For athletes, staying healthy is crucial to remain competitive.
Many female athletes, however, face an increased risk of stress fractures due to a combination of physiological, hormonal and nutritional factors. This can lead to missed time from competition.
To address this issue, an interdisciplinary research team from Missouri State University and North Central College conducted a study assessing the effectiveness of early identification and intervention strategies. By using early screening for energy deficiencies, the goal was to reduce stress fractures and the time lost from sports among collegiate female athletes.
Missouri State has 15 female teams and 269 female athletes, making this research especially relevant to the university’s athletics program.
“Our beginning is a fun story. Back in 2017, at a Missouri State athletics holiday party, we found ourselves in a conversation that took an unexpected turn. As health care providers, we got to talking — what if we teamed up to support student-athletes in a whole new way? One idea led to another and our research team was born,” said registered dietitian Natalie Allen, clinical associate professor of nutrition and dietetics in the School of Health Sciences.
“One common concern that emerged from our discussion was stress fractures in female collegiate athletes and the Female Athlete Triad.”
A condition that affects female athletes, the Female Athlete Triad involves three main issues: low energy availability, menstrual dysfunction and low bone density.
The study began in 2018 but faced delays due to COVID-19. The team persisted and published the research findings in the Internet Journal of Allied Health Sciences and Practice this January. The paper is titled “Strategies for Optimizing Female Athlete Health: A Multidisciplinary Approach to Mitigate Stress Fractures and Minimize Missed Participation in Collegiate Sports.”
Besides Allen, who also serves as team dietitian for Missouri State athletes, the research team comprised:
- Dr. Melissa Penkalski, associate professor and graduate program director in the School of Nursing
- Shannon Hauschildt, associate professor and program director in the department of physician assistant studies
- Dr. Kristin Ann Patel, associate professor and program director of health science at North Central College
Combining their expertise, the researchers identified health gaps in female athletes and developed evidence-based interventions for improved outcomes.
Research specifics and findings
The study involved 234 female athletes across nine Missouri State teams. To identify those who were at risk for low energy availability and related conditions, they underwent pre-season physicals. The physicals included screening using a tool called the Female Athlete Triad Cumulative Risk Assessment (FACTRA).
Athletes with a FACTRA score greater than one received nutrition education and consultation from the team dietitian. Athletes were also referred to doctors, athletic trainers and psychologists as needed.
Before implementing the screening, Missouri State recorded 18 stress fractures among female athletes. This resulted in 848 missed participation days. After early detection and intervention, stress fractures fell to one and missed participation days dropped to 50 — a 95% and 94.6% reduction, respectively.
The athletes also showed marked improvement in their knowledge and understanding of nutrition risks.
“This research showed how screening and intervention can keep athletes competing instead of recovering,” Hauschildt said.
Patel added, “Success comes from a strong multidisciplinary team approach, where coaches and health care providers also work together to support athletes.”
Power of prevention
One key aspect of the study was the role of nutrition education. At-risk female athletes received targeted dietary guidance, helping them optimize their energy availability and overall health.
“FACTRA screening is now a standard for pre-participation physicals at Missouri State, setting a model for female athlete health nationwide,” Allen said.
As a pediatric nurse practitioner, Penkalski notes she sees firsthand how early intervention shapes long-term health.
“This research empowers athletes to take charge of their well-being, both on and off the field.”
But there is more to explore.
The next steps include refining screening tools and investigating new areas, such as iron deficiency in endurance athletes and the impact of Relative Energy Deficiency in Sports on both men and women.
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