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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.