year. Other menstrual dysfunctions include luteal phase deficiency, anovulation, or oligomenorrhea. Menstrual dysfunction typically results in female athletes due to low energy availability, which causes the body to limit or eliminate the period to conserve energy.
When coupled with inadequate nutrition, the high caloric expenditure of exercise training results in a sustained negative caloric balance or low energy availability, which is sensed by the hypothalamus, initiating a complex neuroendocrine adaptive cascade. This cascade is associated with changes in the hypothalamic-pituitary-ovarian axis, such that estrogen levels are decreased, resulting in reproductive and menstrual dysfunction. This lack of estrogen further negatively impacts bone density as estrogen provides a protective effect on bone by inhibiting the function of bone breakdown.
Signs and symptoms of female athlete triad can develop over months and even years and affect the female athlete both medically and in athletic performance. Medical symptoms of female athlete triad include eating disorders, irregular or absent periods, low energy at school, work, or exercise, stress fractures and bone injury, anemia, fluid and electrolyte imbalances, low estrogen, cortisol dysregulation, thermoregulatory issues, cardiac instability, chronic pain, decreased healing ability, and insomnia.
Performance-related symptoms include decreased concentration, fatigue, lightheadedness, decreased muscle contraction rate and reaction time, increased risk of skeletal muscle and bone injuries, atrophy and loss of lean body mass, decreased strength, power, and endurance, dehydration, decreased delivery of oxygen and blood flow to muscles, increased healing time, glycogen depletion, and stress fractures.
Physical Therapy’s Role in Female Athlete Triad Treatment
Physical therapy can help to prevent or resolve female athlete triad, screening for triad risk as they treat female athletes, identify signs, address triad-related injuries, and educate athletes on proper health and fitness for their overall health and athletic training. A physical therapist works with and refers to a multidisciplinary group of medical professionals to provide the best care for the female athlete, including primary care doctors, sports nutritionists, athletic trainers, and sports psychologists.
The goal of treatment of the female athlete triad is to re-establish the menstrual cycle and enhance bone mineral density through changes in exercise training, improving diet and nutritional intake, and increasing overall energy availability. This is accomplished through nutritional counseling and education, modification of unhealthy behaviors and overtraining, and addressing any biomechanical factors that contribute to bone stress.
A physical therapist plays a key role in managing triad-related stress injuries, assessing and altering training regimens, designing a safe exercise program, and providing biomechanical and sport-specific training to reduce injury risk. The physical therapist offers patient education to the athlete on gradually increasing training to minimize stress on the body and allow the body to adjust to the stresses exercise places upon it. The therapist also assesses jumping and landing techniques and helps the athlete build core and hip muscle strength and improve neuromuscular control for improved athletic performance. The therapist also creates a safe return-to-play program for the athlete as they heal from a triad-related injury or energy deficiency.
To prevent female athlete triad:
Maintain a healthy, balanced, and nutritious eating plan for good energy availability.
Implement smart physical training that adapts to the athlete’s needs or is built around energy levels throughout the female menstrual cycle.
Ensure proper rest, recovery, and good sleep, especially during the competitive season.
Should injury occur during the season, work with your doctor and physical therapist from the outset to maximize your recovery and return to sport safely.
Work with your coach to track your athletic training and performance as this allows both athlete and coach to notice any performance or physical symptoms of the female athlete triad early.
Are you a female athlete experiencing female athlete triad? Our physical therapists are here to support you and work with a team of doctors to help you regain optimal health and sports performance safely!
