– Written by Robyn K. Fuchs, Claire M. Mehling, Elli J. Ertl, Diana R. Heyden, Stuart J. Warden, USA
INTRODUCTION
Bones are underappreciated when it comes to athletic performance. Muscles, driven by the motor control system, generate forces, speed, power, and movements that define performance. Through training, these outputs are readily quantifiable and modifiable, making them prominent. However, muscles are not effective unless their forces are applied to something rigid.
Bones are uniquely designed to transmit muscle forces as their extracellular matrix is mineralized. This gives them the stiffness needed to resist deformation, yet, they remain flexible enough to absorb energy and not shatter. These qualities make bones suited to fulfilling their most recognized role—mechanical support. Bones provide internal support to counter gravity, form cavities to protect organs, and provide attachment sites for muscles to produce motion.
Bones perform their mechanical functions inconspicuously, so it is often not until an athlete experiences a bone injury that bone health is considered. Outside of traumatic fractures, the most common bone injury in athletes is a bone stress injury (BSI)1. BSIs, including stress reactions and stress fractures, represent the inability of a bone to withstand repetitive loading. This leads to localized bone weakness and pain2. Such instances develop when microscopic damage (i.e., microdamage) accumulates in a bone at a rate that the bone cells which remove (i.e., osteoclasts) and replace (i.e., osteoblasts) the damage are unable to keep up3.
A BSI does not always mean that an athlete has poor general bone health, since a BSI can develop in an otherwise normal bone due to suboptimal loading (e.g., too rapid progression of training and mechanical overload). However, BSIs more commonly occur when suboptimal loading is superimposed on a bone with compromised health.
WHAT IS BONE HEALTH, AND HOW IS IT ASSESSED?
Bone health relates to the ability of the skeleton to fulfil its functions without injury or disease. In athletes, we are interested in the ability of bones to resist repeated loading to reduce BSI risk by: 1) limiting microdamage formation and, 2) efficiently removing and replacing microdamage. In addition, we need to be conscious of the role bone health developed during an athlete’s active career has on later-life risk for osteoporosis.
It is not currently possible to image bone microdamage, but we do know that stronger bones experience less stress and strain when loaded and develop less damage. Thus, bone strength is an important bone health metric. Unfortunately, like with microdamage, there is currently no means of directly assessing bone strength. Instead, surrogate indicators are used.
The gold-standard for indirectly assessing bone strength is to use dual-energy x-ray absorptiometry (DXA) to assess the amount or quantity of bone. This is reported as bone mineral density (BMD), which is how much bone mineral is present relative to the areal (two-dimensional) projected size of the bones. Correcting by bone size partially corrects for differences in body size. BMD explains a large proportion of bone strength, with DXA being relatively widely available, fast, affordable, precise, and involving minimal radiation (≤1 day of background radiation).
There are reference populations that have been imaged by DXA. Comparing an individual’s BMD to a reference population enables the calculation of a standardized score. In children, pre-menopausal females, and males <50 years of age the key outcome of interest is the z-score. The z-score indicates how many standard deviations an athlete’s BMD is away from people of the same age, sex, race, and ethnicity. There are considerations when interpreting DXA z-scores in athletes (Table 1).
WHAT FACTORS INDICATE AND/OR CONTRIBUTE TO COMPROMISED BONE HEALTH?
DXA-derived BMD is a useful metric that can indicate inferior bone health; however, it does not indicate its cause, and is not always available. There are numerous other factors that can indicate and/or contribute to inferior bone health in athletes (Figure 1).
Bone stress injury history and location
Previous history of a BSI is the biggest risk factor for a BSI11. When an athlete presents with a BSI or a previous history of one or more BSIs, concern regarding underlying bone health is raised. Specifics on the number of previous BSIs, their location/s, and the circumstances of the injury/ies in terms of identifiable contributing factors should be sought.
A history of multiple previous BSIs or a BSI occurring at a central location can be an indicator of poor underlying bone health12,13. Centrally occurring BSIs in the sacrum, pelvis, and femoral neck are strong signs that bone health needs to be explored, as these sites are more susceptible to the impact of systemic factors (e.g., low energy availability and hormonal dysfunction)13,14.
Low energy availability, REDs and athlete triads
Low energy availability (LEA) is a prominent risk factor for altered bone health. Resulting from low dietary energy intake and/or excessive energy expenditure, LEA shifts energy away from other processes, especially those involved in growth, reproduction and maintenance15. Low intake can be intended, either due to a desire to maintain leanness and/or the presence of known or unknown disordered or restricted eating. Alternatively, low intake can be unintended due to a failure to alter energy intake to match changes in expenditure associated with training workload changes.
Normal energy availability is considered at ≥45 kcal/kg of fat-free mass/day, with <30 kcal/kg of fat free mass/day suggested to be associated with compromised performance, altered bone health, and other health issues. However, energy availability is difficult to accurately measure, and cutoffs are not absolute with the consequences of LEA being influenced by its duration, magnitude, and frequency.
The inclusive term Relative Energy Deficiency in Sport (REDs) was introduced to describe the broad consequences of LEA16. As a result a REDs Clinical Assessment Tool has been developed to provide a framework to assist with identifying and guiding management17. Other screening tools include the Low Energy Availability in Females Questionnaire (LEAF-Q)18 and Low Energy Availability in Males Questionnaire (LEAM-Q)19. Alternatively, a free online Personal Energy Availability Questionnaire (PEAQ) is also available20. While potentially useful, these latter questionnaires have not been fully validated across a diverse range of athletes.
Ultimately, suspicion of LEA requires the involvement of a multidisciplinary team approach. This includes the athlete, coach, support team, and a broad range of health professionals, including sport and exercise medicine physicians, registered sport dieticians, and sport psychologists, to name a few.
Reproductive function
Alterations in sex hormones are a strong driver of poor bone health and BSI risk. Hypogonadism in females (evidenced by menstrual dysfunction) is one component of the female athlete triad, along with LEA and low BMD21. A similar male athlete triad exists, with functional hypothalamic hypogonadism (potentially presenting as decreased sexual function and libido) replacing menstrual dysfunction22.
Normal menstrual cycles in females occur every 21-35 days (average = 28 days) and last 3-7 days. Menstrual dysfunction includes primary and secondary amenorrhea, evident by a failure to menstruate by age 15, despite normal secondary sexual development, and absence of 3 or more consecutive menstrual cycles, respectively. However, these indicators can be masked in females using hormonal contraception.
Loss of normal menstrual function results in estrogen deficiency, with estrogen required to limit bone loss due to osteoclastic bone resorption. It is estimated that untreated amenorrhoeic females lose 2-3% of bone mass per year21. In addition, loss of menstrual function combined with LEA decreases testosterone and other hormones, including insulin-related growth factor 1, leptin and triiodothyronine. These hormones impact bone formation, or the gain of bone, such that the triads and REDs impact both bone mass/BMD, as well as the ability to remove and repair microdamage. In males, functional hypothalamic hypogonadism reduces testosterone, which is a key anabolic hormone for stimulating bone formation.
Sport participation and specialization
There is a presumption that all athletes have good bone health as they are regularly exposed to elevated loads. However, poor bone health is prevalent in individuals participating in endurance and aesthetic endeavors where leanness is perceived to be advantageous and there is more prevalent LEA. This includes distance runners, rhythmic gymnasts, synchronized swimmers, and performing artists. Up to 40% of female adolescent cross-country runners have a spine BMD z-score of below -123.
Early specialization in a sport, particularly a leanness sport, or one involving relatively low skeletal loading (e.g., swimming and cycling), may compromise bone health in some athletes. Athletes who specialize in sports with low bone-building potential can enter adolescence and young adulthood with low BMD and elevated risk of BSI. Female high school distance runners who highly specialized in distance running (running >9 month/year), with no participation in other sports, were 5-times more likely to have a DXA z-score <-1.024. In contrast, athletes who played multidirectional sports when younger (i.e., prior to their adolescent growth spurt), developed more robust bones25, and experienced less BSIs than athletes who specialized solely in running26. Sport specialization needs to be addressed prospectively as it is not possible to address after the fact.
Calcium (and phosphorous and magnesium)
Bone achieves its stiffness and rigidity by combining calcium with phosphate and magnesium to form hydroxyapatite crystals. The amount of hydroxyapatite present is what is measured when BMD is assessed. The body does not produce calcium—it is an essential mineral that must be obtained through diet or supplementation. The body absorbs calcium from foods such as dairy products (e.g., milk, cheese, yogurt), leafy green vegetables (e.g., spinach, kale, okra, collards), some beans (e.g., soybeans, white beans), and calcium fortified foods.
The recommended dietary intake in the general adult U.S. population is 1,000 mg/d (1,300 mg/d for adolescents); however, it has been suggested that athletes consume higher amounts (e.g., up to 1,500 mg/d per day) to meet their increased demands27. Female distance runners who consumed less than 800 mg of calcium daily had an almost 6-fold higher BSI rate compared with those who consumed more than 1,500 mg daily28. Special consideration should be given to athletes who are pregnant, breastfeeding or perimenopausal athletes. These groups actively lose calcium; however, it remains unclear whether calcium supplementation can influence the loss29.
The prevalence of calcium deficiency varies across the globe30. Calcium intake can be approximated using an online calculator, such as the one provided by the International Osteoporosis Foundation31. Calcium should be consumed in smaller doses (i.e., 500 mg portions) throughout the day to maximize absorption32. Useful information regarding calcium supplementation and other aspects of calcium (and phosphorous and magnesium) can be found in online factsheets33-35.
There is also a relatively new body of work looking at the impact of exercise-induced declines in serum (i.e., circulating) ionized calcium which stimulates a robust increase in serum parathyroid hormone levels and increase in bone resorption markers36. The long-term impact of these acute temporary changes on bone health remains to be established. Similarly, the benefits of calcium intake immediately prior to exercise remain an active area of research. Coombs et al.37 demonstrated that 1000 mg of calcium supplementation taken one hour prior to exercise in servicewomen prevented the decrease in circulating calcium, suppressed the increase in parathyroid hormone, and decreased bone resorption. Whether these changes have any impact on long-term bone health has yet to be shown.
Vitamin D
Active vitamin D (also known as calcitriol or 1,25-dihydroxycholecalciferol [25(OH)D]) promotes calcium absorption in the gut and reabsorption in the kidneys. Vitamin D is naturally present in some foods (e.g., fatty fish, fish liver oils, egg yolks) but mostly comes from sunlight exposure. Optimal circulating serum levels for athletes is ≥30 ng/ml (75 nmol/L); however, it is common for athletes to have vitamin D deficiency38, indicated by a serum 25(OH)D level of ≤20 ng/ml. The deficiency has potential consequences for BSI risk. In a case-control study of 1,200 white military recruits, low vitamin D levels were significantly associated with BSI39, and the risk of BSI in young female athletes was less for those in the highest quintile of vitamin D intake40.
Vitamin D deficiency varies globally, ranging from 19% in the African Region to 72% in the Eastern Mediterranean Region41. Vitamin D supplementation in individuals with sufficient levels provides limited benefit42; however, deplete athletes may benefit27. In 3,700 military recruits, risk of bone stress injuries was reduced by 20% after daily supplementation with vitamin D (800 IU) and calcium (2000 mg)43.
Iron and ferritin
Iron is an essential component of hemoglobin in red blood cells that transfers oxygen from the lungs to tissues whereas ferritin is the body’s primary iron storage protein serving as an indicator of total iron stores. Normal circulating iron and ferritin levels are indicated by hemoglobin and ferritin concentrations of >120 g/L and >30 ng/ml, respectively. Iron deficiency can cause anemia, contribute to fatigue, hinder bone cell metabolic processes, and limit the energy production necessary for bone building and the removal and replacement of damage44. It is worth noting that iron deficiency is prevalent in athletes, especially female and endurance athletes45.
When assessing iron levels in an athlete it is important to assess both hemoglobin and ferritin levels. Iron comes from a mixture of foods, including meat, fish, poultry, and plants such as beans, lentils, and dark leafy greens. The recommended daily iron intake is 8 mg/d and 18 mg/d for adult males and pre-menopausal women, respectively46. However, requirements in athletes are generally higher and can be obtained with supplementation. Doses of 60-100 mg of elemental iron daily over two months can increase iron stores (i.e., ferritin levels), with iron absorption enhanced by taking supplements with vitamin C (e.g., orange juice).
Stress and sleep
The contributions of psychological factors and sleep to bone health in the general population and athletes are not fully understood. Psychological stress may affect bone health via a cortisol-mediated mechanism47. Normal morning serum cortisol levels range from 5-25 µg/dL (138-690 nmol/L). Chronically elevated cortisol suppresses bone formation and enhances resorption, leading to net bone loss. Psychological stress in athletes may be intertwined with REDs making it difficult to distinguish their isolated effects.
The impact of cortisol may be exacerbated by sleep, including poor quality and duration. Women with a history of BSI were found to be more likely to sleep <7 hours per night compared with those without a BSI history14. Sleep is important for optimal bone health, with bone formation peaking overnight and sleep deprivation impacting a multitude of bone relevant systems (e.g., hormonal, sympathetic, inflammatory pathways, etc.)48.
Lifestyle factors
Individuals with a history of smoking and alcoholic drinking (>10 drinks/week) have a higher risk of developing a BSI49. This is mediated by the negative impact of smoking and alcohol on bone metabolism, repair of damage, and BMD.
SUMMARY
Bone health is a critical, yet often overlooked determinant of athletic performance and resilience. While bones operate quietly in the background to support movement and withstand repetitive loading, their capacity to resist injury is influenced by a complex interplay of biological, nutritional, hormonal, mechanical, and lifestyle factors. Because bone strength cannot be measured directly, clinicians and researchers must rely on surrogate assessments such as DXA-derived BMD, alongside indicators of energy availability, hormonal function, nutritional intake, and lifestyle habits. Recognizing and addressing these factors is essential not only for reducing the risk of BSI during an athlete’s career, but also for safeguarding long-term skeletal health and reducing the future burden of osteoporosis and fracture risk.
Robyn K. Fuchs PhD, FACSM, FASBMR1,2
Claire M. Mehling BS1
Elli J. Ertl BAS1
Diana R. Heyden BA1
Stuart J. Warden BPhysio (Hons), PhD, FACSM, FASBMR2,3
1 Tom and Julie Wood College of Osteopathic Medicine
Marian University
Indianapolis, Indiana, USA
2 Indiana Center for Musculoskeletal Health
Indiana University School of Medicine
Indianapolis, Indiana, USA
3 Department of Physical Therapy
School of Health and Human Sciences
Indiana University Indianapolis
Indianapolis, Indiana, USA
Contact: rfuchs@marian.edu
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Header Image by Roman Biernacki (Cropped)