The document discusses several key points about factors that impact bone health and injury risk for female athletes and military personnel: 1) Nutrition, training load, and other lifestyle factors are interlinked and influence bone health and risk of injury, rather than individual factors alone. Inadequate intake of key nutrients can limit the benefits of exercise on bone health. 2) Past injuries increase future risk of re-injury, highlighting the importance of addressing underlying nutrition, training, and other issues to aid recovery and prevent reoccurrence. 3) Nutrients like calcium, vitamin D, and protein work together synergistically to support bone health, so optimizing one without others may not improve outcomes. A whole diet approach is

1. Quotes
“Substantial research has assessed the risk factors for injury in the military, however, results
are often contradictory and focus on individual factors, when in reality, a large number are
inextricably linked.”
Anderson et al, “Musculoskeletal Lower Limb Injury Risk in Army Populations,” Sports Med Open, 2016 Dec; 2: 22.
“Although physical activities that involve high-intensity skeletal loading are recommended to
optimize and maintain bone mass in young adults, the benefits may not be realized in the
presence of hormonal or dietary deficiencies or an overuse syndrome. The Female Athlete
Triad, consisting of disordered eating, amenorrhea, and osteoporosis, is an example of the
ineffectiveness of exercise to fully counteract the deleterious effects of other factors on bone
health…..”
Kohort et al, Physical Activity and Bone Health, ACSM Position Stand
1

2. "Female athletes depend upon a healthy and complete diet to provide the
nutrients required to maintain and promote physical performance and
protect against injury. However, female athletes may experience difficulties
in maintaining adequate micronutrient status due to the consumption of
energy or nutrient inadequate diets or declines in nutritional status due to
heavy physical activity.”
Female athletes: A population at risk of vitamin and mineral deficiencies
affecting health and performance. McClung et al.

3. Developing healthy, strong bones, and muscles in a training Soldier-Athlete requires:
1. A physical load that stimulates bones and muscles to grow stronger and more resilient within a
training program designed to provide exercise variety, balanced opposing muscle strengths, and
sufficient recovery/rest periods.
2. Sufficient quantities of 20 nutrients to enable the bones and muscles to properly remodel, taking into
account both nutrient losses in sweat and increased nutrient requirements to repair damaged
tissues. The RDA/DRI are not normed on athletes and food nutrient levels have declined (USDA).
3. Poorly designed training with too much workload volume without adequate recovery/rest schedules
and/or insufficient nutrients can lead to injuries, hormonal disruption, and/or osteoporosis.
4. Non-traumatic bone/muscle/tissue injuries and high rates of re-injuries can result from the any
combination of poor training design, inadequate diet/nutrient deficiencies, osteoporosis, and substance
abuse/smoking. Even a well-designed training program with proper workload volume, variety, and
recovery cannot overcome the deleterious effects of inadequate nutrition, entry osteoporosis, and/or
substance abuse/smoking on bone health. Screening prior to a new training program is recommended if
possible (diet survey, bone status, opposing muscle balances, health history, comprehensive blood
chemistry).
5. A preliminary post-injury assessment should include, as relevant, an opposing muscle balance
assessment, bone scan (DEXA volume or pQCT), and a comprehensive 20 nutrient blood chemistry
panel. Treatment should include correcting any identified opposing muscle imbalances, bone
osteopenia/osteoporosis, and nutrient deficiencies. It is important to keep the injured athlete motivated
and involved with athletic training/education courses and other appropriate education/training (resilience
psychology, adaptive skills, emotional IQ, nutrition, health, etc.). Treatment should also include
exercising non-injured muscles/bones (with HCP input) to include alternative cardio-vascular (CV) events
(ex. an arm ergonometer can provide some CV training without stressing an injured leg, etc.).

4. Co-nutrients are nutrients that work together for some process. If one co-nutrient is limited - either
missing or not enough - then the process might also be limited or not able to take place at all.
Using bone status as an example, calcium, vitamin D, protein and magnesium are some of the co-
factors working together to maintain strong and healthy bones. The following charts illustrate how
co-nutrient status can affect a target outcome such as bone status. In each chart, lighter orange
represents optimal intake of each nutrient, while the darker orange is the actual level. When any or
all nutrients are below the optimal level, bone status is impaired at the level of the lowest - the most
limited nutrient. Even if calcium and vitamin D status are optimized, as shown in the bottom chart,
bone status would still be limited by the protein status.
If one were to focus on optimizing vitamin D, without also optimizing Ca, protein and Mg, (such as
in the top chart) no change in bone status would be observed, leading to a false conclusion that
vitamin D does not affect bone status. Because the nutrients interact in the maintenance of bone
health, the effects of a single nutrient may be overlooked if intake of others is not sufficient.

5. "Furthermore, after initial rehabilitation, recruits who suffered a
stress fracture during basic training are at higher risk of sustaining
stress fractures during subsequent training (10.6% incidence within
one year of injury, versus 1.7% in injury-free recruits) [7], thereby
increasing working days lost to injury and the accompanying
financial burden.”
Incidence and Time to Return to Training for Stress Fractures during Military
Basic Training, Wood et al, Journal of Sports Medicine, Volume 2014

6. "A group of 295 Israeli infantry recruits was evaluated in a prospective study of
stress fractures which began in basic training. On the basis of scintigraphy, 91 of
the recruits (31%) were found to have sustained stress fractures during basic
training. Sixty-six of the 91 recruits with stress fractures (72%) were followed for a
minimum of 1 year after basic training to determine the natural history of a soldier
who sustains a stress fracture and resumes training after a period of rest.
Five clinical patterns were observed:
(1) uneventful recovery (47%);
(2) protracted recovery (13.6%);
(3) symptoms consistent with recurrent stress fractures in new sites (19.6%);
(4) intermittent nonstress fracture bone pain (16.7%); and
(5) chronic stress fractures (3%). The incidence of recurrent stress fractures was
10.6%.
A control group of 60 recruits who sustained no stress fractures in basic training
had a 1.7% incidence of stress fractures after basic training. Recruits who
sustained stress fractures in basic training continued to be a higher risk for stress
fractures during subsequent training."
C.Milgrom, M.Giladi, R.Chisin, and R.Dizian, “The long-term followup of soldiers
with stress fractures,” The American Journal of Sports Medicine, vol. 13, no. 6, pp.
398–400, 1985.

7. "Historically, nutrition and bone-related research has followed
a reductionist approach to identify key individual nutrients that
affect bone health (4). Although it is valuable to understand
the effects of individual nutrients, this method fails to capture
the synergy of nutrients and may fail to elucidate individual
nutrient effects because of high correlations between
nutrients within foods (5)."
A dietary pattern rich in calcium, potassium, and protein is associated with tibia
bone mineral content and strength in young adults entering Initial Military Training
Anna T Nakayama, Laura J Lutz, Adela Hruby, James P Karl, James P McClung, and Erin
Gaffney-Stomberg