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.

骨应力损伤 (BSI) 在运动员中很常见，并且复发率很高。然而，多重或复发性 BSI 的风险因素仍未得到充分研究。因此，我们旨在探索能量可用性、月经功能、骨骼健康测量和改进的女性运动员三联征累积风险评估 (CRA) 工具是否与多个 BSI 的病史相关。我们招募了 51 名女性跑步者（年龄 18-36 岁），她们的 BSI ≤1（对照组；n  = 31）或 ≥3 BSI（multiBSI；n = 20) 在这项横断面研究中。我们通过双能 X 射线骨密度仪测量腰椎、全髋和股骨颈区域骨矿物质密度，使用冲击显微压痕测量骨材料强度指数，并通过高分辨率外围定量计算测量体积骨矿物质密度、微结构和估计强度断层扫描。参与者完成了关于病史、低能量骨折史和饮食失调的问卷调查。与对照组相比，multiBSI 的低能量骨折发生率更高（55% 对 16%，p  = .005）和改良三联征 CRA 评分更高（2.90 ± 2.05 对 1.84 ± 1.59，p  = .04）。multiBSI 患者的饮食失调检查问卷较高（0.92 ± 1.03 vs. 0.46 ± 0.49，p = .04) 得分，并且在当前身高下最低和最高体重之间的百分比差异更大（15.5% ± 6.5% vs. 11.5% ± 4.9% p  = .02）。这些初步研究结果表明，与对照组相比，有多个 BSI 病史的女性先前遭受了更多的低能量骨折，并且对能量不足的历史和当前估计值更大。我们的结果为未来的研究提供了强有力的理由，以检查能量缺乏的亚临床指标是否会导致女性跑步者发生多种 BSI 的风险。