What does it take to be an award winning research paper? At the 2016 American Medical Society for Sports Medicine (AMSSM) Annual Meeting, it takes finding a gap in one of the hottest new risk assessment tests for the female athlete—The Female Athlete Triad Cumulative Risk Assessment stratification tool.
This year’s award winning study by Erin Hammer, M.D., Primary Care Sports Medicine Fellow at the University of Wisconsin School of Sports Medicine and Public Health, found that the Female Triad Cumulative Risk Assessment may not be the most useful instrument for determining future stress fractures in female cross-country college athletes.
Instead, said Dr. Hammer, the assessment test needs streamlining and at least one additional piece of information.
The National Collegiate Athletic Association (NCAA) research award was presented to Dr. Hammer at the 2016 American Medical Society for Sports Medicine Annual Meeting in April. Her research presentation generated much discussion about the Female Athlete Triad, which has been examined from a variety of angles since it was named in 1992.
Stress fractures have been a growing risk for female athletes who participate in sports like cross-country running, gymnastics, soccer and others that require speed and endurance. For years, doctors and professionals have noticed that these athletes in particular have three interrelated and dynamic conditions that are influenced by diet and exercise: energy availability, menstrual dysfunction and bone health. “These three components of the Female Athlete Triad can lead to a variety of different problems that exist on a spectrum, including anorexia, osteoporosis, stress fractures, depression and other concerns, so they are hard to track, ” Hammer said.
In 2014, a coalition of sports medicine professionals and doctors developed a consensus statement and guidelines for identifying and treating the Female Athlete Triad. Hammer’s research is among the first to review the Cumulative Risk Assessment tool. The tool uses a risk stratification algorithm and point system to guide physicians when they are determining whether athletes can play or return to play. It also highlights the importance of using a multi-disciplinary team approach when treating athletes and outlines when they should see other medical professionals, Hammer said.
In the paper titled, “Association between Female Athlete Triad Cumulative Risk Assessment and in-season stress fracture in collegiate cross-country athletes, ” Hammer and colleagues (M. Alison Brooks, M.D.; Alyson Kelsey, LAT; Jennifer Sanfilippo, LAT; Kathleen Carr, M.D.) set out to determine if risk stratification using the Female Athlete Triad Cumulative Risk Assessment (CRA) published in the 2014 Consensus Statement on the Female Athlete Triad is associated with the development of stress fractures in collegiate cross-country athletes.
The team reviewed the pre-participation questionnaires of 50 Division 1 female collegiate cross-country athletes during the 2014-2016 seasons to determine the CRA score for dietary history, body mass index, menstrual history, bone mineral density, and stress fracture history. Subsequent in-season stress fractures were documented in weekly injury reports. The Mid-p exact test was utilized to determine the association between risk stratification and the stress fracture development.
They found that 19 athletes (38%) were “low risk”, 31 athletes (62%) “moderate risk, ” and no athletes were “high risk” as stratified by the CRA. Eight moderate risk athletes developed 12 stress fractures during the season. Three low risk athletes developed four stress fractures. There was no significant association between risk stratification score and stress fracture. Seven of 11 athletes with a history of stress fracture developed subsequent stress fractures during the season, which was a significant association.
“This tells us that a history of stress fracture was closely related with developing a new one, which isn’t all that surprising since a history of a condition is the biggest predictor in developing that condition again, ” Hammer said. “As a result, we recommend the tool be changed to more heavily weight a history of stress fractures, though our study doesn’t take into account all of the possible conditions associated with the Female Athlete Triad.”
The research team also found the tool to be difficult to use because it included several lines of additional instructions for some of the identifiers. “The tool would be challenging to use on a mass basis, like at the beginning of the season, ” Hammer said. “There are just so many little notations all over the table that make it hard to use unless you really study the tool. It could be simplified to make it more user-friendly.”
Hammer said some colleges have begun using the tool, but it hasn’t been widely implemented. “Our university has not implemented it as a protocol, largely in part because it hasn’t been tested and then proven to be effective in terms of identifying athletes at risk. When you look at our outcomes, two-thirds of our cross country athletes would have been identified as moderate risk, and per the consensus statement all of those athletes should be evaluated by a dietician, by a physician and by a psychologist. At our university, even with all of our resources, that would be pretty hard to do. In smaller universities, without those resources, it would be impossible.”
“One of the conclusions from our study was that either the recommendations in the statement need to be less rigid and account for the fact that there are differences in the way the universities are structured and the resources within those universities, or the tool needs to be modified to be more specific, ” Hammer continued. “As it is, it was relatively sensitive, but it wasn’t very specific. However, someone needed to develop this tool and the authors developed a very elegant tool to help our female athletes, but it deserves to be studied and to be modified to be better.”
Hammer and her team also looked at the use of oral contraceptives and realized this was an area that could be further studied and developed. Seven athletes used oral contraceptive pills; two had been prescribed them for amenorrhea. “If we assigned additional points for amenorrhea to those athletes, one would have been classified as high risk, ” Hammer said. “She developed two stress fractures during the season.” Regardless of the reason contraceptives are prescribed, their use could mask amenorrhea in susceptible athletes, which could significantly alter the CRA score and recommended treatment.
The CRA could possibly be improved by assigning more weight to history of stress fracture and addressing confounders, Hammer said. “Additionally, it is unclear how often we should screen female athletes for the Female Athlete Triad. We also don’t know how well the CRA tool performs in low-risk populations.”
“I think that we came to some interesting conclusions, and I think people wanted to hear those conclusions, ” Hammer said of the research. “It sparked a lot of debate, which is always important in academia.”
