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1/6/16
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The Female Athlete
Karin VanBaak MD University of Minnesota
Primary Care Sports Medicine Fellow
Overview • Exercise Benefits for Females • Gender Differences: Anatomy & Physiology • Orthopedic Concerns
– Anterior Cruciate Ligament Tears – Stress Fractures
• Medical Concerns Concussions – Female Athlete Triad – Iron Deficiency Anemia – Stress Urinary Incontinence – Depression
Objectives • Appreciate the growth of female participation in
sports worldwide. • Review physiologic difference between female and
male athletes. • Identify which injuries female athletes are at risk for. • Describe the 3 components of the Female Athlete
Triad.
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History • First modern Olympics, Athens 1896
– Baron Pierre de Coubertin, founder of the modern Olympics, says, "It is indecent that the spectators should be exposed to the risk of seeing the body of a women being smashed before their very eyes. Besides, no matter how toughened a sportswoman may be, her organism is not cut out to sustain certain shocks.”
Olympics • Paris Olympics 1900
– 1.9% female
• London Olympics 2012 – > 40% female
• Los Angeles 1984 – First Olympic Marathon for Women
• No women on the IOC until 1981. • International view of females
London 2012 • All countries are represented by male &
female athletes for the first time. • 1st Olympics for female boxers • >40% of all athletes are female Team USA:
269 females & 261 males • Japan & Australia fly male athletes business
class but female athletes fly coach!
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Women’s Ski Jumping • In 2005, Gian Franco Kasper, FIS president
and a member of the IOC, said he didn't think women should ski jump because the sport "seems not to be appropriate for ladies from a medical point of view."
Exercise • Women exercise less than men • Women benefit from exercise!
– Benefits far outweigh risks – Decreased cardiovascular disease, cancer,
osteoporosis, diabetes, HTN, cholesterol
Girls who play sports … • are more confident • have higher self-esteem • have better body images • are less likely to get pregnant or be involved with
drugs • are more likely to graduate from high school • in high school: earn 14 % higher wages for women
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Physiologic Parameters: Women compared to Men • Percent body fat More • Strength Less
– Muscle fiber size Smaller – Proportion of muscle fiber types Similar
• Aerobic capacity Less – Stroke volume Smaller – Lung volumes Smaller – Left ventricular mass Smaller – Hemoglobin/Hematocrit Less – Mitochondrial density Less
• Anaerobic capacity Less • Thermoregulation Similar
Orthopedic Concerns
ACL Tears • 250,000 ACL injuries/yr in USA (1 in 3000)
– $1.5 billion annual cost • > 70% ACL injuries are NON-contact • 80 - 90% return to previous level of play • Season ending injury • Recovery 6-9 mo • Women at higher risk
Boden 2000 Physspportsmed
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ACL Tears in Women • 2-8x ↑risk as male athletes in same sports
– Non-contact ACL tears • Arendt AJSM 1995
– College soccer & basketball – 2.4 & 4.1 times greater chance of incurring ACL
injury compared males in soccer & basketball
Why are women at risk? • Biomechanics • Hormonal influences • Notch width • Alignment
Biomechanics • Poor ham:quad strength • Activate hamstrings more slowly • Land with knees slightly bent
– Boys land with knees more bent
Hewett AJSM 1999, Crosier AJSM 2002, Huston 1996 AJSM, Orchard AJSM 1997, Baratta AJSM 1988
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ACL Injury Prevention Programs • Sportsmetrics • Mykelbust • Knee Ligament Injury Prevention Program
(“KLIP”) • Prevent Injury Enhance Performance (“PEP”) • FIFA 11+
Noyes & Barber Westin, Sports Health 2012;4(1):36-46
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ACL Injury Prevention Programs • 1995-2011: 57 studies (42 programs) • Only 5 published data regarding effects on
injury reduction and performance testing • Sportsmetrics and PEP: statistically
significant decreases in ACL injury incidence rates in HS females in basketball, soccer
• PEP approached significance in collegiate athletes
Noyes & Barber Westin, Sports Health 2012;4(1):36-46
• Before training … • After training!
Barber-Westin, 2006, AJSM; Noyes 2005 AJSM
Stress Fractures • Common injury in sports
– Approx 10% of all injuries seen in sports med clinics
• Females at increased risk – Females suffered 65% of stress fx over 5 yrs in UCLA
track and field athletes Nattiv AJSM 2013
• May be a the “tip of the iceberg” – Overuse – Poor mechanics – Poor bone health
• Assess for other symptoms & signs of the Triad
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Medical Concerns
Concussions in Women • Women may have more concussions and
worse symptoms than men • HS females (in sports played by both sexes)
had an increased incidence of concussions (40% more than men) – Female basketball players had 240% more
concussions – Women had prolonged symptoms compared to
men Gessell 2007
1997 à
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2014
2014
Energy Availability • Amount of dietary energy remaining to support other
physiologic functions after subtracting out exercise training
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Energy Availability • EA =
Dietary Energy Intake – Exercise Energy Expendature Fat Free Mass
Example: 2000 kcal/d – 600 kcal/d / 51 kg =
27.5 kcal/kg FFM / d
What is Low EA? • 45 kcal/kg of FFM per day = energy balance
– Healthy, adequately nourished, sedentary, young adult females
– Amenorrheic athletes restrict EA by 44-67%
• 30 kcal/kg of FFM per day – Near resting metabolic rate – 33% below energy balance – Disrupted LH pulsatility – Impaired bone turnover
Loucks et al; 2003 & 2004
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LH Pulsatility • LH pulsatility is disrupted within 5 days after
decreased EA by 33% in young women • Exercise suppression of LH plasticity can be
restored with increasing caloric intake alone – Exercise is not the culprit!
• Some women may be less susceptible to low energy availability
DeSouza et al; 1998 & 2004, Loucks et al; 1998 & 2003
Amenorrhea: So what?? • BMD ↓ as the # of missed cycles ↑ • ↓ bone formation markers in amenorrheic
athletes • ↑ risk of stress fx 2-4x > than eumenorrheic
athletes • Negative effect on cholesterol • Decreased artery dilation
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Screening
Treatment
Iron Deficiency Anemia • Common problem for women • Anemia impairs performance • Unclear if athletes need more iron than non-
athletes • Assess for other causes of anemia • Dietary counseling • Iron supplements
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Stress Urinary Incontinence • Common but not well recognized problem in
female athletes – 300 elite female athletes: 40% leaked urine while
exercising! – Jumping activities
• Increased intra-abdominal pressure & failure to engage the pelvic floor muscles
• PT w/ therapist specialized in rx this problem
Depression • Women suffer more depression than males • Male & female athletes increased rates of
depression following injuries – Females increased risk
• Screen for depression • Work with a mental health treatment team
References • General:
– Calcium recommendations: http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ – The Female Athlete. Ireland ML and Nattiv A (eds). Elsevier Science, Philadelphia, PE, 2002. – Vitamin D recommendations: http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ World Village of Women
Sport: http://www.womensportvillage.com/ • Anterior Cruciate Ligament:
– Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in National Collegiate Athletic Association basketball and soccer. Am J Sports Med. 2005;33(4):524-530.
– Arendt EA, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med. 23(6):694-701, 1995. Review. http://www.ncbi.nlm.nih.gov/pubmed/8600737
– Quatman CE, Quatman CC, Hewett TE. Prediction and prevention of musculoskeletal injury: a paradigm shift in methodology. Br. J. Sports Med. Dec 2009;43(14):1100-1107.
– Renstrom P, Ljungqvist A, Arendt E,et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med. 42 (6): 394-412, June 2008. http://www.ncbi.nlm.nih.gov/pubmed/18539658
– Rotterud JH, Sivertsen EA, Forssblad M, et al. Effect of gender and sports on the risk of full-thickness articular cartilage lesions in anterior cruciate ligament-injured knees: a nationwide cohort study from Sweden and Norway of 15 783 patients. Am. J. Sports Med. Jul 2011;39(7):1387-1394.
– Shultz SJ, Schmits RJ, Nguyen AD, et.al. ACL Research Retreat V: An Update on ACL Injury Risk and Prevention. J Athletic Training. 45:499-508, 2010 Sports Med. Aug 2013;41(8):1930-1941.
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References • Concussions:
– Center for Disease Control Concussions: http://www.cdc.gov/concussion/sports/facts.html – Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement:
concussion in sport. Br J Sports Med 2013,47, 15–26. Available on-line http://www.amssm.org/Content/pdf%20files/2012_ConcussionPositionStmt.pdf.
– McCrory P, Meeuwisse W, et al.: Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258. Available on-line at http://bjsm.bmj.com/content/47/5/250.full.
• Female Athlete Triad: – Female Athlete Triad Coalition: http://www.femaleathletetriad.org/ – Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand: the female athlete
triad. Med Sci Sports Exerc. 2007;39(10):1867-18 – Sangeis P: IOC Position Stand on the Female Athlete Triad. Available on-line at http://www.olympic.org/
Documents/Reports/EN/en_report_917.pdf • Stress Fractures:
– Arendt E, Agel J, Heikes C, et al. Stress injuries to bone in college athletes: a retrospective review of experience at a single institution. Am J Sports Med. 2003;31(6):959-968.
– Nattiv A, Kennedy G, Barrack MT, et al. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. Am. J. Sports Med. Aug 2013;41(8):1930-1941.
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