Women’s Cross Country Running Panel Discussion
This past week Dr. Hannah DePaul hosted a panel discussion including an amazing crew of professionals speaking to the research, personal experience and medical/coaching advice as it pertains to running; specifically to the high school and collegiate aged female cross country runners.
Amazing information is shared by the panel, and is applicable to all athletes and runners.
- Dr. Hannah DePaul, PT [Sports Physical Therapist @ Adams Sports Medicine]
- Maureen Stoecklein, RD [Dietician @ NY Mets]
- Nicole Sifuentes [Elite Runner and Owner/Coach @ Sifuentes Coaching/Consulting]
- Erin Finn [Pro Runner @ Brooks/Hansons and medical student]
As long stretches of hot summer days become commonplace, it’s perhaps more important than ever to be aware of how to safely train and recover when temperatures climb. There’s no question that body type/mass and genetics can influence an athlete’s performance in the heat; however, our aptitude to conquer the thermometer is by no means set in stone. One of the biggest weapons in our arsenal is hydration.
Let’s be clear. Drinking 8 cups of water per day simply will not cut it for most people, let alone athletes, but good hydration extends beyond just the amount of pure H2O entering your system each day. What matters most is whether or not we are absorbing it.
What is the right amount?
How much fluid you need, and what it should consist of, is based on many individual factors like sweat rate, electrolyte levels, and activity type and duration. Furthermore, training adaptations and variance in heat and humidity significantly change intake requirements too. The good news is that by following some pretty basic guidelines and employing a bit of guess and check, you can likely dial in an approach that works for you.
Keeping under a 2% change in body weight during an exercise session is important, as performance declines and warning signs of heat exhaustion can increase at this point. Depending on the factors mentioned above, individuals may need between 16 and 32 oz per hour while active, and even for one individual, that amount will change based on exercise intensity and climate conditions.
To estimate fluid loss, weigh yourself in the same state before and after after each workout. For each pound lost, replace about 16 ounces of fluid.
To estimate your individual sweat rate, do the same after an hour of intense exercise, factoring in fluid consumed and expelled
Sweat rate = pre exercise body weight − post exercise body weight + fluid intake during exercise − urine produced
- Hydration must be proactive
- Just like overall fueling, fluids should be consumed in anticipation of activity, as well as in response to exercise (you need to rehydrate AND prehydrate)
- Pay especially close attention if you train more than once/day or have back to back longer days on a weekend. Imagine how a long ride or run Sunday is going to feel if you are already at a deficit when you begin your session on Saturday
- It can take up to a day or more to get back to normal after being in a dehydrated state
- Utilize a sports drink or electrolyte supplement
- Water is not enough, especially in the heat, and flooding the body with water alone can lead to low serum sodium levels (hyponatremia)
- Sports drinks and electrolyte tablets are formulated to help us absorb water effectively. Sodium, in particular is crucial for getting water into the cells
- Many other electrolytes play a vital role in muscle and metabolic function
- Test several types of drinks/formulas with training to find what works best for you
- Consider the amount of sugar in your drink. Understand the type of training you are doing and the quantity and type of carbs you need in your system. Some sessions may warrant a higher dose of sugars/carbs while others might be fine for just electrolyte replacement in the form of a tablet. It’s important to realize that sugar is often a friend during intense training and racing. There definitely is a ‘sweet spot’ for how much you should take in.
- Always have more fluid (and fuel) available than you think you need.
- It’s not just about surviving one single workout, it’s all about recovering, adapting, and being ready to continue training and feeling great. Don’t run the risk of bonking or becoming dehydrated.
- Have fluid available for any swim or run over 30min on hot sunny days
- It’s easy to neglect hydration during shorter sessions. Don’t. Purchase and use a hydration belt or handheld bottle, or do loops where you can return to your own aid-station
- Yes, you still sweat and sill need to hydrate when swimming
- Hydrate in frequent, small doses during exercise for optimal absorption
- Nobody likes a ton of liquid sloshing around in the stomach either!
- Keep it cool
- Use some ice and/or insulated bottles if you have them
If you don’t feel like you have your fueling and hydration down to a science, now is the time to begin some trial and error and put your methods to the test. For more information, check out the links below.
When can I return to running? That is a question that we get asked daily at Adams Sports Medicine & Physical Therapy with the large number of runners we help get back to running after injury. It is also a question I asked myself and my doctors after giving birth to my son, Henry, last October. Every runner has a different reason for their love of running. For myself, it’s an activity that makes me feel like me. It’s my time to be outside in nature, to think about everything or nothing at all. Throughout my pregnancy I tried to keep up running in some aspect, even though it ended up being short intervals when doing longer walks. After I had Henry I found there wasn’t much research and little guidance in terms of knowing when and how to get back to running. Here are some of my tips based on my postpartum return to running journey.
- Consult with your OB/Midwife and go see a Women’s Health Physical Therapist
In my opinion this is the most important thing to do before returning to running, or any high impact activity postpartum. At 6 weeks after birth I saw my Midwife and she assessed my pelvic floor strength and healing. She gave me the clear to slowly return to running. However, with my physical therapy background I knew there was a lot more that needed to be examined for me to feel confident that I was ready to run, so I waited until I saw Dr. Nancy Boyd at Ancoeur Wellness. She is a Women’s Health Physical Therapist, and a runner herself. She examined not only my pelvic floor, but also my hip/core strength, functional tests, and balance. We discussed a return to run plan, my goals, and she provided me with a home exercise program. This was huge as it gave me the confidence that I would be able to get back to running.
The exercise program consisted of hip/core strengthening that was the appropriate level of difficulty for where my strength was. I wanted to get back to doing planks and harder core strengthening, but she pointed out that I was putting too much stress on the small diastasis recti that I had. She gave me modifications to exercises that I wanted to do, and it was things that I could easily do when playing on the floor with Henry. She also discussed urge suppression strategies, which provided me with things to do or think about when I felt like I had to go to the bathroom, especially mid-run.
- Everyone is different, and 6 weeks is not the magic number
I don’t think anything will prepare you for the mental and physical recovery you go through after birth. My experience was way tougher than I imagined, and I knew my return to running would be hard considering my first walk around the block after giving birth I felt like everything down there was going to fall out of me! Significant heaviness, swelling, discomfort, and bleeding were my symptoms that I knew needed to get significantly better before even attempting a run. Also, with the unlimited access we have to social media it is easy to get caught up in what and when other moms are doing exercise-wise postpartum. It is important to realize everyone is different and to not compare your journey to others. How active you were when pregnant, your birth mode, any complications you had, and how you are recovering will all factor in.
The timeline for a return to running is going to be different for everyone, and just because your doctor said you are healed at 6 weeks, for most people, does NOT mean you are ready to run at 6 weeks. Tom Goom, aka the Running Physio, along with two Women’s Health Physiotherapists, Gráinne Donnelly and Emma Brockwell, published “Returning to running postnatal – guidelines for medical, health and fitness professionals managing this population”, and they advised not to return to running until you are 3 months postnatal. I did feel like I was ready to run before 3 months, and needed to for my sanity. My first run/walk workout was about 7 weeks after birth.
A recent article published in the Journal of Orthopaedic & Sports Physical Therapy, “From Childbirth to the Starting Blocks: Are We Providing the Best Care to Our Postpartum Athletes?” proposes three stages when returning to activity postpartum (Deering et al. 2020). These stages include recovery, rehabilitation/training, and competition. Every individual progresses through the stages at their own pace.
- Start slow!
When I got home from the hospital I started walking short distances outside with Henry in the stroller, mostly to get some fresh air. I slowly increased my walking distance as my symptoms allowed. At 7 weeks I created my running program based on how I would initiate a return to running protocol for a patient coming back from a stress fracture. I started with 1 minute running and 3 minutes walking intervals. Then slowly increased run and decreased walk durations. I tracked my weekly mileage to make sure I wasn’t increasing by more than 10% each week to decrease the risk of injury. I started my walk/runs on the treadmill due to it being winter, and logistically was easier to try to get the workout in when Henry was napping. This frequently meant stopping the run early, or going upstairs to soothe him mid-run. Having a treadmill though has been a life saver, and I definitely recommend it for any parents wanting to run with a new baby. I started running with him in the jogging stroller when he was almost six months and could sit unassisted.
My body doesn’t feel like it did pre-Henry, and the jury is still out as to if it will ever feel that way again. Initially, I dealt with heaviness symptoms in my pelvic floor, and had to stop to go to the bathroom often. But that is slowly improving, especially with the urge suppression strategies I was given at physical therapy. With time everything is feeling better and my longest run so far has been 11 miles, with no pain and no potty breaks! A win in my book!
- Leaking is common, but not normal!
Luckily when I first started back running I didn’t have much issue with leakage. However, I did the super bowl 5k around four months postpartum and leaked the entire race! This was a major bummer as I thought I was doing so well. I think the leaking was due to the fact that I didn’t use the porta-potty one last time before the race due to the long line. So my advice is always go to the bathroom before you run, and sometimes you are going to need to stop mid-run.
If you are experiencing leakage with any activity postpartum know that it’s common, but not normal. Talk to your women’s health physical therapist to get appropriate exercises to address the leaking. There is so much more to it than just kegels!
- Get the right sports bra
I’m just going to put this out there that having to stop mid-run to go change into a more supportive sports bra was something I never even considered would be an issue pre-Henry. This has happened multiple times though, and I soon figured which of my sports bras work and which don’t. I also suggest if you are nursing that you either nurse your baby or pump right before your run…just do it. It makes everything more comfortable.
Also, I was worried that my milk production would go down if I ran too much. That has not been the case for me, and I have found no difference in my milk production as my training has increased. I make sure I eat enough to support the energy demands of breastfeeding, running, and just mom life with a nine month old (which is the hardest of all).
- Have a goal
It always helps me get out the door to run when I have something I am working towards. Initially it was helpful to have the Bayshore Half Marathon on my schedule to base my training around, which unfortunately as with all the other races was cancelled. Since COVID-19 I have been trying to get my speed back, and have been doing a 5K from my house about every 6 weeks with the goal of setting a PR later this summer.
I hope this helps current or future runner moms! It may seem near impossible to get back to running after having a baby, but don’t give up on your goals and doing an activity that makes you feel whole. Get help, listen to your body, progress slowly, and set realistic goals. Be patient with the process. It will be hard, but come on, you just grew and birthed a human, you can do hard things!
Hannah DePaul is a sports certified Doctor of Physical Therapy, who specializes in treating endurance athletes. She is a runner and triathlete herself, and has completed the Ironman World Championships 2x.
So you want to start running?
While gyms are closed and many of us are working from home – you may be a bit restless and looking for new ways to move your body and stay active while social distancing. With the sun shining bright, Mother Nature is practically begging us to go outside! Running is a great activity to do alone and the best part is – you can start right from your front door!
Here are a few basic tips and tricks to help you start your running journey and fall in love with the sport…
1.Find a good pair of running shoes
Believe it or not – there is no one-shoe-fits-all shoe out there, but there is a perfect shoe for you that will help you feel comfortable and stay injury-free down the road. Your local running store guru can help you narrow down your options by putting you through a proper fit process. Shop local! No one knows your city and the nearby trails better than your local running store, like Gazelle Sports Northville! With retail stores closed right now – it may be difficult to get the advice you need for shoes. However, if you have any shoe specific questions, see the bottom of this article for a reliable resource.
2.Find a good route
There is nothing better than fresh air and sunlight. Whether it is a trail, paved path, or just around the block – make sure you are enjoying WHERE you are running. Explore new places and keep it interesting. This will help you stay motivated!
3. Run at a conversational pace
This is the best piece of advice that I received when I first started running. Not every run needs to be a full effort and you should be running at a pace where you are able to hold a conversation. If you find yourself out of breath – simply slow down a bit. If you have a running buddy, share some miles with them, catch up, and tell some stories. Right now, running with a buddy might not be doable, but you can plug in some headphones, give your friend a call, and go for a virtual run together.
4. Progress slowly
You might be excited to get moving and run all the miles, but be conservative when bumping up your mileage. It will help you stay injury-free! Rule of thumb: do not increase your mileage more than 10% week to week. Respect the sport and listen to your body. If running is brand new to you, you will experience some soreness as your body begins to adapt. It is important to keep up with stretching, foam rolling, and a proper warm-up/cool-down routine.
5. Dress appropriately
Be sure to dress for the weather. There is no such thing as bad weather; only bad clothing. If you only remember one thing from this post: know that cotton is ROTTEN! Wearing moisture-wicking materials like merino wool or a poly-blend are your best bets. (This applies to socks, too!) Always dress like it is 15-20 degrees warmer than it actually is. For cold weather – layering helps. You want to be as comfortable as possible and dressing appropriately will help you to find more joy in your runs! Don’t forget accessories such as gloves, headbands, sunglasses, or whatever it may be that you need to keep yourself protected/prepared for the elements. (Pro tip: that includes sunscreen and body glide for those warmer days like today!)
6. Safety first!
There are a few running safety tips you must know before you hit the pavement…
- Always face traffic so that drivers can see you and you can see them.A headlamp or other reflective gear is always a good call.
- Run with an ID, or ID bracelet or driver’s license in case of an emergency.
- Let someone know the route you are running and how long you expect to be out.
- Take your phone for emergencies.
- Check the weather before your run.
- Don’t run with headphones in. If you need music to stay motivated – I recommend a pair of Aftershokz that allow you to hear cars and people around you.
7. Have fun, be patient, and keep moving
When I first started running – I’ll be honest – I wasn’t sure I was going to like it. But after a few months of pushing myself outside of my comfort zone, I discovered a true passion for the sport and a wonderful community. Running is a beautiful sport that brings me a lot of happiness, but it did not happen overnight. My hope is for you to find the same joy I experience every time I get out there for a run.
Katie Siroonian is an active runner in the community and also works at Gazelle Sports Northville. If you have any shoe specific questions, she can help you navigate the Gazelle Sports website and narrow down your options! Katie can be reached at [email protected]. Learn a little bit more about Katie and the rest of our team here!
Whether you’re still making necessary travel to the office each day or sidelined to home, with or without much work to do, there’s no denying that life for most of us has drastically changed in the last few weeks. For this reason it’s especially important to establish structure again, giving a sense of purpose to time that may otherwise easily drift into a blur. By the way, today is Tuesday, in case you weren’t sure.
While we have still remained open on abbreviated hours here for post-operative/emergent patients and staying in touch remotely with others, we are all taking a proactive approach to using extra time in clinic and at home to discuss treatment techniques, hone our manual skills, and get creative with new exercises.
Since pools are no longer available, and the lakes are still a little cold for even the most neoprene-equipped among us, many triathletes and swimmers are wondering what to do. I have always been a fan of resistance tubing for swim specific strengthening and now I am using it regularly to make the most of these days on dry land. Having a set time to work out, along with my usual walk/runs with my dog in the morning and afternoon, is helping me maintain normalcy and focus before winding down with a good meal and checking in with friends and family in the evenings.
Below are two articles and a video, ranging from practical to perhaps a little off the wall, that might just provide a little spark of motivation to stay in control of life during uncertainty.
Aaron Bachman is a Physical Therapist Assistant, endurance coach, and former elite triathlete. As a PTA, Aaron also offers sports massage and running gait analysis services. Read Aaron’s bio here.
Check out our latest video from Dr. Hannah DePaul! Hannah answers a question that she hears frequently from the endurance athletes she treats: When is it ok to train through pain?
Hannah – Ironman, triathlete, and elite-level runner – knows what it’s like to train, compete, and suffer injuries, which makes her an expert on this topic. She is passionate about helping people reach their goals and dedicated to helping our patients prevent future injury and enjoy the activities they love.
All that said…during this challenging time – it is easy for many of us to feel unmotivated to train with races cancelled and so much preparation that is seemingly all for nothing. But it is NOT for nothing! What we are training for is life; to be strong when we are faced with obstacles, to have hope to carry us through difficult times, to be able to endure the tough times that make the good times that much better. Keep training, stay positive, and stay healthy!
As a healthcare clinic…we remain open and dedicated to our community
At all times our TEAM is vigilant to the health of our athletes and patients. We are trained in universal precautions in order to prevent the transfer of viral and bacterial infections. We have staff that follow the protocols and policies in place for the routine cleaning of patient-use equipment, hand washing techniques/use of hand sanitizers, and educating our community on best-practices.
With that being said, we are open and treating our patients. We are complaint with the State of Michigan / Governor Whitmer’s Executive Order 2020-07 [LINK] in asking triage questions to best reduce the spread of COVID19 and other Influenza Viruses. We remain vigilant with the care of our patients, and are up to date on the current state in our community. As Executive Orders change, we will continue to adopt the new orders and educate our staff, patients and community.
What can you do???
Educate yourself. We have included some links below and a podcast that may help to inform and decrease over-reaction and fear.
Limit your exposure. Wash your hands. Minimize contact. Keep your hands out of your eyes, nose and mouth, as this is a doorway for virus and bacteria to enter your body. Review the CDC recommendations.
HOW LONG WILL THIS continue?
We honestly have no idea. The landscape is changing daily, if not hourly. We are working diligently to stay abreast of the most recent recommendations and information.
What if i have to cancel…or what if i still need PT treatment?
We are working hard with requests for rescheduling. Our staff is staying flexible with getting our patients in based on their needs and schedules. If you cannot make your scheduled appointments, we are asking that you contact our clinic to cancel and make arrangements for rescheduling your appointment.
If you cannot make it into the clinic but still have questions for our Team, we will work hard to answer your concerns by phone or email.
More to come….
Please stay tuned, reach out with questions, and most of all: take care of yourself and loved ones, and stay healthy and positive.
Do you feel like you’ve done just about everything to improve your performance, recover faster, or bounce back from a string of injuries? The missing ingredient might be before your very eyes. Maybe all you need to do is close them!
The concept of sleep is as buzzworthy as ever. How much should you get? Should you sleep 4 hours each night like Elon Musk in order to be successful? (Hint: No. And athletes likely need more than double that, every day).
When we sleep, the body does some of its most amazing work, repairing itself from all we put it through, every cell, in every intricate chemical reaction, renovated, rejuvenated, and restocked to take on a new day. Sleep can make the difference in being prepared for your next triathlon, making or missing a shot, staying focused at work and school, preventing injury, and even helping you get the breakthrough you’re looking for in PT. It impacts our learning, recovery, attention, and mood, and while sleep may not be magic, its effects can certainly feel that way. At Adams Sports Medicine, we educate our patients on the importance of sleep in both performance and recovery, because we have experienced first hand, as athletes and clinicians, the impact it has. Taking it seriously is crucial.
What Science Says
Decreases in sleep duration and quality can have significant effects on endurance athletes, including reduced muscle glycogen storage7 and an increase in perceived exertion with activity3. Sleep deprivation is also strongly linked to impaired immune function. If you average less than 7 hours per night, you may actually be 3x more likely to get an upper respiratory infection compared to those sleeping over 8 hours2. Additionally, sleep loss has been found to correlate with decreased inhibitory control and increased perceived stress and depression symptoms6.
In regard to increased sleep, researchers have also observed significant changes in accuracy among ball-sport athletes, including a 40% improvement in serving in college tennis players8, and a 9% increase in free throw shooting percentage in college basketball players4.
How much do you really need?
Adolescents, roughly ages 10-20, need 8-10 hours of sleep per night, while the average adult needs between 7 and 9 hours 1. Since the vast majority of cellular repair and training adaptations take place when we sleep, serious athletes may do best at the upper end of these ranges to maximize improvements in performance and reduce injury risk. Did you notice that everyone needs almost the same amount, regardless of age?
When and How?
Consistency is your secret weapon! Sleep timing should be as regular as possible from day to day. The body responds incredibly well to routines. So, if the time you wake up and go to sleep each day varies, you may benefit from adopting a more regular schedule, including staying within just a 1-2 hour difference on weekends.
If you’re unfamiliar with the concept of sleep hygiene, take some time to look up other tips for increasing the quality and duration of your sleep. Changing meal timing and reducing screen time in the late evening are two notable factors. Harvard has some great recommendations here.
The Bottom Line
Many of us us need to sleep several hours per night more than we are, and do so with consistency. If you aren’t getting enough, now is the perfect time to ask why and see what can be done to make sleep possible. Time management and prioritizing your sleep schedule are good places to start. Sleep is just one facet of the recovery and performance picture, but it holds almost everything else together. We need to commit to getting this piece right.
So, whether you’re hoping for faster recovery between workouts, improved performance, or better overall health, sleeping more may just be your ticket. Make a plan, make your bedroom conducive for great sleep, and close those eyes! You might be surprised just how far doing absolutely nothing can take you.
Aaron Bachman, PTA
- Bird SP. Sleep, recovery, and athletic performance: a brief review and recommendations. Strength Cond. J. 2013; 35:43–7.
- Cohen S, Doyle WJ, Alper CM, et al. Sleep habits and susceptibility to the common cold. Arch. Intern. Med. 2009; 169:62–7.
- Fullagar HH, Skorski S, Duffield R, et al. Sleep and athletic performance: the effects of sleep loss on exercise performance, and physiological and cognitive responses to exercise. Sports Med. 2015; 45:161–86.
- Mah CD, Mah KE, Kezirian EJ, Dement WC. The effects of sleep extension on the athletic performance of collegiate basketball players. Sleep. 2011; 34:943–50.
- Milewski MD, Skaggs DL, Bishop GA, et al. Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J. Pediatr. Orthop. 2014; 34:129–33.
- Rossa KR, Smith SS, Allan AC, Sullivan KA. The effects of sleep restriction on executive inhibitory control and affect in young adults. J. Adolesc. Health. 2014; 55:287–92.
- Skein M, Duffield R, Edge J, et al. Intermittent-sprint performance and muscle glycogen after 30 h of sleep deprivation. Med. Sci. Sports Exerc. 2011; 43:1301–11.
- Schwartz J, Simon RD Jr. Sleep extension improves serving accuracy: a study with college varsity tennis players. Physiol. Behav. 2015; 151:541–4.
- von Rosen P, Frohm A, Kottorp A, et al. Multiple factors explain injury risk in adolescent elite athletes: applying a biopsychosocial perspective. Scand. J. Med. Sci. Sports. 2017.
- Watson A, Brickson S, Brooks A, Dunn W. Subjective well-being and training load predict in-season injury and illness risk in female youth soccer players. Br. J. Sports Med. 2016.
There is a lot of discussion in the news lately about Relative Energy Deficiency in Sport (RED-S) and it is a topic that we at Adams Sports Medicine and Physical Therapy talk a lot about. Dr. Hannah DePaul and Dr. Katie Noble spend time educating high school cross country and track teams about how to be healthy and fast. We respect and admire Mary Cain and other women who have come forward with their personal struggles with RED-S. RED-S has dangerous, long-term consequences to the health of both female and male athletes. As Mary Cain highlights, in order to navigate the complexities of sport, body image and self-worth – the support and guidance an athlete has is critical to avoid the disorder.
So what is RED-S? It’s having an inadequate amount of energy to support bodily functions for optimal health and performance, which can lead to serious health and performance consequences (see diagram below).1 When runners don’t eat or recover enough to support training, an energy deficit is created. When this energy deficit persists, an athlete will experience decreased performance, strength, and endurance and has increased risk of depression and physical injury. In a culture that often glamorizes #norestdays, young athletes need to be protected from developing habits that feed this disorder.
For women, RED-S can lead to menstrual dysfunction, which weakens bones and can lead to fractures. This is especially concerning in young athletes, as teens are developing peak bone mass that they will rely on for the rest of their lives. Periods are a barometer of overall health and if it’s lost, an athlete should seek medical help. Losing a period from training is never normal. For men, low testosterone can lead to thinning bones. While the signs of low testosterone aren’t as obvious as a lost menstrual cycle, knowing the risk factors for RED-S can help male athletes stay ahead of it.
Historically, the culture of distance running has included a “thinner is faster” ideal. Research now proves that this thinking is dangerous to health and performance. A recent study found that male runners who responded “yes” to the statement “being thinner means being faster” were more likely to have low bone mineral density and an increased risk of fractures.2 A runner’s thoughts and beliefs about body image has real effects on physical health. There is no truth that the lightest runner is the best runner. The best runner is well-supported, well-rested, well-fueled, and wisely trained.
Nutrition and sleep also play a huge role in preventing RED-S. A study found that women who consumed less than 800 mg of calcium per day had nearly 6x the rate of stress fracture than women who consumed more than 1500 mg of calcium.2 It’s shown that sleep deprivation can lead to bone loss.3
RED-S isn’t just a physical health issue, it’s a cultural problem with sport. The culture of a sport and team can bring out the best in a runner or can be toxic to well-being. Breakthrough performances elevate sport and inspire humanity. The future of the sport lies within young athletes. Coaches, health care providers, parents, and everyone within an athlete’s support system has a responsibility to foster performance without sacrificing an athlete’s long-term physical and mental health.
- De Souza MJ, Nattiv A, Joy E, et al. Br J Sports Med 2014;48:289.
- Tenforde, Adam & Fredericson, Michael & Sayres, Lauren & Cutti, Phil & Sainani, Kristin. (2015). Identifying Sex-Specific Risk Factors for Low Bone Mineral Density in Adolescent Runners. The American journal of sports medicine. 43. 10.1177/0363546515572142.
- Tenforde AS, Sayres LC, Sainani KL, Fredericson M. Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature.” PM R. 2010;2(10):945-949. Article Summary on PubMed. (http://www.ncbi.nlm.nih.gov/pubmed/20970764)
- Ben-Sasson, et al. Extended duration of vertical position might impair bone metabolism. Eur J Clin Invest, 1994