Published online July 16, 2007
PEDIATRICS Vol. 120 No. 2 August 2007, pp. e364-e372 (doi:10.1542/peds.2006-2145)
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ARTICLE

Family History Predicts Stress Fracture in Active Female Adolescents

Keith J. Loud, MDCM, MSca, Lyle J. Micheli, MDb, Stephanie Bristol, BSc, S.Bryn Austin, ScDc and Catherine M. Gordon, MD, MScc,d

a Divisions of Adolescent Medicine and Sports Medicine, Children's Hospital Medical Center, Akron, Ohio; Divisions of
b Sports Medicine
c Adolescent Medicine
d Endocrinology, Children's Hospital, Boston, Massachusetts

OBJECTIVE. Increased physical activity and menstrual irregularity have been associated with increased risk for stress fracture among adult women active in athletics. The purposes of this study were to determine whether menstrual irregularity is also a risk factor for stress fracture in active female adolescents and to estimate the quantity of exercise associated with an increased risk for this injury.

PATIENTS AND METHODS. A case-control study was conducted of 13- to 22-year-old females diagnosed with their first stress fracture, each matched prospectively on age and self-reported ethnicity with 2 controls. Patients with chronic illnesses or use of medications known to affect bone mineral density were excluded, including use of hormonal preparations that could alter menstrual cycles. The primary outcome, stress fracture in any extremity or the spine, was confirmed radiographically. Girls with stress fracture had bone mineral density measured at the lumbar spine by dual-energy x-ray absorptiometry.

RESULTS. The mean ± SD age of the 168 participants was 15.9 ± 2.1 years; 91.7% were postmenarchal, with a mean age at menarche of 13.1 ± 1.1 years. The prevalence of menstrual irregularity was similar among cases and controls. There was no significant difference in the mean hours per week of total physical activity between girls in this sample with stress fracture (8.2 hours/week) and those without (7.4 hours/week). In multivariate models, case subjects had nearly 3 times the odds of having a family member with osteoporosis or osteopenia. In secondary analyses, participants with stress fracture had a low mean spinal bone mineral density for their age.

CONCLUSIONS. Among highly active female adolescents, only family history was independently associated with stress fracture. The magnitude of this association suggests that further investigations of inheritable skeletal factors are warranted in this population, along with evaluation of bone mineral density in girls with stress fracture.

Key Words: stress fracture • adolescent health • bone mineral density • bone strength • exercise

Abbreviations: BMD—bone mineral density • MI—menstrual irregularity • DXA—dual-energy x-ray absorptiometry • OR—odds ratio • CI—confidence interval

Accepted Jan 29, 2007.