By: Dr. Patricia Graham
There has been a dramatic increase in female sports participation in recent years. More than 30 percent of women now participate in college sports, and about 40 percent of high school women participate in athletics.
To obtain the maximum benefits from sports, issues unique to female athletes require gender-specific coaching, training, psychological support and treatment.
In part because of a shorter upper arm, women have 40 to 75 percent of the arm strength of men, and 60 to 80 percent of their leg strength. Less capacity for muscle bulk increase with training may also lead to women’s relatively lower endurance (6-15 percent less) relative to men. However, since women have the same capacity for strength gains as men, exercise programs that focus on improving muscle tone, as well as flexibility, agility and speed, may optimize athletic performance.
Injuries to female athletes are most frequent in basketball, soccer and volleyball. Females may be more susceptible to strains, sprains and other injuries as a result of having hyper-flexible ligaments. In particular, there is a higher risk for injury to the knee, especially at the Anterior Cruciate Ligament (ACL) in sports like soccer, basketball and downhill skiing.
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‘Building bone density in young females is very important between ages 11 and 18; nutritional factors, such as increased calcium intake, weight-bearing activities and posture are essential factors.’ Dr. Patricia Graham
Physiatrist The Medical Center at Princeton |
ACL injury may be due to differences in women’s ACL size, anatomical variance, thigh muscle recruitment patterns, landing patterns when jumping, training errors or shoe-surface interfaces. Symptoms can include a popping sensation (with acute trauma), knee buckling, swelling and inability to walk. Rest, bracing, physical therapy, medications and surgery may be needed, depending on the severity of injury.
Pain at the kneecap is most common in the younger female athlete and can follow an ACL injury. Symptoms include anterior knee pain that is worse with walking stairs, squatting exercises or with prolonged sitting. Athletes with a wider pelvis, misalignment of hip and knee, weak quadriceps muscles and/or altered foot mechanics are predisposed to what has come to be known as "miserable misalignment syndrome."
Dislocation and laxity of the knee cap is also more common in females. In most cases, with physical therapy, bracing and pain medications, surgery is avoided.
Hip injuries such as hip flexor tendonitis are less likely and are most commonly secondary to overuse in sports and dance. Rarely, steroid use and osteoporosis can predispose the athlete to erosion of the femoral head, the "ball" of the hip’s "ball and socket" joint configuration and can require a surgical prosthetic replacement.
Building bone density in young females is very important between ages 11 and 18; nutritional factors, such as increased calcium intake, weight-bearing activities and posture are essential factors. Paradoxically, however, over-training, in combination with other factors, can predispose a young female athlete to decreased bone density and susceptibility to fractures. In fact, women athletes have nearly triple the risk of stress fractures than males, with hip, pelvic, tibial and mid-foot bones the most likely sites of injury.
Risk factors include low bone density, irregular menses, nutritional factors (inadequate calories and/or calcium), low body weight and fat, bone geometry (females have a narrower tibia) and training errors. Although X-rays can be used for the diagnosis of stress fractures, often a bone scan is more sensitive.
Taking a break from the athletic activity, pain medications, decreased weight bearing to the affected limb and physical therapy can permit a slow return to athletic activities. Surgery is rarely needed.
With the peer pressures of adolescence and the loss of family support with transition to college, young females are much more susceptible to the stress of realizing the thin, lithe female ideal. This can lead to poor nutrition, depression and anxiety. The female athlete triad is a term used to describe the most serious consequences of these factors disordered eating habits (anorexia and bulimia) and disruption of menstrual cycles, which can lead to osteoporosis.
Although the incidence of eating disorders in young female athletes is similar to that of the general population, the high caloric demand of athletic training results in a much higher physical and medical impact. This predisposes these women to osteoporosis at a very young age. In effect, a 25-year-old athlete can have the bone density of a 50-or 70-year-old woman.
Unfortunately, research has consistently shown that osteoporosis in this setting does not respond to medical treatment as in post-menopausal women and is, in effect, irreversible.
Other risk factors that can predispose a young athlete to this triad include a family history of obesity or eating disorder, an emphasis on over-achieving, compulsive attitudes toward exercise and low body weight, and limited social activities besides sports.
Gymnasts are particularly susceptible because their sport involves subjectively-scored performances, categorized by weight, and requires body contour-revealing clothing. Runners are at risk as well, because lower body weight, if not extreme, can enhance performance.
The definitive test to assess bone density loss and provide a diagnosis of osteoporosis is a DEXA scan. Treatment with calcium-rich diet, calcium supplements, vitamin D and hormone replacement therapy may be needed to prevent further loss of bone integrity.
Women are also more likely to experience involuntary loss of urine because of increased intra-abdominal pressure during exercise, especially running and jumping sports. Pelvic muscle exercises and avoidance of excessive fluids prior to sports events can offset this problem; evaluation of menstrual and anatomical abnormalities may be needed.
Although there has been no proven difference in athletic performance in females during different phases of the menstrual cycle, onset of menstruation can be delayed and cycles can become irregular with growth spurts, over-training, stress or poor nutrition.
Thus, it is important for female athletes to receive appropriate medical screening prior to undertaking vigorous sports activities, to identify the strengths and weaknesses unique to their body. For example, a history of previous fractures, sprains or strains can define areas at risk of new injury. Mitral valve prolapse and low blood pressure are more common in female athletes and can lead to lower performance.
A history of eating disorders or osteoporosis in the family needs to be discussed. Proper counseling and education regarding these areas of risk, in combination with proper exercise training, allow the female athlete to enjoy the benefits of sports activities more fully.
Dr. Patricia Graham is a physiatrist specializing in pain management, musculoskeletal and nerve injury, and women’s health issues; she is on staff at The Medical Center at Princeton. Health Matters appears Fridays in the Lifestyle section of The Princeton Packet and is contributed by The Medical Center at Princeton.