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Problem: Awareness and knowledge of the Female Athlete Triad (Triad) among physicians and allied health professionals is well studied; however, awareness of Relative Energy Deficiency in Sport (RED-S) is largely unknown. The purpose of this study is to assess awareness and comfort in treating patients with Triad and RED-S among providers attending a sports medicine conference.Methods: Cross-sectional study of physicians and allied health professionals attending a sports medicine conference. Conference attendees (n=163, 54% female) completed a survey on awareness of and confidence in treating Triad and RED-S (response rate=42%). Results: Most participants (76%) were aware of Triad compared to fewer with awareness regarding RED-S (29%). More participants (33%) reported feeling comfortable treating athletes with the Triad compared to RED-S (13%) (p

Denosumab is a human monoclonal antibody against RANKL. This antibody decreases bone turnover markers and increases bone mineral density (BMD) in postmenopausal women. In phase 3 studies including more than 1100 women, denosumab achieved greater increases in lumbar spine, total hip, distal 1/3 radius, and total BMD than alendronate 70 mg weekly. Recent data suggest that denosumab also decreases vertebral and non-vertebral fractures. This drug seems to be safe, although the most frequent side effects are arthralgia, back pain, and nasopharyngitis. No increased incidence of neoplasia has been found compared to placebo or alendronate. However, infections requiring inpatient treatment were more frequent in study groups treated with denosumab. These were common community acquired infections and were treated with standard antibiotics. No opportunistic infections were reported. Denosumab is a very promising new drug for the treatment of osteopenia and osteoporosis, and hopefully more long-term safety information and further fracture data will support its commercial use in the near future. [ABSTRACT FROM AUTHOR]

Objective: To determine the association between survey-based self-reported problematic low energy availability indicators (LEA-I) and race performance and intra-event medical encounters during the Boston Marathon., Methods: 1030 runners who were registered for the 2022 Boston Marathon completed an electronic survey (1-4 weeks pre-race) assessing LEA-I, training and medical history. De-identified survey data were linked to event wearable timing chips and medical encounter records. LEA-I was defined as: an elevated Eating Disorder Examination Questionnaire score, elevated Low Energy Availability (LEA) in Females Questionnaire score, LEA in Males Questionnaire with a focus on gonadal dysfunction score and/or self-report of diagnosed eating disorder/disordered eating., Results: The prevalence of LEA-I was 232/546 (42.5%) in females and 85/484 (17.6%) in males. Athletes without LEA-I (non-LEA-I) achieved significantly better race times versus those with LEA-I (accounting for demographic and anthropomorphic data, training history and marathon experience), along with better division finishing place (DFP) mean outcomes (women's DFP: 948.9±57.6 versus 1377.4±82.9, p<0.001; men's DFP: 794.6±41.0 versus 1262.4±103.3, p<0.001). Compared with non-LEA-I athletes, LEA-I athletes had 1.99-fold (95% CI: 1.15 to 3.43) increased relative risk (RR) of an intra-event medical encounter of any severity level, and a 2.86-fold increased RR (95% CI:1.31 to 6.24) of a major medical encounter., Conclusion: This is the largest study to link LEA-I to intra-event athletic performance and medical encounters. LEA-I were associated with worse race performance and increased risk of intra-event medical encounters, supporting the negative performance and medical risks associated with problematic LEA-I in marathon athletes., Competing Interests: Competing interests: KEA is a deputy editor for BJSM, (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: Purpose: To examine the relationship between menstrual cycle (MC) phase-dependent fluctuations of estrogen and progesterone and virtual cycling race performance, with a secondary aim of correlating perceived MC-related symptoms with performance.Methods: In a novel observational study design, thirty-seven female cyclists/triathletes not using any hormonal contraception completed one virtual cycling race [19.5 km time trial (TT)] per week across a one-month period (totaling four races). Participants completed MC characterization and tracking, including urinary ovulation kits, across two complete MCs. Venous blood samples were collected within 21 h of racing to determine serum 17-β-estradiol and progesterone concentrations, as well as an assessment of self-reported, perceived race-day MC and gastrointestinal (GI) symptoms, which were all then correlated to race performance.Results: There was no relationship between race completion time and individual estradiol (r = -0.001, p = 0.992) or progesterone (r = -0.023, p = 0.833) concentrations. There was no difference between race time between MC phases (follicular/luteal, p = 0.238), whether MC bleeding or not bleeding (p = 0.619) and ovulating or not ovulating (p = 0.423). The total number of perceived MC symptoms recorded on race day was positively correlated to increased race time [r = 0.268 (95% CI 0.056 to 0.457), p = 0.014], as was the number of GI symptoms of at least "moderate" severity before the race (r = 0.233 [95% CI 0.021 to 0.425], p = 0.031), but not post-race (r = 0.022, p = 0.841).Conclusions: When implementing a novel, virtual cycling race, fluctuations in ovarian hormone concentrations across the MC do not appear to affect real-world cycling performance among trained cyclists, while perceived negative MC and GI symptoms may relate to impaired performance. Therefore, the management of negative MC and GI symptoms appears important for athletic performance enhancement or to mitigate performance decline., Competing Interests: Conflict of Interest and Funding Source: The authors acknowledge the support of this work by the Wu Tsai Human Performance Alliance. This project was co-funded by the Australian Catholic University and Wu Tsai Human Performance Alliance., (Copyright © 2024 by the American College of Sports Medicine.)

Objectives: To determine the association between surrogates of low energy availability (EA) and proposed health and performance outcomes of Relative Energy Deficiency in Sport (REDs) in a clinical sample of adolescent and young adult male athletes., Methods: Male athletes ages 15-30 years presenting to a sports medicine clinic at two tertiary care centres were invited to complete a survey about athlete health and well-being. Participants were divided into low EA and adequate EA groups based on survey responses. The associations between low EA and REDs outcomes were evaluated using χ 2 tests and ORs were calculated using binomial logistic regression (significance: p<0.05)., Results: Low EA was associated with increased frequency of self-reported immunological, metabolic, psychological, cardiovascular and gastrointestinal dysfunction; reduced endurance performance, response to training, judgement, coordination and muscle strength; and increased irritability and depression. Low EA athletes were more likely to have self-reported cardiovascular dysfunction (OR 2.87, 95% CI 1.56 to 5.26) and psychological illness (OR 3.23, 95% CI 1.91 to 5.41), decreased training response (OR 2.64, 95% CI 1.38 to 5.03) and endurance performance (OR 2.26, 95% CI 1.13 to 4.52) and were less likely to have self-reported gonadal dysfunction (OR 0.49, 95% CI 0.30 to 0.81), than adequate EA athletes (p<0.05)., Conclusions: Low EA surrogates are associated with many adverse health outcomes and performance effects of REDs in male athletes. More prospective REDs research in males is needed to improve various aspects of REDs screening in young male athletes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To co-construct a sports medicine and exercise science research and translational agenda with Team USA elite female athletes serving as the experts on their health, performance and well-being., Methods: 40 Team USA female athletes across sports disciplines participated in an online, anonymous, modified Delphi survey by ranking topics on a Likert scale (1='strongly disagree' and 5='strongly agree') and providing qualitative justification regarding whether they believed having more information and research on each topic would support their athletic performance, health and well-being. After each Delphi round, quantitative rankings of topics and qualitative justifications were analysed, informing revisions to the list of topics for review in the subsequent round. Researchers provided athletes with a detailed report of findings and revisions following each round., Results: The final list contained 14 ranked topics. The top five were menstrual cycle symptoms (4.58±0.74), recovery (4.58±0.59), birth control (4.55±0.89), mental health (4.50±0.55) and fueling and the menstrual cycle (4.43±0.74). New topics originating from athletes included recovery, menstrual cycle symptoms, fueling and the menstrual cycle, mental health and sports performance, team dynamics, and institutionalised sexism., Conclusion: This is the first study to co-construct a research and translational agenda with Team USA elite female athletes. The list of sports science research topics developed by focusing on elite female athletes' voices lays the foundation for future research and provides valuable insight into the specific needs of female athletes., Competing Interests: Competing interests: KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To investigate the effects of acute diet and exercise manipulation on resting metabolic rate (RMR) measurement variability and dual energy x-ray absorptiometry (DXA) body composition estimates., Methods: 10 male and 10 female endurance athletes (12 cyclists, 5 triathletes, 4 runners) of Tier 2 (n = 18) to Tier 3 (n = 2) calibre underwent five conditions using a Latin square counterbalance design. For 24 hours, athletes consumed a diet providing excessive energy availability (75 kcal‧kg fat free mass (FFM) -1 ) without exercise (GEA rest ), high energy availability (45 kcal‧kg FFM -1 ) without (HEA rest ) or with exercise (HEA ex ), or low-energy availability (15 kcal‧kg FFM -1 ) without (LEA rest ) or with exercise (LEA ex ). Exercise involved two bouts of cycling (morning bout: 149 ± 34 min at 55% of maximal aerobic capacity (VO 2 max); afternoon bout: 60 min at 65% of VO 2 max) that resulted in a cumulative exercise energy expenditure of 30 kcal‧kg FFM -1 . The following day, RMR and DXA measurements occurred after a 10-hour fast and 12-hours post-exercise., Results: There were no sex differences in relative RMR ( p = 0.158) nor effects of any of the five conditions on RMR ( p = 0.358). For both male and female athletes, FFM estimates were decreased following the LEA rest (-0.84 ± 0.66 kg; p = 0.001) and LEA ex (-0.65 ± 0.86 kg; p = 0.016) conditions compared to the GEA rest condition and following the LEA rest (-0.73 ± 0.51 kg; p = 0.001) and LEA ex (-0.54 ± 0.79 kg; p = 0.024) conditions compared to the HEA ex condition. There was no effect of condition on fat mass estimates ( p = 0.819)., Conclusion: Acute periods of diet and exercise manipulation did not create artifacts in next-day RMR measurements. However, as changes in estimates of FFM were seen, diet and exercise should be controlled in the 24-hours prior to DXA scans., (Copyright © 2024 by the American College of Sports Medicine.)

Introduction: Few studies have assessed athletic identity levels in young patients. This study examined athletic identity in adolescents and explored associations between athletic identity, patterns of sport participation, and coping skills., Methods: Patients aged 12 to 18 years who received sports medicine care completed a one-time, voluntary, anonymous survey. Surveys included demographics, sport participation information, Athletic Identity Measurement Scale (AIMS), and Athletic Coping Skills Inventory (ACSI). Statistical analysis included Fisher exact test, Student t test, Wilcoxon rank sum test, Kruskal-Wallis test, and Pearson correlation., Results: Three hundred thirty-four patients (mean ± SD age 15.0 ± 1.8 years, 64.7% girls) completed questionnaires. The mean AIMS and ACSI scores were 45.2 ± 11.5 and 50.2 ± 10.9, respectively. No notable differences were observed in AIMS scores between age groups or sexes. An increase in mean AIMS scores (higher athletic identity) was seen with greater weekly hours of sport participation (P < 0.001) and months per year of primary sport participation (P < 0.001). Multisport per season athletes had higher AIMS scores than single-sport athletes (48.2 ± 10.1 vs. 43.0 ± 11.9, P < 0.001). Team sport athletes reported higher athletic identities than individual sport athletes (47.0 ± 10.7, 41.4 ± 11.4, P < 0.001). Athletic Identity Measurement Scale scores positively correlated with ACSI scores (r = 0.31, P < 0.0001). Athletes with the highest athletic identity had markedly higher scores on ACSI subscales of Coachability, Concentration, Confidence and Achievement Motivation, Goal Setting and Mental Preparation, and Peaking Under Pressure than athletes with the least athletic identity. However, those with the highest athletic identities reported significantly lower scores on the ACSI Freedom From Worry subscale (P < 0.001)., Discussion: Athletic identity did not differ among adolescents by age or sex. Athletic identity was higher in team sport athletes and those with increased sport participation volumes. While high athletic identity was associated with higher scores on favorable coping skill dimensions, these athletes may also worry more, potentially placing them at greater psychological risk after injury., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Low energy availability, particularly when problematic (i.e., prolonged and/or severe), has numerous negative consequences for health and sports performance as characterized in relative energy deficiency in sport. These consequences may be driven by disturbances in endocrine function, although scientific evidence clearly linking endocrine dysfunction to decreased sports performance and blunted or diminished training adaptations is limited. We describe how low energy availability-induced changes in sex hormones manifest as menstrual dysfunction and accompanying hormonal dysfunction in other endocrine axes that lead to adverse health outcomes, including negative bone health, impaired metabolic activity, undesired outcomes for body composition, altered immune response, problematic cardiovascular outcomes, iron deficiency, as well as impaired endurance performance and force production, all of which ultimately may influence athlete health and performance. Where identifiable menstrual dysfunction indicates hypothalamic-pituitary-ovarian axis dysfunction, concomitant disturbances in other hormonal axes and their impact on the athlete's health and sports performance must be recognized as well. Given that the margin between podium positions and "losing" in competitive sports can be very small, several important questions regarding low energy availability, endocrinology, and the mechanisms behind impaired training adaptations and sports performance have yet to be explored., (© 2024. The Author(s).)

Purpose: To investigate the temporal effects of ~1,800 m altitude exposure and energy availability (EA) manipulation on resting metabolic rate (RMR)., Methods: Twenty elite female race walkers underwent a 3-week training camp at an altitude of ~1,800 m. During the first two weeks, athletes consumed a high EA (HEA) diet of 45 kcal·kg fat free mass (FFM) -1 ·day -1 . During the final week, half the athletes consumed a low EA (LEA) diet of 15 kcal·kg FFM -1 ·day -1 while the others continued on a HEA diet. Athletes followed individualized training plans throughout the study. To assess the effect of altitude on RMR, athletes in the HEA group had RMR measured at baseline (~580 m) prior to altitude exposure (Pre-alt), at 36-hours (36 h-alt), 2 weeks (Wk2-alt) and 3 weeks into altitude exposure (Wk3-alt), and at 36 hours post-altitude exposure at ~580 m (36 h-post). To assess the effect of LEA exposure on RMR while at altitude, athletes in the LEA group underwent RMR measurements at Pre-alt and before (Wk2-alt) and after the 7-days of LEA (Wk3-alt)., Results: Compared to Pre-alt, the RMR of HEA athletes was increased at 36 h-alt (+5.3 ± 3.1%; p = 0.026) and Wk2-alt (+4.9 ± 4.9%; p = 0.049), but was no longer elevated at Wk3-alt (+1.7 ± 4.2%; p = 0.850). The RMR of HEA athletes at 36 h-post was lower than all timepoints at altitude (p < 0.05) but was not different from Pre-alt (-3.9 ± 7.2%; p = 0.124). The 7-day period of LEA exposure at altitude did not affect RMR (p = 0.347)., Conclusions: RMR was transiently increased with ~1,800 m altitude exposure in female athletes and was unaffected by short-term LEA. However, the altitude-induced increase was small (~25-75 kcal/day) and was unlikely to have clinically significant implications for daily energy requirements., Competing Interests: Conflict of Interest and Funding Source: The authors acknowledge support of this work by the Wu Tsai Human Performance Alliance and the Joe and Clara Tsai Foundation, Athletics Australia, and Australian Catholic University. The authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Sports Medicine.)

Objective: This cross-sectional retrospective and prospective study implemented the 2023 International Olympic Committee Relative Energy Deficiency in Sport (REDs) Clinical Assessment Tool version 2 (CAT2) to determine the current severity of REDs (primary outcome) and future risk of bone stress injuries (BSI, exploratory outcome) in elite athletes., Methods: Female (n=143; 23.3±4.3 years) and male (n=70; 23.1±3.7 years) athletes (performance tier 3 (52%), tier 4 (36%), tier 5 (12%)) participated in a baseline CAT2 (with minor modifications) assessment, including a self-report questionnaire (menstrual function (females), BSI, Eating Disorder Examination Questionnaire (EDE-Q)), bone mineral density (BMD via DXA) and fasted blood analysis (triiodothyronine (T3), testosterone, cholesterol). Athletes were assigned a green, yellow, orange or red light via CAT2. The prospective risk of new self-report of physician-diagnosed BSI was assessed over a subsequent 6-24 months., Results: REDs prevalence was 55% green, 36% yellow, 5% orange and 4% red light. The CAT2 identified a greater prevalence of amenorrhoea and BSI and lower T3, testosterone and BMD (p<0.01) in red, orange and yellow (those with REDs) versus green light. ORs for a prospective self-reported BSI (majority physician diagnosed) were greater in orange vs green (OR 7.71, 95% CI (1.26 to 39.83)), in females with severe amenorrhoea (OR 4.6 (95% CI 0.98 to 17.85)), in males with low sex drive (OR 16.0 (95% CI 4.79 to 1038.87)), and athletes with elevated EDE-Q global scores (OR 1.45 (95% CI 0.97 to 1.97))., Conclusion: The CAT2 has high validity in demonstrating current severity of REDs, with increased future risk of self-reported BSI in athletes with a more severe REDs traffic light category., Competing Interests: Competing interests: MM and KEA are deputy editors of the BJSM., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The female athlete triad (Triad) and relative energy deficiency in sport (REDs) describe potential health and performance consequences of low energy availability., Objective: We surveyed female cross-country athletes to assess differences in educational impact scores (EIS; knowledge score × confidence score factor) of Triad and REDs. Associations between EIS and participant characteristics (eg, mileage [current and peak], years of running experience, age, bone stress injury history, division level participation, academic area of study, Triad or REDs diagnoses, and Triad or REDs education) were explored., Main Outcome Measure(s): An evidence-based online survey was developed and administered via Qualtrics to female collegiate cross-country athletes (n = 275; age = 20 ± 1 years)., Results: A weak correlation existed between peak career mileage and EIS (r = 0.195; P = .010). Educational impact scores significantly differed in athletes with a related academic area of study versus those without (21.91 ± 5.16 and 16.11 ± 5.54, respectively). Educational impact scores significantly differed in athletes with Triad and REDs diagnoses (21.69 ± 5.85 and 22.58 ± 6.82, respectively) versus those without (16.80 ± 6.54 and 17.20 ± 6.34, respectively). Educational impact scores were higher in those who had received Triad education versus those who had not (21.03 ± 6.86 and 18.12 ± 6.82, respectively). A significant interaction between peak career mileage and Triad diagnosis was found (P = .005)., Conclusions: Significant education-based and diagnosis differences suggest that Triad diagnoses correlate with peak career mileage. These findings support the facilitation of education to improve not only the treatment but also the prevention of Triad and REDs., (© by the National Athletic Trainers’ Association, Inc.)

We examined performance across one menstrual cycle (MC) and 3 weeks of hormonal contraceptives (HC) use to identify whether known fluctuations in estrogen and progesterone/progestin are associated with functional performance changes. National Rugby League Indigenous Women's Academy athletes [n = 11 naturally menstruating (NM), n = 13 using HC] completed performance tests [countermovement jump (CMJ), squat jump (SJ), isometric mid-thigh pull, 20 m sprint, power pass and Stroop test] during three phases of a MC or three weeks of HC usage, confirmed through ovulation tests alongside serum estrogen and progesterone concentrations. MC phase or HC use did not influence jump height, peak force, sprint time, distance thrown or Stroop effect. However, there were small variations in kinetic and kinematic CMJ/SJ outputs. NM athletes produced greater mean concentric power in MC phase four than one [+0.41 W·kg -1 (+16.8%), p = 0.021] during the CMJ, alongside greater impulse at 50 ms at phase one than four [+1.7 N·s (+4.7%), p = 0.031] during the SJ, without differences between tests for HC users. Among NM athletes, estradiol negatively correlated with mean velocity and power (r = -0.44 to -0.50, p < 0.047), progesterone positively correlated with contraction time (r = 0.45, p = 0.045), and both negatively correlated with the rate of force development and impulse (r = -0.45 to -0.64, p < 0.043) during the SJ. During the CMJ, estradiol positively correlated to 200 ms impulse (r = 0.45, p = 0.049) and progesterone to mean power (r = 0.51, p = 0.021). Evidence of changes in testing performance across a MC, or during active HC use, is insufficient to justify "phase-based testing"; however, kinetic or kinematic outputs may be altered in NM athletes., (© 2024 The Author(s). European Journal of Sport Science published by Wiley‐VCH GmbH on behalf of European College of Sport Science.)

Background: Bone stress injury (BSI) is a common overuse injury in active women. BSIs can be classified as high-risk (pelvis, sacrum, and femoral neck) or low-risk (tibia, fibula, and metatarsals). Risk factors for BSI include low energy availability, menstrual dysfunction, and poor bone health. Higher vertical load rates during running have been observed in women with a history of BSI., Purpose/hypothesis: The purpose of this study was to characterize factors associated with BSI in a population of premenopausal women, comparing those with a history of high-risk or low-risk BSI with those with no history of BSI. It was hypothesized that women with a history of high-risk BSI would be more likely to exhibit lower bone mineral density (BMD) and related factors and less favorable bone microarchitecture compared with women with a history of low-risk BSI. In contrast, women with a history of low-risk BSI would have higher load rates., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Enrolled were 15 women with a history of high-risk BSI, 15 with a history of low-risk BSI, and 15 with no history of BSI. BMD for the whole body, hip, and spine was standardized using z scores on dual-energy x-ray absorptiometry. High-resolution peripheral quantitative computed tomography was used to quantify bone microarchitecture at the radius and distal tibia. Participants completed surveys characterizing factors that influence bone health-including sleep, menstrual history, and eating behaviors-utilizing the Eating Disorder Examination Questionnaire (EDE-Q). Each participant completed a biomechanical assessment using an instrumented treadmill to measure load rates before and after a run to exertion., Results: Women with a history of high-risk BSI had lower spine z scores than those with low-risk BSI (-1.04 ± 0.76 vs -0.01 ± 1.15; P < .05). Women with a history of high-risk BSI, compared with low-risk BSI and no BSI, had the highest EDE-Q subscores for Shape Concern (1.46 ± 1.28 vs 0.76 ± 0.78 and 0.43 ± 0.43) and Eating Concern (0.55 ± 0.75 vs 0.16 ± 0.38 and 0.11 ± 0.21), as well as the greatest difference between minimum and maximum weight at current height (11.3 ± 5.4 vs 7.7 ± 2.9 and 7.6 ± 3.3 kg) ( P < .05 for all). Women with a history of high-risk BSI were more likely than those with no history of BSI to sleep <7 hours on average per night during the week (80% vs 33.3%; P < .05). The mean and instantaneous vertical load rates were not different between groups., Conclusion: Women with a history of high-risk BSI were more likely to exhibit risk factors for poor bone health, including lower BMD, while load rates did not distinguish women with a history of BSI., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Funding was received from the Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, the United States Department of Defense and United States Army, and the American Medical Society for Sports Medicine. K.E.A. has received consulting fees from Hologic. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from Mass General Brigham Inc (ref No. 2016P001695)., (© The Author(s) 2024.)

The cyclical changes in sex hormones across the menstrual cycle (MC) are associated with various biological changes that may alter resting metabolic rate (RMR) and body composition estimates. Hormonal contraceptive (HC) use must also be considered given their impact on endogenous sex hormone concentrations and synchronous exogenous profiles. The purpose of this study was to determine if RMR and dual-energy X-ray absorptiometry body composition estimates change across the MC and differ compared with HC users. This was accomplished during a 5-week training camp involving naturally cycling athletes (n = 11) and HC users (n = 7 subdermal progestin implant, n = 4 combined monophasic oral contraceptive pill, n = 1 injection) from the National Rugby League Indigenous Women's Academy. MC phase was retrospectively confirmed via serum estradiol and progesterone concentrations and a positive ovulation test. HC users had serum estradiol and progesterone concentrations assessed at the time point of testing. Results were analyzed using general linear mixed model. There was no effect of MC phase on absolute RMR (p = .877), relative RMR (p = .957), or dual-energy X-ray absorptiometry body composition estimates (p > .05). There was no effect of HC use on absolute RMR (p = .069), relative RMR (p = .679), or fat mass estimates (p = .766), but HC users had a greater fat-free mass and lean body mass than naturally cycling athletes (p = .028). Our findings suggest that RMR and dual-energy X-ray absorptiometry body composition estimates do not significantly differ due to changes in sex hormones in a group of athletes, and measurements can be compared between MC phases or with HC usage without variations in sex hormones causing additional noise.

Purpose: The purpose of this study is to describe the implementation of a novel research protocol for conducting research with highly trained female athletes, including characterizing menstrual cycle (MC) function, hormonal profiles and symptoms of the participating athletes., Methods: Twenty-four Australian First Nation female Rugby League athletes completed this study, which involved 11 wk of cycle tracking, followed by attendance at a 5-wk training camp. Throughout the study, athletes completed a daily survey, reporting their MC function and any associated symptoms. During the training camp, athletes reported to the laboratory on three occasions and provided a venous blood sample, which was analyzed for reproductive hormones. For naturally cycling athletes (athleteNC, n = 11), this included phase 1, 2, and 4 of the menstrual cycle, whereas athletes using hormonal contraception (athleteHC; n = 13) were tested at three equally spaced time points in which consistent exogenous hormone provision occurred., Results: In the athleteNC cohort, just one athlete reached criteria for classification as eumenorrheic, with five athletes showing evidence of MC dysfunction. The prevalence of symptoms on any given day was similar between athleteNC (33.7%) and athleteHC (22.9%; P = 0.376); however, more symptoms were reported in athleteNC, suggesting that they were more likely to report multiple symptoms. Regardless of MC function, there was a significant, positive association between bleeding and symptoms ( P < 0.001), where athletes were more likely to report one or more symptoms on bleeding (50.1%) compared with nonbleeding days (22.0%)., Conclusions: We describe an innovative strategy to investigate the effect of MC function and MC phase in a high-performance sport environment, including approaches to address the challenges of undertaking research with female athletes with MC variability and those using exogenous hormonal therapies., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Sports Medicine.)

The idiom 'more high-quality research is needed ' has become the slogan for sport and exercise physiology-based research in female athletes. However, in most instances, it is challenging to address this gap of high-quality research in elite female athletes at a single study site due to challenges in recruiting enough participants with numerous menstrual cycle and contraceptive pill permutations. Accordingly, we have assembled an international multisite team to undertake an innovative project for female athletes, which investigates the effects of changes in endogenous and exogenous oestrogen and progesterone/progestins across the menstrual cycle and in response to second-generation combined monophasic contraceptive pill use, on aspects of exercise physiology and athletic performance. This project will employ the current gold-standard methodologies in this area, resulting in an adequately powered dataset. This protocol paper describes the consortium-based approach we will undertake during this study., Competing Interests: Competing interests: KJE-S has received funding/honoraria from Arsenal Football Club, The UK Sports Institute, the European Club Association, Gatorade Sport Science Institute, Hologic, Science in Sport, and the UK Ministry of Defence to support female athletes. None of these funds have direct competing interests with the Feminae project. TRF has no competing or conflicts of interest. SMA has received funding from the US Department of Defence, United States Marine Corps, the Board of Medicine, and various industry sources to support research on athletic females. None of these funds have direct competing interests with the Feminae project. ED is supported by a research grant from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP: 2019/05616-6 and 2019/26899-6) for a project unrelated to this one. She has no competing interests or conflicts to declare. BS is supported by a research grant from the São Paulo Research Foundation (Fundação de Amparo à Pesquisa do Estado de São Paulo, FAPESP: 2021/06836-0) for a project unrelated to this one. None of these funds have direct competing interests with the Feminae project. MH has no competing or conflicts of interest. JI has no competing or conflicts of interest. RM has no competing or conflicts of interest. CM has received funding from the Australian Institute of Sport, the Queensland Academy of Sport, and an industry partner (cannot be named here) to conduct research on female athletes. None of these grants have direct competing interests with the Feminae project. JST is a Canada Research Chair funded by the Canadian Institutes of Health Research. This funding does not have a direct competing interest with the Feminae project. KEA has received funding/honoraria from the Wu Tsai Human Performance Alliance, Gatorade Sport Science Institute, Hologic, UptoDate, and the United States Olympic and Paralympic Committee. This funding does not have a direct competing interest with the Feminae project. CML has no competing or conflicts of interest. CS has received funding from the UK Ministry of Defence to conduct research on female military personnel. This funding does not have direct competing interests with the Feminae project. TS has received funding/honoraria from the Wu Tsai Human Performance Alliance, Ineos, Science in Sport (Sis) Own The Podium, Gatorade Sport Science Institute and Lululemon Athletica to support research, including projects on female participants. None of these grants have a direct competing interest with the Feminae project. PS has no competing or conflicts of interest. ACH has no competing or conflicts of interest., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Over a 10-year time frame, this study aimed to evaluate diagnosis, treatment, and referral trends for adolescent runners seeking care for running-related injuries (RRIs) at a clinic that specializes in running medicine., Methods: This study was a retrospective chart review of 392 adolescent runners (2,326 encounters) who sought care for RRIs between the years 2011 and 2021. Descriptive statistics were used to summarize clinical assessments, referrals, assistive devices, and medications prescribed or administered overall and by injury type. Chi-square analyses were used to compare proportions of services rendered across the 10-year time frame., Results: Patients most frequently received manual evaluations or special tests during clinic visits. Most visits resulted in at least one referral (91%), primarily for physical therapy or gait-training. Assistive devices and medications/supplements were offered at only 18% of patient visits. The majority of assessments (X2 = 69.7, p = 0.002), treatments (X2: 23.6-43.8, p: <  0.001-0.003), and referrals (X2 = 132, p <  0.001) were for shin injuries. Larger proportions of nutrition assessments (X2 = 40.7, p <  0.001), interventions (X2 = 26.8, p = 0.003), and referrals (X2 = 27.5, p = 0.002) were performed in or after the year 2015., Conclusion: Clinic visits for shin injuries required the most clinical resources per episode of care. There were observed shifts in clinical assessment and treatment approaches to include more expanded nutritional and physiologic considerations.

Objective: To evaluate clinic visits and running-related injury (RRI) characteristics among child and adolescent runners seeking care at an outpatient clinic over a 10-year time frame., Design: Retrospective chart review., Setting: Outpatient hospital-affiliated Injured Runners Clinic., Patients: Children and adolescent runners (6-17 years) with RRIs., Independent Variables: We examined electronic medical records (EMRs) among child and adolescent patients in the hospital database from 2011 to 2021 to obtain RRI characteristics and key demographic factors., Main Outcome Measures: We assessed volume and frequency of patient visits to the clinic by RRI characteristics. Chi square analyses were used to compare the proportion of clinic visits over time and injury trends by body region and diagnosis., Results: There were 392 patients (sex: 277 F; mean age: 16.1 ± 1.3 years) and an average of 5 clinic visits per diagnosis (5 ± 4 visits; min: 1 visit, max: 31 visits). Number of visits generally increased over time up to 2016 but declined most drastically during the years of the pandemic (2020-2021; χ 2 = 644, P < 0 .001). Of the 654 new injury diagnoses, 77.68% were attributed to repetitive stress. Bone stress injuries to the tibia were the most common RRI (χ 2 = 1940, P < 0 .001; N = 132; 20.2% of all injuries) and constituted most of the clinic visits (χ 2 = 9271, P < 0 .001; N = 591; 25.4% of all visits)., Conclusion: We identified that adolescents with overuse injuries, particularly bone stress injuries to the tibia, constituted most of the visits to the outpatient healthcare setting. Clinicians should emphasize injury prevention efforts in clinical practice to reduce RRI burden., Competing Interests: Dr. W. P. Meehan receives royalties from (1) ABC-Clio publishing for the sale of his books, Kids, Sports, and Concussion: A guide for coaches and parents and Concussions; (2) Springer International for the book Head and Neck Injuries in Young Athlete ; and (3) Wolters Kluwer for working as an author for UpToDate . His research is funded, in part, by philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament and a grant from the National Football League. Dr. A. F. DeJong Lempke is an independent contractor for Running USA on separate projects. There are no additional conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Sufficient high-quality studies in sport science using women as participants are lacking, meaning that our knowledge and understanding of female athletes in relation to their ovarian hormone profiles is limited. Consortia can be used to pool talent, expertise and data, thus accelerating our learning on a given topic and reducing research waste through collaboration. To this end, we have assembled an international multisite team, described here, to investigate the effects of the menstrual cycle and contraceptive pill phase on aspects of exercise physiology and sports performance in female athletes. We intend to produce an adequately powered, high-quality dataset, which can be used to inform the practices of female athletes. Our approach will also employ research transparency-through the inclusion of a process evaluation-and reproducibility-through a standardised study protocol., Competing Interests: Competing interests: KES has received funding from Arsenal Football Club, The English Institute of Sport, the European Club Association and the UK Ministry of Defence to conduct research on female athletes. None of these grants have direct competing interests with the Feminae project. KA has received funding/honoraria from the Wu Tsai Human Performance Alliance, Gatorade Sport Science Institute, Hologic, UptoDate and the US Olympic and Paralympic Committee. This funding does not have a direct competing interest with the Feminae project. CML has no competing or conflicts of interest. CM has received funding from the Australian Institute of Sport, the Queensland Academy of Sport, and an industry partner (cannot be named here) to conduct research on female athletes. None of these grants have direct competing interests with the Feminae project. CS has received funding from the UK Ministry of Defence to conduct research on female military personnel. This funding does not have direct competing interests with the Feminae project. TS has received funding/honoraria from the Wu Tsai Human Performance Alliance, Ineos, Science in Sport (Sis) Own The Podium, Gatorade Sport Science Institute and Lululemon Athletica to support research, including projects on female participants. None of these grants have a direct competing interest with the Feminae project. PAS has no competing or conflicts of interest. ACH has no competing or conflicts of interest., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Context: Female athletes, particularly runners, with insufficient caloric intake for their energy expenditure [low energy availability (EA) or relative energy deficiency] are at risk for impaired skeletal integrity. Data are lacking in male runners., Objective: To determine whether male runners at risk for energy deficit have impaired bone mineral density (BMD), microarchitecture, and estimated strength., Design: Cross-sectional., Setting: Clinical research center., Participants: 39 men (20 runners, 19 controls), ages 16-30 years., Main Outcome Measures: Areal BMD (dual-energy x-ray absorptiometry); tibia and radius volumetric BMD and microarchitecture (high-resolution peripheral quantitative computed tomography); failure load (microfinite element analysis); serum testosterone, estradiol, leptin; energy availability., Results: Mean age (24.5 ± 3.8 y), lean mass, testosterone, and estradiol levels were similar; body mass index, percent fat mass, leptin, and lumbar spine BMD Z-score (-1.4 ± 0.8 vs -0.8 ± 0.8) lower (P < .05); and calcium intake and running mileage higher (P ≤ .01) in runners vs controls. Runners with EA

Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps., Competing Interests: Competing interests: MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP. EV is an Associate Editor of the BJSM, an Associate Editor of the BJSM IPHP and Editor in Chief of BMJ Open Sports and Exercise Medicine. RB is the IOC Medical and Scientific Director. LE is the IOC Head of Science Activities and an Editor of BJSM IPHP. UE is an IOC member and the Chair of the IOC Medical and Scientific Commission., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research.This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred , Used and Recommended or Potential Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care., Competing Interests: Competing interests: KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP. MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. EV is an Associate Editor of the BJSM, an Associate Editor of the BJSM IPHP and Editor in Chief of BMJ Open Sports and Exercise Medicine., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP. EV is an Associate Editor of the BJSM, an Associate Editor of the BJSM IPHP and Editor in Chief of BMJ Open Sports and Exercise Medicine. RB is the IOC Medical and Scientific Director. LE is the IOC Head of Science Activities and an Editor of BJSM IPHP. UE is an IOC member and the Chair of the IOC Medical and Scientific Commission.

The 2023 International Olympic Committee (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) notes that exposure to low energy availability (LEA) exists on a continuum between adaptable and problematic LEA, with a range of potential effects on both health and performance. However, there is variability in the outcomes of LEA exposure between and among individuals as well as the specific manifestations of REDs. We outline a framework for a 'systems biology' examination of the effect of LEA on individual body systems, with the eventual goal of creating an integrated map of body system interactions. We provide a template that systematically identifies characteristics of LEA exposure (eg, magnitude, duration, origin) and a variety of moderating factors (eg, medical history, diet and training characteristics) that could exacerbate or attenuate the type and severity of impairments to health and performance faced by an individual athlete. The REDs Physiological Model may assist the diagnosis of underlying causes of problems associated with LEA, with a personalised and nuanced treatment plan promoting compliance and treatment efficacy. It could also be used in the strategic prevention of REDs by drawing attention to scenarios of LEA in which impairments of health and performance are most likely, based on knowledge of the characteristics of the LEA exposure or moderating factors that may increase the risk of harmful outcomes. We challenge researchers and practitioners to create a unifying and dynamic physiological model for each body system that can be continuously updated and mapped as knowledge is gained., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Relative Energy Deficiency in Sport (REDs) is common among female and male athletes representing various sports at different performance levels, and the underlying cause is problematic low energy availability (LEA). It is essential to prevent problematic LEA to decrease the risk of serious health and performance consequences. This narrative review addresses REDs primary, secondary and tertiary prevention strategies and recommends best practice prevention guidelines targeting the athlete health and performance team, athlete entourage (eg, coaches, parents, managers) and sport organisations. Primary prevention of REDs seeks to minimise exposure to and reduce behaviours associated with problematic LEA. Some of the important strategies are educational initiatives and de-emphasising body weight and leanness, particularly in young and subelite athletes. Secondary prevention encourages the early identification and management of REDs signs or symptoms to facilitate early treatment to prevent development of more serious REDs outcomes. Recommended strategies for identifying athletes at risk are self-reported screening instruments, individual health interviews and/or objective assessment of REDs markers. Tertiary prevention (clinical treatment) seeks to limit short-term and long-term severe health consequences of REDs. The cornerstone of tertiary prevention is identifying the source of and treating problematic LEA. Best practice guidelines to prevent REDs and related consequences include a multipronged approach targeting the athlete health and performance team, the athlete entourage and sport organisations, who all need to ensure a supportive and safe sporting environment, have sufficient REDs knowledge and remain observant for the early signs and symptoms of REDs., Competing Interests: Competing interests: MLM is a deputy editor of the BJSM and a member of the BJSM IPHP editorial board. KEA is a deputy editor of the BJSM and an associate editor of the BJSM IPHP., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The IOC made recommendations for recording and reporting epidemiological data on injuries and illness in sports in 2020, but with little, if any, focus on female athletes. Therefore, the aims of this supplement to the IOC consensus statement are to (i) propose a taxonomy for categorisation of female athlete health problems across the lifespan; (ii) make recommendations for data capture to inform consistent recording and reporting of symptoms, injuries, illnesses and other health outcomes in sports injury epidemiology and (iii) make recommendations for specifications when applying the Strengthening the Reporting of Observational Studies in Epidemiology-Sport Injury and Illness Surveillance (STROBE-SIIS) to female athlete health data.In May 2021, five researchers and clinicians with expertise in sports medicine, epidemiology and female athlete health convened to form a consensus working group, which identified key themes. Twenty additional experts were invited and an iterative process involving all authors was then used to extend the IOC consensus statement, to include issues which affect female athletes.Ten domains of female health for categorising health problems according to biological, life stage or environmental factors that affect females in sport were identified: menstrual and gynaecological health; preconception and assisted reproduction; pregnancy; postpartum; menopause; breast health; pelvic floor health; breast feeding, parenting and caregiving; mental health and sport environments.This paper extends the IOC consensus statement to include 10 domains of female health, which may affect female athletes across the lifespan, from adolescence through young adulthood, to mid-age and older age. Our recommendations for data capture relating to female athlete population characteristics, and injuries, illnesses and other health consequences, will improve the quality of epidemiological studies, to inform better injury and illness prevention strategies., Competing Interests: Competing interests: ISM and HPD are an Associate Editor of BJSM. JST and NSM are Editors of BJSM. KEA, PCZ and MM are Deputy Editors of BJSM. EV is the Editor in Chief of BMJ Open Sports and Exercise Medicine., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one's environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee's REDs Clinical Assessment Tool-V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and 'weighted' in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Studies in estrogen deficiency states such as primary ovarian insufficiency and Turner syndrome suggest that estrogen status may be an important modulator of mood and emotions. In this study we compared depressive and anxiety symptoms between adolescent and young adult female oligo-amenorrheic athletes (AA) and eumenorrheic females (EM), and explored structural, and functional changes in related brain areas during reward processing, a behavioral construct that is altered in depression and anxiety., Methods: We included (i) 24 AA participating in ≥4 hours/week of aerobic exercise or running ≥20 miles/week for ≥6 months in the preceding year, with lack of menstrual cycles for ≥3 months within at least 6 preceding months of oligo-amenorrhea, OR in premenarchal girls, absence of menses at >15 years), and (ii) 27 EM aged 14-25 years. Participants completed the Beck Depression Inventory-II (BDI-II), State and Trait Anxiety Inventory (STAI), and Mood and Anxiety Symptoms Questionnaire (MASQ). Structural MRI and brain activation during a functional MRI (fMRI) task that probes reward and punishment processing was examined in a subset of 10 AA and 23 EM., Results: Median (IQR) age and BMI of AA and EM groups were 20.6 (19.0-22.6) vs. 20.6 (19.2-23.7) years, p=0.6 and v 20.3 (18.8-21.5) vs. 21.9 (19.6-23.5) kg/m2, p=0.005, respectively. While groups did not differ for BDI-II scores, AA had higher anhedonic depression MASQ scores (p=0.04), and STAI (p=0.03) scores vs. EM. In the fMRI subset, AA had higher caudate volumes vs. EM [F(1, 29)=9.930, p=0.004]. Lower activation observed in the right caudate during reward anticipation in AA compared with EM (p=0.036) suggests blunted reward processing in the striatum in estrogen deficient states., Conclusion: Athletes with amenorrhea had higher depressive and anxiety symptomatology compared to eumenorrheic young women. Exploratory analyses demonstrated increased caudate volumes and decreased caudate activation during reward processing in athletes with amenorrhea suggesting that estrogen may play a role in reward processing., Competing Interests: Over the past 3 years, DP has received consulting fees from Albright Stonebridge Group, Boehringer Ingelheim, Compass Pathways, Engrail Therapeutics, Neumora Therapeutcis former BlackThorn Therapeutics, Neurocrine Bioscences, Neuroscience Software, Otsuka Pharmaceuticals, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals; honoraria from the Psychonomic Society for editorial work and Alkermes, and research funding from NIMH, Dana Foundation, Brain and Behavior Research Foundation, Millennium Pharmaceuticals. In addition, he has received stock options from Compass Pathways, Engrail Therapeutics, Neumora Therapeutics former BlackThorn Therapeutics, and Neuroscience Software. Over the past 3 years, MM has received consulting fees from Sanofi and Abbvie, and served on the scientific advisory board for Abbvie and Ipsen. No funding from these entities was used to support the current work, and all views expressed are solely those of the author. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Baskaran, Kumar, Plessow, Nimmala, Ackerman, Eddy, Pizzagalli and Misra.)

The aim of this audit was to assess the representation of female athletes, dietary control methods, and gold standard female methodology that underpins the current guidelines for chronic carbohydrate (CHO) intake strategies for athlete daily training diets. Using a standardized audit, 281 studies were identified that examined high versus moderate CHO, periodized CHO availability, and/or low CHO, high fat diets. There were 3,735 total participants across these studies with only ∼16% of participants being women. Few studies utilized a design that specifically considered females, with only 16 studies (∼6%) including a female-only cohort and six studies (∼2%) with a sex-based comparison in their statistical procedure, in comparison to the 217 studies (∼77%) including a male-only cohort. Most studies (∼72%) did not provide sufficient information to define the menstrual status of participants, and of the 18 studies that did, optimal methodology for control of ovarian hormones was only noted in one study. While ∼40% of male-only studies provided all food and beverages to participants, only ∼20% of studies with a female-specific design used this approach for dietary control. Most studies did not implement strategies to ensure compliance to dietary interventions and/or control energy intake during dietary interventions. The literature that has contributed to the current guidelines for daily CHO intake is lacking in research that is specific to, or adequately addresses, the female athlete. Redressing this imbalance is of high priority to ensure that the female athlete receives evidence-based recommendations that consider her specific needs.

Background: Bone stress injuries (BSIs) are common in female runners, and recurrent BSI rates are high. Previous work suggests an association between higher impact loading during running and tibial BSI. However, it is unknown whether impact loading and fatigue-related loading changes discriminate women with a history of multiple BSIs. This study compared impact variables at the beginning of a treadmill run to exertion and the changes in those variables with exertion among female runners with no history of BSI as well as among those with a history of single or multiple BSIs., Methods: We enrolled 45 female runners (aged 18-40 years) for this cross-sectional study: having no history of diagnosed lower extremity BSI (N-BSI, n = 14); a history of 1 lower extremity BSI (1-BSI, n = 16); and diagnosed by imaging, or a history of multiple (≥3) lower extremity BSIs (M-BSI, n = 15). Participants completed a 5-km race speed run on an instrumented treadmill while wearing an Inertial Measurement Unit. The vertical average loading rate (VALR), vertical instantaneous loading rate (VILR), vertical stiffness during impact via instrumented treadmill, and tibial shock determined as the peak positive tibial acceleration via Inertial Measurement Unit were measured at the beginning and the end of the run., Results: There were no differences between groups in VALR, VILR, vertical stiffness, or tibial shock in a fresh or exerted condition. However, compared to N-BSI, women with M-BSI had greater increase with exertion in VALR (-1.8% vs. 6.1%, p = 0.01) and VILR (1.5% vs. 4.8%, p = 0.03). Similarly, compared to N-BSI, vertical stiffness increased more with exertion among women with M-BSI (-0.9% vs. 7.3%, p = 0.006) and 1-BSI (-0.9% vs. 1.8%, p = 0.05). Finally, compared to N-BSI, the increase in tibial shock from fresh to exerted condition was greater among women with M-BSI (0.9% vs. 5.5%, p = 0.03) and 1-BSI (0.9% vs. 11.2%, p = 0.02)., Conclusion: Women with 1-BSI or M-BSIs experience greater exertion-related increases in impact loading than women with N-BSI. These observations imply that exertion-related changes in gait biomechanics may contribute to risk of BSI., (Copyright © 2022. Production and hosting by Elsevier B.V.)

The National Collegiate Athletic Association (NCAA) Summit on Gender Identity and Student-Athlete Participation was convened to identify institutional/athletic department strategies that may support the well-being of trans and gender nonconforming (TGNC) collegiate student-athletes in the USA. The Summit's purview did not include policy-level changes to eligibility rules. A modified Delphi consensus process was used to identify strategies for supporting collegiate TGNC student-athlete well-being. Key steps included an exploration phase (learning, generating ideas), and an evaluation phase (rating ideas in terms of their utility and feasibility). Summit participants (n=60) included individuals meeting at least one of the following criteria: current or former TGNC athlete, academic or healthcare professional with topical expertise, collegiate athletics stakeholder who would be involved in implementing potential strategies, representative from leading sports medicine organisation, or representative from relevant NCAA membership committee. Summit participants identified strategies in the following domains: healthcare practices (patient-centred care and culturally sensitive care); education for all stakeholders involved in athletics; and administration (inclusive language, quality improvement processes). Summit participants also proposed ways that the NCAA, through its existing committee and governance structures, could help support the well-being of TGNC athletes. NCAA-focused concepts were in the following domains: policy making processes; eligibility and transfer processes; resource development and dissemination; and visibility and support for TGNC athletes. The strategies developed represent important and relevant approaches that member institutions, athletic departments, NCAA committees, governance bodies and other stakeholders might consider in their efforts to support TGNC student-athlete well-being., Competing Interests: Competing interests: KEA is a member of the World Rowing Gender Advisory Panel and the US Rowing Gender Identity Policy Working Group. EK is a paid consultant of the NCAA., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Bone stress injuries (BSIs) are classified in clinical practice as being at low- or high-risk for complication based on the injury location. However, this dichotomous approach has not been sufficiently validated. The purpose of this systematic review was to examine the prognostic role of injury location on return-to-sport (RTS) and treatment complications after BSI of the lower extremity and pelvis., Design: Systematic review and meta-analysis., Data Sources: PubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021., Eligibility Criteria for Selecting Studies: Peer-reviewed studies that reported site-specific RTS of BSIs in athletes., Results: Seventy-six studies reporting on 2974 BSIs were included. Sixteen studies compared multiple injury sites, and most of these studies (n=11) described the anatomical site of injury as being prognostic for RTS or the rate of treatment complication. Pooled data revealed the longest time to RTS for BSIs of the tarsal navicular (127 days; 95% CI 102 to 151 days) and femoral neck (107 days; 95% CI 79 to 135 days) and shortest duration of time for BSIs of the posteromedial tibial shaft (44 days, 95% CI 27 to 61 days) and fibula (56 days; 95% CI 13 to 100 days). Overall, more than 90% of athletes successfully returned to sport. Treatment complication rate was highest in BSIs of the femoral neck, tarsal navicular, anterior tibial shaft and fifth metatarsal; and lowest in the fibula, pubic bone and posteromedial tibial shaft., Conclusion: This systematic review supports that the anatomical site of BSIs influences RTS timelines and the risk of complication. BSIs of the femoral neck, anterior tibial shaft and tarsal navicular are associated with increased rates of complications and more challenging RTS., Prospero Registration Number: CRD42021232351., Competing Interests: Competing interests: KEA: KEA is a deputy editor of BJSM., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The aim of this audit was to assess the representation of female athletes within the literature that has led to current guidelines for carbohydrate (CHO) intake in the acute periods surrounding exercise and the quality of this research., Methods: We conducted a standardized audit of research assessing CHO loading protocols, CHO mouth rinse, and CHO intake before, during, and after exercise., Results: A total of 937 studies were identified in this audit. There were a total of 11,202 participants across these studies, with only ~11% being women. Most studies involved male-only cohorts (~79%), with a mere 38 studies (~4%) involving female-only cohorts and 14 studies (~2%) including a methodological design for comparison of sex-based responses. The frequent use of incorrect terminology surrounding menstrual status and the failure of most studies (~69%) to provide sufficient information on the menstrual status of participants suggests incomplete understanding and concern for female-specific considerations among researchers. Of the 197 studies that included women, only 13 (~7%) provided evidence of acceptable methodological control of ovarian hormones, and no study met all best-practice recommendations. Of these 13 studies, only half also provided sufficient information regarding the athletic caliber of participants. The topics that received such scrutiny were CHO loading protocols and CHO intake during exercise., Conclusions: The literature that underpins the current guidelines for CHO intake in the acute periods around exercise is lacking in high-quality research that can contribute knowledge specific to the female athlete and sex-based differences. New research that considers ovarian hormones and sex-based differences is needed to ensure that the recommendations for acute CHO fueling provided to female athletes are evidence based., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Sports Medicine.)

Introduction: Although an acute exercise session typically increases bone turnover markers (BTM), the impact of subsequent sessions and the interaction with preexercise calcium intake remain unclear despite the application to the "real-life" training of many competitive athletes., Methods: Using a randomized crossover design, elite male rowers ( n = 16) completed two trials, a week apart, consisting of two 90-min rowing ergometer sessions (EX1, EX2) separated by 150 min. Before each trial, participants consumed a high (CAL; ~1000 mg) or isocaloric low (CON; <10 mg) calcium meal. Biochemical markers including parathyroid hormone (PTH), serum ionized calcium (iCa) and BTMs (C-terminal telopeptide of type I collagen, osteocalcin) were monitored from baseline to 3 h after EX2., Results: Although each session caused perturbances of serum iCa, CAL maintained calcium concentrations above those of CON for most time points, 4.5% and 2.4% higher after EX1 and EX2, respectively. The decrease in iCa in CON was associated with an elevation of blood PTH ( P < 0.05) and C-terminal telopeptide of type I collagen ( P < 0.0001) over this period of repeated training sessions and their recovery, particularly during and after EX2. Preexercise intake of calcium-rich foods lowered BTM over the course of a day with several training sessions., Conclusions: Preexercise intake of a calcium-rich meal before training sessions undertaken within the same day had a cumulative and prolonged effect on the stabilization of blood iCa during exercise. In turn, this reduced the postexercise PTH response, potentially attenuating the increase in markers of bone resorption. Such practical strategies may be integrated into the athlete's overall sports nutrition plan, with the potential to safeguard long-term bone health and reduce the risk of bone stress injuries., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Sports Medicine.)

Bone stress injuries are common in athletes, resulting in time lost from training and competition. Diets that are low in energy availability have been associated with increased circulating bone resorption and reduced bone formation markers, particularly in response to prolonged exercise. However, studies have not separated the effects of low energy availability per se from the associated reduction in carbohydrate availability. The current study aimed to compare the effects of these two restricted states directly. In a parallel group design, 28 elite racewalkers completed two 6-day phases. In the Baseline phase, all athletes adhered to a high carbohydrate/high energy availability diet (CON). During the Adaptation phase, athletes were allocated to one of three dietary groups: CON, low carbohydrate/high fat with high energy availability (LCHF), or low energy availability (LEA). At the end of each phase, a 25-km racewalk was completed, with venous blood taken fasted, pre-exercise, and 0, 1, 3 hours postexercise to measure carboxyterminal telopeptide (CTX), procollagen-1 N-terminal peptide (P1NP), and osteocalcin (carboxylated, gla-OC; undercarboxylated, glu-OC). Following Adaptation, LCHF showed decreased fasted P1NP (~26%; p < 0.0001, d = 3.6), gla-OC (~22%; p = 0.01, d = 1.8), and glu-OC (~41%; p = 0.004, d = 2.1), which were all significantly different from CON (p < 0.01), whereas LEA demonstrated significant, but smaller, reductions in fasted P1NP (~14%; p = 0.02, d = 1.7) and glu-OC (~24%; p = 0.049, d = 1.4). Both LCHF (p = 0.008, d = 1.9) and LEA (p = 0.01, d = 1.7) had significantly higher CTX pre-exercise to 3 hours post-exercise but only LCHF showed lower P1NP concentrations (p < 0.0001, d = 3.2). All markers remained unchanged from Baseline in CON. Short-term carbohydrate restriction appears to result in reduced bone formation markers at rest and during exercise with further exercise-related increases in a marker of bone resorption. Bone formation markers during exercise seem to be maintained with LEA although resorption increased. In contrast, nutritional support with adequate energy and carbohydrate appears to reduce unfavorable bone turnover responses to exercise in elite endurance athletes. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR)., (© 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).)