Comparison of DXA and HR-pQCT Measures Among Female Runners at Risk for Relative Energy Deficiency in Sport (REDs): A Pilot Study

Objectives: Relative Energy Deficiency in Sport (REDs) is a syndrome driven by problematic low energy availability, impairing physiological and/or psychological function. While REDs assessment typically utilizes dual energy X-ray absorptiometry (DXA) of areal bone mineral density (BMD), high-resolution peripheral quantitative computed tomography (HR-pQCT) offers additional insight into bone microarchitecture, geometry, and volumetric BMD. This study aimed to evaluate bone health among female runners at risk for REDs using DXA and HR-pQCT measures. Methods: Female runners aged 18-30 years, training at least 5 hours/week, were recruited and underwent anthropometric measurements, VO2 max testing, clinical laboratories, DXA scans, and HR-pQCT imaging of the tibia. REDs risk was assessed using validated questionnaires, clinical laboratories, and physician interviews. Participants were categorized as no-risk (green) or at-risk (yellow/orange/red) for REDs. Results: Twenty-one participants (age 26 ± 3 years) completed the study. Six were classified as no-risk and fifteen as at-risk for REDs. Sub-clinically low BMD (z-score ≤-1) was the most prevalent indicator in at-risk participants. The at-risk group reported significantly higher weekly mileage (>40 miles/week: 66.7% vs 33.3%, p=0.043) and lower maximum extensor strength on muscular endurance testing (p=0.015). While no other between-group differences reached statistical significance, 12 of 14 HR-pQCT values showed poorer outcomes in the at-risk group. Conclusions: Despite the small sample size, this pilot revealed consistent HR-pQCT trends suggesting potential links between REDs risk and compromised bone geometry, microarchitecture, and volumetric BMD. Integration of HR-pQCT with REDs screening may provide a more comprehensive characterization of bone health compared to DXA alone.