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Female Soccer Players At Risk for Stress Fractures, Long-Term Health Problems: Study

One in five reported irregular menstual cycles, while 14% had stress fractures in past year

Elite female soccer players are at risk for menstrual irregularities and stress fractures from the combination of intense training and insufficient nutrition, says a new study.1 Female soccer player running

Researchers recruited 220 female soccer players from nationally ranked clubs in the St. Louis area, an NCAA Division I university and a professional soccer team with an average of 16 and asked them to fill out a questionnaire about the age of their first menstrual period (menarche), menstrual history, and history of any musculoskelatal injury, including stress fracture, and to answer questions about their body perception and attitudes towards eating using an Eating Attitudes Test.

They found that:

  • Irregular menstrual cycles (fewer than 28 days or more than 34 days) were reported by
    • 19 percent of the 15-17 age group
    • 18 percent of college athletes
    • 20 percent of the pros.
  • Stress fractures (tiny cracks in the bone caused by overuse which are too small for detection by x-rays but which can be seen with an MRI scan) were reported in 14.3% of all athletes, with the majority occurring in the ankle and foot. 
  • Most scored in the normal range on the test of eating attitudes, with only one player scoring in the high risk range and 8.8% scored in the potentially at risk range on the test of body perception and eating attitudes, which assesses the risk of eating disorders.

Elite female soccer players are thus at risk for delayed onset of menarche, menstrual dysfunction, and stress fractures, concluded the study's authors, despite reporting appropriate body perception and attitudes towards eating.  The likely culprit: a failure to consume the appropriate high-calorie diet.  

First to study female athlete triad in soccer players

The female athlete triad consists of three interrelated conditions: disordered eating, menstrual irregularity/absence of menstration, and osteoporosis.  Athletes in so-called "aesthetic sports" (gymnastics, dance, figure skating) and endurance sports (running, marathon, triathlons) have long been considered to be at risk for developing disorders related to the condition, but the prevalence of and risk factors for the female athlete triad has not been previously studied in soccer, despite the sport being the most-played sport by girls in the U.S. as far as sheer numbers. 

Researchers expected to find that elite female soccer athletes would have low rates of menstrual dysfunction, disordered eating attitudes, and stress fractures, but were surprised by the high rates reported by athletes of menstrual irregularity and stress fracture. 

"Girls who have menstrual dysfunction are at risk for long-term health problems," Prather said in an interview with MSNBC. "When you have menstrual dysfunction and you are not regularly having a period, your body is not receiving the appropriate amount of estrogen load it should."  Too little estrogen can impact bone health, leading to the bone-thinning disease, osteoporosis.  The "relatively high and even alarming rate of stress fractures" were also a concern, said Dr. Mininder Kocher, associate director of the division of sports medicine at Children's Hospital Boston.

The message for female athletes and their coaches, said lead author, Heidi Prather, MD, associate professor and chief of the physical medicine and rehabilitation section at Washington University School of Medicine in St. Louis, is to make sure they are not compromising their long-term health in their desire to achieve excellence in sports. 


  • Balanced Diet. First, and foremost, a proper balance of exercise, body weight, calcium intake, Vitamin D (400 IU's daily) and estrogen is critical to prevent osteoporosis (1500 mg. of calcium if irregular menses, 1200 mg. if regular periods, either via 3 to 4 dairy products a day or supplements). If necessary, you should take your daughter to a dietician or nutritionist who works with adolescent athletes.
  • Screening. To screen for the triad, make sure your daughter undergo a pre-participation physical evaluation. It is essential that, in taking the medical history, your daughter's pediatrician asks questions about nutrition, menstruation, evidence of bone mineral loss (stress fractures; Dual Energy X-Ray Absorptiometry scan), and body image . Because athletes tend to be more honest about menstrual history and are typically dishonest about eating patterns, an abnormal menstrual history is a red flag for eating disorders and psychological issues (this is why your daughter should keep track of her periods).
  • No Pressure. As a parent you should avoid pressuring your daughter to achieve an unrealistically low body weight, such as by comments about appearance, good or bad foods, dieting and nutrition (this advice holds true for your sons as well, particularly swimmers and wrestlers) You should be wary of coaches who conduct out-of-competition weigh ins or measurement of body fat, especially public ones which can highlight for teenage girls the already sensitive issue of their weight (one prominent Southern California swim club that counts among its alumni numerous Olympic gold medal winners labeled members with what it deemed too high a body fat ratio as members of the "Blub Club"). One eating disorder specialist theorizes that a relationship exists between eating disorders and girls going through the natural separation in adolescence of girls from their fathers because they are particularly vulnerable during this time to viewing their coach as a substitute father figure. Because girls tend to internalize criticism more than boys, if the coach is critical of her weight, he or she can have a negative effect on a female athlete's self-esteem.
  • No Secrets. Fourth, if you suspect that your daughter exhibits symptoms of one or more elements of the triad, let her know that you want to help but that you can't keep the matter a secret, nor can you solve the problem on your own. If she is found to have disordered eating, experts recommend a multidisciplinary treatment approach (doctor, nutritionist, mental health professional).

Above all, be patient. Don't engage your daughter in a test of wills.

1.  Prather H, McKeon K, Hunt D, Brophy R. The Female Triad (Menstrual Dysfunction, Eatting Attitudes, Stress Fractures) in Soccer Athletes. http://www.abstractsonline.com/Plan/ViewAbstract.aspx?mID=2841&sKey=cb7f... (Presented to American Academy of Orthopaedic Surgeons, February 7, 2012). [Note: Research presented at medical meetings should be considered preliminary until published in a peer-reviewed medical journal].

Posted February 14, 2012