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The Female Athlete

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

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

  2. 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

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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

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

  10. 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

  11. 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

  12. FEMALE ATHLETE TRIAD

  13. 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”

  14. 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. 

  15. 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.

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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.

  22. 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

  23. Exercise and Pregnancy

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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 (?)

  30. 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

  31. 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

  32. Injuries in Female Athletes

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

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

  35. ACL

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

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

  42. Patellofemoral Pain Syndrome

  43. 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

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

  45. 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

  46. 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)

  47. 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

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