Special concerns of the female athlete

I found this article while going through one of the sports medicine journals. I figured it may prove to be an interesting (and long) read for the female members of DB.com.
 
Enjoy.
 
 
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Special concerns of the female athlete
(Source: Clinics in Sports Medicine Vol. 23 (2004) 281– 298)
 
 
Since the adoption of Title IX in the early 1970s women’s sports participation
has dramatically increased. The majority of the injuries sustained by
female athletes are due to participation in the sport rather their sex, but there are
anatomic, hormonal, and functional differences between the sexes which must
be considered when caring for the female athlete. Differences between men’s
and women’s versions of sports such as lacrosse and gymnastics and similarities
between sports such as men’s and women’s basketball and soccer should also
be understood.
 
The benefits of exercise are extensive. Females involved in sports are less
likely to become pregnant during the teenage years, less likely to become
involved in an abusive relationship, and more likely to finish high school and
to go on to college. Women involved in sports have better self-esteem and self
image. [1] Weightbearing exercise has a positive effect on bone mass in participants
of all ages. There are also the cardiovascular and weight control benefits
of exercise to be considered, especially in older athletes.
Sex differences
 
After age 10 to 12 years there are significant differences in all aspects of
physical performance when comparing males with females. Females reach
physiological and skeletal maturity and achieve peak height velocity before
males. Women have more body fat and less lean body mass than males, a
difference that can be attributed to increased estrogens in the female and
increased androgens in the male. [2] Females have less upper body strength,
which even with training remains 30% to 50% less than that of males. Lower
extremity strength is much closer in parity. [3] Men also have higher red blood
cell counts and hemoglobin levels than women. Work capacity studies show that
there is only a slight difference between males and females in oxygen uptake
when the data are expressed relative to body size and composition. [4] Despite
these differences women show the same physiological training changes
as males and experience significant increases in strength, power, and muscular
endurance. [5]
 
Women have a wider pelvis, are more flexible, and have less developed
musculature than men. Lower extremity alignment differs in the female and may
predispose to injury. The so-called miserable malalignment syndrome of excessive
forefoot pronation, pes planus, external tibial torsion, quadriceps angle of
greater than 15 degrees, increased femoral anteversion, hypoplastic vastus
medialis obliquus, and heel valgus angulation demonstrates the extreme of lower
extremity differences between males and females (Fig. 1). Women have shorter
limbs relative to body length. However, the center of gravity of men and women
is only slightly different. This difference may account for differences in upper
limb musculature with a shorter lever arm for movement and power. [6]
 
Injury rates
 
There have been many studies comparing injury rates between male and
female athletes. [7–10] Studies comparing males and females have been done at
the military academies. [11] The National Collegiate Athletic Association
(NCAA) has collected data on injury rates for 16 sports since 1982 and for 21
sports since 1997. Soccer, lacrosse, gymnastics, and basketball are the four
NCAA sports for which data were collected and in which both males and females
compete. The data are reported as the number of injuries per 1000 athletic
exposures. Due to differences in equipment and rules for competition in lacrosse
and gymnastics, comparisons of injury rates between men and women in these
two sports must be made carefully. Arendt and Dick [12] and Arendt et al [13]
reported anterior cruciate ligament (ACL) injury rates for soccer and basketball
over a total 10-year period (1989–1993, 1994–1998). The rates of injury in
females compared with males were 2.6 times greater in soccer and 3.6 times
greater in basketball.
 
Using the 1997–1998 data, for women the highest rate of injury in collegiate
sports was in soccer followed by spring soccer, gymnastics, lacrosse, basketball,
fall lacrosse, softball, field hockey, volleyball, and spring volleyball (Table 1).
Men’s spring football and lacrosse had the highest overall injury rates for men or
women. There appears to be a trend in most sports toward more injuries occurring
during practices than during games. However, more knee injuries, and ACL,
collateral ligament, and meniscus tears occur in games. Compared with males,
females sustained greater rates of knee injuries involving the ACL (4.9 times
greater), collateral ligament (2.5 times), and meniscus (1.9 times) (Fig. 2). The
NCAA classification combines patella and patellar tendon; therefore, no specific
diagnosis is documented. The ankle is the most commonly injured body part for
both males and females. [9]
 
Certain injuries are more common in females, although most sports medicine
research has been done on males. More research with female athletes needs to be
done to prevent injury in the future and to answer the question of why certain
injuries are more common in females. Only one long-term study has been done to
date on female athletes. The majority of these athletes had continuing problems
related to injuries sustained during their collegiate athletic careers. This is of
concern. This indicates that we do not know the long-term effects of athletic
injuries on women and more research in this area need to be done. [14]
 


 
Ankle injuries
The ankle remains the most frequently injured joint in both male and female
athletes. Osteochondritis dissecans of the talus, tibiotalar impingement syndrome,
high ankle sprain, chronically subluxating peroneal tendons, and posterior
impingement should be included in the differential diagnosis of ankle sprains
failing to respond to conservative care. Stress fractures of the tarsal navicular
should be ruled out in athletes at risk with foot pain. Medial tibial stress
syndrome or shin splints are a common complaint among athletes and should
be differentiated from exertional compartment syndrome and stress fracture. [15]
 
Knee injuries
Compared with males, females have an increased rate of anterior knee pain,
patellofemoral disorders, and ACL injuries. [16–18] Dynamic movement patterns,
core stability, and hip strength are different in males and females (Fig. 3). In
our experience, anterior knee pain is more common in women and has an
extensive differential diagnosis, which is summarized in Table 2. A specific
diagnosis should be made in patients with anterior knee pain.
It has been well established that females have a higher rate of ACL injury than
males. The reason is most likely multifactorial. Differences in training, neuromuscular
responses, laxity, hormonal influences, and anatomic differences all
play a role. Hip weakness, anterior hip tightness, and quality of pattern of movement
are other contributing factors. The elastin and collagen tissue in females
may contribute to the completeness of ACL tears and scar formation. Due to their
lesser muscular development and lower extremity alignment differences, females
rely more on the ACL and less on hamstring control. Ligamentous reconstruction
should be considered in the ACL-dominant female as she is at high risk for
significant meniscal and articular surface injury. [3,10]
 
Review of video footage reveals that compared with males, females tend to be
in a more upright position, with less hip and knee flexion and their knees in more
valgus angulation when landing from jumps as demonstrated in (Fig. 4). This
‘‘point of no return’’ with the athlete more upright with an externally rotated pronated lower extremity may predispose to injury. Isokinetic strength testing has
revealed a higher hamstring-to-quadriceps peak torque ratio in the trail leg at
60 degrees per second in volleyball players, which is the one statistically
significant difference that has been found between males and females. A
plyometric jump training program was done in female volleyball players. After
training, females showed increased jump heights, increased hamstring strength,
decreased peak landing forces, and decreased knee abduction and adduction
moments. The females also showed peak torque ratios similar to males athletes
after training. [19] This is significant inasmuch as the hamstring strength is
increased, there is less strain on the ACL, and this strengthening program could
affect the number of ACL injuries in female athletes.
There have been studies showing that there are estrogen receptors within
ligamentous structures, including the ACL. Estrogen inhibits type I procollagen
synthesis and proliferation fibroblasts in vitro at physiological estradiol concentrations,
but the in vivo function of these receptors has yet to be elucidated. [20]
There have been further studies linking phase of menstrual cycle to the risk of
injury to the ACL. In one study there appeared to be more ACL tears during the
ovulatory phase of the menstrual cycle. [21] More work in this area needs to be
done with a larger series of athletes.
 
The majority of ACL injuries sustained by females are of a noncontact mechanism. The American Orthopedic Society for Sports Medicine, the National Athletic Trainers Association, the NCAA, and the Orthopedic Research and Education Foundation sponsored a consensus conference to address the issue of noncontact ACL injuries and define risk factors and directions for future research.[22]
 
The members of the symposium concluded that at-risk situations for noncontact ACL  injury include deceleration, cutting or changing directions, and landing. The shoe surface coefficient of friction may increase the risk of ACL injury. There is no evidence that knee braces prevent ACL injury. There is no consensus regarding the role of the notch in ACL injury owing to difficulties in obtaining reliable and reproducible measurements. There are insufficient data on ACL size as measured by notch size to support ligament size related to risk of injury. There is no consensus regarding hormonal influences on the ACL and risk of ACL injury. There is no basis for modification of participation during various phases of the menstrual cycle or manipulation of sex-specific hormones to
prevent ACL injuries. [22]
 


Shoulder injuries
In younger females, joint laxity and decreased strength can cause shoulder
problems. With generalized laxity, sport-dependent problems involving the
shoulder can occur. The vicious cycle of physiological instability, rotator cuff
weakness, pain, posterior tightness, and further imbalance results in persistent
pain and dysfunction in overhead activities. Care should be taken to address
scapular dysfunction. A specific diagnosis of the cause of the pain should be made. Restoration of normal range of motion and strength with proper sport
biomechanics should be the goal. [23] The cheerleader shown in Fig. 5 has
bilateral multidirectional shoulder laxity. She can voluntarily posteriorly subluxate
her glenohumeral joint (Fig. 5A) as she moves into horizontal adduction and
reduce moving into external rotation (Fig. 5B).
 
Elbow injuries
Females have shorter upper extremities, an increased valgus-carrying angle,
decreased upper extremity strength, and increased ligamentous laxity compared
with males. Osteochondritis dissecans of the elbow with possible loose body
formation should be considered as a diagnosis in axially loading sports such as
gymnastics, diving, cheerleading, and tumbling. Elbow dislocations are not
infrequent in sports requiring aerial maneuvers. [3] A cheerleader sustained an
elbow dislocation when she fell attempting a double back stunt (Fig. 6). Repeated
attempts at reduction by bystanders were unsuccessful. An arterial injury
occurred as well. Despite counseling, she returned to cheerleading 6 months
after the injury with a range of motion of 10 to 140 degrees and full pronation
and supination.
 


Hand and wrist injuries
Contact injuries in sports such as ice or field hockey or lacrosse can result in
fractures to the hand or wrist. Overuse injuries to the wrist are common in
gymnastics, golf, weightlifting, racquet sports, and bicycling. In gymnastics the
upper extremity becomes a weightbearing limb and studies indicate the incidence
of wrist pain in gymnasts to be as high of 73%. [24] The differential diagnosis
in chronic wrist pain in any athlete should include triangular fibrocartilage tears,
injury to the distal radial physis, ulnar impaction syndrome, dorsal wrist
ganglion, dorsal wrist capsulitis, and carpal instability. Other possible sources of wrist pain are hamate fracture, carpal tunnel syndrome, tendinitis, and ulnar nerve compression.
 
 
Stress fractures
There are several populations of female athletes at increased risk for stress
fracture. There is a high association between menstrual irregularities and stress
fracture which is discussed below. [25–27] Distance runners, ballet dancers,
gymnasts, and those with poor nutrition and menstrual irregularities are at
increased risk. [3] A detailed nutritional and gynecological history should be
obtained in female athletes presenting with stress fracture.
 
The spine in the female athlete
Scoliosis is more common in females than males. Early screening with
appropriate intervention should be done as part of the preparticipation physical
examination. Spondylolisthesis and spondylolysis should be considered in
athletes who perform repetitive flexion and extension activities. The radiographic
examination should include oblique and standing lateral views. Back pain with a
negative radiographic examination should be evaluated with a single-photon
emission computed tomography (SPECT) bone scan to rule out fracture. Sciatica
can occur with or without spondylolisthesis or lysis and should be evaluated
accordingly. Vertebral body fractures, pedicle stress fractures, and multiple
compression fractures have also been reported in female athletes and should be
in the differential diagnosis of an athlete complaining of back pain. [3] Fig. 7
demonstrates a case of spondylolysis.
 
The female athlete triad
The female athlete triad is defined as amenorrhea, disordered eating, and
osteoporosis. The triad is a multifactorial problem. The earlier the diagnosis, the better the chance for establishment of normality. Activities such as dancing,
cheerleading, gymnastics, figure skating, and distance running, which emphasize
a prepubertal body type, perfectionism, thinness, have revealing clothing, and are
subjectively judged place women at increased risk for developing this disorder.
[28] Other risk factors include a drive to excel at any cost, pressure from coaches
or parents, lack of knowledge regarding nutrition, a family history of eating
disorders, and a history of abuse. Young athletes who are approaching puberty
appear to be at increased risk as well. When evaluating an athlete suspected of
having the triad it is of utmost importance to take a detailed nutritional and
menstrual history. [29] The true prevalence of the female athlete triad is
unknown. The best treatment for the female athlete triad is prevention through
preparticipation physical examination, education, nutritional counseling, and
screening. If the triad is already established, the treatment is multidisciplinary with a physician, psychiatrist or psychologist, and nutritionist involved in the
care of the athlete. [30] Cure is rare. Educational programs are available.
[31] This 22-year-old gymnast died of starvation or nutritional deficiencies
(Fig. 8). [31a]
 


Disordered eating
There is a wide spectrum of eating disorders among athletes, ranging from
anorexia nervosa and bulimia, to restrictive eating behaviors, to poor nutritional
habits. The risk factors for disordered eating are the same as those listed earlier
under The Female Athlete Triad. Those athletes with anorexia nervosa or bulimia
are of obvious concern but athletes with less extreme disordered eating patterns
are at risk for certain endocrine, skeletal, and psychiatric problems. [32] Eating
disorders are 10 times more prevalent in women than in men. The exact
prevalence in athletes is unknown but ranges from 15% to 62% of athletes
depending on the sport. The prevalence of eating disorders in the nonathlete is
estimated at between 1% and 3%. The prognosis for eating disorders is poor.
Among nonathletes, 50% do well, 30% struggle and relapse, and there is a 10%
to 20% mortality rate. There have been no published studies to date regarding the
prognosis of eating disorders in female athletes and it is unknown how often
disordered eating patterns resolve after college or competitive athletics. Many
continue to struggle with weight concerns and body image after their athletic
careers are over. [33]
 
Anorexia nervosa is defined by the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition (DSM-IV) as refusal to maintain minimal body
weight for height (less than 85% of expected weight), intense fear of weight gain,
disturbed body image, and three consecutive months of amenorrhea in postmenarchal
females or failure to begin menstruating by age 16. Signs and symptoms of anorexia include amenorrhea, fat loss, muscle loss, dry hair, dry skin, cold and discolored extremities, decreased body temperature, lanugo, lightheadedness, decreased ability to concentrate, and bradycardia. [34]
 
Bulimia nervosa is defined by the DSM-IV as recurrent binge eating within
any 2-hour period; overeating; a sense of lack of control over eating during any
2-hour period; recurring behavior compensation for overeating by vomiting,
abuse of laxatives, or other drugs; fasting or excessive exercise; binge eating
and purging at least twice weekly for 3 months; and negative self–body image
and self-image. Disturbed behavior does not occur exclusively during times of
anorexia nervosa. Signs and symptoms include swollen parotid glands, chest
pain, sore throat, abdominal pain, erosion of tooth enamel, face edema, extremity
edema, diarrhea, constipation, menstrual irregularities, knuckle scars, nail
changes, and bloodshot eyes. [34]
 


Menstrual irregularities
Primary amenorrhea is defined as absence of menstruation by age 16 in a girl
with secondary sex characteristics. Secondary amenorrhea is absence of three
of more consecutive menstrual cycles after menarche. Oligomenorrhea is a menstrual
cycle greater than 36 days. The prevalence of amenorrhea in the general
population is 2% to 6% and in athletic populations, between 3.4% and 66%. All
three of these disorders can result in decreased bone mineral density (BMD) and
put the patient at risk for early osteoporosis and stress fracture. The exact cause of
amenorrhea in athletes is unknown, but it most likely has a hypothalamic origin
and results in decreased ovarian hormone production and hypoestrogenemia
similar to menopause.[35,35a–c]
 
The significance of athletic amenorrhea is the observed skeletal demineralization
seen in nonmenstruating athletes which predisposes them to injury,
especially stress fracture and early osteoporosis. [36] The long-term effects to
bone health caused by athletic amenorrhea are unknown. The danger is that these
women are losing bone at a time in their lives when they should be laying it down
and they may never achieve peak bone mass. [35] There is also a theoretical risk
of increased incidence of cardiovascular disease, infertility, reproductive system
cancer, and osteoporosis. Athletic amenorrhea is a symptom of an underlying
problem and should be treated in the first 3 months. After ruling out other causes
of amenorrhea, treatment of athletic amenorrhea in a woman who has been
menstruating for less than 3 years is to decrease exercise intensity and improve
nutrition. [37] For an athlete who is more than 3 years post-menarche, treatment
is low-dose oral contraceptives. [35]
 
Osteoporosis
Osteoporosis is a disease characterized by low bone mass and microarchitectural
deterioration of bone tissue leading to enhanced skeletal fragility and
increased risk of fracture. Women are four times more likely to develop os-
M.L. Ireland, S.M. Ott / Clin Sports Med 23 (2004) 281–298 293
teoporosis than men. [38] Osteoporosis is defined in terms of BMD. Bone
densitometry by dual photon radiographic absorptiometery is the modality of
choice to evaluate BMD. Weightbearing exercise has a positive effect on bone
mass and may reduce the rate of bone loss in adult women but it will not produce
a large increase. [39] In the face of athletic amenorrhea, the positive effects of
weightbearing exercise are negated. This method is quicker, less expensive, and
can image specific body sites more easily than previous scanning methods. [35]
Athletes suspected of early osteoporosis, the female athlete triad, and those with
oligomenorrhea or amenorrhea should undergo bone densitometry. Educational
programs are available. [40,41]
 
Iron deficiency anemia
Women are at greater risk than men for anemia. Forty percent to 50% of
adolescent female athletes demonstrate some degree of iron depletion or
decreased iron stores without overt anemia. [42] Twenty percent to 30% of
female adolescents and young adults (athletes and nonathletes) demonstrate iron
deficiency. [32] Runners appear to be at increased risk for iron deficiency anemia
during their training season. Black adolescent female runners have twice the
incidence of iron deficiency anemia of white adolescent female runners. True iron
deficiency anemia should be differentiated from pseudoanemia or sports anemia
which results from expanded plasma volume with a normal red blood cell count.
[1] Only those athletes at high risk for anemia or those with a previous history of
iron deficiency anemia should be screened.
 
The aging female athlete
As our society becomes more fitness-oriented it has become more acceptable
for older women to pursue exercise. Women are continuing to be active in sports
which they enjoy and some of those who have never before exercised are
beginning fitness programs. Most information on the aging female athlete has
been extrapolated from male data, but there have been a few studies suggesting
the following positive aspects of exercise in the aging female athlete. As we age
we lose muscle mass, flexibility, and bone mass, and aerobic capacity declines.
[43] Body weight decreases due to loss of muscle mass while the percentage of
body fat increases. Despite these changes, exercise training can still increase the
size and strength of conditioned muscle. Exercise programs should take into
account prior fitness levels, bone demineralization, and type of exercise. In
addition to increased muscle strength, cardiovascular benefits, increase in lean
body mass, and increased bone mineralization are other positive outcomes of
exercise. Treatment of injuries in older females should be based on activity level
and physiological age rather than chronological age.
 


The pregnant athlete
As women’s sports participation increases, so too will the number of women
who wish to continue their exercise programs throughout their pregnancy. Of
importance is the physical fitness level of the patient before conception. In most
cases women can safely continue an exercise program during their pregnancy.
This should be done in coordination with the athlete’s obstetrician. The major
concerns for pregnant athletes are the effects of elevated maternal temperature on
the fetus, the effect of exercise on blood flow to the fetus, and the effects of
exercise on the weight of the fetus. [38] The American College of Obstetricians
and Gynecologists guidelines for exercise during pregnancy and contraindications
to exercise during pregnancy are summarized in Table 3. [44,45] The benefits of exercise during pregnancy include weight control, improved muscle
tone, improved self-esteem, decreased incidence of varicosities, decreased
incidence of back pain, and decreased incidence of sleep disturbance. [46]
 
Conclusion
Appreciation of the unique situations that exist for female athletes will
improve their care and treatment. Medical personnel who have added these
insights to their armamentarium can make diagnoses more efficiently and
institute treatment earlier. The epidemic of knee injuries in females is of concern
and requires further research. Very important factors in prevention are strengthening
of the trunk and core, low back, and hip musculature and analysis of
dynamic movement patterns. The high incidence of eating disorders and
hormonal and nutritional imbalances increases the risk for stress fracture.
Treatment of eating disorders and menstrual irregularities should be instituted
quickly to avoid adverse sequelae to the bone. Exercise can be performed safely
in most pregnant patients in conjunction with their obstetrician and in keeping
with their prepregnancy level of fitness. Sports participation and physical fitness
should be encouraged in women of all ages.