











































MANUSCRIPT TYPE


QUALITY IMPROVEMENT REPORTS 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

Quality Improvement in Athletic Training Education on Female Athlete 
Triad 
Kristen A. Paloncy-Patel, EdD, ATC*; Melissa R. Penkalski, DNP, APRN, CPNP-PC, AE-C†; Shannon M. 
Hauschildt, MA, PA-C†, Natalie B. Allen, MEd, RDN†  
*North Central College, Naperville, IL; †Missouri State University, Spring Field, MO 
 

 
ABSTRACT 

There are significant health risks associated with the female 
athlete triad (Triad), therefore early detection and 
prevention is key. Athletic trainers often serve as the frontline 
defense and can have a crucial role in identifying the Triad. 
Yet knowledge, confidence, and practice standards in the 
recognition, referral and treatment is lacking. The purpose of 
the following Quality Improvement document is to provide 
athletic trainers with a framework for improving Triad-
specific knowledge, confidence, and practice standards. The 
2014 Female Athletic Triad Coalition consensus statement 
provides an evidence-based risk stratification system for 
detection and referral of the Triad. The Coalition suggests 
including Triad-specific preparticipation examination (PPE) 
screening questions and utilization of the Female Athlete 
Triad Cumulative Risk Assessment on all clearance and return 
to play decisions for female athletes. Though there are 
efforts to educate athletic trainers about disordered eating 
in athletes, these efforts do not specifically include the Triad. 
Many female athletes are currently being cleared at their 
PPE without being adequately assessed for this syndrome or 
without appropriate referral for management and treatment. 
Therefore, it is important for ATs to improve their knowledge, 
confidence, and practice standards specific to the Triad.  

Key Phrases 
Injury risk reduction, preparticipation exams and screening, 
college and university patient population, female athlete 
triad 
 
Correspondence 
Dr. Kristen Paloncy-Patel, North Central College, 30 North 
Brainard, Stadium Room 308. Naperville, IL 60540. 
E-mail: Kapaloncy@noctrl.edu  
 
Full Citation 
Paloncy-Patel K, Penkalski M, Hauschildt S, Allen N. Quality 
Improvement in Athletic Training Education on Female 
Athlete Triad. Clin Pract Athl Train. 2020;3(2):6-14. 
https://doi.org/10.31622/2020/0002.3.   
 

Submitted: November 6, 2019 Accepted: June 8, 2020 

 

CURRENT MODEL  

The syndrome of female athlete triad (Triad) 

was defined in 1997 in an American College of 
Sports Medicine position statement.1 Modified 
from its original definition, the three components 
of the Triad now include low energy availability 
with or without disordered eating, menstrual 
dysfunction, and low bone mineral density.1,2 
Previously, the prevalence of the Triad was 
thought to be 1-4% and impacting mostly 
endurance athletes.1,2 However the current 
definition is much more encompassing and 
emphasizes the fact that the components do not 
need to present simultaneously. Therefore, the 
prevalence of the Triad expected to be much 
higher and among a much larger population.1,2 

Since the Triad was identified, recognition and 
prevention strategies have emphasized a 
collaborative effort among healthcare 
providers.2-4 Due to the nature of many traditional 
athletic training settings and the high level of 
interaction with athletes, certified athletic trainers 
(ATs) often act as the frontline defense and an 
integral part of the Multidisciplinary team in 
identifying athletes at risk for eating disorders.4 

The current processes in place to educate entry-
level athletic trainers on the assessment, 
identification, and management of the Triad fall 
under competency PHP-43, PHP-46, and PHP-47 
in the 5th edition of the competencies published 
by the Commission on Accreditation of Athletic 
Training Education (CAATE).5 The competencies 
are5: 

• PHP-43: describe the principles and methods 
of body composition assessment to assess a 

mailto:Kapaloncy@noctrl.edu
https://doi.org/10.31622/2020/0002.3


Quality Improvement in Athletic Training Education on Female Athlete Triad 
 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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patient’s health status and to monitor changes 
related to weight management, strength 
training, injury, disordered eating, menstrual 
status and/or bone density status. 

• PHP-46: Identify and describe the signs, 
symptoms, physiological and psychological 
responses of patients with disordered eating 
or eating disorders.  

• PHP-47: Describe the methods of appropriate 
management and referrals for patients with 
disordered eating or eating disorders in a 
manner consistent with current practice 
guidelines. (NATA, 2011, p.15). 

A new edition of the competencies will be 
published in 2020 by the CAATE, however the 
new standards continue to not specifically mention 
the Triad.6 In 2008, the National Athletic Trainers’ 
Association (NATA) published a position statement 
on preventing, detecting, and managing 
disordered eating in athletes.4 This statement 
emphasizes that a crucial action for the AT is to 
establish a screening approach for disordered 
eating that “recognizes signs and symptoms of the 
full spectrum of maladaptive eating and weight 
loss behaviors, as well as predisposing risk factors 
associated with their development” (p.81).4 This 
can be achieved through medical history questions 
on the PPE as well as standardized, self-reported 
screening questionanaires.4 These questionnaires 
are not without their flaws for the athletic 
population. Athletes can feel shame, guilt, and 
denial associated with eating disorders or could 
be worried that their athletic careers could be 
jeopardized if their coach found out about their 
eating disorder. Therefore, the accuracy of 
responses in a self-reported screening 
questionnaire may be poor.4,7-9 Numerous 
screening instruments have been designed 
specifically for the athletic population. However, 
the concern about these screening instruments is 
the lack of extensive testing for internal and 

criterion validity, response bias, and 
generalizability.4,10 Therefore, the combination of 
screening methods to include the PPE, 
standardized self-reported questionnaires, 
individual interviews, and direct observation of 
athletes is described to be best practices for 
identifying and preventing disordered eating.4 

The dissemination of knowledge regarding the 
screening and treatment of the Triad is lacking.11, 

12 In a recent investigation of collegiate athletic 
trainers’ knowledge of the Triad, it was found that 
while about half of ATs have heard of the Triad, 
most could not accurately define the disorder.12 
Further, most ATs are not engaging in 
appropriately targeted screening or treatment 
recommendations.12 It is possible that since CAATE 
competencies and the NATA position statement 
addresses disordered eating as a more general 
category and do not specifically address the 
Triad, the knowledge, identification, appropriate 
screening, and treatment of the Triad remain 
low12 and do not lend to early detection of this 
syndrome specifically.12 Specifically, only 38% of 
ATs are able to correctly identify the three 
components of the Triad. While about half of 
athletic trainers screen collegiate athletes for 
unspecific eating disorders, only 26% of ATs 
screen specifically for the Triad.11, 12 Furthermore, 
only 18% of ATs felt comfortable treating the 
Triad.11 In 2014, a consensus statement was 
published which included the “Female Athlete 
Triad Cumulative Risk Assessment Score” focusing 
on the clinical management of athletes affected 
by the Triad.13 The publication also includes a 
screening tool to identify and assess at-risk 
athletes. These guidelines, which are uniquely 
specific to the Triad rather than other screening 
instruments identifying unspecific disordered 
eating, were not found in most athletic training 
literature or implemented into practice within the 
athletic training profession.  



Quality Improvement in Athletic Training Education on Female Athlete Triad 
 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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In a review of the practice processes for athletic 
trainers at the target collegiate setting, we found 
no formal screening tool were used to evaluate 
for the Triad. For two years prior to the start of 
the current study, 18 stress fractures in female 
athletes were recorded out of 234 total female 
athletes’ measures (rate of .077 per 100 athlete-
exposures (AEs)). For national comparison, data 
from a 10-year NCAA Injury Surveillance 
Program reported a total of 671 stress fractures 
over 1,1778,145 AEs for an overall injury rate of 
5.70 per 100,000 AEs.14 Within our practice 
review, athletes who suffered these injuries lost a 
total of 848 days of sport participation, 
averaging 56 days of lost time. Of the 18 female 
athletes with recorded stress fractures, 14 saw the 
team Registered Dietitian (RD). Two athletes quit 
their athletic participation and no longer received 
services so were excluded from the study and two 
other females were referred but never met with 
the RD. Of the 14 athletes seen by the team RD, 
85% were identified as having low energy 
availability with or without disordered eating and 
other Triad components. At this time, we 
questioned if there may be an improved process 
to help ATs increase knowledge specific to the 
Triad and confidence in early recognition which 
would result in improved practice. 

The purpose of this quality improvement study was 
to determine if there were significant gains in 
knowledge, recognition/referral confidence, and 
practice standards in the Triad through an 
educational in-service and introduction to PPE 
Triad-specific screening questions and the Female 
Athlete Triad Cumulative Risk Assessment in a 
four-year, Division I institution with 17 collegiate 
ATs.  

PDSA CYCLE  

Plan 

We first began by researching the specific 
recommendations for screening female athletes 
for the Triad and the Female Athlete Triad 
Cumulative Risk Assessment. Recommendations are 
to screen female athletes focusing on full 
menstrual history, energy availability, disordered 
eating history, and reasons for hormonal therapy 
use.15 In this research phase, we found the Triad 
Coalition reported that early detection of athletes 
at risk for the Triad is crucial to prevention. While 
there are concerns of efficacy for many screening 
tools, the recommendation is that all female 
athletes undergo annual screening with the triad-
specific self-report questionnaire.13 A list of 
recommended screening questions may be viewed 
in Table 1. The Triad Coalition further 
recommends that if the athlete has any risk for one 
Triad component as identified through the 
screening process, a more in-depth interview and 
evaluation should occur. In addition, evidence on 
risk factors for the Triad demonstrate that low 
bone mineral density and bone stress injuries is 
greater with cumulative risk factors for the Triad 
and therefore should be considered before 
making clearance or return to participation 
decisions.13,16,17 The Female Athlete Triad 
Cumulative Risk Assessment developed by the 
Triad Coalition provides an objective method of 
determining the athlete’s risk for the Triad by 
using evidence-based factors and assigning a 
point value based on the magnitude of risk (low, 
medium, high) for assessment criteria and scores.13 
This risk assessment tool was used with permission 
and may be viewed in Table 2. The Triad 
Coalition recommends utilization of the Female 
Athlete Triad Cumulative Risk Assessment for all 
participation and return to participation decisions 
for female athletes.13 

Next, we had conversations with our Team 
Physician, Team RD, and the Head AT. We first 
spoke with the Team Physician to see if he would 
support the implementation of the Female Athlete 
Triad Cumulative Risk Assessment and screening  



Quality Improvement in Athletic Training Education on Female Athlete Triad 
 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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Table 1: Triad Consensus Panel Screening 
Questions* 
Have you ever had a menstrual period?  
How old were you when you had your first 
menstrual period?  
When was your most recent menstrual period?  
How many periods have you had in the past 
12 months?  
Are you presently taking any female hormones 
(oestrogen, progesterone, birth control pills)? 
▸ Do you worry about your weight?  
Are you trying to or has anyone recommended 
that you gain or lose weight?  
Are you on a special diet or do you avoid 
certain types of foods or food groups?  
Have you ever had an eating disorder?  
Have you ever had a stress fracture?  
Have you ever been told you have low bone 
density (osteopenia or osteoporosis)?  
*The Triad Consensus Panel recommends 
asking these screening questions at the time of 
the sport pre-participation evaluation. 
Reprinted with permission 

 
questions into the preparticipation physical 
examinations for all female athletes. We 
explained that he would have a role in ordering 
the bone dual-energy X-ray absorptiometry 
(DEXA) scans on all athletes (part of the Female 
Athlete Triad Cumulative Risk Assessment) as well 
as reviewing all scores and screening question 
responses before giving final clearance in the 
preparticipation physical examinations. We 
discussed the risks and benefits of preforming 
bone DEXA scans on all athletes and ultimately 
decided, given the very low radiation used, it was 
important to include these scans so that we could 
follow the Female Athlete Triad Cumulative Risk 
Assessment protocol in its entirety. We also 
explained that we would involve the ATs by first 
educating them on the Triad through an in-service 
and then having them take a role in 
administering/reviewing screening questions and 
conducting aspects of the Female Athlete Triad 
Cumulative Risk Assessment. He reviewed the 
evidence and agreed to support this. 

We spoke to the Team RD (who was also part of 
the interdisciplinary research team) about her role 
in implementing the Female Athlete Triad 
Cumulative Risk Assessment and screening 
questions in the preparticipation physical exam. 
Her role would be to educate athletes that scored 
a moderate or high risk in the assessment on the 
Triad and develop nutrition goals with the athlete 
through individual meetings. She agreed to take 
on this role. It is important to note that the RD for 
our institution is based on-campus and has a high 
amount of direct interaction weekly within the 
athletic training room. There is potential for push-
back on requiring large commitments from 
interdisciplinary team members such as the RD at 
institutions if their services are structured 
differently.   

Finally, we spoke with the Head AT about 1) 
implementing the Female Athlete Triad Cumulative 
Risk Assessment and screening questions into all 
pre-participation physical examinations for all 
female athletes at the college, and 2) meeting 
with and educating all collegiate ATs on the tools 
and process. We predicted that by meeting with 
and educating all collegiate ATs on the tools and 
processes, their knowledge of the Triad, 
confidence in recognition and when to refer, as 
well as practice standards involving the Triad 
would increase. We determined as a group that 
was best to plan for the implementation of these 
two goals prior to both pre-participation physicals 
and before fall practices began. 

The last step we took in planning was to develop 
a knowledge, confidence, and practice standards 
assessment tool that we could deliver to the 
athletic trainers. The research team created a 22–
question survey assessment that measured all 
variables. The knowledge, confidence, and 
practice standards survey assessment were 
examined for face validity by a panel of experts 
(n=5) who had experience in survey design. No 
changes were made to the survey instrument 



Quality Improvement in Athletic Training Education on Female Athlete Triad 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

  
 

 

 

 

 

 

 

 

 

 

based on their feedback. Reliability of the survey 
instrument was determined by running a Cronbach 
alpha on a sample of athletic trainers (n=17) to 
determine the internal consistency or average 
correlation of the items in the survey instrument. 
The overarching alpha for the whole instrument 
was calculated as a value of 0.92 which suggests 
the instrument has acceptable reliability.  

Do 

A pretest posttest design with the survey 
instrument was utilized to assess if knowledge, 
confidence, and practice standards in the Triad 
improved through the educational session and 
implementation of the PPE screening questions 
and Female Athlete Triad Cumulative Risk 
Assessment. On the day of the athletic training 
educational session, the survey instrument was 
administered to all 17 ATs (10 full time, 7 
intern/graduate assistants) at the college. 
Responses served as the pretest assessment of 
Triad knowledge, confidence, and practice 
standards.  

Following the pretest, in an educational session 
that lasted approximately one hour, the team RD 
presented information utilizing a self-developed 

PowerPoint Presentation on the Triad including 
components, effects of the syndrome, risks, signs 
and symptoms to watch for, and when to refer. In 
addition, information specifically on the 
universities’ history with missed time for female 
athletes with previous Triad diagnoses and goals 
of the quality improvement study including the 
athletic trainers’ role in the study was included. 
Finally, a review of the Triad-specific PPE 
screening questions and the components of the 
Female Athlete Triad Cumulative Risk Assessment 
tool was provided. It was explained to the ATs 
that they would have a role in assisting in the 
review of the PPE screening questions to identify 
areas of concern. It was also explained to the 
ATs that they also may have a role in assisting in 
administering the Female Athlete Triad 
Cumulative Risk Assessment. The research team 
decided it was best for the Team RD to lead this 
educational session because they were most 
familiar with the Triad and the Female Athlete 
Triad Cumulative Risk Assessment tool. 
Immediately after participating in the 
educational in-service, the survey instrument was 
again given to the athletic trainers which served 
as the posttest assessment of Triad knowledge, 
confidence, and practice standards.  

Table 1. Female Athlete Triad: Cumulative Risk Assessment 



Quality Improvement in Athletic Training Education on Female Athlete Triad 
 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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The educational in-service with the ATs was the 
quality improvement strategy that we focused on 
for this study as a way to improve ATs’ Triad-
specific knowledge, confidence, and practice 
standards as measured by the results of the 
pretest posttest survey. However, we would like 
to disclose that following this educational in-
service, action did occur to further implement 
what was discussed. Like other years, ATs 
assisted in the preparticipation physical 
examinations of new and returning athletes on 
their assigned athletic teams which coincided with 
the start of specific athletic seasons. It was the 
ATs’ role to review all screening questions (now 
including those specific to the Triad) in the 
medical history section of the PPE with the 
athletes on their team(s). Following this, several 
graduate assistant ATs completed the Female 
Athlete Triad Cumulative Risk Assessment on all 
female athletes in the universities’ biomedical 
laboratory. When considering implementation of 
this process, please note DEXA scans must be 
completed by a trained administrator and it is 
not required that this person be an AT. DEXA 
scans were performed on all female athletes by 
the ATs under the order of the Team Physician. 
Lastly, after the review of all PPE screening 
questions and the generation of a score for the 
Female Athlete Triad Cumulative Risk Assessment, 
those who scored a moderate or high risk for the 
triad were identified and referred to the Team 
RD for follow up. We followed this detailed 
process annually over the next 3 full academic 
years and tracked new Triad referrals and 
diagnoses over this time period.  

Study  

Prior to computing analyses, the responses on the 
knowledge assessment was screened for 
accuracy, missing data, outliers and assumptions 
(normality). The knowledge assessment had 9 
items on the pretest and posttest; however, a 
summary score for both tests were derived and 

these values were screened and included in the 
statistical analysis. Data appeared to be 
accurate without missing values. Also, there were 
no outliers assessed by boxplots in JASP. Lastly, 
the data did not appear to be normal as the 
distribution of the data showed a slight negative 
skew and had a significant value, using the 
p<.05 criterion, for the Shapiro-Wilk Test of 
Normality (p= .022). However, given that a 
Paired Samples t-Test is considered a robust 
analysis, especially with a large sample size, this 
was the test performed with a total sample size 
of 17.  

A Paired Samples t-test was performed to 
examine differences in knowledge between the 
pretest and posttest. Results revealed a 
significant difference between these two 
measures, t(16) = -8.90, p< .001, d= -2.16. In 
other words, knowledge in the Triad significantly 
increased after participating in the education 
seminar (Pretest; M= 6.53, S = 0.80, Posttest; 
M= 8.47, S= 0.62).  See Figure 1 for a visual 
display of the means and +2 standard 
deviations. 

Prior to computing analyses, the responses on the 
confidence and practice standards assessment 
was screened for accuracy, missing data, outliers 
and assumptions (normality). The confidence 
assessment had 6 items on the pretest and 
posttest while the practice standards assessment 
had 7 items; however, a summary score for both 
assessments for each test (i.e. pretest and 
posttest) were derived and these values were 
screened and included in the statistical analysis. 
Data appeared to be accurate without missing 
values or outliers assessed by boxplots in JASP. 
Lastly, the data appeared to be normally 
distributed as assessed by the distribution and 
the Shapiro-Wilk Test of Normality (confidence, 
p= .859; practice standards, p= .193). There 
was a total sample size of 17 participants. 



Quality Improvement in Athletic Training Education on Female Athlete Triad 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

A Paired Samples t-Test was performed to 
examine differences in confidence between the 
pretest and posttest. Results revealed a 
significant difference between these two 
measures, t(16) = -3.46, p= .003, d= -0.84. In 
other words, confidence significantly increased 
after participating in the seminar (Pretest; M= 
35.24. S = 10.20, Posttest; M= 40.82, S= 9.22).  

A Paired Samples t-test was performed to 
examine differences in practice standards 
between the pretest and posttest. Results 
revealed a significant difference between these 
two measures, t(16) = -4.24, p< .001, d= -1.03. 
In other words, practice standards significantly 
increased after participating in the education 
seminar (Pretest; M= 4.06. S = 1.78, Posttest; 
M= 5.12, S= 1.32). 

The most significant barrier we found to 
implementing this educational session was finding 
a common time where the 17 ATs would all be 
together and fitting this into their already busy 
schedules. We determined it was best to provide 
the educational session separate from the annual 
in-service day. Due to this barrier it was 
determined that it should be explored if future 
educational sessions could be offered as an 
electronic training module to be completed 
independently.  

Act 

Based on what we learned from this quality 
improvement investigation study, short-term  
knowledge, confidence, and practice standards 

in ATs’ recognition and referral of the Triad can 
be significantly improved with a specific 
educational in-service including an introduction to 
utilizing Triad-specific screening question on the 
PPE and the Female Athlete Triad Cumulative 
Risk Assessment as a guideline for athletic 
clearance determinations.  

Despite widespread awareness and efforts of 
the Triad, many female athletes are currently 
being cleared at their PPE without being 
adequately assessed for this syndrome or without 
appropriate referral for management and 
treatment.13,18 Even with structured education in 
athletic training education programs and the 
NATA Consensus Statement as a practice guide, 
there is a lack of standard of care guidelines for 
the evaluation and management of the Triad.13,18 
Female athletes with the Triad have significant 
health risks therefore early detection and 
prevention is key. The 2014 Female Athlete 
Triad Coalition Consensus Statement on 
Treatment and Return to Play of the Female 
Athlete Triad Expert Panel provides an evidence-
based approach to a developed risk 
stratification system that helps to increase the 
knowledge, confidence, and practice standards 
in detection and referral for the Triad. This 
quality improvement study provides evidence 
that when athletic trainers receive specific 
education on the Triad and utilize the PPE 
screening questions and Female Athlete Triad 
Cumulative Risk Assessment, their knowledge, 
confidence, and practice standards for the Triad 
significantly improves.  

ACKNOWLEDGEMENTS 

Thank you to Jessica Willis, RStats Coordinator at 
RStats Institute in Springfield, Missouri for 
assistance with statistical calculations.  

REFERENCES 

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Figure 1. Athletic Trainers' Knowledge on the Female Athlete 
Triad Assessment 



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Quality Improvement in Athletic Training Education on Female Athlete Triad 
 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 3- Issue 2 - June 2020 
 

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