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Common Problems in the Female Athlete

Common Problems in the Female Athlete. Jennifer Roth, MD Family & Sports Medicine Consultant Mayo Clinic Florida. DISCLOSURE. Relevant Financial Relationships None Off Label Usage None. Benefits of Athletics. Improved physical fitness Enhanced self-esteem

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Common Problems in the Female Athlete

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  1. Common Problems in the Female Athlete • Jennifer Roth, MD • Family & Sports Medicine Consultant • Mayo Clinic Florida

  2. DISCLOSURE • Relevant Financial Relationships • None • Off Label Usage • None

  3. Benefits of Athletics • Improved physical fitness • Enhanced self-esteem • Improved physical and mental health • Promotion of peak bone mass • Encourage team building and leadership skills

  4. Title IXPatsy T Mink Equal Opportunity in Education Act • June 23, 1972 • "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 education program or activity receiving Federal financial assistance..." • —United States Code Section 20

  5. Title IX • Since 1972, 10 fold increase in sports participation in High School girls • Female athlete participation 2009 • 178,000 NCAA • 3,000,000 high school

  6. Sex Differences • Children- • similar characteristics and body mass • Growth phases

  7. Sex Differences • Strength • Equal muscle fiber ratio, but females have smaller fibers • After puberty, women only have small amount of increase in strength Greydanus, D The Adolescent Female Athlete, Ped Clin N Am, 2010

  8. Sex Differences • Body composition • Female ~25% body fat vs 14% male • Male greater muscle mass due to androgen effect • Performance • For same body weight (and training), FEMALES have • Smaller heart  lower stroke volume • Lower blood pressure • Smaller lungs  decreased VO2max • Lower blood volume, lower Hgb • …decreased endurance performance

  9. Knee Injuries Common to the Female Athlete • Patellofemoral Pain (PFPS) • Anterior Cruciate Ligament (ACL) tears

  10. ACL Tears- Why more common in females? • NCAA female athletes 2-8x more likley to sustain ACL tear than males • Anatomy • Hormonal • Biomechanical • Environmental

  11. ACL Tears in Female Athletes • Noncontact Injury 85% > Contact 15% • 29% Planting/cutting • 28% Straight knee landing • 26% One-step landing with knee in hyperextenison 11

  12. ACL Tears in Female AthletesANATOMY • 2 bundles- resist anterior translation of tibia relative to femur • Female ACLs smaller in size • Decreased intracondylar knotch width in females http://www.scoi.com/aclrecon.htm

  13. ACL Tears in Female AthletesHORMONES • Estrogen receptors found in fibroblasts, decreases collagen formation • High levels of estrogen may decrease neuromuscular control • may increase laxity • Injury rate highest during preovulatory phase compared to postovulatory

  14. ACL Tears in Female AthletesBIOMECHANICS • “Miserable Malalignment” • excessive foot pronation • pes planus • external tibial rotation • Q-angle >15 deg • Femoral anteversion • Hypoplastic VMO • Heel valgus angulation

  15. Q-Angle • Angle measured in full hip and knee extension • ASIS to midpoint patella • Midpoint patella to tibial tubercle • Normal female Q-angle 17° (men 14°) • Higher angles increases lateral pull of quadriceps • May increase risk of ACL tear or PFPS 15 Boles CA The Female Athlete, 2010

  16. Position of No Return (A) • Body upright • Extension, adduction, IR of hip • Knee in valgus with ER of tibia • Pronation and eversion of foot • Body weight on ball of foot • (B) safer landing • Hip flexion • Little-no adduction • Foot balanced Boles CA The Female Athlete, 2010

  17. Position of No Return http://www.exercisebiology.com/index.php/site/articles/how_to_prevent_acl_injuries

  18. Position of No Return • Females are quadriceps dominant • Decreased medial recruitment (VMO) • Decreased gluteal and hip adductor activation • Fatigue adds to decreased hip flexion and increased valgus • *More ACL tears during practice than games • Exposure time vs fatigue?

  19. ACL Tears in Female AthletesENVIRONMENT • Surface • Drier surfaces increases friction • Artificial turf mixed results • Shoe type • Cleat size and pattern • Knee braces • INEFFECTIVE to prevent ACL tear • Long term may decrease quad strength

  20. ACL TreatmentSurgical vs Nonsurgical • Surgical • Younger, active athletes • Autograft vs allograft • Nonsurgical • Older, less active • Increased risk early degenerative changes

  21. ACL Tear Prevention • PEP Programs • (Prevent injury Enhance Performance) • Increased hamstring strength • Increases dynamic stability of ACL • Appropriate warm up • Landing techniques • Hamstring • strengthening

  22. Patellofemoral Pain SyndromePFPS • 25% all knee complaints • 20% female > 7.4% male • Retropatellar/ anterior knee pain with stable patella • DDx: • Patellar tendinopathy or instability • Plica syndrome • Osgood Schlatters • Sinding Larson Johanson

  23. PFPS: Causes • Quad dysfunction • VMO to vastus lateralus imbalance • Static Malalignment • Q-angle • Larger angle increased lateral forces • Femoral neck anteversion, external tibial torsion, hyperpronation • Extensor mechanism malalignment • Patellar maltracking • Dynamic Malalignment-cutting & landing • Hip adduction and internal rotation, contralateral pelvic drop

  24. PFPS: Treatment • Conservative • VMO strengthening, quad stretch • Hip abductor strengthening • Bracing- mixed evidence • Orthotics- arch support for navicular drop • Surgical • Lateral (retinaculum) release • Debridement

  25. Female Athlete Triad Disordered Eating Amenorrhea Osteoporosis 25

  26. Female Athlete Triad • 1992- ACSM Task Force on Women's Issues • Identified 3 interrelated disorders • 1997- ACSM Position Statement • Classic definition • Defined prevalence & consequences • Call for research • 2007- ACSM Position Statement- revised • Low energy availability is key disorder • Athletes can exist along a spectrum 26

  27. Energy Availability Menstrual Function Bone Health 27

  28. FIGURE 1—Female athlete triad. The spectrums of energy availability, menstrual function, and bone mineral density along which female athletes are distributed (narrow arrows). An athlete’s condition moves along each spectrum at a different rate, in one direction or the other, according to her diet and exercise habits. Nattiv et al. ACSM Female Athlete Triad Position Stand, Medicine & Science of Sport and Exercise Oct 1 2007.

  29. ↓Energy Availability ↑Stress IRREVERSIBLE LOSS OF BMD… ∆ Hypothal GnRH ⇑Risk of amenorrhea ∆ Metabolic mediators of bone formation ⇓ LH pulse ⇧ Risk of Stress Fractures ⇓ Estrogen ⇑ Bone resorption ⇓Bone formation ⇩⇩Bone Mineral Density ∆Menstrual Function

  30. Female Athlete TriadRisk Factors/ Red Flags • Sports that emphasize appearance • Ballet, figure skating, gymnastics, cheerleading • Pressure to maintain low body mass for optimal performance • Cross country, swimming, martial arts • Overtraining • Outside scheduled practice or until exhaustion • Training even if sick or injured • Traumatic event: injury, poor performance, coach

  31. Energy AvailabilityOptimal Energy ↔ Low Energy Energy Input Energy Output Energy Availability • Normal caloric intake 30 kcal/kg/day • After 5 days of restriction <30kcal/kg/d • LH pulse frequency  estradiol • Bone formation • Bone resorption • Severe under-nutrition impairs reproductive and skeletal health. • ACSM Recommendation Statement-Evidence category A

  32. Disordered Eating • More prevalent in sports that emphasize: • Appearance- gymnastics, figure skating, diving, cheerleading • Leanness- track & field, crew, distance running • *ACSM Evidence Statement A • Food restriction • Ex: high fat, protein, carbs • Binge/Purge • Self induced, diet pills, laxatives, diuretics, excessive exercise

  33. Eating Disorders (DSM-IV) • Anorexia nervosa • Restrictive eating • Distorted view that pt is overweight • Intense fear of gaining weight • >15% underweight (BMI <18.5) • Amenorrhea is a DSMIV criteria • Bulimia nervosa • Normal weight range • Binge  purge > 2 times/week • Eating disorder NOS

  34. Anorexia Athletica • Distinctly associated w sports training: • Perfectionism • Compulsiveness • Competitiveness • High self motivation • Menstrual disturbances • Unhealthy weight control (at least ONE) • Fasting, vomiting, diet pills, laxatives, diuretics

  35. Menstrual FunctionEumenorrhea ↔ Amenorrhea • Oligomenorrhea: menses occurring >35 day cycles • Amenorrhea: menses occurring >90 day cycles • Primary: delay in the age of menarche >15 yo in a girl with secondary sexual characteristics • Or- absence of any secondary sexual characteristics by age 14 • Competition in sports at younger ages ex: gymnastics, skating, cheerleading • Secondary: cessation of menses after menarche • Most common form of athletic amenorrhea

  36. Menstrual FunctionEumenorrhea ↔ Amenorrhea • Prevalence of menstrual dysfunction: • General population 2-5% • Female athletes 6-79% • Mechanism: ENERGY DEFECIT  functional hypothalamic amenorrhea • Hypothalamic-pituitary-ovarian axis • Suppression of GnRH • Via stress, energy deficit or decreased leptin during calorie restriction • Decrease in LH pulse frequency • Decrease in circulating estrogen

  37. Bone Mineral DensityOptimal Bone Health ↔ Osteoporosis • Post-menopausal Adults: • accelerated bone mineral loss • Hypoestrogen state • Adolescent Athletes: • failure to accumulate optimal BMD • Hypoestrogen, but also decreased growth factors (GH, insulin, cortisol, leptin, TSH) • Athletes in weight bearing sports should have 5-15% HIGHER BMD than non-weight bearing sports… • Bone loss may occur rapidly in the first 2-3 years after menstrual disturbance ~ 4% per year

  38. Bone Mineral DensityOptimal Bone Health ↔ Osteoporosis • Risk Factors: • Nutritional deficits • Hypoestrogenism • Stress fractures T-score: mean of zero, compares to peak BMD of healthy young woman. Z-score: relative to age, better correlation for young females <20 yrs old

  39. Bone Mineral DensityStress Fractures Stress fx of tibia in runner. • Overuse injuries where resorption outpaces formation • Exacerbated in athletes with poor bone quality or poor nutritional intake. • Direct correlation between number of months of amenorrhea and number of stress fractures. • *Menstrual irregularities and low BMD increases stress fracture risk. (RR 2-4 fold) • - ACSM Recommendation Statement Evidence category A

  40. Bone Mineral DensityStress Fractures • Bony resorption >> formation • Any bone in the body, varies by sport 40

  41. Bone Mineral DensityStress Fractures • Imaging • Xray • Depends on acuity • Bone Scan • Non-specific, r/o tumor, infection • MRI • Periosteal and marrow edema = Stress reaction • Fracture line = stress fracture 41

  42. Female Athlete TriadDetection • Screening is continuous… • Detection of one component should trigger investigation for all three • Screening questions address • Menstrual hx • Dietary behaviors • Mental health/perception/outside pressures • Injuries (*stress fx) • Lab testing (if indicated) • ** ßhcg, TSH, LH/FSH, Chem7, prolactin • Imaging (if indicated) • DXA scan • Xray vs bone scan vs MRI (determine acuity) 42

  43. Multidisciplinary Team physician PA or NP Registered Dietitian Mental Health Provider ATC Coaches Parents/family *ACSM Evidence C EDUCATION!! Optimizing energy availability Nutritional requirements Maximize bone mineral health Importance of weight bearing activity Menstrual function NOT “normal” to miss a few periods while training… Female Athlete TriadTreatment 43

  44. Female Athlete TriadTreatment • Overall Increase energy availability • energy intake energy expenditure • Disordered Eating • Refer to mental health practitioner • Supplements: Ca, Vit D, Vit K, protein • Must comply w tx for sport participation • Meds: SSRI plus cognitive behavioral therapy • *not Wellbutrin! 44

  45. Female Athlete TriadTreatment • Functional Hypothalamic Amenorrhea • Weight gain is key to normalize menses and increase BMD. • OCPs - delay and reduce likelihood of restoring regular menstrual cycle • OCPs will not normalize metabolic factors that impair bone formation. • If BMD declines in athlete >16yo w persistent FHA, despite adequate nutrition and body weight • OK to consider OCP to minimize further bone loss • No guidelines for OCPs in athletes <16yo 45

  46. Female Athlete TriadTreatment • Stress Fracture treatment • **REST** until pain free • Restoration of adequate nutrition & menstrual cycle  GRADUAL return to play • Few surgical indx (poor vascular supply) • Femoral neck, base 5th MT, tarsal navicular • Low Bone Mineral Density • Bisphosphonates should NOT be used • Unproven efficacy in women of child-bearing age • Bisphosphonates may reside in bone for years potential harm to developing fetus • * In FHA, increases in BMD are more closely associated with increases in weight than with OCP/HRT. • *ACSM Evidence Statement, Category C 46

  47. Female Athlete TriadRx effect on BMD • In FHA, increases in BMD are more closely associated with increases in weight than with OCP/HRT. (or bisphosphonate) • *ACSM Evidence Statement, Category C BMI best predictor of BMD

  48. Heat Related Illness • Females sex NOT considered increased risk for heat related illness • Risk factors ~ 3 athletes/year die • Children • Generate more heat, slower acclimatization, higher SA to body • Obesity • Illness (fever) • Prescription drugs (NSAIDs, diuretics, SSRI) • Environment- heat, humidity

  49. Heat Related Illness Definitions • Heat Illness • Minor sx of edema, cramping, lightheaded • Tx: move to cooler area, shade, Na supp, rehydration, supine position • Heat Exhaustion • Multisystemic sx of dizziness, nausea, vomiting, weakness, tachycardia • Core temp 38-40.0 C (<104 F) • Tx- as above, monitor closely

  50. Heat Related IllnessDefinitions • Heat Stroke • Symptoms of heat exhaustion AND Core temp >40 C (104F) • MEDICAL EMERGENCY • Tx: Immediate cooling • Ice water immersion, cool NS • Cool to 102F before transfer

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