The Female Athlete

1. The Female Athlete Terry Adirim, MD, MPH Office of Health Affairs Department of Homeland Security June 17, 2008

3. 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

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

5. 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 women’s Olympic marathon in 1984 • Women’s WR in the marathon is 2:15:25; Men’s is 2:04:26

7. 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

8. 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

9. 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

10. 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

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

12. Economic Benefits to Society • Women buy more athletic shoes and clothes than men • Women’s professional sports • Men’s sports over saturated • Men’s sports out price families • Women’s sports are becoming lucrative • Women watch men’s teams/Men watch women’s teams

13. 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

14. FEMALE ATHLETE TRIAD

15. 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”

16. 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 Triad’s clinical conditions. • Treatment team should include physician or other hcp, reg. dietitian, and with eating disorders, a mental health counselor. 

17. 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.

18. Female Athlete Triad • Disordered eating: • Either all the criteria for Anorexia Nervosa or Bulimia except that despite weight loss, the girl’s 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

19. Female Athlete Triad • Why • Intense pressure to have low percentage of body fat for appearance and performance • Society’s pressure on women to be thin • Elite athletes are goal-oriented and perfectionist

20. 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

21. 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

22. 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

23. 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 athlete’s need.

24. 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 Athlete’s ideal weight • Diet guidelines • Aware of emotional stressors

25. Exercise and Pregnancy

26. ACSM Position • Current Comment in August 2000 • Safety concerns—avoid activities that can injure abdomen or cause fatigue rather than feeling of well being • Environment—hydrate and avoid heat stress • Growth and development—monitor proper weight gain • Mode—swimming and cycling; walking, jogging and low impact aerobics • Intensity—”probably” should not seriously compete • Exercise is encouraged by this statement

27. 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

28. 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

29. 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 training—not studied; but heavy lifting is discouraged • Increased injuries not reported

30. 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

31. 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 (?)

32. 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

33. 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

35. Injuries in Female Athletes

36. Injuries in Female Athletes • Common injuries in women/girls include: • Anterior cruciate ligament (ACL) injuries • Patellofemoral pain syndrome • Stress fractures

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

38. ACL

39. Intrinsic factors: Joint laxity Hormones Limb alignment Ligament size Intercondylar notch size Extrinsic factors: Conditioning Experience Skill Strength Muscle recruitment patterns Landing techniques ACL Injuries

40. 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

41. 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

42. 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

43. 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

44. Patellofemoral Pain Syndrome • Probably more than one etiology • Chondromalacia • Malalignment of patella

45. Patellofemoral Pain Syndrome

46. 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

47. Patellofemoral Pain Syndrome • Causes of PFPS • Anatomical • Larger “Q” angle • Leads to abnormal tracking of the patella

48. 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

49. 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)

50. 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