{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,2]],"date-time":"2026-11-02T23:13:32Z","timestamp":1793661212054,"version":"4.5.1"},"reference-count":57,"publisher":"SAGE Publications","issue":"4","license":[{"start":{"date-parts":[[2014,2,24]],"date-time":"2014-02-24T00:00:00Z","timestamp":1393200000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Am J Sports Med"],"published-print":{"date-parts":[[2014,4]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Purpose:<\/jats:title>\n                    <jats:p>To evaluate the effect of single or combined risk factors as defined by the female athlete triad\u2014a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass\u2014with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Design:<\/jats:title>\n                    <jats:p>Cohort study; Level of evidence, 3.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>At baseline, participants\u2019 (N = 259; mean age, 18.1 \u00b1 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body composition. Participants were followed prospectively for the occurrence of injuries; those injuries confirmed by a physician were recorded.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>\n                      Twenty-eight participants (10.8%) incurred a BSI. Forty-six percent of those who had \u226512 h\/wk of purposeful exercise, a bone mineral density (BMD) Z score &lt;\u20131.0, and who exhibited 3 to 4 of the following: BMI &lt;21.0 kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      , oligo- or amenorrhea, elevated dietary restraint, and\/or participation in a leanness sport exercise\/activity at baseline, incurred a BSI during the prospective study period. Single factors significantly ( P &lt; .05) associated with the development of a BSI included \u226512 h\/wk of purposeful exercise (14.7%), BMI &lt;21.0 kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      (15.3%), and low bone mass (BMD Z score &lt;\u20131.0; 21.0%). The strongest 2- and 3-variable combined risk factors were low BMD ( Z score &lt;\u20131.0) + \u226512 h\/wk of exercise, with 29.7% incurring a BSI (odds ratio [OR], 5.1; 95% CI, 2.2-12.1), and \u226512 h\/wk of exercise + leanness sport\/activity + dietary restraint, with 46.2% incurring a BSI (OR, 8.7; 95% CI, 2.7-28.3).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion:<\/jats:title>\n                    <jats:p>In the sample, which included female adolescents and young adults participating in competitive or recreational exercise activities, the risk of BSIs increased from approximately 15% to 20% for significant single risk factors to 30% to 50% for significant combined female athlete triad\u2013related risk factor variables. These data support the notion that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/0363546513520295","type":"journal-article","created":{"date-parts":[[2014,2,25]],"date-time":"2014-02-25T00:26:40Z","timestamp":1393288000000},"page":"949-958","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":310,"title":["Higher Incidence of Bone Stress Injuries With Increasing Female Athlete Triad\u2013Related Risk Factors"],"prefix":"10.1177","volume":"42","author":[{"given":"Michelle T.","family":"Barrack","sequence":"first","affiliation":[{"name":"California State University, Northridge, Northridge, California, USA"},{"name":"University of California, Los Angeles, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jenna C.","family":"Gibbs","sequence":"additional","affiliation":[{"name":"Pennsylvania State University, University Park, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary Jane","family":"De Souza","sequence":"additional","affiliation":[{"name":"Pennsylvania State University, University Park, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy I.","family":"Williams","sequence":"additional","affiliation":[{"name":"Pennsylvania State University, University Park, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeanne F.","family":"Nichols","sequence":"additional","affiliation":[{"name":"University of California, San Diego, La Jolla, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mitchell J.","family":"Rauh","sequence":"additional","affiliation":[{"name":"San Diego State University, San Diego, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aurelia","family":"Nattiv","sequence":"additional","affiliation":[{"name":"University of California, Los Angeles, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2014,2,24]]},"reference":[{"key":"bibr1-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1097\/00005768-199912000-00017"},{"key":"bibr2-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/03635465030310063601"},{"key":"bibr3-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/036354658801600302"},{"key":"bibr4-0363546513520295","doi-asserted-by":"publisher","DOI":"10.2165\/00007256-199928020-00004"},{"issue":"3","key":"bibr5-0363546513520295","first-page":"69","volume":"28","author":"Bennell KL","year":"1996","journal-title":"Aust J Sci Med Sport"},{"key":"bibr6-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1097\/00042752-199510000-00004"},{"key":"bibr7-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/036354659602400617"},{"key":"bibr8-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/036354659602400217"},{"key":"bibr9-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1359\/jbmr.1997.12.1.6"},{"key":"bibr10-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1001\/archpediatrics.2011.34"},{"key":"bibr11-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1097\/RMR.0b013e3180421c8c"},{"key":"bibr12-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1093\/ajcn\/51.5.779"},{"key":"bibr13-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/036354658701500504"},{"key":"bibr14-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1249\/MSS.0b013e3182a03b8b"},{"key":"bibr15-0363546513520295","first-page":"188","volume":"18","author":"Goolsby MA","year":"2008","journal-title":"Clin J Sport Med"},{"key":"bibr16-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1123\/ijsnem.15.2.147"},{"key":"bibr17-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/0363546503261708"},{"key":"bibr18-0363546513520295","first-page":"73","volume-title":"Diabetes Mellitus: Diagnosis and Treatment","volume":"1964","author":"Hamwi G"},{"key":"bibr19-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1152\/ajpendo.2000.278.1.E43"},{"key":"bibr20-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1006\/appe.1997.0148"},{"key":"bibr21-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1359\/JBMR.040410"},{"key":"bibr22-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1079\/BJN19970053"},{"key":"bibr23-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/036354659402200216"},{"key":"bibr24-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/036354659202000414"},{"key":"bibr25-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1249\/mss.0b013e318074e54b"},{"key":"bibr26-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1038\/sj.ejcn.1600432"},{"key":"bibr27-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/03635465010290030901"},{"key":"bibr28-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1007\/s001980170155"},{"key":"bibr29-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1210\/jc.2009-1046"},{"key":"bibr30-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1249\/00005768-198608000-00002"},{"key":"bibr31-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1152\/jappl.1998.84.1.37"},{"key":"bibr32-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2004-1868"},{"key":"bibr33-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2006-2145"},{"key":"bibr34-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1002\/(SICI)1098-108X(199904)25:3<349::AID-EAT15>3.0.CO;2-M"},{"key":"bibr35-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/036354658701500107"},{"key":"bibr36-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1080\/02640410701607338"},{"key":"bibr37-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1136\/bjsm.2007.037077"},{"key":"bibr38-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1016\/S1440-2440(00)80036-5"},{"key":"bibr39-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/0363546513490645"},{"key":"bibr40-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1249\/mss.0b013e318149f111"},{"key":"bibr41-0363546513520295","first-page":"S347","volume":"32","author":"Nattiv A","year":"2000","journal-title":"Med Sci Sports Exerc"},{"key":"bibr42-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1123\/ijsnem.17.4.364"},{"key":"bibr43-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1016\/j.pmrj.2010.04.020"},{"key":"bibr44-0363546513520295","doi-asserted-by":"publisher","DOI":"10.22203\/eCM.v006a05"},{"key":"bibr45-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1249\/MSS.0b013e3181a9e772"},{"key":"bibr46-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1249\/01.mss.0000227543.51293.9d"},{"key":"bibr47-0363546513520295","doi-asserted-by":"publisher","DOI":"10.4085\/1062-6050-45.3.243"},{"key":"bibr48-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1177\/0363546505278703"},{"key":"bibr49-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1016\/j.csm.2005.08.005"},{"key":"bibr50-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1016\/0022-3999(85)90010-8"},{"key":"bibr51-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1097\/00003086-198407000-00028"},{"key":"bibr52-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1249\/MSS.0b013e3182963d75"},{"key":"bibr53-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1136\/bjsm.2003.011338"},{"key":"bibr54-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1385\/ENDO:17:1:43"},{"key":"bibr55-0363546513520295","doi-asserted-by":"publisher","DOI":"10.1210\/jcem.86.11.8024"},{"key":"bibr56-0363546513520295","volume-title":"The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines","author":"World Health Organization","year":"1992"},{"key":"bibr57-0363546513520295","volume-title":"Physical Status: The Use and Interpretation of Anthropometry","author":"World Health Organization","year":"1995"}],"container-title":["The American Journal of Sports Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/0363546513520295","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/0363546513520295","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/0363546513520295","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T09:47:50Z","timestamp":1777369670000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/0363546513520295"}},"subtitle":["A Prospective Multisite Study of Exercising Girls and Women"],"short-title":[],"issued":{"date-parts":[[2014,2,24]]},"references-count":57,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2014,4]]}},"alternative-id":["10.1177\/0363546513520295"],"URL":"https:\/\/doi.org\/10.1177\/0363546513520295","relation":{},"ISSN":["0363-5465","1552-3365"],"issn-type":[{"value":"0363-5465","type":"print"},{"value":"1552-3365","type":"electronic"}],"subject":[],"published":{"date-parts":[[2014,2,24]]}}}