Special Concerns Of The

Female Athlete

Rebecca M. Northway, MD, FAAP

October 3, 2018

Internal Medicine-Pediatrics

Primary Care Sports Medicine

USA Hockey NTDP Team Physician

Disclosure

• I have no relevant financial relationships with the

manufacturer(s) of any commercial product(s) and/or provider of

commercial services discussed in this CME activity

• I do not intend to discuss an unapproved/investigative use of a

commercial product/device in my presentation

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Objectives

• Review normal growth and maturation differences in female

athletes

• Review common sports injuries and concerns

• Discuss treatment and prevention

• Importance of PPE screening

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Female Athletes

• Since Title IX in 1972 there has been a dramatic increase in sports participation by girls

– 1 in 27 in 1972 vs 1 in 2.5 in 2002

– Proportion of college female athletes 2% in 1972 vs 43% in 2002

• Also increase in active girls, health club members, and “sports” addicts across all age ranges

• Physicians who care for female athletes may be unaware of their unique needs and potential for injury

• Should be considered a separate population in study of exercise-athletics

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Growth and Maturation

• Onset of puberty for girls is 10.5 years

(vs 12.5 years for boys)

• Growth is steady between boys and girls

but at the end, girls may be taller and

heavier than boys of the same age

• Between ages 6-12 years

– Highest proportion of laxity

– Girls have better balance compared to boys

– Strength and balance are equal

– Continued mastery of skills

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Growth and Maturation

• Early Adolescence 13-15 years

– Post pubertal changes of increase muscle mass and strength

• Increase in limb mass is 2x the increase in limb length leading to imbalance of forces resulting in decreased lower extremity control and function

– Widening pelvis in girls

– Girls plateau in jumping, throwing and sprinting compared to boys

• During peak height velocity biochemical properties of bone change

– Relative skeletal weakness during peri-pubertal growth

• Late Adolescence 16-20 years

– Girls continue to accumulate fat mass which may have a negative effect on performance

– Also hormonal influences

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• Aging

– Muscle weakness

– Balance and fall risk

– Coronary artery disease

• Increase in women after

menopause

– Stress urinary incontinence

• Vaginal deliveries, reduction

of estrogen, high impact

activities

– Osteopenia and

Osteoporosis

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Growth and Maturation

• Women are more likely to

sustain musculoskeletal

injury during physical

activity

– More lower extremity injuries

in general

• Biomechanics, weakness

in local musculature,

coordination and fatigue

differences, and ligament

and tendon properties

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Injury Risk

ACL Injuries

• ACL injury rate is 2-6x higher in female athletes

– Higher risk of non contact

– Commonly occur during deceleration, landing or cutting

– Most occur in late teens to early 20’s

– Higher risk of contralateral ACL injury

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• Biomechanical differences

– Jumping-landing and side to side movements

• Land with knees less flexed and more valgus (turned in)

– Q angle

• Increases genu valgus

• Even slight increase in Q angle can increase force on ACL 3 fold

– Women have on average 4.5° greater genus valgus during jump landings

– Pes planus

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Injury Risk

Injury Risk

• Anatomical differences

– Smaller and narrower intercondylar

notch through which the ACL passes to

attach to the tibia

• Increases risk of the ACL impingement

• Neuromuscular fatigue

– Neuromuscular control is important in

landing from a jump, moving side to

side

– Accumulated fatigue negatively

impacts the force generating capacity

of the muscles, affects motor control

and slows reaction time

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https://www.howardluksmd.com/sports-medicine/anterior-cruciate-

ligament-tears-prevention-is-the-key/

Injury Risk

• Gait differences

– Greater pelvic obliquity → less energy expended to lift body up and down

• More biomechanically efficient but more stress on the joints

– Flexibility

• Greater joint laxity and therefore less stability of joints

• May be related to hormones

– Several studies suggest increase knee laxity around ovulatory and postovulatory phases

– Hormones

• Effect on connective tissue via collagen synthesis

• Estrogens inhibit collagen synthesis after a heavy load

• Lower rate of tissue repair after exercise

– Decreased recovery time, higher injury risk

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• Treatment

– Surgical evaluation and intervention

– Increased risk of osteoarthritis

• Prevention

– Tests that assess neuromuscular factors

• Competence in landing and cutting- LESS and box drop

• Hip and core strength- single leg squat

– ACL prevention programs

• Dynamic stretching and strengthening, functional balance, agility, plyometrics

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ACL Injury

PFPS

• Normal patellofemoral mechanics involve a balance between

bone alignment, articular cartilage, soft tissue, coordinated

neuromuscular activation

– Dysfunction results from structural problems, macro-trauma and micro-

trauma

• Patella alta, trochlear dysplasia, malalignment, increased

flexibility/hypermobility, muscle weakness of the pelvic-femoral region and

knee, poor neuromuscular control, hormonal, overuse

• Structurally normal knee

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• Evaluation:

– Look at full kinetic chain, strength, posture, flexibility, knee joint

– Glute and core strength, single leg squat, balance

• Treatment

– Rehab, education, taping, orthotics, gait analysis

• Prevention

– Risk factors are knee valgus and early sports specialization

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PFPS

Stress Fractures

• When bone is subjected to repetitive loads that exceed capacity to repair or intrinsically brittle bone

• Continuation of load on the bone results in progression of damage

– Stress injury/reaction → stress fracture → frank fracture

• Risk factors

– Extrinsic: foot wear, training volumes, intensity, surface

– Intrinsic: biomechanics, muscle strength, balance, alignment)

– Medical/psychological: low energy availability, menstrual dysfunction, low BMI, eating disorders

• Common areas

– Foot, tibia, fibula, femur, pelvis, sacrum

– Multiple stress injuries or trabecular bone should warrant concern

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• At least 2x as likely to have a stress fracture

– More common in female athletes with menstrual irregularities and/or low BMD

– Not only sideline female athletes but reduce competitive performance

• Important to assess if any concurrent menstrual dysfunction and energy deficiency

– Athletes with amenorrhea have 4x greater risk of stress fracture

– Estrogen plays an important role in bone health

• Certain sports are more at risk

– Distance running

– Gymnastics

– Dance

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Stress Fracture

https://pubs.rsna.org/doi/pdf/10.1148/rg.322115022

Kahanov L, et al. Diagnosis, treatment and rehabilitation of stress fracture in the

lower extremity in runners. Open Access J Sports Med. 2015; 6: 87-95

Stress Fractures

• Older female athletes are at risk for stress fractures

– Insufficiency and fragility

• Important to assess for osteopenia/osteoporosis

– If multiple stress fractures

– If low BMD

• Increased body weight is associated with a decreased risk of fracture

• Few treatments to reverse bone loss

– Focus should be on prevention

• Proper nutrition, adequate energy availability, risks of low BMD and stress fractures

• Adequate calcium and Vitamin D intake

– Bisphosphonates may stabilize bone loss

– Little evidence that HRT has benefit to BMD and decreasing risk of stress injuries

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Bone Health

• Females start with a lower bone mass and lose it more quickly as they age

• Peak bone mass is reached at skeletal maturity or around 20 years of age

• ~30% of women have osteoporosis with projected increase to 50% in the next generations

• Exercise should have a positive effect on BMD

– Depends on type of exercise

– Depends on the magnitude of the load, how quickly it is introduced and how often it is repeated

• Effect of BMI, menstrual regularity and energy availability

– Girls with later menarche & lower weight have lower BMD compared to others

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Menstrual Disorders

• Eumenorrhea is regular cycles at intervals between 21-35 days

– Adolescents the cycles range between 21-45 days

• Primary amenorrhea is no menarche by age 15

– 7% overall in collegiate athletes, highest (22%) in cheerleading, diving and gymnastics

• Secondary amenorrhea is absence of 3 consecutive cycles post menarche

– Estimated in collegiate women from 2% to 5% and as high as 69% in dancers and 65% in long-distance runners

• Oligomenorrhea is cycle > 45 days

• Abnormal hormone levels, inadequate body fat stores, low energy availability and exercise stress can all contribute

– Rapid or significant fat mass reduction even < 1 month can affect

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Disordered Eating

• Energy availability

– Amount of energy available for physiologic processes and ADLS after

subtracting energy used for exercise

• Low Energy Availability may be the result of increased exercise

without increasing dietary energy OR reducing dietary energy

without reducing exercise expenditure OR both

• Disordered eating is a continuum

– Inadvertent undereating → Appropriate eating and occasional use of

more extreme weight loss methods → clinical eating disorders with

abnormal eating behaviors, distorted body image, weight fluctuations,

medical complications, and affect on athletic performance

– Prevalence is 13% among adolescent female elite athletes

– DSM-5 classifies anorexia nervosa, bulimia, binge eating ED and other

specified feeding or ED and unspecified feeding or ED21

• Energy intake does not compensate for expenditure → adverse effects on reproductive, bone & cardiovascular health

• Involves any components

– low energy availability with or without disordered eating

– menstrual dysfunction

– low bone mineral density

• Female athletes often present with one or more of the three triad components

– 0% - 16% in all female athletes meet 3

– 4% to 18% of female high school athletes meet 2

– 16% to 54% meet 1

• Early intervention is essential to prevent progression

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Female Athlete Triad

Relative Energy Deficiency in Sport

• Syndrome resulting from relative

energy deficiency that affects many

aspects of physiological function

• Underpinning the Triad is an energy

deficiency relative to the balance

between dietary energy intake and

the energy expenditure required to

support homoeostasis, health and

the activities of daily living, growth

and sporting activities

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• Disordered eating

associated with lower BMD

in athletes

– BMD is lower in amenorrheic

females than eumenorrheic

females

• May always have a lower

BMD once it is decreased

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Effects of RED-S/FAT

• The cumulative risk

assessment

provides an

objective method of

determining an

athlete’s risk

• Then is used to

determine an

athlete’s clearance

for sport

participation

– Diagnosis for AN

with BMI<16 or

moderate-severe BN

should be restricted25

Risk Stratification

• Unintentional disordered eating may be treated with

nutritional counseling to increase dietary intake

• Intentional DE will require a multidisciplinary team

– Physician, dietician, ATC, behavioral health clinician, +/- exercise

physiologist

– Improve energy availability

– Gradual increase in caloric intake

– May take 1 yr or longer to restore appropriate energy availability

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Treatment of RED-S/FAT

• Manage exposure to overload activity

• Promote strength training

– Muscle contractions place a strain on the bone which induces remodeling and increases bone strength

– Identify muscle imbalances

• Educate on proper nutrition and energy needs

– Appropriate Calcium and Vitamin D intake

– Menstrual regularity

• Screening

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Prevention

Concussion

• Reported rate of concussion is higher in female athletes

– Unclear if worse initial outcomes

– Female athletes tend to have more contact with equipment than player

• Tend to report more symptoms and higher severity and longer to

recover

• Hormonal issues

– Recent study showed concussion can lead to abnormal menstrual

patterns

• Differences upper body musculature and how react to collisions

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• Medical history form has been considered to be the most important aspect of the PPE

• Current form includes non specific questions about nutrition, body image, menstruation, evidence of bone loss and overuse injuries

• No standardization in the US or Canada

• Should be done annually

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Prevention- Screening PPE

• 20% of pediatricians, 50%

of family medicine

physicians and 41% of

orthopedic surgeons were

able to correctly identify all

3 components of the triad

• BMI <17.5 or <85% of

expected body weight

• Change in performance,

weight, mood, academics

• Have a low threshold for

further evaluation

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Prevention - Screening

• 2 minute ortho exam

– Evaluate also for particular

concerns of injury

– Evaluate for biomechanical

abnormalities

• Innominate pelvis, pes plans,

posture

• Dynamic/functional

evaluation

– Single leg squat

– Bridge

– Resisted side lying extension

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Prevention- Screening

http://www.scottsdalesportsmedicine.com/content/single-leg-

squats-case-pain-butt

Stress Incontinence

• 47% of women who regularly engage in exercise report some

degree of urinary incontinence (mean age, 38.5 years)

– Most in high-impact exercise

– significant number of women alter their exercise patterns

– Even experienced in young nulliparous athletes

• Treatment:

– Mechanical interventions may be helpful, as suggested

• placement of a super-absorbency tampon or pessary before exercise

– Pelvic floor PT

• Kegel’s

• Addressing diastasis

• Diaphragmatic breathing

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Pregnancy

• ACOG recommends that women should exercise regularly during pregnancy

• Associated with several benefits

– reduced rates of excessive weight gain, gestational diabetes, and preeclampsia.

• Several studies have found no adverse effects associated with moderate intensity exercise throughout pregnancy

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Conclusion

• In children and Adolescents

– Use the PPE forms and take detailed history

• Ask about training, injuries, menstruation, nutrition

– Identify risk factors for injury

• Muscle imbalances, sport specialization,

– Screen for disordered eating and low energy availability

• Appropriate caloric intake and also calcium and Vitamin D

– Evaluate for menstrual irregularity

• It is NOT normal to NOT menstruate as an athlete

– Educate

• Family, athletes, coaches

– Consider referrals when indicated

• PT, Dietician, Eating Disorder Clinic, Endocrinology, OB/Gyn

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Conclusion

• In Adult and Older women

– Continue to screen for RED-S and Female Athlete Triad

– Continue to screen for risk of overuse injuries

• Muscle imbalance

– Continue appropriate calcium and vitamin D intake

• DEXA at appropriate age or sooner if indicated

– Educated on the benefits of and encourage resistance training

Screen for urinary incontinence

– Pregnancy is NOT a reason to NOT exercise

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Thank You

References

• Committee on Sports Medicine and Fitness. Medical concerns in the female athlete. Pediatrics. 2000; 106:610-613

• Female athlete issues for the team physician: a consensus statement- 2017 update. Curr Sports Med Reports. 2018; 17(5): 163-171.

• Groeger M. ACSM’s Health & Fitness J. 2010; 14 (4):14-21

• Ireland ML, Ott SM. Special concerns of the female athlete. Clin Sports Med. 2004; 23(2):281-298.

• Joy E, et al. 2014 Female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Curr Sports Med Reports. 2014; 13 (4): 219-232

• Joy E, Van Hala S, Cooper L. Health related concerns of the female athlete: a lifespan approach Am Fam Physician. 2009;79(6):489-495

• Kelly A, Hecht S, Council On Sports Medicine and Fitness. The Female Athlete Triad. Pediatrics. 2016;137(6) :e20160922

• Mountjoy M, et al. The IOC consensus statement: beyond the female athlete triad- relative energy deficiency in sport. Br J Sports Med; 2014;48:491–497.

• Moyer V. Vitamin D and calcium supplementation to prevent fractures in adults: U.S. preventive services task force recommendation statement. Annals of Int Med. 2013; 158(9):691-696

• Rumball J,Lebrun C. Preparticipation physical examination: selected issues for the female athlete. Clin J Sport Med 2004;14:153–160

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