Bone Health and Females: Why Orthopaedic Surgeons Should Care

Elizabeth Rose Dennis, MD MS, UNITED STATES Elizabeth A. Arendt, MD, UNITED STATES

ISAKOS eNewsletters   Current Perspective 2025   Not yet rated

A symposium at the ISAKOS Biennial Congress in Munich, June 2025, chaired by Elizabeth Arendt and Lars Engebretson, highlighted the importance of bone health in females through the ages.

Relative Energy Deficiency Syndrome (REDS)

Dr. Jeanna Schultz discussed Relative Energy Deficiency (REDS)¹, a syndrome of impaired physiological and/or psychological function experienced by both male and female athletes, caused by exposure to low energy availability (LEA). This syndrome can have both health and performance-related consequences. Risk factors for REDS include sports specialization at an early age, especially among those participating in sports involving aesthetic, lean and weigh-in sports. For the orthopaedist, when diagnosing a stress fracture in an active and athletic patient, it is important to investigate for the presence of LEA. For those working with athletic teams, a comprehensive female preseason physical exam is essential. Patients who have undergone surgery also need to understand the importance of healthy eating in the postoperative time frame if their usual sports competition has been suspended during the healing phase. Many athletes will reduce their caloric intake during a time of decreased energy expenditure.

The importance of early detection and a sport-specialized multidisciplinary treatment approach that includes increasing energy availability and addressing hormonal, psychological, and bone health concerns is important for optimal management. Screening tools can help to identify and prevent progression². Most important aspect of LEA management is to increase caloric intake and /or decrease energy expenditure. This often involves a community of trained professionals, coaches, family, and others who interface with the athlete.

Dr. Schulz also shared findings from her own research on REDs awareness in Canadian athletes and coaches, highlighting the need for targeted education and coach-athlete communication to improve prevention and early intervention³.

Emerging Technologies for Enhancing Athletes' Performance and Postoperative Recovery

In her ISAKOS presentation, Dr. Katherine Coyner explored the integration of artificial intelligence (AI), wearable technology, and load-management strategies to optimize athlete performance and guide safe return-to-play. She emphasized the limitations of traditional time-based protocols and highlighted tools such as the acute:chronic workload ratio (ACWR) and real-time data from GPS and insole-based sensors to objectively assess readiness and reduce reinjury risk. The presentation underscored the need to align surgical recovery with individualized performance metrics and advocated for AI-enhanced, data-informed decision-making in modern sports medicine.

IOC and Bone Health Perspectives

Dr. Lars Engebretson, past Head of Medical Sciences in the International Olympic Committee (IOC), shared the primary goal of the IOC, which is to protect the health of the athlete. The IOC recognizes the importance of bone health in athletes; it has issued consensus statements and guidelines addressing this topic including relative energy deficiency and sports (REDS). This includes guidelines for recognition, treatment and prevention strategies of REDS¹.

Bone Stress Injuries in Female Athletes: Japanese Perspectives

Dr. Haruka Kaneko presented original research on the multifactorial causes of bone stress injuries in athletes, with a focus on the Japanese population. Her talk emphasized the significant role of overtraining, nutritional deficiencies, and regional dietary patterns—particularly limited access to vitamin D-fortified foods and low sun exposure—in contributing to stress fractures. A cross-sectional study of 155 female athletes revealed a high incidence of stress fractures, particularly in aesthetic and endurance sports, and highlighted the impact of Relative Energy Deficiency in Sport (REDs) on bone and overall health. Despite clear associations between menstrual dysfunction, low energy availability, and injury risk, a survey of orthopaedic surgeons in Japan found that only 15% routinely inquire about menstrual history in athletes with stress fractures. Dr. Kaneko called for increased awareness and screening efforts among orthopaedic providers to help prevent these injuries through early recognition and nutritional optimization⁴.

Bone Health in Post-Menopausal Women

Dr. Elizabeth R. Dennis delivered a talk highlighting the critical role of bone health in optimizing surgical outcomes, particularly in female patients. She underscored the prevalence of osteoporosis—affecting over 200 million women worldwide—and its impact on musculoskeletal health and postoperative complications. Osteoporosis, or low bone mineral density (BMD), has a significant prevalence in post-menopausal women, withthe annual decline in in BMD doubling for group. Dr. Dennis emphasized the need for early intervention, including DXA screening before the traditional age of 65 years, to allow for the opportunity to diagnose and treat before accelerated decline in BMD commences. She also detailed the role of vitamin D in reducing retear and revision rates, pain after shoulder surgery, and postoperative complications. Drawing from evidence-based research, she outlined actionable strategies, including preoperative screening, strength training, targeted supplementation (vitamin D, magnesium, collagen, and vitamin K2), and the judicious use of menopausal hormone therapy (MHT). With a particular focus on shoulder and knee surgery, the talk served as a call to action for orthopaedic surgeons to integrate bone health optimization into routine perioperative care⁵.

Future Perspectives on Bone Health in Female Athletes

A prudent approach to bone health optimization is to include bone health awareness and treatment guidelines in medical school curriculum, as well as orthopedic training. Ideally, strategies for minimizing osteoporotic risk factors and optimizing bone health should be incorporated into the routine management of the musculoskeletal assessment at all ages.

Better understanding of the impact of hormonal changes in the life cycle of males and females would be useful to maximize bone mineral density in the developmental years and minimize bone mineral density decline in later years.

Modern medicine has seen an explosion of pharmacologic treatment and physical therapy strategies for maintaining and improving bone health across the life spectrum. Incorporation of these into perioperative management with allow for improvement of bone micro-architecture and subsequent overall risk reduction and outcome optimization.

References

1. Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med 2023;57(17):1073-1097. (In eng). DOI: 10.1136/bjsports-2023-106994.
2. Stellingwerff T, Mountjoy M, McCluskey WT, Ackerman KE, Verhagen E, Heikura IA. Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)-by a subgroup of the IOC consensus on REDs. Br J Sports Med 2023;57(17):1109-1118. (In eng). DOI: 10.1136/bjsports-2023-106914.
3. Schulz jM, White J, Edwards C, Liu S, Thornton J. Responding to Relative Energy Deficiency in Sport (REDs): a multidisciplinary care pathway for safe return to sport. Sports Psychiatry 2025;4(2):49-107. DOI: doi/pdf/10.1024/2674-0052-a000111.
4. de la Puente Yagüe M, Collado Yurrita L, Ciudad Cabañas MJ, Cuadrado Cenzual MA. Role of Vitamin D in Athletes and Their Performance: Current Concepts and New Trends. Nutrients 2020;12(2) (In eng). DOI: 10.3390/nu12020579.
5. Moon AS, Boudreau S, Mussell E, et al. Current concepts in vitamin D and orthopaedic surgery. Orthop Traumatol Surg Res 2019;105(2):375-382. (In eng). DOI: 10.1016/j.otsr.2018.12.006.

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