Updated: 9/20/2018

The Female Athlete

Topic
Review Topic
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Questions
13
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Evidence
14
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Videos
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https://upload.orthobullets.com/topic/3125/images/valgus medial knee collapse.jpg
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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
    • insufficient energy availability
      • insufficient caloric intake 
        • is the most common cause of amenorrhea in female athletes 
      • may or may not be associated with an eating disorder
    • 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
  • No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any educational program or activity receiving federal financial assistance
 

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(SBQ07SM.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? Review Topic

QID: 1460
FIGURES:
1

Neurofibromatosis Type 1

0%

(4/1043)

2

Osteofibrous dysplasia

4%

(46/1043)

3

Poor caloric intake

93%

(971/1043)

4

Formation of a fusion protein (EWS-FLI1)

1%

(8/1043)

5

Focal fibrocartilaginous dysplasia

1%

(12/1043)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ12.129) A 15-year-old female who is an avid runner has started developing increasing pain along her right leg. She indicates that the pain has developed in the past few months and has progressed in the past few weeks to where she cannot tolerate weightbearing on the limb. She runs approximately 10 miles per day and is set on a collegiate running career. She notes that her menses began at age 11, but she has not had a menstrual cycle for 3 months presently. She denies sexual activity. On examination, she is exquisitely tender over the right tibia at the level of the middle to distal third. Radiographs are seen below in Figure A and Figure B. Which of the following should be included as part of this patient’s management? Review Topic

QID: 4489
FIGURES:
1

Observation with continuation of physical activity

1%

(34/3806)

2

Discontinuation of running with weightbearing in CAM walker

10%

(377/3806)

3

Intramedullary nailing of the tibia

1%

(27/3806)

4

Casting of the affected lower extremity

1%

(55/3806)

5

Discussion of eating habits and training regimens

87%

(3293/3806)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(SBQ07SM.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? Review Topic

QID: 1456
FIGURES:
1

Osteoporosis

0%

(0/283)

2

Anorexia

0%

(1/283)

3

Secondary amenorrhea

0%

(0/283)

4

Answer 2 and 3

17%

(48/283)

5

All of the above

82%

(233/283)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(SBQ04SM.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? Review Topic

QID: 4
1

ACL size

1%

(35/2441)

2

Estrogen levels

3%

(81/2441)

3

Neuromuscular coordination and training

76%

(1844/2441)

4

Intra-articular notch size

6%

(147/2441)

5

Valgus leg alignment

13%

(324/2441)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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

QID: 1055
1

Eating disorder

90%

(1268/1411)

2

Stress fractures

8%

(106/1411)

3

Ligamentous laxity

1%

(13/1411)

4

Increased rate of ACL tears

0%

(4/1411)

5

Hirsutism

1%

(18/1411)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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

QID: 3053
1

Calcium and Vitamin D

1%

(5/627)

2

Oral contraceptive pills

20%

(128/627)

3

Reduced intensity of training

2%

(13/627)

4

Bisphosphonates

74%

(466/627)

5

Psychological counseling

2%

(14/627)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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