Sex Differences in Stress Fracture Incidence and Risk Factors in Athletes: A Narrative Review
DOI:
https://doi.org/10.12775/QS.2026.54.70527Keywords
stress fracture, bone stress injury, female athlete, sex differences, Female Athlete Triad, Relative Energy Deficiency in Sport, biomechanics, bone geometryAbstract
Background. Stress fractures are a prevalent overuse injury in athletes, with female athletes consistently reporting higher incidence rates than males. This disparity is driven by an interplay of anatomical, hormonal, biomechanical, and training-related factors.
Aim. This narrative review aims to synthesise the current evidence on sex differences in stress fracture incidence and to identify the key risk factors underlying this disparity.
Methods. A narrative literature review was conducted using PubMed, Web of Science, and Scopus. Studies published between 2015 and 2026, with an emphasis on 2020–2026, were included. Peer-reviewed original research articles, systematic reviews, and meta-analyses addressing stress fractures in athletes with sex-stratified data were considered.
Results. Female athletes exhibit higher rates of tibial, metatarsal, and tarsal stress fractures compared to males. Contributing factors include smaller bone cross-sectional geometry, lower cortical bone density, and distinct trabecular microarchitecture. Hormonal disruptions associated with the Female Athlete Triad and Relative Energy Deficiency in Sport further impair bone metabolism in women. Sport-specific loading, early specialisation, low body mass index, and menstrual irregularities compound this risk.
Conclusions. The excess stress fracture risk in female athletes is multifactorial. Effective prevention requires sex-specific screening for energy deficiency, menstrual health monitoring, and individualised training load management.
References
1. Abbott A, Bird ML, Wild E, Brown SM, Stewart G, Mulcahey MK. Part I: epidemiology and risk factors for stress fractures in female athletes. Phys Sportsmed. 2020;48(1):17-24. https://doi.org/10.1080/00913847.2019.1632158
2. Hollander K, Rahlf AL, Wilke J, et al. Sex-Specific Differences in Running Injuries: A Systematic Review with Meta-Analysis and Meta-Regression. Sports Med. 2021;51(5):1011-1039. https://doi.org/10.1007/s40279-020-01412-7
3. De Souza MJ, Williams NI, Misra M, et al. 2025 Update to the Female Athlete Triad Coalition Consensus Statement Part 1: State of the Science and Introduction of a New Adolescent Model. Sports Med. 2026;56(2):327-373. https://doi.org/10.1007/s40279-025-02333-z
4. Beck B, Drysdale L. Risk Factors, Diagnosis and Management of Bone Stress Injuries in Adolescent Athletes: A Narrative Review. Sports (Basel). 2021;9(4):52. Published 2021 Apr 16. https://doi.org/10.3390/sports9040052
5. Rizzone KH, Ackerman KE, Roos KG, Dompier TP, Kerr ZY. The Epidemiology of Stress Fractures in Collegiate Student-Athletes, 2004-2005 Through 2013-2014 Academic Years. J Athl Train. 2017;52(10):966-975. https://doi.org/10.4085/1062-6050-52.8.01
6. Koltun KJ, Sekel NM, Bird MB, et al. Tibial Bone Geometry Is Associated With Bone Stress Injury During Military Training in Men and Women. Front Physiol. 2022;13:803219. Published 2022 Feb 11. https://doi.org/10.3389/fphys.2022.803219
7. Crunkhorn ML, Etxebarria N, Toohey LA, Charlton P, Watson K, Drew M. The Natural History of Bone Stress Injuries in Athletes: From Inception to Resolution. Sports Med. 2025;55(10):2415-2428.
https://doi.org/10.1007/s40279-025-02280-9
8. Ishida T, Tohyama H. Identification of Predictive Risk Factors for the Development of a Stress Fracture Within 6 Months in Highly Trained Female Long-Distance Runners: A Prospective Cohort Study. Orthop J Sports Med. 2026;14(1):23259671251399820. Published 2026 Jan 9. https://doi.org/10.1177/23259671251399820
9. Bruce OL, Baggaley M, Khassetarash A, Haider IT, Edwards WB. Tibial-fibular geometry and density variations associated with elevated bone strain and sex disparities in young active adults. Bone. 2022;161:116443. https://doi.org/10.1016/j.bone.2022.116443
10. Hughes JM, Taylor KM, Guerriere KI, et al. Changes in Distal Tibial Microarchitecture During Eight Weeks of U.S. Army Basic Combat Training Differ by Sex and Race. JBMR Plus. 2023;7(4):e10719. Published 2023 Mar 2. https://doi.org/10.1002/jbm4.10719
11. Gaudette LW, Ackerman KE, Bouxsein ML, et al. Biomechanics associated with bone stress injury in athletes differ by proximal and distal anatomical locations: a cross-sectional analysis. BMJ Open Sport Exerc Med. 2025;11(2):e002469. Published 2025 Jun 30.
https://doi.org/10.1136/bmjsem-2025-002469
12. Popp KL, Outerleys J, Gehman S, et al. Impact loading in female runners with single and multiple bone stress injuries during fresh and exerted conditions. J Sport Health Sci. 2023;12(3):406-413. https://doi.org/10.1016/j.jshs.2022.02.004
13. Grabia M, Perkowski J, Socha K, Markiewicz-Żukowska R. Female Athlete Triad and Relative Energy Deficiency in Sport (REDs): Nutritional Management. Nutrients. 2024;16(3):359. Published 2024 Jan 25. https://doi.org/10.3390/nu16030359
14. Heikura IA, McCluskey WTP, Tsai MC, et al. Application of the IOC Relative Energy Deficiency in Sport (REDs) Clinical Assessment Tool version 2 (CAT2) across 200+ elite athletes. Br J Sports Med. 2024;59(1):24-35. Published 2024 Dec 23. https://doi.org/10.1136/bjsports-2024-108121
15. MacMillan C, Olivier B, Viljoen C, van Rensburg DCJ, Sewry N. The Association Between Menstrual Cycle Phase, Menstrual Irregularities, Contraceptive Use and Musculoskeletal Injury Among Female Athletes: A Scoping Review. Sports Med. 2024;54(10):2515-2530. https://doi.org/10.1007/s40279-024-02074-5
16. Cheng J, Santiago KA, Abutalib Z, et al. Menstrual Irregularity, Hormonal Contraceptive Use, and Bone Stress Injuries in Collegiate Female Athletes in the United States. PM R. 2021;13(11):1207-1215. https://doi.org/10.1002/pmrj.12539
17. Vannatta CN, Heinert BL, Kernozek TW. Biomechanical risk factors for running-related injury differ by sample population: A systematic review and meta-analysis. Clin Biomech (Bristol). 2020;75:104991. https://doi.org/10.1016/j.clinbiomech.2020.104991
18. Rauh MJ, Tenforde AS, Barrack MT, Rosenthal MD, Nichols JF. Sport Specialization and Low Bone Mineral Density in Female High School Distance Runners. J Athl Train. 2020;55(12):1239-1246. https://doi.org/10.4085/1062-6050-0547.19
19. Lane AR, Hackney AC, Smith-Ryan AE, Kucera K, Register-Mihalik JK, Ondrak K. Energy Availability and RED-S Risk Factors in Competitive, Non-elite Male Endurance Athletes. Transl Med Exerc Prescr. 2021;1(1):25-32. Doi:10.53941/tmep.v1i1.29
20. Mroz KH, Sterczala AJ, Sekel NM, et al. Differences in Body Composition, Bone Density, and Tibial Microarchitecture in Division I Female Athletes Participating in Different Impact Loading Sports. Calcif Tissue Int. 2025;116(1):35. Published 2025 Jan 29.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Jakub Rudnicki, Maciej Szczupaj, Iga Michalicha, Wiktoria Leja, Maciej Błaszczak, Katarzyna Latalska, Andżelika Pastuszak, Konrad Borkowski, Jakub Kot, Zeeshan Zulfiqar
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Stats
Number of views and downloads: 42
Number of citations: 0
