The Female Athlete

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The Female Athlete

• Terry Adirim, MD, MPH
• Office of Health Affairs
• Department of Homeland Security
• June 17, 2008

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Topics to be Discussed

• History of Girls and Women in Sports
• The Benefits of Exercise
• The Female Athlete Triad
• Exercise and Pregnancy
• Gender Differences and Injuries

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Introduction

• Millions of girls participate in organized sports
  on all levels
• Professional teams of women
• Basketball
• Football

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Background

• Before the 1970s, girls were discouraged from
  participating in sports
• Not until 1950s that distances of greater than
  200 meters for women introduced into Olympic
  games
• First woman marathoner had to enter with her
  initials (1967)
• First womens Olympic marathon in 1984
• Womens WR in the marathon is 21525 Mens is
  20426

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Title IX

• Title IX of the Education Amendments of 1972
• Is a federal anti-discrimination law
• Mandated nondiscrimination in admissions, access,
  and treatment in all educational programs offered
  by institutions that were recipients of federal
  funds

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Title IX

• 1 in 27 girls in 1972 to 1 in 2.5 girls in 2006
• An all-time high of more than 3 million girls
  playing high school sports
• Girls still receive 1.3 million fewer
  participation opportunities than boys at the high
  school level
• Girls comprise 49.0 of the high school
  population but only receive 41.2 of all athletic
  participation opportunities
• National Center for Education Statistics,
  2005-2006

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Benefits

• Teenage female athletes
• Are less than half as likely to get pregnant
• Are more likely to report that they have never
  had sexual intercourse
• Are more likely to experience their first
  intercourse later
• Active women feel greater confidence, self-esteem
  and pride in their physical and social selves

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Benefits

• Girls who participate in sports are more likely
  to achieve academic success and graduate high
  school.
• Female student athletes graduate college at
  higher rates
• Higher self-esteem and less depression

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Benefits

• Also sports teaches
• Teamwork
• Goal-setting
• Pursuit of excellence in performance
• 80 of female executives at Fortune 500
  companies describe themselves as tomboys

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Economic Benefits to Society

• Women buy more athletic shoes and clothes than
  men
• Womens professional sports
• Mens sports over saturated
• Mens sports out price families
• Womens sports are becoming lucrative
• Women watch mens teams/Men watch womens teams

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Barriers

• Discrimination in employment of highly qualified
  coaches
• Access to weight rooms
• Assignment of athletic trainers
• Quality of athletic facilities
• These factors relate to injury prevention

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FEMALE ATHLETE TRIAD
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Female Athlete Triad

• New definition is Disordered eating, Menstrual
  Dysfunction and low bone mineral density
• Original ACSM position statement in 1997 Revised
  definition and recommendations in 2007
• Increased emphasis on energy availability

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Female Athlete Triad ACSM

• Low energy availability important factor--impairs
  reproductive and skeletal health.
• Prevention and early intervention, (and
  education) are priorities.
• Athletes should be assessed for Triad at PPE /or
  annual health screening, and whenever athlete
  presents with any of the Triads clinical
  conditions.
• Treatment team should include physician or other
  hcp, reg. dietitian, and with eating disorders, a
  mental health counselor. 

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Female Athlete Triad ACSM

• First aim is increase energy availability by
  increasing energy intake /or reducing energy
  expenditure.
• Athletes with eating disorders should be required
  to meet established criteria to continue
  exercising, and their training and competition
  may need to be modified.
• No pharmacologic agent adequately restores bone
  loss or corrects the metabolic abnormalities that
  impair health and performance in athletes with
  amenorrhea.

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Female Athlete Triad

• Disordered eating
• Either all the criteria for Anorexia Nervosa or
  Bulimia except that despite weight loss, the
  girls weight is in the normal range and/or the
  binge eating and compensatory mechanisms occur at
  a frequency of less than twice a week for a
  duration less than 3 months.
• Can have amenorrhea without eating disorder

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Female Athlete Triad

• Why
• Intense pressure to have low percentage of body
  fat for appearance and performance
• Societys pressure on women to be thin
• Elite athletes are goal-oriented and perfectionist

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Female Athlete Triad

• Consequences for adolescent athletes
• Higher prevalence of delayed menarche
• Higher rates of primary and secondary amenorrhea
• Highest rates in ballet dancers and runners

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Female Athlete Triad

• Prevalence
• Difficult to determine secretive nature of
  disorder dieting considered normal behavior
• Reportedly between 4 and 39 of collegiate
  athletes
• Additive risk factors
• Chronic dieting, low self-esteem, family
  dysfunction, physical or sexual abuse, biologic
  factors, perfectionism and lack of nutrition
  knowledge

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Female Athlete Triad

• Sports-specific triggers
• Emphasis on body weight for performance or
  appearance
• External pressure to lose wt.
• Drive to win at any cost
• Self-identity as an athlete only
• Sudden increase in training
• Vulnerable times

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Female Athlete Triad

• Prevention
• Teach athletes-- no optimal body fat or weight
  for performance
• If weight loss necessary, then closely monitor
• Nutrition education
• Teach that the diet should provide adequate
  calories to meet the athletes need.

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Female Athlete Triad

• Diagnosis Treatment
• Detailed H and P/Labs if indicated
• Many need hormone treatment (OCPs)
• Goal is at least 90 of IBW
• Decrease activity by 10-20
• Education
• The Athletes ideal weight
• Diet guidelines
• Aware of emotional stressors

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Exercise and Pregnancy
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ACSM Position

• Current Comment in August 2000
• Safety concernsavoid activities that can injure
  abdomen or cause fatigue rather than feeling of
  well being
• Environmenthydrate and avoid heat stress
• Growth and developmentmonitor proper weight gain
• Modeswimming and cycling walking, jogging and
  low impact aerobics
• Intensityprobably should not seriously compete
• Exercise is encouraged by this statement

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Exercise and Pregnancy

• Years ago it was discouraged
• ACOG now actively encourages it 2002 statement
• Concerns included
• increases in body temperature,
• stress hormones,
• caloric expenditure,
• biomechanical stresses
• Medical literature does not support this

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Exercise and Pregnancy

• Benefits of exercise during pregnancy
• Reduces musculoskeletal complaints
• Enhances feeling of well-being
• Improves body image
• Decreases maternal weight gain and fat deposition
• Less likelihood of developing pre-eclampsia
• May make labor and delivery easier
• Less infant fat deposition

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Exercise and Pregnancy

• Common beneficial activities in pregnancy
• Stationary cycling and swimming-- considered
  safest
• Walking is the most common
• Improves sense of well-being, but did not
  decrease maternal weight gain
• Weight trainingnot studied but heavy lifting is
  discouraged
• Increased injuries not reported

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Exercise and Pregnancy

• Benefits for perinatal period
• Infants of exercising mothers are smaller
• Gestation tends to be shorter in exercising women
  than in their sedentary counterparts
• Labor is usually shorter

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Exercise and Pregnancy

• Some evidence that babies may be healthier
• Leaner body mass at age 5
• Better motor skills
• Higher intelligence
• Less insulin resistance as adults (?), better CV
  profile, athletic proficiency (?)

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Exercise and Pregnancy

• Cardiovascular and fitness benefits
• Exercise increases plasma volume which is
  additive to the increase in pregnancy
• Effect of increased cardiac output may persist
  postpartum (up to a year)
• Ninety percent of women who exercise in
  pregnancy, continue after the birth and 70 reach
  or exceed their pre-pregnancy fitness level

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Exercise and Pregnancy

• Other benefits to women
• Exercising women are more likely to to achieve
  their pre-pregnancy weight within a year
• Increase abdominal tone more rapidly
• Much less incidence of loss of bladder control at
  1 year postpartum

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Injuries in Female Athletes
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Injuries in Female Athletes

• Common injuries in women/girls include
• Anterior cruciate ligament (ACL) injuries
• Patellofemoral pain syndrome
• Stress fractures

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ACL

• Women have an increased predisposition to ACL
  injury
• Many theories, but no one proven definitive cause

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ACL
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ACL Injuries

• Intrinsic factors
• Joint laxity
• Hormones
• Limb alignment
• Ligament size
• ?Intercondylar notch size

• Extrinsic factors
• Conditioning
• Experience
• Skill
• Strength
• ?Muscle recruitment patterns
• ?Landing techniques

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ACL

• Intercondylar notch width well studied
• Some studies have shown differences in size
  between the sexes others have not
• Smaller notch may mean smaller and weaker ACL
• Or the same size ACL, but smaller notch may cause
  impingement on the ligament

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ACL

• Conditioning
• Some evidence that as conditioning improves in
  women, the overall injury rates become the same
  for men and women
• Fatigue may be a contributor
• Not well studied

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ACL

• Skill and Experience
• As women are gaining in both, ACL injury rates
  have remained the same
• Hamstring activation is protective of the ACL
• Female athletes rely less on their hamstrings and
  more on quads and gastrocs
• Landing techniques in women are different
• Unclear if it is training differences or innate
  neuromuscular function

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ACL

• What to do?
• Teach preventative skills
• Learn how to fall, jump and to cut
• Plyometric training
• Reduce landing forces and improve strength ratios
• Increase hamstring activation

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Patellofemoral Pain Syndrome

• Probably more than one etiology
• Chondromalacia
• Malalignment of patella

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Patellofemoral Pain Syndrome
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Patellofemoral Pain Syndrome

• Clinical Features and Exam -
• pts may report anterior knee pain
• pain with climbing stairs and/or sitting for
  prolonged periods of time
• compression of patella may cause pain along
  medial lateral retinacula
• compression of the patella during flexion
  extension of knee may elicit crepitation and
  discomfort
• Abnormal patellar tracking

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Patellofemoral Pain Syndrome

• Causes of PFPS
• Anatomical
• Larger Q angle
• Leads to abnormal tracking of the patella
  

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Patellofemoral Pain Syndrome

• Other causes
• Muscle imbalances
• Foot type (either pes planus or pes cavus)
• Shoes
• Overuse
• Treatment includes decreasing activity,
  addressing any biomechanical issues, physical
  therapy

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Stress Fractures

• Chronic, overuse injury
• Most common in weight bearing bones
• Feet, tibia, femoral neck
• Seen commonly in Female Athlete Triad
• Chronic diseases
• Diagnosis by x-ray, bone scan or MRI
• Treatment is rest, address biomechanical
  issues---some fxs are surgical (e.g. femoral
  neck)

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Conclusion

• Sports and exercise benefit women
• Women are gaining in skill and participation
• Women athletes have special concerns
• May be susceptible to Female Athlete Triad
• May have different injury patterns