Female athlete triad affects rat intestinal morphology and sucrase-isomaltase expression.

Female athletes follow a strict diet and perform rigorous exercise to boost their performance, which induces health issues called the female athlete triad (FAT), defined as the combination of disordered eating, amenorrhoea and low bone mineral density. It is known to have a significant effect on bones. However, its effects on the small intestine, which is responsible for nutrient uptake into the body, remain unclear. In this study, we created an animal model of FAT to examine its effects on digestive and absorptive molecules in the small intestine. Thirty 5-week-old female Sprague-Dawley (sd) rats with an initial body weight of about 147 g were divided into control (Con, n = 7), exercise (Ex, n = 7), food restriction (FR, n = 8) and exercise plus food restriction (FAT, n = 8) groups. The rats were subjected to 4 weeks of wheel running (Ex, FAT) and 50-40 % food restriction (FR, FAT) to examine the effects on bone and typical digestive enzymes and transporters in the jejunum. Two-way ANOVA and the Kruskal-Wallis test were used for statistical analysis of normal and non-normal data, respectively. Four weeks of exercise and food restriction decreased bone weight (vs. other group P < 0·01) and bone breaking power (vs. other group P < 0·01). Villus height decreased in the jejunum (vs. other group P < 0·01), but the expression of typical macronutrients digestive enzyme and absorptive molecules remained unchanged. In contrast, sucrase-isomaltase gene (v. Ex P = 0·02) and protein expression were increased (vs. other group P < 0·05). The study findings show that FAT affects sucrase-isomaltase without histone methylation changes.

Title IX's Unintended Consequences: The Female Athlete Triad and the Need for Special Treatment.

This Note examines the effects of Title IX's equal treatment framework on female collegiate athletes in the context of the female athlete triad. It describes the shortcomings of Title IX's equal treatment approach and its deleterious effects on the health of female student athletes. It argues for the adoption of the special treatment approach as a remedy.

Female Athlete Triad and Male Athlete Triad Syndrome Induced by Low Energy Availability: An Animal Model.

Energy availability (EA) is defined the difference in energy intake and exercise energy expenditure. Reduction of EA (i.e. Low energy availability, LEA) often causes abnormalities of reproduction system and drastic bone loss in some female athletes, the phenomenon is called as female athlete triad. More than ever before, it is considered a serious problem, the reason of these are (1) the syndrome occurred in female athletes but also male athletes, (2) LEA is leads to dysfunction of various organs other than reproductive system (Relative energy deficiency in sport, RED-S). On the other hand, we have focused on this syndrome and have proposed novel insights into the physiological effects of LEA on bone and solutions through nutritional treatment by recreating it in animal models. In this review, we will summarize the epidemiological and physiological perspectives of these diseases from historical background to recent findings, and introduce the usefulness of using animal models to explore mechanisms and treatments.

Restrictive Eating and Prior Low-Energy Fractures Are Associated With History of Multiple Bone Stress Injuries.

Bone stress injuries (BSIs) are common among athletes and have high rates of recurrence. However, risk factors for multiple or recurrent BSIs remain understudied. Thus, we aimed to explore whether energy availability, menstrual function, measures of bone health, and a modified Female Athlete Triad Cumulative Risk Assessment (CRA) tool are associated with a history of multiple BSIs. We enrolled 51 female runners (ages 18-36 years) with history of ≤1 BSI (controls; n = 31) or ≥3 BSIs (multiBSI; n = 20) in this cross-sectional study. We measured lumbar spine, total hip, and femoral neck areal bone mineral density by dual-energy X-ray absorptiometry, bone material strength index using impact microindentation, and volumetric bone mineral density, microarchitecture, and estimated strength by high-resolution peripheral quantitative computed tomography. Participants completed questionnaires regarding medical history, low-energy fracture history, and disordered eating attitudes. Compared with controls, multiBSI had greater incidence of prior low-energy fractures (55% vs. 16%, p = .005) and higher modified Triad CRA scores (2.90 ± 2.05 vs. 1.84 ± 1.59, p = .04). Those with multiBSI had higher Eating Disorder Examination Questionnaire (0.92 ± 1.03 vs. 0.46 ± 0.49, p = .04) scores and a greater percentage difference between lowest and highest body mass at their current height (15.5% ± 6.5% vs. 11.5% ± 4.9% p = .02). These preliminary findings indicate that women with a history of multiple BSIs suffered more prior low-energy fractures and have greater historical and current estimates of energy deficit compared with controls. Our results provide strong rationale for future studies to examine whether subclinical indicators of energy deficit contribute to risk for multiple BSIs in female runners.

Does Supplemental Estrogen Improve Bone-Related Symptoms of Female Athlete Triad in Female Athletes? A Critically Appraised Topic.

Clinical Scenario: Due to the Female Athlete Triad (Triad) being a 3-pronged syndrome, treatments can vary depending on the symptoms that clinicians focus on. With reproductive and bone health compromised, assessment and recovery methods include monitoring menstrual regularity and dual-energy X-ray absorptiometry scans. Low levels of estrogen have demonstrated negative effects on bone mineral density (BMD). Clinical Question: Does supplemental estrogen improve BMD in athletes with Female Athlete Triad symptoms? Summary of Key Findings: Supplemental estrogen does improve BMD with estrogen patches demonstrating increased improvement compared with oral contraceptive pills. Clinical Bottom Line: Restoration of regular menstruation, improvement of BMD, and ensuring optimal energy levels is the best approach for treating Triad symptoms. Transdermal patches are a new treatment option that address both menstrual function and BMD but still require further research. Strength of Recommendation: Available studies demonstrated a level 2 evidence for supplemental estrogen (oral contraceptive pills and estrogen patches) providing improvements for bone health related to the Triad.

[Relative energy deficiency in sport: modern approaches to diagnostics, treatment and prevention].

In recent years, close attention has been paid to energy deficiency in professional athletes. More and more studies confirm the widespread prevalence of relative energy deficiency syndrome in sports and its relationship with various pathological conditions that lead to a decrease in the level of athletic performance. Nowadays the possibilities of early diagnosis and treatment of this syndrome are being carefully studied, and clinical protocols are being actively developed to facilitate the early detection of energy deficiency. The aim of the study was to summarize the modern data on the influence of the syndrome of relative energy deficiency in sports on the health and performance of athletes, as well as to consider effective methods for the diagnosis, treatment and prevention of this syndrome. Material and methods. The search was carried out using the Google Academy engine and electronic databases PubMed, MEDLINE, EMBASE, Scopus, Web of Science, eLIBRARY for the period from 2017 to 2021. For the search, we used keywords and their combinations: "relative energy deficit in sports", "female athlete triad", "menstrual dysfunction", "osteoporosis". Results. Based on our analysis, we can conclude that the syndrome of relative energy deficit in sports has a multicomponent negative effect on the athlete's organism and negatively affects his performance, well-being and sports results. Diagnosis of this condition is challenging due to the nonspecificity and variety of symptoms. Key diagnostic methods include physical examination, anamnesis gaining, dual energy X-ray absorptiometry, bioimpedance body composition analysis, and hormonal profile studies. Additional methods include: electrocardiography, study of the basal metabolic rate, hematological examination (hemoglobin, ferritin, etc.), determining the level of energy consumption using diaries of food and physical activity, determining blood vitamin level, etc. To facilitate the screening, diagnosis and follow-up of athletes, it is possible to use specially developed clinical protocols. Non-drug nutritional correction and optimal training plan are the main methods of treatment and prevention of energy deficiency. If this type of treatment is ineffective, hormone therapy should be considered. It is recommended to use transdermal estrogen therapy in combination with shortterm progestin therapy. In some cases, when very low bone mineral density or delayed fracture consolidation is detected, it is possible to use recombinant parathyroid hormone. Conclusion. Due to the relatively high prevalence of relative energy deficiency syndrome in athletes of both sexes and its long-term negative impact on athlete health and performance, further research is needed to improve the effectiveness of early diagnosis, prevention and treatment of pathological conditions associated with malnutrition.

Advancement in female sports medicine and preventive medicine.

Sport plays a major role in maintaining and improving physical function and health of women from adolescence to sexual maturity, through to menopause and old age, and it also plays a key role in social productivity and medicine from the perspective of preventive medicine. However, in routine clinical practice, there are many gynecological problems that affect the condition and performance of female athletes due to a lack of appropriate medical intervention, such as neglect of amenorrhea and menstruation-related symptoms. In addition, the number of athletes aiming to return to competition post-partum has been increasing in recent years, but there is little medical data on the well-being of female athletes during pregnancy and the post-partum period. I previously conducted clinical research on three separate topics, with the aim of clarifying the current issues unique to female athletes, mainly in terms of conditioning and injury prevention. The goal was that clinical research was to examine the situation of athletes with and without disabilities and provide feedback from the survey results to athletes and coaches. This paper divides the clinical studies conducted to date into three topics that will be explored herein: (i) research on the female athlete triad (Triad); (ii) research on oral contraceptives/low-dose estrogen-progestin; and (iii) research on pregnancy and post-partum period.

Disordered Eating, Development of Menstrual Irregularity, and Reduced Bone Mass Change After a 3-Year Follow-Up In Female Adolescent Endurance Runners.

This prospective study evaluated the 3-year change in menstrual function and bone mass among 40 female adolescent endurance runners (age 15.9 ± 1.0 years) according to baseline disordered eating status. Three years after initial data collection, runners underwent follow-up measures including the Eating Disorder Examination Questionnaire and a survey evaluating menstrual function, running training, injury history, and prior sports participation. Dual-energy X-ray absorptiometry was used to measure bone mineral density and body composition. Runners with a weight concern, shape concern, or global score ≥4.0 or reporting >1 pathologic behavior in the past 28 days were classified with disordered eating. Compared with runners with normal Eating Disorder Examination Questionnaire scores at baseline, runners with disordered eating at baseline reported fewer menstrual cycles/year (6.4 ± 4.5 vs. 10.5 ± 2.8, p = .005), more years of amenorrhea (1.6 ± 1.4 vs. 0.3 ± 0.5, p = .03), and a higher proportion of menstrual irregularity (75.0% vs. 31.3%, p = .02) and failed to increase lumbar spine or total hip bone mineral density at the 3-year follow-up. In a multivariate model including body mass index and menstrual cycles in the past year at baseline, baseline shape concern score (B = -0.57, p value = .001) was inversely related to the annual number of menstrual cycles between assessments. Weight concern score (B = -0.40, p value = .005) was inversely associated with lumbar spine bone mineral density Z-score change between assessments according to a multivariate model adjusting for age and body mass index. These finding support associations between disordered eating at baseline and future menstrual irregularities or reduced accrual of lumbar spine bone mass in female adolescent endurance runners.

The Utility of the Low Energy Availability in Females Questionnaire to Detect Markers Consistent With Low Energy Availability-Related Conditions in a Mixed-Sport Cohort.

The Low Energy Availability in Females Questionnaire (LEAF-Q) was validated to identify risk of the female athlete triad (triad) in female endurance athletes. This study explored the ability of the LEAF-Q to detect conditions related to low energy availability (LEA) in a mixed sport cohort of female athletes. Data included the LEAF-Q, SCOFF Questionnaire for disordered eating, dual-energy X-ray absorptiometry-derived body composition and bone mineral density, Mini International Neuropsychiatric Interview, blood pressure, and blood metabolic and reproductive hormones. Participants were grouped according to LEAF-Q score (≥8 or <8), and a comparison of means was undertaken. Sensitivity, specificity, and predictive values of the overall score and subscale scores were calculated in relation to the triad and biomarkers relevant to LEA. Fisher's exact test explored differences in prevalence of these conditions between groups. Seventy-five athletes (18-32 years) participated. Mean LEAF-Q score was 8.0 ± 4.2 (55% scored ≥8). Injury and menstrual function subscale scores identified low bone mineral density (100% sensitivity, 95% confidence interval [15.8%, 100%]) and menstrual dysfunction (80.0% sensitivity, 95% confidence interval [28.4%, 99.5%]), respectively. The gastrointestinal subscale did not detect surrogate markers of LEA. LEAF-Q score cannot be used to classify athletes as "high risk" of conditions related to LEA, nor can it be used as a surrogate diagnostic tool for LEA given the low specificity identified. Our study supports its use as a screening tool to rule out risk of LEA-related conditions or to create selective low-risk groups that do not need management as there were generally high negative predictive values (range 76.5-100%) for conditions related to LEA.

Low-Energy Availability and the Electronic Preparticipation Examination in College Athletes: Is There a Better Way to Screen?

ABSTRACT: The electronic preparticipation physical examination (ePPE) is commonly used to identify health conditions that would affect participation in sports for athletes, including disordered eating and/or low energy availability (EA). A secondary analysis was performed using a cohort study of female college athletes attending a Division 1 university between 2008 and 2014. Descriptive statistics and logistic regression analyses were used to explore the association between responses to questions on the ePPE related to eating behaviors and Female Athlete Triad (Triad). Risk categories (low, moderate, or high) were assigned to 239 athletes participating in 16 sports. The majority of responses on the ePPE did not identify athletes associated with moderate-/high-risk categories. Our findings suggest that ePPE may not sufficiently identify athletes at elevated risk for health concerns of the Triad. Our findings suggest that future ePPE may consider validated screening tools for disordered eating to help identify athletes at risk of low EA.

The Female Athlete Triad - What it is and Why it is Important in Primary Care.

The female athlete triad (FAT) is a disorder involving greater energy expenditure than energy consumption leading to 1) low energy availability (EA) with or without disordered eating 2) menstrual irregularities or amenorrhea and 3) low bone mineral density. Consequences of FAT include osteoporosis, stress fractures, increased cardiovascular risk, infertility, and negative psychological effects. The key risk factor for FAT is inadequate caloric intake when compared to the amount and intensity of exercise. All female athletes should be screened at least annually at pre-participation physicals or with signs of disordered eating, weight loss, abnormal growth or development, menstrual dysfunction, recent injuries, decreased athletic performance, or mood changes. Presence of one of the components of the triad necessitates further investigation. Treatment involves a multidisciplinary approach with increased energy intake and decreased exercise intensity being the primary goal of treatment. Understanding FAT is important for preventative medicine, as some consequences, such as infertility and loss of bone mineral density may not be reversible.

Sports and Metabolic Bone Disease.

Physical activity (PA) increases bone mass and bone strength through different mechanisms and also reduces the risk of falls in the elderly, through proprioception and balance training. The benefits seen in adolescence continue into adulthood. Exercise delays and attenuates the effects of osteoporosis, and particular sports activities may be recommended to improve bone mineral density (BMD) of the spine or regional BMD, improve balance, and prevent falls. Stress injuries related to exercise are more common in osteopenic and osteoporotic individuals.Sports activity may in some cases be detrimental for bone health, with nutrition restriction a frequent cause for negative effects of the practice of PA on bone. The examples are the so-called female athlete triad of menstrual dysfunction resulting in reduced estrogen levels, low energy due to malnutrition, and decreased BMD. A similar triad is described in male athletes. This review analyzes the effects of sport on bone metabolism and in particular its relationship with metabolic bone disease.

Female Athlete Triad and Relative Energy Deficiency in Sport: A Focus on Scientific Rigor.

We examine the scientific evidence supporting The Female Athlete Triad and Relative Energy Deficiency in Sport (RED-S) syndromes. More research is necessary to advance the understanding of both syndromes; however, it is premature to consider RED-S as an evidence-based syndrome. Future research should specifically define RED-S components, determine its clinical relevance, and establish the causality of relative energy deficiency on RED-S outcomes.

Risk factors of stress fractures due to the female athlete triad: Differences in teens and twenties.

BACKGROUND: The female athlete triad (Triad), defined by the American College of Sports Medicine as low energy availability (LEA) with or without disordered eating, menstrual dysfunction, and low bone mineral density (BMD), is associated with stress fractures and athletes aged 16-17 years are most susceptible. PURPOSE: To examine whether the Triad increases the risk of stress fractures, athletes were assigned to a "teenage" group and a "20s" group. METHODS: This prospective study enrolled 390 elite female athletes and was conducted from 2012 to 2016 at Japan Institute of Sports Sciences. Blood concentrations of various hormones were examined, and BMD was measured at the lumbar spine and throughout the whole body using dual-energy X-ray absorptiometry. LEA was defined as body weight ≤85% of the ideal body weight for teenage athletes, or BMI ≤17.5 for athletes in their 20s. Low BMD was defined as a BMD Z-score of <-1.0 in the lumbar spine and the whole body. RESULTS: Among 390 athletes enrolled, 36 developed new stress fractures within 3 months of registration. The risk for stress fractures due to the Triad in teenage athletes was higher than for athletes in their 20s. In teenage female athletes, secondary amenorrhea, low BMD for the whole body, and a low ratio of actual body weight to ideal body weight increased the risk for stress fractures by 12.9 times, 4.5 times, and 1.1 times, respectively. CONCLUSION: To prevent stress fractures in female athletes with the Triad, age of athletes should be taken into consideration.

Low energy availability, menstrual dysfunction, and impaired bone health: A survey of elite para athletes.

INTRODUCTION: The Female Athlete Triad (Triad) is a syndrome describing three interrelated conditions: low energy availability (LEA), menstrual dysfunction, and low bone mineral density (BMD). Relative Energy Deficiency in Sport (RED-S) expands the Triad to include multiple physiologic consequences of LEA in both sexes. The purpose of this study is to determine the prevalence of factors associated with the Triad/RED-S in an elite para athlete population. METHODS: Athletes were U.S. elite para athletes training to qualify for the 2016 or the 2018 Paralympic Games. Participants completed an online questionnaire characterizing nutrition, menstrual status (in females), bone health, and awareness of the Triad/RED-S. RESULTS: The athletes were 260 elite para athletes (150 male, 110 female). While few reported prior eating disorder (3.1%), 32.4% had elevated Eating Disorder Examination Questionnaire (EDE-Q) pathologic behavior subscale scores. Most athletes (95 male, 65 female) were attempting to change their body composition or weight to improve performance. Forty-four percent of premenopausal females had oligomenorrhea/amenorrhea. Bone stress injury was reported in 9.2% of athletes; of these, 54.5% (n = 12) had low BMD. Less than 10% of athletes reported awareness of the Triad/RED-S. CONCLUSIONS: Factors associated with the Triad/RED-S are present in an elite para athlete population, regardless of sex or sport type. Awareness of the Triad/RED-S in para athletes is low. The consequences of LEA in para athlete populations are poorly understood. However, the high prevalence of factors observed suggests value in advancing screening tools and education efforts to optimize health in this population.

Injuries of the adolescent girl athlete: a review of imaging findings.

With the rising participation of girls in sports at both the recreational and elite levels, there has also been increased awareness of injuries common in this athlete population. Anatomic differences between boys and girls cause girl athletes to be predisposed to certain injuries. Certain behavioral patterns, such as eating disorders, also cause problems specific to girl athletes that may result in injury. Imaging plays a large role in diagnosis and ongoing management, but there has been only scant literature dedicated to the specific topic of imaging in girl athletes. The purpose of this article is to review the imaging findings and recommendations for injuries and other conditions affecting the adolescent girl athlete. This article first provides an overview of the key anatomic differences between boys and girls, including both static and dynamic factors, as well as non-anatomic differences, such as hormonal factors, and discusses how these differences contribute to the injury patterns that are seen more typically in girls. The article then reviews the imaging findings in injuries that are commonly seen in girl athletes. There is also a discussion of the "female athlete triad," which consists of osteoporosis, disordered eating, and amenorrhea, and the role of imaging in this condition.

Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport.

Low energy availability (EA) is suspected to be the underlying cause of both the Female Athlete Triad and the more recently defined syndrome, Relative Energy Deficiency in Sport (RED-S). The International Olympic Committee (IOC) defined RED-S as a syndrome of health and performance impairments resulting from an energy deficit. While the importance of adequate EA is generally accepted, few studies have attempted to understand whether low EA is associated with the health and performance consequences posited by the IOC. OBJECTIVE: The purpose of this cross-sectional study was to examine the association of low EA with RED-S health and performance consequences in a large clinical population of female athletes. METHODS: One thousand female athletes (15-30 years) completed an online questionnaire and were classified as having low or adequate EA. The associations between low EA and the health and performance factors listed in the RED-S models were evaluated using chi-squared test and the odds ratios were evaluated using binomial logistic regression (p<0.05). RESULTS: Athletes with low EA were more likely to be classified as having increased risk of menstrual dysfunction, poor bone health, metabolic issues, haematological detriments, psychological disorders, cardiovascular impairment and gastrointestinal dysfunction than those with adequate EA. Performance variables associated with low EA included decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression and decreased endurance performance. CONCLUSION: These findings demonstrate that low EA measured using self-report questionnaires is strongly associated with many health and performance consequences proposed by the RED-S models.

Bone stress injuries in male distance runners: higher modified Female Athlete Triad Cumulative Risk Assessment scores predict increased rates of injury.

OBJECTIVES: Bone stress injuries (BSI) are common in runners of both sexes. The purpose of this study was to determine if a modified Female Athlete Triad Cumulative Risk Assessment tool would predict BSI in male distance runners. METHODS: 156 male runners at two collegiate programmes were studied using mixed retrospective and prospective design for a total of 7 years. Point values were assigned using risk assessment categories including low energy availability, low body mass index (BMI), low bone mineral density (BMD) and prior BSI. The outcome was subsequent development of BSI. Statistical models used a mixed effects Poisson regression model with p<0.05 as threshold for significance. Two regression analyses were performed: (1) baseline risk factors as the independent variable; and (2) annual change in risk factors (longitudinal data) as the independent variable. RESULTS: 42/156 runners (27%) sustained 61 BSIs over an average 1.9 years of follow-up. In the baseline risk factor model, each 1 point increase in prior BSI score was associated with a 57% increased risk for prospective BSI (p=0.0042) and each 1 point increase in cumulative risk score was associated with a 37% increase in prospective BSI risk (p=0.0079). In the longitudinal model, each 1 point increase in cumulative risk score was associated with a 27% increase in prospective BSI risk (p=0.05). BMI (rate ratio (RR)=1.91, p=0.11) and BMD (RR=1.58, p=0.19) risk scores were not associated with BSI. CONCLUSION: A modified cumulative risk assessment tool may help identify male runners at elevated risk for BSI. Identifying risk factors may guide treatment and prevention strategies.

Serum Brain-derived Neurotrophic Factor Levels Mirror Bone Mineral Density in Amenorrheic and Eumenorrheic Athletes.

Amenorrhea and osteoporosis are strongly associated in female athletes. Amenorrheic women show lower serum levels of brain-derived neurotrophic factor (BDNF) than eumenorrheic women. BDNF is known to regulate bone tissue development and remodeling; thus, athletes with low serum BDNF levels may show low bone mass. This study investigated the associations between serum BDNF, estradiol, and bone mineral density (BMD) in female athletes. This study included 160 elite female athletes (21.7±4.3 years). Serum levels of BDNF and estradiol were in 195 blood samples obtained from 132 eumenorrheic athletes (EA) and 63 amenorrheic athletes (AA). BMD was measured in the radius, lumbar spine, pelvis, and legs using dual-energy X-ray absorptiometry. AA showed significantly lower serum BDNF levels than EA (p=0.017). Serum BDNF levels were positively and significantly associated with both serum estradiol levels (p=0.0004) and the BMD measured at all sites (all p<0.05). 10 AA received transdermal estrogen therapy, and serum BDNF levels were measured at baseline and 6 months after therapy. Hormone-treated AA demonstrated a significant increase in serum BDNF levels after 6 months (p=0.022). Thus, serum BDNF levels may be associated with decreased BMD and serve as an indicator of the therapeutic effect of estradiol supplementation in female athletes with osteoporosis.

Comparison of Female Athlete Triad Coalition and RED-S risk assessment tools.

The Female Athlete Triad Coalition (Triad Coalition) and Relative Energy Deficiency in Sport (RED-S) consensus statements each include risk assessment tools to guide athlete eligibility decisions. This study examined how these tools categorized the same set of individuals to an overall risk factor score and qualitatively compared athlete eligibility decisions resulting from each tool. Exercising women (n = 166) with complete screening/baseline datasets from multiple previously conducted studies were assessed. Data used for risk assessment included: anthropometric measurements, dual-energy x-ray absorptiometry scans, exercise and health status surveys, and two disordered eating questionnaires (Three Factor Eating Questionnaire and Eating Disorder Inventory). Individuals were scored on each tool and subsequently categorized as either fully cleared, provisionally cleared, or restricted from play. Based on the Triad Coalition tool, 25.3% of subjects were classified as fully cleared, 62.0% as provisionally cleared, and 12.7% as restricted from play. Based on the RED-S tool, 71.7% of subjects were classified as fully cleared, 18.7% as provisionally cleared, and 9.6% as restricted from play. The Triad Coalition and RED-S tools resulted in different clearance decisions (p < 0.001), with the Triad Coalition tool recommending increased surveillance of a greater number of athletes.