The Female Athlete

Author: Deborah Allen

Topic updated on 02/15/13 12:30pm

Introduction
Physiologic differences exist between men and women Women have a higher body fat % lower maximal oxygen consumption and hemoglobin lower cardiac output decreased muscle mass and strength Athletic injuries woman have increased incidence of patellofemoral disorders stress fractures ACL injuries
ACL injury
Risk of injury is 2-10x greater than males especially with pivoting sports ACL injury is more common in females due to landing biomechanics and neuromuscular control differences conditioning and strength play the biggest role females land with their knees in more extension and valgus due to hip internal rotation smaller notches smaller ACL size cyclic hormonal levels ACL at greater risk for injury during the first half (preovulatory phase) of the menstrual cycle leg alignment genetic predisposition underrepresentation of CC genotype of a COL5A1 gene sequence in females with ACL ruptures Preventions incidence can be reduced with neuromuscular training (jump training)
Female athlete triad (anorexia athletica)
A condition seen in female athletes that consists of amenorrhea resulting from energy imbalance, low body fat, and hypothalamic-pituitary axis changes secondary amenorrhea (cessation of menses for 6 months after at least one normal cycle) is often caused by hormonal disturbances incidence in elite runners is nearly 50% leads to bone demineralization and stress fractures disordered eating insufficient caloric intake is the most common cause of amenorrhea in female athletes osteoporosis obtain a DEXA scan in female athletes with a history of amenorrhea and stress fractures Treatment a multidisciplinary approach should include psychological counseling as the core education and counseling for eating behaviors dietary management should begin by establishing an energy balance increase weight/food intake and decrease exercise increase calcium and vitamin D in diet reduced training intensity and cross-training to decrease risk of stress fractures calcium and vitamin D supplements should be taken for osteoporosis may consider cyclic estrogens or progesterones in treating osteoporosis oral contraceptive pills may be beneficial in treating amenorrhea
Pregnancy
Increased estradiol leads to ligamentous laxity Increased oxygen increased body weight leads to a 16-32% increase in oxygen consumption
Title IX
Law stating that females have equal access to training rooms

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(SBQ07.71) A 26-year-old long distance runner presents with insidious onset of hip and groin pain. An MRI of her hip is shown in Figure A. Work-up should include evaluation for which of the following conditions? Topic

Review Topic

FIGURES: A

1. Osteoporosis
2. Anorexia
3. Secondary amenorrhea
4. Answer 2 and 3
5. All of the above

PREFERRED RESPONSE ▶

DISCUSSION: An evaluation of eating disorders, osteoporosis, and amenorrhea should be performed in a young female athlete who presents with a stress fracture.

The "female athlete triad" consists of disordered eating, secondary amenorrhea, and osteoporosis (which often manifests as a stress fracture). Treatment includes a multidisciplinary approach including psychological counseling, dietary management, training modifications, calcium and vitamin D supplements, and possibly oral contraceptive pills.

Bennell et al. followed track and field athletes over 12 months. They looked at the risk factors for stress fractures, which occurred in 21% of their population. In female athletes, significant risk factors included lower bone density, a history of menstrual disturbance, less lean mass in the lower limb, a discrepancy in leg length, and a lower fat diet.

Barrow et al. looked at menstrual irregularity in female athletes. Stress fractures occurred in 49% of the very irregular runners, 39% of the irregular runners, and 29% of the regular runners. Forty-seven percent of the amenorrheal group admitted to an eating behavior disorder.

Figure A is a coronal MRI image showing marrow edema in the inferior aspect of the femoral neck consistent with a stress fracture.

REFERENCES:

1. Bennell KL, Malcolm SA, Thomas SA, Reid SJ, Brukner PD, Ebeling PR, Wark JD. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996 Nov-Dec;24(6):810-8. PMID:8947404 (Link to Abstract)

2. Barrow GW, Saha S. Menstrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med. 1988 May-Jun;16(3):209-16. PMID:3381976 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD, Ben Taylor MD,

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(SBQ07.75) An 18-year-old female cross-country runner presents with right leg pain for 2 months. Her body mass index is 16 and her last menses was 7 months ago. She reports that she had a benign tumor removed from her left ovary 3 years ago. Her urine pregnancy test is negative. She denies constitutional symptoms. She is tender along the tibial crest and is neurovascularly intact in the extremity. A T1 MRI of the tibia is shown in Figure A. What is the most likely etiology for her presentation? Topic

Review Topic

FIGURES: A

1. Neurofibromatosis Type 1
2. Osteofibrous dysplasia
3. Poor caloric intake
4. Formation of a fusion protein (EWS-FLI1)
5. Focal fibrocartilaginous dysplasia

PREFERRED RESPONSE ▶

DISCUSSION: This female athlete presents with a tibial stress fracture shown in Figure A, a low BMI, and secondary amenorrhea. Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete.

Secondary amenorrhea is defined as the cessation of menses for 6 months after at least one normal cycle. The "female triad" includes amenorrhea, disordered eating, and osteoporosis (which may result in stress fractures).

Bennell et al performed a Level 2 study of 53 female and 58 male track and field athletes. Over 1 year they found a 21% incidence of stress fractures in their athletes. Significant risk factors for stress fracture in female athletes included lower bone density, a history of menstrual disturbance, less lean mass in the lower limb, a discrepancy in leg length, and a lower fat diet.

Incorrect Answers:
Answer 1: Neurofibromatosis Type 1 is associated with malignant peripheral nerve sheath tumors and tibial bowing
Answer 2: Osteofibrous dysplasia creates an anterior eccentric tibial lesion in child that often leads to tibial bowing.
Answer 4: Formation of a fusion protein (EWS-FLI1) is associated with Ewing's sarcoma.
Answer 5: Focal fibrocartilaginous dysplasia is associated with an abrupt varus at the metaphyseal–diaphyseal junction of the tibia

REFERENCES:

Question Authors:

Michael Hughes MD, John Badylak MD, Patrick McCulloch MD,

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(SBQ04.16) Women athletes have a higher rate of ACL tears than male athletes in the same sport. While the cause is likely multi-factorial, which of the following factors has been shown to contribute most significantly to this observation? Topic

Review Topic

1. ACL size
2. Estrogen levels
3. Neuromuscular coordination and training
4. Intra-articular notch size
5. Valgus leg alignment

PREFERRED RESPONSE ▶

DISCUSSION: There are many theories to account for the increased incidence of ACL tears in women athletes. While each of the answers may contribute, recent studies have shown that differences in the level of neuromuscular training and coordination play the most significant role. This is a potentially modifiable factor and jump training and plyometric conditioning programs have been shown to decrease the rates of ACL injury in women.

The Griffin and the Harmon papers are reviews by experts in ACL injury which list all of the answers as contributing factors to increased ACL injury rates seen in women athletes. Of these, neuromuscular imbalances were felt to be both the most significant and of particular interest because they are potentially modifiable.

The Zebis reference states that neuromuscular training increased EMG activity for the medial hamstring muscles, thereby decreasing the risk of dynamic valgus. This observed neuromuscular adaptation during sidecutting could potentially reduce the risk for non-contact ACL injury.

REFERENCES:

1. Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, Demaio M, Dick RW, Engebretsen L, Garrett WE Jr, Hannafin JA, Hewett TE, Huston LJ, Ireland ML, Johnson RJ, Lephart S, Mandelbaum BR, Mann BJ, Marks PH, Marshall SW, Myklebust G, Noyes FR, Powers C, Shields C Jr, Shultz SJ, Silvers H, Slauterbeck J, Taylor DC, Teitz CC, Wojtys EM, Yu B. Understanding and preventing noncontact anterior cruciate ligament injuries: A review of the Hunt Valley II Meeting. Am J Sports Med. 2006;34:1512-32. PMID:16905673 (Link to Abstract)

2. Harmon KJ, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clin Sports Med 2000;19:287-302. PMID:10740760 (Link to Abstract)

3. Zebis MK, Bencke J, Andersen LL, Døssing S, Alkjaer T, Magnusson SP, Kjaer M, Aagaard P. The effects of neuromuscular training on knee joint motor control during sidecutting in female elite soccer and handball players. Clin J Sport Med. 2008;18(4):329-37. PMID:18614884 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD, Michael Hughes MD,

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(OBQ09.240) A 16-year-old gymnast is diagnosed with the female athletic triad. Which of the following treatments is the least appropriate management? Topic

Review Topic

1. Calcium and Vitamin D
2. Oral contraceptive pills
3. Reduced intensity of training
4. Bisphosphonates
5. Psychological counseling

PREFERRED RESPONSE ▶

DISCUSSION: Bisphosphates are the least appropriate step in management of the female athlete triad.

The female athlete triad consists of eating disorders, amenorrhea, and osteoporosis. Treatment should consist of:
1. Consultation with a psychiatrist or psychologist for counseling to deal with self esteem issues and eating disorders.
2. Training should be limited until menses resume.
3. Supplemental vitamin D and calcium should be initiated as well as consideration of oral contraceptive pills.

Nattiv et al examines the relationship between the components of the triad and how the disorder may lead to significant morbidity and even mortality.

Sabatini argues that the components of the triad are linked pathophysiologically, and emphasizes the importance of a multidisciplinary treatment approach, with psychological counseling being the core.

REFERENCES:

1. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 345-352

2. Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad: The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994;13:405-418 PMID:8013041 (Link to Abstract)

3. Sabatini S. The female athlete triad.Am J Med Sci. 2001 Oct;322(4):193-5. PMID:11678514 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Eric Shirley MD,

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(OBQ05.169) The female athlete triad refers to those athletes with: amenorrhea, osteoporosis, and what other entity? Topic

Review Topic

1. Eating disorder
2. Stress fractures
3. Ligamentous laxity
4. Increased rate of ACL tears
5. Hirsutism

PREFERRED RESPONSE ▶

DISCUSSION: The female athlete triad refers to the combination of disordered eating, amenorrhea and osteoporosis. This disorder often goes unrecognized and can affect many female athletes. The consequences of lost bone mineral density can be devastating for the female athlete. Premature osteoporotic fractures can occur, and lost bone mineral density may never be regained. Early recognition of the female athlete triad can be accomplished with an integrated intervention between the family physician, coaches, parents and patient. Often these patients first present to the Orthopaedic surgeon or team physician for management of an osteoporotic fracture. Instituting an appropriate diet and moderating the frequency of exercise may result in the natural return of menses.

REFERENCES:

1. Nattiv A, Agostini R, Drinkwater B, et al. The female athlete triad: The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994; 13: 405-18. PMID:8013041 (Link to Abstract)

2. Garrick JG (ed): OKU: Sports Medicine III. Rosemont, Il AAOS, 2004, p 345-52.

Question Authors:

Patrick McCulloch MD, Derek Moore, Ben Taylor MD,

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ABOS II: The Female Athlete

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Bennell KL, Malcolm SA, Thomas SA, Reid SJ, Brukner PD, Ebeling PR, Wark JD. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996 Nov-Dec;24(6):810-8. PMID:8947404 (Link to Abstract)
Zebis MK, Bencke J, Andersen LL, Døssing S, Alkjaer T, Magnusson SP, Kjaer M, Aagaard P. The effects of neuromuscular training on knee joint motor control during sidecutting in female elite soccer and handball players. Clin J Sport Med. 2008;18(4):329-37. PMID:18614884 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, Demaio M, Dick RW, Engebretsen L, Garrett WE Jr, Hannafin JA, Hewett TE, Huston LJ, Ireland ML, Johnson RJ, Lephart S, Mandelbaum BR, Mann BJ, Marks PH, Marshall SW, Myklebust G, Noyes FR, Powers C, Shields C Jr, Shultz SJ, Silvers H, Slauterbeck J, Taylor DC, Teitz CC, Wojtys EM, Yu B. Understanding and preventing noncontact anterior cruciate ligament injuries: A review of the Hunt Valley II Meeting. Am J Sports Med. 2006;34:1512-32. PMID:16905673 (Link to Abstract)
Harmon KJ, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clin Sports Med 2000;19:287-302. PMID:10740760 (Link to Abstract)
Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad: The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994;13:405-418 PMID:8013041 (Link to Abstract)
Sabatini S. The female athlete triad.Am J Med Sci. 2001 Oct;322(4):193-5. PMID:11678514 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 345-352

Undefined

Bennell KL, Malcolm SA, Thomas SA, Reid SJ, Brukner PD, Ebeling PR, Wark JD. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996 Nov-Dec;24(6):810-8. PMID:8947404 (Link to Abstract)
Barrow GW, Saha S. Menstrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med. 1988 May-Jun;16(3):209-16. PMID:3381976 (Link to Abstract)
Nattiv A, Agostini R, Drinkwater B, et al. The female athlete triad: The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994; 13: 405-18. PMID:8013041 (Link to Abstract)
Garrick JG (ed): OKU: Sports Medicine III. Rosemont, Il AAOS, 2004, p 345-52.

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The Female Athlete

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