Stress fractures are prevalent among female athletes, particularly in disciplines that emphasise leanness and endurance, due to the combined effects of low energy availability (LEA) and menstrual dysfunction. These factors compromise bone health and significantly elevate fracture risk, forming the core of the Female Athlete Triad and the broader Relative Energy Deficiency in Sport (RED-S) framework. This review explores the physiological mechanisms linking LEA and menstrual irregularities to impaired bone remodelling and increased stress fracture risk, drawing on recent literature from 2015 to 2024. LEA suppresses the hypothalamic-pituitary-gonadal axis, leading to reduced oestrogen levels and disrupted bone metabolism, while menstrual dysfunction and low bone mineral density further heighten vulnerability to fractures. Diagnostic tools such as the Low Energy Availability in Females Questionnaire (LEAF-Q) and RED-S Clinical Assessment Tool (CAT), along with targeted nutritional and training interventions, offer effective prevention strategies. Ultimately, early identification and correction of LEA and menstrual disturbances through a multidisciplinary approach are crucial for preventing stress fractures and ensuring long-term skeletal health and athletic performance.
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