Emily A. Ricker

Introduction: Musculoskeletal injury (MSK-I) and pain (MSK-P) pose a substantial burden to Active Duty Service Members (ADSM) and are a leading cause of medical encounters and lost duty days. Evidence indicates that barriers exist to musculoskeletal (MSK) health care-seeking, which can result in exacerbation of MSK conditions (e.g., MSK-I, MSK-P), chronic pain, and greater healthcare costs. The objective of this qualitative study was to interview ADSM about their experiences navigating MSK health during their military careers to inform the development of tools and resources that better equip ADSM and military medical providers to prevent and manage MSK conditions. Methods: Semi-structured individual interviews were conducted with male and female ADSM ( n = 60). Interviews assessed ADSMs' experiences with MSK-I/P during military service, the use of military resources to maintain MSK health, and barriers and facilitators to seeking care for MSK-I/P. Interviews lasted 20–60 min, were conducted in-person or over video conference, and were audio recorded and transcribed. Transcript data were analyzed using applied thematic analysis (ATA). Results: Participants included male ( n = 31) and female ( n = 29) ADSM (age=38 ± 10 years, 16 ± 9 years of service) representing all military branches except for the Space Force. The ATA resulted in seven themes: military impact, care-seeking, Military Health System (MHS), prevention and optimization, leadership, mental health, and gender. Discussion: ADSM revealed that while the military culture promotes physical fitness, it also encourages a “push through pain” mentality, leading to delayed care due to fears of career repercussions or being seen as weak or a burden to one's unit. Additionally, ADSM pointed to certain challenges within the MHS, including long wait times, inconsistent access to specialized care, and a perception that some providers dismiss ADSM pain. Results revealed additional areas of investigation and intervention, such as a bidirectional link between MSK-P and mental health, and identified gender-specific challenges, such as a lack of resources for women's health issues like postpartum MSK conditions. Overall, the findings identified opportunities for systemic and cultural changes to destigmatize MSK issues, prioritize prevention and proactive care-seeking, and improve healthcare access for MSK conditions during military service.

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This paper is the first of two publications comprising a 2025 update to the 2014 Consensus Statement on treatment and return-to-play guidelines on the Female Athlete Triad (Triad), defined as three inter-related components including energy status, reproductive function, and bone health. The Triad is initiated by exposure to varying degrees of energy deficiency with or without disordered eating/eating disorders with primary pathological outcomes to the reproductive and skeletal systems. This first paper includes a detailed update on the scientific underpinnings of the Triad and introduces a new Triad model specific to the adolescent female athlete. Energy deficiency and “metabolic compensation” are added to the energy status continuum to describe adaptations that reflect energy conservation. Ovarian steroid hormone exposure and functional hypothalamic oligo-amenorrhea are added to the reproductive function continuum. Bone stress injury is added to the bone health continuum. Rates of change are depicted for the induction and recovery of clinical outcomes within the adult model. Evidence-based statements are presented throughout the paper and supported by a high number of level A and B grades.

This is the second of two publications comprising the 2025 update to the 2014 Consensus Statement on treatment and return to play guidelines on the Female Athlete Triad (Triad). This paper pairs with the 2025 Update to the Female Athlete Triad Coalition Consensus Statement Part 1: State of the Science and Introduction of a New Adolescent Model (Sports Medicine, 2025), to focus on evidence-based revisions for screening, diagnosis, treatment, and clearance and return to play. Revised recommendations for managing eating disorders (ED)/disordered eating (DE) and non-pharmacological and pharmacological treatment of bone loss and abnormal menstrual cycles are included, as are the most recent clearance and return to play recommendations, inclusive of adolescent athletes. Recent research supports the adoption of revised criteria for defining and treating energy deficiency, moving away from the concept of an energy-availability threshold. Energy deficiency-induced menstrual disturbances can be reversed with a moderate increase in food intake and modest weight gain, but restoration of menses alone is not associated with high rates of ovulation or increased ovarian steroid levels until multiple consecutive normal length menstrual cycles are achieved. Revised guidelines for the diagnosis and treatment of functional hypothalamic oligo/amenorrhea are included with guidance on the confounding effects of hyperandrogenemia. Gynecological age and psychological stress are factors impacting the individual susceptibility to the Triad. The bone health spectrum of the Triad now includes bone stress injuries. Routes of administration via epidermal patch versus oral for pharmacological treatment of low bone density are discussed. The diagnosis, treatment, and return to play approaches for adolescents with the Triad are unique compared with those employed for adults and require age-appropriate clinical guidelines. The strength of the evidence-based statements is graded using an accepted taxonomy in which randomized controlled trials and observational data are considered the highest level of evidence.

Elite female tennis players are among those at high risk for developing the Female Athlete Triad (Triad), characterized by three interrelated conditions: energy deficiency/low energy availability, menstrual dysfunction, and low bone mineral density. From 1996 to 2022, the Women’s Tennis Association (WTA) developed and implemented prevention, education, and management plans for female athletes at risk for, or exhibiting symptoms of, the Triad. This article reviews the WTA Triad protocol, developed in 2018 and utilized through 2022, in collaboration with subject matter experts in the Women’s Health and Exercise Laboratory at The Pennsylvania State University. The WTA Triad protocol (1996–2022) includes prevention and management programs implemented by a multidisciplinary Performance Health Team to include screening for “red flags” during annual physicals or upon clinical presentation of a menstrual problem, bone disorder, or nutritional concern; targeted education for players, coaches, and other support team members with handouts and lectures on nutrition and body image to prevent energy deficiency; and a multidisciplinary protocol to guide treatment and return-to-play decisions. Other sport governing bodies can adopt similar multi-layered programs and practices for their athletes, coaches, and support teams to educate, screen, manage, and help to prevent the development of the Triad.

Introduction: Active duty service members (ADSMs) may be at heightened risk for eating disorders (EDs) and sub-clinical disordered eating (DE). ADSMs are also at a high risk for musculoskeletal injury (MSK-I). Given the risk for EDs/DE among ADSMs as well as robust physical requirements of military training, additional research is needed to elucidate links between DE and risk for MSK-I among ADSMs. The aim of the present study was to assess the prevalence of DE and associations with MSK-I among Marine Corps officers entering a 6 month leadership course. Materials and Methods: The current cross-sectional study is part of a large, prospective study, the Initiation of Marine Physiological Assessment of Combat Training (IMPACT) study. Participants completed the Eating Disorder Examination-Questionnaire Short (EDE-QS) and self-reported the presence of a recent (≤6 months) MSK-I upon entry to an officer training course. A logistic regression was used to assess the association between elevated DE (EDE-QS ≥15) and recent MSK-I, adjusting for age, race, sex, and commissioning source. Results: N = 1,382 officers (11.6% female, MAge: 24.8 ± 2.9 years, 26.6% racial/ethnic minority) completed the questionnaires. Seven percent had elevated DE (EDE-QS score ≥15) (female: 10.6%, male: 6.9%, P = .10); 18.3% self-reported recent MSK-I (female: 26.3%, male: 17.3%; P = .009). Females had 17% greater odds of MSK-I compared to males (aOR: 1.17, 95% CI: 1.03-1.33, P = .02). Moreover, females with elevated DE had greater odds of MSK-I than males with elevated DE (aOR= 1.38); among females, odds of MSK-I were greatest among those with elevated DE (aOR= 1.35). Conclusions: In this sample of Marine officers, DE was associated with greater odds of a recent MSK-I among women only. Results align with previously reported relationships between DE and skeletal health in female athletes. Prospective research is needed to elucidate the temporal nature of these relationships.

Military culture is historically rooted in masculine characteristics and ideals. Yet, as of 2016, all occupational specialties in the United States military are open to women and, as such, the number of women that make up the Services is projected to continue rising. The growing presence of women within the military ranks may be at odds with the traditionally masculine military culture, potentially resulting in gender-based stigmatization of female Service members. The current study qualitatively assessed perceived gender stigmatization among newly commissioned male (n = 654, 87%) and female (n = 101, 13%) US Marine Corps officers entering The Basic Course (BOC) at The Basic School (TBS), a six-month secondary training course. A thematic analysis of open-ended survey questions identified that males and females described aspects of gender stigma similarly, with emphases on females' tendency to be viewed as weaker and needing to "prove themselves," and a call for equal physical fitness standards for both genders. There were mixed opinions as to whether gender stigmatization should be acknowledged and addressed or dismissed and ignored. Some participants voiced that bringing gender stigma to the attention of Service members could artificially inflate the magnitude of the issue and increase gender stigmatization that is otherwise negligible or non-existent. The insights offered by the participants of this study can help shape the direction of policies and procedures aimed at increasing equality and opportunities for success for Marine officers of all genders. Ultimately, the goal is to optimize physical and mental health and readiness for all Service members.