Considering a Male Athlete Triad

May 15, 2019

This article first appeared in the July/August 2016 issue of Training & Conditioning.

Almost 25 years ago, the Female Athlete Triad was identified, and it’s become a well-known concept in sports medicine circles. A new paper has proposed that a similar condition presenting with deficits in nutrition, reduction in sex hormones, and/or impaired bone health may also affect male athletes.

Titled “Parallels with the Female Athlete Triad in Male Athletes,” the article appeared in an issue of the journal Sports Medicine. “Our review goes over the prevalence of each of the three symptoms in male athletes, what we already know, and where we recommend research be conducted so we can better understand how nutrition and sex hormones affect bone health and overall health in this population,” says the paper’s lead author, Adam Tenforde, MD, Assistant Professor of Physical Medicine and Rehabilitation at Harvard Medical School and Sports Medicine Physician at the Spaulding National Running Center in Cambridge, Mass.

A former professional runner and an All-American at Stanford University, Tenforde says his interest in the subject stemmed from trends he had seen in his practice. “There seemed to be a subset of male athletes I cared for, mostly endurance athletes like runners and cyclists, with a history of stress fractures,” he says. “In many cases, I questioned whether they were optimally fueling, and I often found they had low testosterone levels and low bone-mineral levels on their DEXA scans.”

When Tenforde delved further into the topic, he found his observations had significance. “Some studies show male endurance athletes are at a higher risk of having a reduced nutrition intake and not matching the demands of their sport,” he says. “We also reviewed literature that showed male endurance athletes tend to have lower sex hormones, including testosterone.”

These findings are preliminary, however, and Tenforde says a lot more research needs to be done to determine whether a Male Athlete Triad really does exist and how it relates to the Female Athlete Triad. “We saw a pattern of medical conditions in male athletes that appeared analogous to the Female Athlete Triad, but we’d rather not lump the two sexes together yet,” he says. “Although there are some similarities, there are likely to be significant differences, as well.”

That doesn’t mean athletic trainers can’t be proactive about the issue, Tenforde adds. He advises them to be on the lookout for male athletes who suffer unexplained nagging injuries, especially stress fractures or problems with the pelvic bone and femoral neck. Tenforde recommends checking these athletes for abnormal endocrine hormones, thyroid function, testosterone level, and vitamin D deficiency.

“It’s important to look at all the possible contributors to injury,” Tenforde says. “When a male athlete has low testosterone, for example, it’s easy to start him on hormone therapy. This is very similar to what was previously prescribed for female athletes who had amenorrhea. However, in time, we learned that this approach didn’t address the underlying issue, which was that the body was responding to suboptimal nutrition in a negative way by reducing metabolic and reproductive hormones.”

When athletic trainers do have an at-risk male athlete, Tenforde suggests they consult with those professionals who handle questions about the Female Athlete Triad. “Sports medicine providers who commonly treat overuse and bone stress injuries are typically more open to exploring different options, including the athlete’s nutrition status,” he says.

There’s no need to wait until athletes get injured, either. “A lot of prevention comes down to education,” Tenforde says. “Nutrition can have the same role as medication in preventing injury, but many athletes don’t understand how to maintain a positive energy balance throughout the day. Just reinforcing simple ideas like not skipping breakfast, having a snack after workouts, and eating every few hours can make a big difference.”

Regardless of whether the Male Athlete Triad is ever officially established, Tenforde hopes his paper creates renewed dialog about nutrition and bone health in athletes. “Having a condition called the Female Athlete Triad can be a little stigmatizing because it seems to suggest that only one sex is set up to have these issues,” he says. “Instead, people should be thinking about the importance of proper fueling for both sexes. This will allow for appropriate responses to training and reduce the risk of injury.”

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