By BUILD Sports Performance Lab and Physical Therapy / July 28, 2022

The Male Athlete Triad: Part 2

Part 2

By Evan Culbert, PT, DPT

Diagnosis and Management of The Male Athlete Triad
To recap part 1, we know that The Male Athlete Triad is comprised of three interrelated conditions: 
1) Low energy availability (EA): Energy intake < Energy expended. Important bodily functions are suppressed as the athlete continues to train in an energy deficient state. Low EA can be present with or without disordered eating. 
2) Impaired Bone Health: Low bone mineral density, often manifesting in bone stress injuries in athletes.
3) Suppression of hormone function: Specifically, the hypothalamic-pituitary gonadal (HPG) function, resulting in decreased testosterone concentrations and decreased sex drive.
But how do we prevent and identify The Male Athlete Triad in athletes? 
Increased awareness of signs and symptoms among medical professionals, coaches, parents, athletes, and sports organizations is an important step, but early screening and monitoring for RED-S and the Male Athlete Triad must become common practice for at-risk groups.
At-risk groups for developing 1+ components of the triad include “adolescent and young adult male athletes in sports that emphasize a lean physique (lean-sport athletes), especially endurance and weight-class athletes.” Screening of athletes in these sports (distance running, swimming, cycling, wrestling, etc.) should be a part of pre-participation physical exams beginning in middle school. While especially important in middle school – college-aged athletes due to peak bone development happening during this time, it is also important to continue to screen post-collegiate athletes in lean-sports. Formal screening should also happen when an athlete presents with common symptoms of the Triad :

  • Persistent fatigue and lethargy – this one can be tricky. For many endurance athletes, fatigue is a part of training. We all know the feeling of being in the middle of a training block and feeling tired just walking up a flight of stairs. Fatigue is a part of endurance sports. However, concerning signs may include feeling fatigued after appropriate rest days, when expected to be relatively fresh for intense training sessions, or fatigue that carries through tapering. 
  • Decreased libido and the absence of morning erections 
  • Decreased beard growth – needing to shave less often 
  • Negative performance changes in their sport 
  • Mood changes that are unaccounted for 
  • Getting sick more often than normal 
  • Recurring injuries 
Many endurance athletes have experienced or know of someone who has sustained a bone stress injury (BSI). It’s crucial to complete screening for other components of the triad when BSIs occur to prevent more serious outcomes, like long-term hormonal function and bone health, to name a couple.
What is involved with screening?
Unlike the Female Athlete Triad, at this time there are limited screening tools that are practical and specific to The Male Athlete Triad. 
Fredericson et al. (2021) recommends the questions listed in the table below as a screening tool. It’s important to keep in mind that male athletes do not need to be actively restricting intake or losing weight to develop the Triad. While disordered eating or concerns about weight are risk factors related to the Triad, they are not always present in cases of the Male Athlete Triad. 
Kraus et al (2019) developed the risk assessment tool below which can be used to identify risk for The Male Athlete Triad and guide return to sport decisions, particularly when returning from bone stress injury or series of bone stress injuries.
Management of the Male Athlete Triad
If you take one thing away from this, take this: it takes a team approach to successfully diagnose and manage the Male Athlete Triad. This multidisciplinary team should include:
  • Team Physician or sports specific physician
  • Sports Dietician
  • Mental Health Professional if disordered eating or eating disorder is present. 
  • Physical Therapist or Athletic Trainer competent in managing energy deficiency in sport. 
  • The Athlete! In youth athletes, parents should be a part of this team as well
  • Endocrinologist when hormonal involvement (Hypogonadotropic Hypogonadism) present
The team approach is crucial to identifying and managing the components of the Male Athlete Triad. It is crucial to explore both signs and symptoms, and athlete behaviors in detail. Dietary behaviors, weight changes, weight goals, behaviors to control weight are all intertwined with endurance sport. Weight does impact performance. Endurance athletes tend to be very lean, and low BMI is often the nature of the sport. But absolute BMI is not the best method to reflect nutritional status in youth with disordered eating. As of now, there is no exact way to measure EA. Identifying behaviors that contribute to undereating (intentionally or unintentionally), along with medical history and other factors, is the best approach for identifying low EA. Working with a multidisciplinary team can help athletes better understand how to optimize performance while maintaining appropriate energy availability is important to avoid crossing into energy-deficient territory and increasing risk of the Male Athlete Triad.
To return to our metaphor from part one, the priority of treatment should be restoring energy dollars in your checking account, and keeping your account in the green while training. In other words, returning to a state of adequate energy availability and maintaining it with training is critical. 
Optimizing fueling by ensuring high nutrient snacks and meals around training sessions so that the athlete can perform well and recover well will not only prevent health consequences but will lead to better, more consistent development and performance.
Dieticians can help to ensure adequate macro and micronutrients – supplements may be helpful but the goal is getting most of these nutrients from the diet when possible. Participation in weight-bearing sports or plyometric cross-training with multidirectional movements can be helpful for bone health. Multiple studies show time and time again that strength training has protective effects against bone stress injury. 
Again, the Male Athlete Triad is multifactorial with several physical, social, and mental factors playing a role. This is where the team approach comes in – addressing all of the contributing factors and underlying causes is important and requires this multifaceted approach.
There is no gold standard for clearing an athlete to return to sport. Many times the return comes after repetitive injury or bone stress injury. The Male Athlete Triad Cumulative Risk Assessment tool mentioned earlier has guidelines for returning to sport based on risk factors in the individual athlete. Again, this tool should be used at regular pre-season exams, or when signs/symptoms of the triad arise.
Recommendations for the endurance community
Sports teams should incorporate education on nutrition and fueling to perform. Keeping the energy “bank account” full going into workouts and post-workouts to ensure appropriate energy availability is important. Coaches, teams, parents, and healthcare professionals should be mindful of the language they use, with a focus on optimizing energy availability, rather than increasing body weight. Healthcare providers must be comfortable with asking uncomfortable questions related to libido and sexual function – questionnaires can be a helpful tool for navigating this, but it must be a part of pre-participation exams in at-risk athletes and incorporated when concern for the Male Athlete Triad is present. 
Discussion about body image and views can be important in uncovering athlete beliefs and potential risk factors. Establishing a positive training environment, free of critical comments specific to body shape and weight, and rather focused on strong and healthy athletes is important. Creating realistic and healthy goals related to weight and body comp with the help of a dietician can be beneficial. And creating awareness that good performance does not always indicate that an athlete is healthy – focus on maintaining a state of energy availability that will lead to sustainable healthy training and therefore more consistent positive results.
Reversibility of the Male Athlete Triad is possible with proper management, but the timeline for recovery is based on the severity and how long an athlete has been training in an energy-deficient state.
For more information on RED-S and The Male Athlete Triad, check out the articles referenced below:
Kraus E, Tenforde AS, Nattiv A, et al. Bone stress injuries in male distance runners: higher modified female athlete triad cumulative risk assessment scores predict increased rates of injury. Br J Sports Med. 2019;53:237–242.
Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine 2014;48:491-497. 
Nattiv A, De Souza MJ, Koltun KJ, Misra M, Kussman A, Williams NI, Barrack MT, Kraus E, Joy E, Fredericson M. The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis. Clin J Sport Med. 2021 Jul 1;31(4):335-348. doi: 10.1097/JSM.0000000000000946. PMID: 34091537.
Fredericson M, Kussman A, Misra M, Barrack MT, De Souza MJ, Kraus E, Koltun KJ, Williams NI, Joy E, Nattiv A. The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play. Clin J Sport Med. 2021 Jul 1;31(4):349-366. doi: 10.1097/JSM.0000000000000948. PMID: 34091538.
Raj MA, Creech JA, Rogol AD. Female Athlete Triad. 2021 Aug 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28613538.

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