DOI: 10.1097/jsm.0000000000001180 ISSN:

Higher Triad Risk Scores Are Associated With Increased Risk for Trabecular-Rich Bone Stress Injuries in Female Runners

Megan Roche, Aurelia Nattiv, Kristin Sainani, Michelle Barrack, Emily Kraus, Adam Tenforde, Andrea Kussman, Emily Miller Olson, Brian Kim, Katherine Fahy, Emily Miller, Elyse Diamond, Sonya Meraz, Sonal Singh, Aurelia Nattiv, Michael Fredericson
  • Physical Therapy, Sports Therapy and Rehabilitation
  • Orthopedics and Sports Medicine


Bone stress injuries (BSIs) in trabecular-rich bone are associated with greater biological risk factors compared with cortical-rich bone. We hypothesized that female runners with high Female Athlete Triad (Triad)-related risk would be at greater risk for trabecular-rich BSIs than runners with low Triad-related risk.


Prospective cohort study.


Two NCAA institutions.


Female runners were followed prospectively for up to 5 years.


The intervention consisted of team nutrition presentations focused on optimizing energy availability plus individualized nutrition sessions. Triad Cumulative Risk Assessment (CRA) categories were assigned yearly based on low-energy availability, menstrual status, age of menarche, low body mass index, low bone mineral density, and prior BSI.

Main Outcome Measures:

The outcome was the annual incidence of trabecular- and cortical-rich BSI. Generalized Estimating Equations (GEE, to account for the correlated nature of the observations) with a Poisson distribution and log link were used for statistical modeling.


Cortical-rich BSI rates were higher than trabecular-rich BSI rates (0.32 vs 0.13 events per person-year). Female runners with high Triad-related risk had a significantly higher incidence rate ratio of trabecular-rich BSI (RR: 4.40, P = 0.025) and cortical-rich BSI (RR: 2.87, P = 0.025) than women with low Triad-related risk. Each 1-point increase in Triad CRA score was associated with a significant 26% increased risk of trabecular-rich BSI (P = 0.0007) and a nonsignificant 14% increased risk of cortical-rich BSI (P = 0.054).


Increased Triad CRA scores were strongly associated with increased risk for trabecular-rich BSI. Incorporating Triad CRA scores in clinical care could guide BSI prevention.

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