Sole Purpose 92
Treating Female Athletes

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I was recently at a course and ended up talking with an attending surgeon who had been a high-level gymnast up through the NCAA. We found ourselves lamenting the realities of the female athlete triad—sharing our own horror stories of stress fractures, under-fueling, difficult experiences with team medical staff, and the slowly shifting (but still lingering) toxic belief that female athletes need to be smaller to perform stronger or faster. I can only speak from my own experience as a college cross country and track athlete, but I’ve seen firsthand the traumatic and devastating impact that improper fueling—and a lack of appropriate medical support—can have on young athletes. This issue is so personal to me that I recently lectured on perioperative considerations for the low-BMI athlete at both the Indiana Podiatric Medical Association meeting and The National Scientific APMA conference.

What Is the Female Athlete Triad?
The Female Athlete Triad is an older term used to describe a spectrum of interrelated conditions involving low energy availability, menstrual dysfunction, and decreased bone mineral density. At its core, the triad is driven by inadequate energy intake—whether intentional or unintentional. Screening should include a history of menstrual irregularities, stress fractures, restrictive eating or dieting behaviors, overtraining, and personality traits such as perfectionism, obsessiveness, or heightened anxiety.^2,3

Speaking from personal experience, when I was growing up and running competitively, it was almost normalized—and even celebrated—to be “fit enough” to lose your menstrual period. While the culture around this is slowly shifting, it remains an issue that requires awareness and proactive support for our female athletes. Amenorrheic athletes are at significantly higher risk for low bone mass (premature osteoporosis) and stress fractures. In fact, stress fractures occur 2-4 times more often in female athletes than in their peers.^2,3,6 A 2021 study on self-reported restrictive eating behaviors found that the prevalence of menstrual irregularities among high school female athletes ranged from 18.8% to 54%, highlighting just how widespread and under-recognized this issue remains.⁶

What Is RED-S?
Relative Energy Deficiency in Sport (RED-S) is a broader, more accurate framework that recognizes energy imbalance can affect all athletes—both men and women.⁶ Issues with proper fueling are especially common in endurance sports, aesthetic sports, and weight-class sports, where pressure to maintain a certain physique or weight is often high. The older term, “Female Athlete Triad,” mistakenly suggested this problem was limited to female athletes and failed to capture the complex, multisystem nature of the condition. RED-S, on the other hand, acknowledges the full spectrum of consequences that arise from inadequate energy intake, including hormonal dysregulation, impaired bone health, cardiovascular effects, and a range of performance and recovery challenges.⁶

Why Is This Important for Us to Know?
First, the risk of these athletes becoming injured and ending up in our offices is high.

When I was 16 and dealing with a stress fracture, the orthopedic physician I saw told me I was built “more like a linebacker than a gazelle,” implying that my body type explained my chronic overuse injuries. I couldn’t have weighed more than 120 pounds, yet I was consistently labeled as “bigger” for a female cross-country runner. Nearly all of my competitive running peers have similar stories—physicians, trainers, and coaches discussing their weight, linking injuries to body size, and reinforcing the belief that “the thin girls win medals.”

For every person who contributed to that toxic culture, there were many who pushed back against it. Sharing accurate information about treating these athletes helps strengthen that positive, evidence-based side of the conversation. While I may have had that negative experience with a singular doctor and some others, I had plenty of amazing and uplifting coaches and medical providers I have had the privilege of working with.

A Maryland study of orthopedic surgeons examined how many had received training in the Female Athlete Triad and how many felt competent identifying it. While 69% reported receiving training, only 42% believed they could recognize the signs and symptoms in patients. Although the study sample was small—only 64 respondents—it highlights a clear gap between knowledge and confident clinical practice.⁸

What to Look for
A typical patient suffering from RED-S might be a young person (or someone at any point in their life) in their late teens or early twenties who participates in a high-volume, high-pressure sport—often distance running, gymnastics, dance, or endurance training. They may present with a history of increasing fatigue, recurrent overuse injuries, or persistent bone pain that doesn’t match their level of activity. When asked, she reports irregular or absent menstrual periods and might describe this as “normal for athletes” or even something she’s been praised for by coaches or peers.⁶

They might be noticeably lean, but not always—many athletes with the triad do not appear underweight. What’s more telling is their relationship with food and training. They may quietly restrict their calorie intake, skip meals, or feel anxious about eating “too much.” They often train intensely, sometimes adding extra workouts or miles despite pain or exhaustion. Personality traits like perfectionism or a fear of gaining weight may surface during conversation, even if they try to downplay them.

Clinically, this patient may have a history of stress fractures, decreased bone density on imaging or DEXA, chronic musculoskeletal discomfort, or signs of low energy availability such as dizziness, cold intolerance, or slowed recovery. Lab work may show hormonal suppression—low estrogen, vitamin D deficits, or thyroid abnormalities.^6,8

What Can We Do to Help?
We start by knowing the signs and understanding what to look for. Any athlete with a BMI below 19 should be considered an immediate red flag, but numbers aside, patterns matter most. Spotting concerning behaviors early—and having open, honest conversations about an athlete’s motivations, goals, and long-term health—is crucial.⁷

Under-fueling and overtraining can create quick, temporary performance gains, which is exactly why athletes cling to them and why these habits are sometimes reinforced unintentionally by coaches or parents. And while I’m fully convinced that kids today are light-years faster than I ever was at their age (wow, I’m getting old), I tell them the same thing every time: my favorite part about running now is that it’s a lifelong sport. I’m not nearly as competitive anymore, and it’s definitely not my top priority, but it’s still something I genuinely love most because it no longer hurts every single time I lace up.

The only reason I can still enjoy running is because I didn’t cause permanent damage from chronic injuries, overtraining, and under-fueling. Not everyone is that lucky. Overuse injuries are no joke. I had several stress fractures of my own and it took years to get my bone density back to normal range for my age. One of my closest friends suffered multiple pelvic stress fractures. Another crashed her longboard on the way to class and her tibia—so fragile from under-fueling—fractured so severely she needed an external fixator. A teammate of mine even broke her tibia clean through in the middle of her warm-up at the national cross-country championships.

Professional runner Lauren Fleshman captures this reality perfectly in her book, Good for a Girl: A Woman Running in a Man's World. I recommend it to every young athlete I see showing concerning patterns or who shares a history of chronic injuries. Her perspective validates what so many experience but struggle to understand: talent cannot survive without proper fueling and recovery.

One of the most effective interventions we can offer is early referral to a mental health provider and a nutritionist.⁷ This team-based approach teaches athletes how to properly fuel and strengthen their bodies, while also helping them build the psychological tools needed to embrace healthier habits. It’s support that protects not just performance—but longevity in the sport.

In Conclusion
Understanding the Female Athlete Triad and RED-S isn’t just an academic exercise—it’s essential to providing safe, responsible, and compassionate care to the athletes who trust us. These athletes often present with problems that land squarely in our offices: stress fractures, chronic overuse injuries, delayed healing, and bone stress reactions that don’t match their training load. But beneath those injuries is often a deeper story—one shaped by pressure, perfectionism, misinformation, and a culture that has historically valued performance over health.

As clinicians, we are in a unique position to interrupt that cycle. By recognizing the early signs of low energy availability, asking the right questions, and approaching these conversations with empathy rather than judgment, we can change the trajectory of a young athlete’s life. Effective treatment isn’t just about diagnosing a stress fracture; it’s about helping athletes rebuild their relationship with food, training, and their bodies. It’s about creating an environment where health is prioritized and where performance is fueled—not restricted.

The more we educate ourselves and one another, the more empowered we become to advocate for these athletes. And ultimately, that advocacy is what protects them, keeps them competing safely, and allows them to thrive long after their competitive years are behind them.