Move Forward Guide
Physical Therapist's Guide to
Female Athlete Triad
Female Athlete Triad is a syndrome that involves an unbalanced relationship among a female athlete's energy levels, bone mineral density (BMD), and menstrual function that can lead to a series of health concerns. Female Athlete Triad can have negative effects in the early stages of its development, and have long-term effects on overall health and well-being as females age.
What is Female Athlete Triad?
Female Athlete Triad is a syndrome that can manifest across a broad spectrum, but involves the interplay between three measurable factors: how much energy you have available to use for activity, the quality and strength of your bones, and your menstrual cycle. Clinically, imbalances in any one of these areas can lead to eating problems, osteopenia/osteoporosis, and/or menstrual dysfunction. The Triad has been described as a syndrome that involves both the physical and mental aspects of health.
Energy availability is calculated by how much energy you gain from dietary sources minus the amount of energy that you expend during activity. Typically with the Triad, poor energy availability is the driving force behind abnormal BMD and menstrual dysfunction. Nutrients act to provide the necessary source of fuel for bones and muscles. Poor nutrition can also have a negative effect on the part of the brain that controls hormones that regulate the menstrual cycle.
Bone mineral density defines one aspect of bone health. When your bones are not supplied with necessary nutrients or are stressed too much through overexercising, they may begin to weaken. This can lead to osteopenia (lower than normal BMD) and further, osteoporosis (a loss of bone strength that predisposes a person to increased risk of fractures). When a person has low BMD, she may be at an increased long-term risk of bone mineral loss and fracture as she ages.
Menstrual dysfunction refers to abnormal menstrual periods. This spectrum can range from eumenorrhea (normal menstruation) to oligomenorrhea (inconsistent menstrual cycles) to amenorrhea (absence of a menstrual period) in females who are of a reproductive age.
Female athletes are at an increased risk of developing the Triad due to the high demand that athletics place on the female body physically, as well as the increasing societal pressures for performance and image. For example, a female runner may feel that altering or restricting caloric intake will make her a faster runner, therefore gaining an edge on the competition and earning greater success in her sport. The Triad can be present in any female athlete, from the elite athlete striving to reach high-performance goals, to the adolescent female whose body is going through normal changes related to puberty. In any case, there are physical and psychological aspects of this syndrome that affect its extent, impact, and treatment.
How Does it Feel?
The Triad is not caused by a sudden traumatic injury, so there are typically no immediate symptoms. Instead, symptoms related to the 3 components of the Triad may develop over time, ranging from months to years.
A female athlete may begin experiencing the following symptoms, conditions, or changes (separately or together) that may indicate she is developing Female Athlete Triad:
- Low energy during school, work, or exercise
- Irregular or absent menstrual cycles
- Stress-related bone injuries (stress reactions or fractures)
- Difficulty concentrating
- An unexplained drop in performance
- Changes in eating habits
- Altered sleeping patterns
- An unusually high focus on performance or image
- Experiencing high levels of stress
How Is It Diagnosed?
A multi-disciplinary team of medical providers typically diagnoses Female Athlete Triad. The team may include medical doctors, nutritionists, physical therapists, certified athletic trainers, and psychologists. However, nonmedical individuals, such as parents, friends, coaches, teammates, teachers, and work colleagues can also be resources to help identify female athletes who demonstrate signs of the Triad, as these are all people who spend time with the athlete.
If it is suspected that an athlete may be demonstrating 1 or more components of the Triad, various medical and psychological tests and consultations may be recommended, including:
- Diagnostic imaging of bone health: x-ray, bone density scan (DEXA), MRI
- Referral to a nutritionist for dietary assessment
- Referral to a primary care/family medical doctor for monitoring of menstrual function or related medical tests (blood tests, assessment of the natural stages of development, such as the onset of puberty, etc.)
- Referral to a physical therapist for functional assessment (motion, strength, movement quality)
- Because the Triad involves multiple components of health, an athlete who is able to receive care from all relevant health care practitioners has the best chance of developing a comprehensive plan to return to good health and athletic participation/performance.
How Can a Physical Therapist Help?
Physical therapists are trained to identify signs and symptoms of the Female Athlete Triad and initiate multidisciplinary care as appropriate and needed. They are also trained to understand the implications that the Triad may have on exercise prescription. For example, it would not be recommended that an athlete with a stress fracture due to low BMD perform jumping and running activities. Once an athlete's symptoms are resolved, her physical therapist will be able to design an individualized return to activity program that encourages a safe, progressive level of activity. Physical therapists are trained to educate athletes and their families on the Female Athlete Triad, and work with athletes to prevent or resolve the condition, and guide the athlete back to safe, optimal performance levels. In many cases, this attention to and care for a female athlete's overall health can improve performance in school and athletics, and even overall self-esteem. Many athletes report that they are more confident, stronger, and better equipped to achieve their goals when they feel they have a strong support and a plan for sustained health.
Can this Injury or Condition be Prevented?
The Female Athlete Triad is a very preventable condition.
The most effective approach to prevention is education. As both the level of female participation in competitive sports and the incidence of the Triad have risen over the last 2 decades, a stronger emphasis has been put on educating athletes, parents, and coaches on strategies to prevent the development of causal factors for the Triad. It is important to begin educating young female athletes as early as middle-school age on topics such as healthy eating, smart physical training, recovery and rest, and taking care of their bodies.
Coaches should monitor training and its impact on the overall health of the athlete by encouraging pain-free participation in sports; they may also track training and performance in order to notice any abnormal health or behavioral signs. Individuals involved in the life of a female athlete should promote an open, honest, and safe environment for the athlete so that she feels comfortable discussing challenges or issues she may be facing without the risk of external pressure or judgment.
Real Life Experiences
Jenna is a 17-year-old junior in high school who runs cross-country and track, and swims on a competitive, year-round club swim team. Jenna is a very talented athlete. She has been swimming since age 5, and last year, at the encouragement of her coaches, she decided to start running to improve her fitness for swimming. She immediately was in the top 5 runners on the school’s cross-country team. Jenna recently started receiving phone calls from college swim coaches. It has been her dream to earn a scholarship to swim in college, and as she begins to feel like it may be a real possibility, she commits to training harder than ever for both running and swimming.
For several weeks, she practices both sports every day, rushing from the track to the pool with no time to rest or grab a snack. Junior year is the hardest academic year at her school, so she has been swamped with homework and only gets around 5 hours of sleep each night.
After finishing in the top 10 at the state cross-country meet in November, Jenna started 2-a-day swim practices without taking any time off. During her weight-room sessions, she started noticing that her shin was growing very sore with each workout, and she wasn’t able to increase her weights like she did last season. Her shin didn’t bother her in the pool, but she had a hard time completing workouts and hitting her running times. She just felt tired all the time, and began to grow discouraged and unmotivated. Her mom took her to see a physical therapist.
Jenna's physical therapist asked her specific questions about her training. Jenna felt comfortable being honest with her. Jenna mentioned she had started skipping lunch so that she wouldn’t feel lethargic for practice, and rarely had time to eat a full dinner because of her homework load. She told her physical therapist that she was beginning to feel like her chances of getting a college scholarship were slipping away.
Jenna and her physical therapist had a long discussion about the best plan to help her return to good health and achieve her goals. Her physical therapist helped her see that her desire to perform at a high level had become out-of-balance with her ability to take care of her body. She encouraged Jenna not to feel guilty, but to feel positive about her opportunity to address her challenges. Jenna was frustrated by the situation, but excited to work toward returning to full health. They discussed the plan with her coaches and parents, and everyone was on board.
Jenna's physical therapist referred her to an orthopedic physician for evaluation of her bone health, as well as to a nutritionist to evaluate her diet and come up with a proper fueling plan that met the high physical demands of swimming and running. After resting for several weeks, Jenna returned to physical therapy, and learned an individualized program to restore and enhance her strength, endurance, and movement quality. She and her coaches worked on a training plan that would allow adequate rest and recovery.
By the national swim meet that March, Jenna was in the best shape of her life and placed first in her event, setting a new personal-best time. That summer, the college of her choice called with a scholarship offer. Jenna felt happy and healthy entering her senior year, excited for the adventures ahead!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to identify the Female Athlete Triad. However, you may want to consider:
- A physical therapist who is experienced in working with people who have Female Athlete Triad. Some physical therapists have a practice with an orthopedic or musculoskeletal focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with Female Athlete Triad.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of female athlete triad. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Nichols JF, Rauh MJ, Lawson MJ, et al. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160(2):137–142. Free Article.
Donaldson ML. The female athlete triad: a growing health concern. Orthop Nurs. 2003;22(5):322–324. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Laura Stanley, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.