Triad Cumulative Risk Assessment (T-CRA) Successfully Predicts Bone Stress Injury (BSI) Risk in Female Athlete Triad: A Systematic Review and Meta-Analysis
DOI:
https://doi.org/10.53646/p6x5w421Keywords:
Bone stress injury, female athlete triad, screening tools, injury prevention, female athelteAbstract
BACKGROUND: The Female Athlete Triad (FAT) is characterized by low energy availability (LEA), menstrual dysfunction, and decreased bone mineral density (BMD). A major consequence of compromised BMD is bone stress injury (BSI). The Triad Cumulative Risk Assessment (T-CRA) is a validated screening tool for FAT, yet its ability to predict BSI risk remains unclear. This study aimed to determine the relationship between T-CRA scores and BSI risk by analyzing pooled per-point risk ratios (RRs) from the available literature. We hypothesized that increasing T-CRA scores would correlate with higher BSI risk.
Methods: A systematic search of PubMed, OVID (Medline), and Embase was conducted. Studies were included if they reported BSI incidence in female athletes and utilized T-CRA. Data extraction focused on study characteristics, T-CRA scores, and BSI outcomes. A forest plot and pooled per-point RR were derived using a random-effects model, and study quality was assessed via MINORS criteria. Publication bias was examined using a funnel plot and Egger’s regression.
Results: Five studies met inclusion criteria, encompassing 1,097 female athletes across 31 sports; the weighted mean age of the overall SRMA cohort was 20.07 years (95% CI, 20.01–20.14). The pooled per-point RR for BSI was 1.35 (95% CI, 1.20-1.51; I² = 76.1%), indicating a 35% increased risk of BSI per unit increase in T-CRA score. No significant publication bias was detected (Egger’s p = 0.747). Most included athletes were over 18 years old. Running-adjacent sports were well-represented (N = 340), whereas aesthetic sports (i.e., gymnastics and figure skating) had limited inclusion (N = 60, N = 3).
Conclusion: A higher T-CRA score is associated with increased bone stress injury risk, reinforcing its potential as a clinical screening tool. Future research should focus on younger athletes and expand representation across sports to improve risk assessment and injury prevention.
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Copyright (c) 2026 Julie Paska, BA, Samantha L. Watson, BS, Laura C.M. Ndjonko, BA, Vehniah K. Tjong, MD
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