title: Correlates of stress fractures among preadolescent and adolescent girls.
abstract: OBJECTIVE
  Although stress fractures are a source of significant morbidity in active populations, particularly among young female athletes, the causes of stress fractures have not been explored among females <17 years of age or in the general population. The purpose of this study was to examine correlates of stress fractures in a large, population-based, national, cohort study of preadolescent and adolescent girls.
  
  
  METHODS
  A cross-sectional analysis of data from 5461 girls, 11 to 17 years of age, in the Growing Up Today Study, an ongoing longitudinal study of the children of registered female nurses participating in Nurses' Health Study II, was performed. Mothers self-reported information regarding their children's histories of stress fractures on their 1998 annual questionnaire. Growing Up Today Study participants self-reported their weight and height, menarcheal status, physical activity, dietary intake, and disordered eating habits on annual surveys.
  
  
  RESULTS
  In 1998, the mean age of the participants was 13.9 years. Approximately 2.7% of the girls had a history of stress fracture, 3% engaged in disordered eating (using fasting, diet pills, laxatives, or vomiting to control weight), and 16% participated in > or =16 hours per week of moderate to vigorous activity. Age at menarche, z score of BMI in 1998, calcium intake, vitamin D intake, and daily dairy intake were all unrelated to stress fractures after controlling for age. Independent of age and BMI, girls who participated in > or =16 hours per week of activity in 1998 had 1.88 greater odds of a history of stress fracture than did girls who participated in <4 hours per week (95% confidence interval [CI]: 1.18-3.30). Girls who participated in > or =16 hours per week of activity were also more likely than their peers to engage in disordered eating (4.6% vs 2.8%); however, disordered eating did not have an independent association with stress fractures (odds ratio [OR]: 1.33; 95% CI: 0.61-2.89). Independent of age and BMI, each hour per week of high-impact activity significantly increased the risk of stress fracture (OR: 1.05; 95% CI: 1.02-1.09). Among the high-impact physical activities, only running (OR: 1.13; 95% CI: 1.05-1.22) and cheerleading/gymnastics (OR: 1.10; 95% CI: 1.01-1.21) were independently associated with greater odds of stress fracture.
  
  
  CONCLUSIONS
  These findings suggest that, although activity can be beneficial for bone health, there is a threshold over which the risk of stress fracture increases significantly among adolescent girls. High-impact activities, particularly running, cheerleading, and gymnastics, appear to be higher risk than other activities. Prospective studies are needed to explore the directionality of these relationships, as well as the role of menstrual history. In the meantime, clinicians should remain vigilant in identifying and treating disordered eating and menstrual irregularities among their highly active, young, female patients.
authors.affiliation: Division of Adolescent/Young Adult Medicine, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts 02115, USA.
authors.forename: Keith J
authors.initials: KJ
authors.lastname: Loud
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Gordon
authors.forename: Lyle J
authors.initials: LJ
authors.lastname: Micheli
authors.forename: Alison E
authors.initials: AE
authors.lastname: Field
mesh_terms: D000293:Adolescent; D017677:Age Distribution; D015519:Bone Density; D002648:Child; D003430:Cross-Sectional Studies; D015444:Exercise / Q000502:physiology*; D001068:Feeding and Eating Disorders / Q000503:physiopathology; D005260:Female; D015775:Fractures, Stress / Q000453:epidemiology* / Q000209:etiology; D006173:Gymnastics / Q000502:physiology; D006801:Humans; D008572:Menarche; D016017:Odds Ratio; D015995:Prevalence; D012420:Running / Q000502:physiology; D011795:Surveys and Questionnaires; D013997:Time Factors