Date of Award
Master of Science (MS)
Kevin S. Heffernan
bone stress injury, educational training, Female Athlete Triad, female distance runners, low energy availability, Relative Energy Deficiency in Sport
Medicine and Health Sciences
There has been an increased participation of female athletes competing in the NCAA for the past thirty years. Amongst these female athletes, there is an increased risk of stress fracture (SFx) injury, which is highly prevalent among female endurance sports. Female athletes, especially those participating in endurance sports (i.e. distance running), exhibit an increases risk of developing The Female Athlete Triad (the Triad) and Relative Energy Deficiency in Sport (RED-S). The Triad and RED-S are conditions that explore the health and performance consequence of low energy availability (LEA) amongst athletes. Few studies to date have assessed the knowledge that athletes, coaches, and athletic trainers have regarding the triad and RED-S. Proper education and knowledge have been shown to be effective in properly addressing other sports medicine concerns in athletes, yet the current recommendations for continuing education for the triad and RED-S are not required by institutions. PURPOSE: The primary purpose of this study was to assess the knowledge and confidence of identifying, screening, treating, and preventing the Triad and RED-S via knowledge, confidence, and a composite impact score. Scores were assessed amongst collegiate female distance runners, coaches of collegiate female distance runners, and athletic trainers (ATs) of collegiate female distance runners. HYPOTHESES: It was hypothesized that female distance runners will demonstrate the lowest scores (confidence, knowledge, and impact) regarding the Triad/RED-S. While it is hypothesized ATs will demonstrate the highest scores regarding the Triad/RED-S. METHODS: Two-hundred-sixty participants completed this study: 175 collegiate female distance runners (age 20 ± 1, 175 female), 55 coaches of collegiate female distance runners (age 36 ± 11, 29 male, 26 female), and 30 ATs (age 34 ± 9, 26 female, 3 male). The Triad and RED-S questionnaire was developed and used to assess the knowledge and confidence (37-items) of the triad and RED-S through a series of questions targeted at the identification, screening, treatment, and prevention of the Triad and RED-S models. Other questionnaire items were included to understand interactions between participants characteristics and total impact scores, as well as to characterize the current and continuing education of participants regarding the triad and RED-S. Between group differences were assessed using a one-way ANOVA. Scores of knowledge, confidence, and impact were assessed by categorical and continuous variables using independent samples T-test and Pearson’s and Spearman’s correlations, respectively. Univariate GLM was used to assess interactions of participant characteristics to impact scores in a multivariate approach. RESULTS: Scores of knowledge, confidence, and impact were highest in ATs and lowest in female distance runners. Female distance runners’ total knowledge, confidence, and impact scores (mean scores of 25.00 ± 5.27, 95.42 ± 28.83, 18.81 ± 7.05 respectively) were significantly different from the total knowledge confidence, and impact scores of coaches (mean scores of 26.92 ± 5.02, 111.35 ± 24.14 and 22.41 ± 6.33) and ATs (mean scores of 28.66 ± 4.02, 117.67 ± 22.53, and 23.93 ± 5.69) (p < 0.05). There was a weak, but significant correlation between peak career mileage and impact scores in female distance runners (r = 0.195; p < 0.05). Impact scores significantly differed in female distance runners with a related academic area of study compared to female distance runners with an unrelated academic area of study (mean scores of 21.91 ± 5.16, 16.11 ± 5.54, respectively; p < 0.01). Impact scores significantly differed in female distance runners at NCAA DI institutions (19.98 ± 7.05) versus non-DI institutions (mean score of 17.35 ± 6.82) (p < 0.05). Impact scores significantly differed in female distance runners with positive Triad and RED-S diagnosis (mean scores of 21.69 ± 5.85 and 22.58 ± 6.82, respectively) compared to negative Triad and RED-S diagnosis (mean scores of 16.80 ± 6.54 and 17.20 ± 6.34, respectively). Impact scores significantly differed in coaches at NCAA DI institutions (mean score of 24.13 ± 4.57) versus non-DI institutions (mean score of 20.35 ± 7.55) (p < 0.05). With respect to receiving educational programming on the Triad and RED-S provided by the athletic department, 69.32% of female distance runners, 52.63% of coaches, and 51.61% of ATs report receiving no educational programming. Impact scores significantly differed in female distance runners who received training on the Triad (mean score of 21.03 ± 6.86) vs. female distance runners who did not receive training on the Triad (mean score of 18.12 ± 6.82) (p < 0.05). Impact scores significantly differed in coaches who received training on the Triad (mean score of 25.10 ± 4.50) vs. coaches who did not receive training on the Triad (mean score of 20.99 ± 6.75) (p < 0.05). 77.59% of female distance runners, 70.18% of coaches, and 40.00% of ATs reported not receiving training on RED-S. Impact scores significantly differed in coaches who received RED-S training (mean score of 25.81 ± 4.41) vs. coaches who did not receive RED-S training (mean score of 21.02 ± 6.52) (p < 0.01). Multivariate analysis, in female distance runners, revealed a non-significant interaction between peak career mileage and division level participation (p > 0.05; Table 18; Figure 7) and a significant interaction between peak career mileage and Triad diagnosis (p < 0.05; Table 18; Figure 8). CONCLUSION: This study illustrates that knowledge of the Triad and RED-S was lowest in female distance runners compared to coaches and ATs, represented by total knowledge and impact scores. Knowledge of the Triad and RED-S was highest in ATs compared to coaches and female distance runners, expressed by total knowledge and impact scores. This is important because female distance runners who are knowledgeable about the Triad and RED-S may more readily seek out medical help to address subsequent health and performance consequences related to the Triad and RED-S. This study suggests that participant characteristics had little effect on total scores (confidence, knowledge, and impact). However, significant differences that were revealed often related to education-based and diagnoses differences (i.e. Triad and RED-S training, related academic area of study, and positive Triad and RED-S diagnoses). Multivariate analysis revealed an important interaction between peak career mileage and Triad diagnosis in female distance runners, suggesting that a positive Triad diagnosis depends on peak career mileage. These findings are in support of educational training, which should be considered as the primary tool to increase knowledge in all population groups in order to improve the prevention and treatment of the Triad and RED-S, ideally prior to the development of the Triad and RED-S.
Lodge, Melissa, "Knowledge of the Female Athlete Triad and Relative Energy Deficiency in Sport Amongst Female Distance Runners and Their Support Staff" (2020). Theses - ALL. 449.