The Female Athlete

Emergence of Competitive Sport for Women

As Wizemann and Pardue noted in 2001, “Males and females have different patterns of illness and injury. Understanding the core of gender-based differences is important to the development of novel approaches to prevention, diagnosis and treatment.” This statement rings true for sports medicine along with other fields of medicine. Competitive sporting events for women have rapidly developed in the past several decades, with a corresponding emergence of an increasing number of excellent competitive women athletes. Prior to the 1970s, few women participated in organized sport. However, the passage of Title IX of the Educational Assistance Act of 1972 required institutions receiving federal money to offer equal opportunities to both males and females in all programs, including athletics. Title IX was the impetus for rapid growth not only in collegiate women’s sport but also in athletic opportunities available to high school and recreational female athletes ( Table 32-1 ).

TABLE 32-1


Participation Level 1971-1972 2000-2001 2010-2011
High school 294,015 2,784,154 3,173,549
Collegiate 29,972 150,916 190,000
Olympic 1264 (15.5% of all athletes) 4935 (37.8% of all athletes) 5091 (46.6% of all athletes)

Before the 1980s, women’s sporting gear was difficult to obtain. However, after the passage of Title IX, the demand for female-specific sport clothes and equipment has increased exponentially. Prior to this era, female athletes often wore men’s shoes (a practice that was associated with an increase in foot problems), men’s warm-up clothing, and men’s sport protection equipment (e.g., shin guards in soccer, eye protection in racket sports, and mouth guards). However, in the 1990s business boomed for women’s sports gear, including warm-ups, shorts, skirts, shirts, sports bras, shoes, braces, and protective pads. Because they are now sized to women’s figures, braces and other protective sport gear now fit more comfortably. Shoes developed specifically for women have a more comfortable fit, which has resulted in fewer foot problems. Furthermore, sportswear has turned into a fashion statement for many women. Lightweight clothing that wicks away perspiration is common and is offered in pinks, purples, and other bright colors to enhance style ( Fig. 32-1 ). Sports clothes that emphasize both optimal function and elegance have resulted in a multibillion dollar business for numerous companies, including Nike, Adidas, Title Nine, and Athleta, among others.


Sports gear made for women.

Before 1970, women’s sports rarely received media coverage in newspapers, sports magazines such as Sports Illustrated, or on television or radio; however, this trend is changing ( Fig. 32-2 ). In the past several years the Tennessee, University of Georgia, and University of Connecticut women’s basketball teams have all headlined USA Today , Sports Illustrated, and other sport publications. Women’s golf and tennis events are now aired on prime-time television. The world knows the names of female athletes such as Michelle Wie and Anna Kournikova. The Women’s National Basketball Association (WNBA) aired 47 games in 2002, which increased to 132 for the 2011 season, and thanks to “WNBA Live Access,” approximately 200 games were televised during the 2012 season. Yahoo has reported that 7 of the top 10 searches of 2012 Olympic athletes were for women, and the most searched Olympian on their Web site was Hope Solo.


News coverage of women’s sports has increased significantly in the past several decades.

Parallel to and, perhaps arguably, secondary to the increased emphasis on women’s sport participation, women’s performance in swimming and running events has improved ( Table 32-2 ). Furthermore, the speed of basketball, soccer, tennis, and volleyball games has increased because of the improvement in women’s skills and overall athleticism. In 2003, Annika Sorenstam was a competitive player in a PGA event, and the world was enthralled by the gold-winning performance of Mia Hamm and the members of the USA women’s soccer team at the 2004 Olympic Games. In the 2012 Olympics in London, the USA women’s teams won 60% of the overall tally of U.S. medals.

TABLE 32-2


Olympics 1972 1996 2012
100-m free 59.44 54.50 53.00 OR
400-m free 4 : 19.89 4 : 07.25 4 : 01 : 45 OR
800-m free 8 : 59.69 8 : 27.89 8 : 14 : 63 AR
800-m run 2 : 03 1 : 57.04 1:56:19
1500-m run 4:26.5 4:00.83 4:10:23
Collegiate Events * 1972 1996 2012
50-yd free 23.16 22.59 21.48
100-yd free 49.37 49.04 46.88
500-yd free 4:41.61 4:42.46 4:36.66
1650-yd free 16:02.34 16:06.23 15:38.79
800 m 2:05.22 2:03.27 2:02.58
1500 m 4:17.90 4:17.92 4:11.69
10,000 m 33:36.51 32:56.63 32:41.63
High School 1972 1998 2012
800 m 2:04.7 2:06.30 2:03.34
3200 m 10:51.0 10.25.99 10:08.11
Boston Marathon 1972 1996 2011
3:10:26 2:27:12 2:22:36

AR, American record; OR, Olympic record.

* Sanctioned in 1982.

General Considerations


Ongoing debate has ensued about whether conditioning techniques used for men are appropriate for women. Articles have been written about the subject, and presentations at scientific meetings have discussed the need (or lack thereof) to alter training and conditioning practices into several women’s sports, including soccer, softball, basketball, volleyball, and lacrosse. It has been recommended that women incorporate more agility and balance exercises into their training to decrease the frequency of noncontact anterior cruciate ligament (ACL) injuries in these sports. The adage “stronger is better” is now being modified because strong muscles that fire at inappropriate times can cause harm rather than ensure protection from injury during an athletic event. Programs in women’s sports with a high risk for ACL injuries are adopting training and conditioning routines that emphasize not only customary strength, flexibility, and aerobic conditioning exercises but also drills aimed at enhancing balance and agility. Incorporating plyometric drills appears to be appropriate in both men’s and women’s programs (this topic is discussed in detail in the ACL Injuries section of this chapter).

A greater emphasis on core strengthening also may be appropriate for women, who have been reported to have more anterior pelvic tilt than do men. Medial quadriceps exercises should be emphasized in women with increased knee valgus, and these exercises should commence during the prepubescent age and continue through the pubertal years and into postpuberty maturation. By building strength in the vastus medialis, patellofemoral pain may be diminished.

Because postpubertal women are reported to have increased flexibility compared with men, strengthening scapular stabilizers and the muscles of the rotator cuff to prevent shoulder instability issues is recommended in swimmers, volleyball, lacrosse, and softball players, and athletes involved in racquet sports. “Prevention rather than cure” should be the norm and can prove to be beneficial.

After puberty, training and conditioning programs should also account for inherent gender-based physical and physiologic differences ( Table 32-3 ). Men are more fully developed in the upper body and have a narrow pelvis and hence a higher center of gravity, whereas women have narrower shoulders compared with men yet possess a proportionally wider pelvis, resulting in a lower center of gravity. Men have more muscle mass per body weight, whereas women athletes, even those who are considered to be well conditioned, have more body fat than men (18% to 20% in women vs. 10% to 15% in men). Men have a greater thoracic capacity and hence a greater maximal oxygen consumption (V o 2 max) than do women. In addition, women have less overall aerobic capacity compared with men. Hence, although women athletes have improved athletic performance significantly during the past decade, their performance times in both anaerobic and aerobic running events are not equal to those of men ( Table 32-4 ). A few conditioning tips for women athletes are listed in Box 32-1 .

TABLE 32-3


Parameter Postpubertal Girls Postpubertal Boys Impact
Oxygen pulse (efficiency of cardiorespiratory system) Lower Higher Higher oxygen pulse provides boys with an advantage in aerobic activity
V o 2 max (reflects level of aerobic fitness) Lower Higher Boys have greater aerobic capacity
Metabolism (BMR) 6%-10% lower (when related to body surface area) 6%-10% higher (when related to body surface area) Girls need fewer calories to sustain the same activity level as boys
Thermoregulation Equals boys Equals girls Equal ability to adequately sweat in a hot environment to decrease core body temperature
Endocrine system
Testosterone Lower Higher Boys have increased muscle size, strength, and aggressiveness
Estrogen Higher Lower Unknown if related to increase in ligamentous laxity or rate of ACL injuries
Height 64.5 in 68.5 in Increased height and weight in boys give them structural advantages
Weight 56.8 kg 70.0 kg
Limb length Shorter Longer Boys can achieve a greater force for hitting and kicking
Articular surface Smaller Larger May provide boys with greater joint stability; boys have greater surface area to dissipate impact force
Body shape Narrower shoulders
Wider hips
Legs 51.2% of height
More fat in lower body
Wider shoulders
Narrower hips
Legs 52% of height
More fat in upper body
Girls have a lower center of gravity and therefore greater balance ability; girls have increased valgus angle at the knee that increases knee injuries; boys and girls have different running gaits
% Muscle/total body weight * 36% 44.8% Boys have greater strength and greater body speed
% Fat/total body weight 22%-26% 13%-16% Girls are more buoyant and better insulated; they may be able to convert fatty acid to metabolism more rapidly
Age at skeletal maturation 17-19 years 21-22 years Girls develop an adult body shape/form sooner than boys do
Cardiovascular system
Heart size Smaller Larger Stroke volume in girls is less, necessitating an increased heart rate for a given submaximal cardiac output; cardiac output in girls is 30% less than in boys; the risk of hypertension may be less in girls
Heart volume Smaller Larger
Systolic blood pressure Lower Higher
Hemoglobin 10%-15% > per 100 mL blood The oxygen-carrying capacity of blood is greater in boys
Pulmonary system
Chest size Smaller Larger Total lung capacity is greater in boys than in girls
Lung size Smaller Larger
Vital capacity Smaller Larger
Residual volume Smaller Larger

ACL, Anterior cruciate ligament; BMR, basal metabolic rate; V o 2 max, maximum oxygen uptake.

From Yurko-Griffin LY, Harris S: Female athlete. In Sullivan JA, Anderson SJ, editors: Care of the young athlete, Rosemont, IL, 2000, American Academy of Orthopaedic Surgery.

* No appreciable differences are found in these parameters prior to puberty, and thus prepubertal boys and girls can compete on a fairly equal basis.

TABLE 32-4


High School Track 1972 1998 2012
800 m 2:04:7 2:06:30 2:03:34
3200 m 10:51:0 10:25:99 10:08:11
10,000 m 33:36:51 32:56:63 32:41:63
Boston Marathon 1972 1996 2011
3:10:26 2:27:12 2:22:36

Box 32-1

Conditioning Tips for Recreational Athletes

  • Emphasize core strength to minimize stress on lower extremities.

  • Emphasize strengthening of scapular stabilizers and muscles involved in dynamic stabilization of the glenohumeral joint to minimize laxity issues of this joint.

  • Emphasize vastus medialis obliques strength when doing lower extremity strengthening exercises to improve patellar tracking.

  • Minimize loading the patellofemoral joint in a fully flexed knee position; that is, consider short arc extension and leg press exercises in place of squats, lunges, and full arc extension exercises.

  • Perform upper extremity strengthening exercises at shoulder height and below to minimize stress on the rotator cuff (e.g., pull-downs and overhead dumbbell press).

Nutrition and Hydration

Sports nutrition is currently recognized as one of the most important aspects for improving sports performance. Both the content and timing of optimal nutrition may have a significant impact on the female athlete’s performance. Adequate consumption of carbohydrates, protein, and other macronutrients are critical to replace glycogen stores and repair tissue damaged by sports participation. If energy intake is typically less than 1800 kcal per day, the female athlete will acquire a persistent state of “negative energy balance,” resulting in weight loss and decreased athletic performance. If energy intake is chronically low, nutrient deficiencies will eventually develop.

Restriction of carbohydrates has been shown to be more detrimental to sport participation than protein deficiency and leads to decreased glycogen storage and loss of endurance capacity. Carbohydrate intake should be about 4.2 to 5 g/kg per day depending on the number and intensity of workouts. Protein requirements are similar to those for men (0.8 g/kg per day) and should be able to be obtained through a normal diet without added protein supplements. Athletes involved in strength and power sports often believe that a much higher level of protein is required to meet their demands than is obtained via a normal diet, but this belief is not supported scientifically.

Micronutrients, which include vitamins and minerals, also play a vital role in sports nutrition. Vitamin D is being recognized as an increasingly important micronutrient for health. Vitamin D deficiency is associated with low bone mineral density, cancer, heart disease, autoimmune problems, and infections. Vitamin D is needed for absorption of calcium, which is critical to bone health, and it is also important for nervous system and skeletal muscle development and function. Female athletes living in northern latitudes who participate in indoor sports are at risk for vitamin D deficiency, and indoor sport athletes are nearly twice as likely as outdoor sport athletes to have a vitamin D deficiency. Although sun exposure is important for achieving ideal vitamin D levels, low dietary intake may also lead to deficiency of this vitamin.

Vitamin D can be obtained by one of two methods. Endogenous vitamin D is synthesized in the skin after direct sun exposure, whereas exogenous vitamin D is ingested in foods or can be obtained in supplements. A recent interesting observation suggests a blunted immune system response and an increased risk for upper respiratory tract infections in persons with low vitamin D levels. Intriguingly, respiratory infections are a leading medical cause of “lost time” for female athletes. Athletes at risk for vitamin D deficiency, especially those aged 19 to 49 years, may benefit from 200 IU of vitamin D supplementation per day. Female athletes with either the “female athlete triad” or risk factors for osteoporosis may need 400 to 800 IU supplementation per day, as discussed in the Female Athlete Triad and Osteoporosis and Osteopenia sections of this chapter.

Adequate calcium intake is essential for proper bone mineralization. Compared with male athletes, female athletes may have a higher risk for low calcium intake, because females more frequently restrict food and often avoid eating dairy products because of a concern that they are high in calories. However, options such as low-fat milk, cottage cheese, yogurt, and string cheese are all high in calcium content but low in calories. Table 32-5 lists the daily required calcium needs for women of various ages. Three servings of calcium products daily are sufficient to meet daily requirements. Female athletes should be encouraged to drink low-fat milk for breakfast and eat two servings of low-fat yogurt or string cheese daily to fulfill their calcium needs. Table 32-6 lists the calcium content of common foods.

TABLE 32-5


Age Group (Yr) Suggested Intake (mg/day)
1-3 500
4-8 800
9-18 1300
19-50 1000
51-70 1200
>70 1200
Amenorrheic athletes (all ages) 1500
Pregnant/lactating women 1500

From the National Osteoporosis Foundation ( ).

TABLE 32-6


Food Calcium Content (mg)
Sardines (with bones) 370 per cup
Macaroni and cheese 360 per cup
Whole milk 300 per cup
Yogurt 270-350 per cup
Swiss cheese 270 per cup
Calcium-fortified orange juice 200-250 per cup
Broccoli 200 per cup
Cottage cheese 200 per cup
Ice cream 200 per cup
Dark green leafy vegetables 200 per cup
Waffles 180 per waffle
American cheese 170 per cup
Salmon (canned with bones) 170 per cup
Tofu 150 per 4 oz
Oysters (raw) 110 per 7-9 oz
Shrimp (canned) 100 per 3 oz
Beans (dried, cooked) 90 per cup
Eggs 50 per 2 eggs
Orange 50 per medium orange
Bread 25 per slice

Iron is a mineral that has long been known to affect athletic achievements in the female athlete, and it is well established that iron deficiency limits endurance training and sports performance. Iron is required for hemoglobin and myoglobin production. Hemoglobin carries oxygen to muscles, and thus adequate levels are vital during exercise, especially for athletes in endurance sports. Female athletes are especially at risk for iron deficiency because of cyclical menstrual blood loss and poor dietary intake. Vegetarian athletes have a greater risk of iron deficiency because they don’t eat red meat, which are an excellent source of iron. Furthermore, iron loss and deficiency can be induced by training at high altitudes; losses of iron in sweat, feces, and urine; foot strike hemolysis; and intravascular hemolysis. Screening for “iron status is best accomplished by measuring serum ferritin. Measurement of hemoglobin, as part of a complete blood cell count, is used to screen for anemia. A female athlete with iron deficiency anemia will have low ferritin and hemoglobin.

Replenishment of iron stores in persons who have a significant iron deficiency can take approximately 3 to 6 months after institution of dietary changes and supplementation. Therefore diagnosing deficiency early or identifying athletes at risk is pivotal for sustained athletic performance. Augmenting iron through supplementation in the iron-deficient athlete results in increased work capacity by enabling increased oxygen uptake, decreasing lactate concentration, and reducing heart rate during exercise. Examples of iron-rich foods are listed in Box 32-2 .

Box 32-2

Iron-Rich Foods

  • Liver

  • Lean read meats, including beef, pork, and lamb

  • Seafood, such as oysters, clams, tuna, salmon, and shrimp

  • Beans, including kidney, lima, navy, black, pinto, soy, and lentils

  • Iron-fortified whole grains, including cereals, breads, rice, and pasta

  • Greens, including collard greens, kale, mustard greens, spinach, and turnip greens

  • Vegetables, including broccoli, Swiss chard, asparagus, parsley, watercress, and Brussels sprouts

  • Chicken and turkey

  • Blackstrap molasses

  • Nuts

  • Egg yolks

  • Dried fruits, such as raisins, prunes, dates, and apricots

  • Curry powder, paprika, and thyme

The timing of food intake prior to participation in exercise or games is now known to be a crucial component of peak athletic performance. Precompetition food intake should be planned to ensure that the body’s carbohydrate stores are ready for competition. The athlete should be able to restore glycogen stores used during competition with a day’s intake of a carbohydrate-rich diet. The pregame meal should be low in fat and fiber, moderate in protein, and adequate in carbohydrate content to compensate for anticipated energy expended during competition. The low fat and fiber content will help avoid undesirable gastrointestinal symptoms during competition. Carbohydrates consumed should have a lower rather than a higher glycemic index and need to be consumed during competition, especially for endurance events lasting longer than 1 hour. Although carbohydrates may aid performance, absorption of their various forms may be varied and should be considered when counseling athletes on the content of the pregame meal. Compared with glucose alone, combined glucose and fructose facilitates absorption. Box 32-3 provides an example of pregame meals for a female basketball player.

Box 32-3

Examples of Pregame Meals for Women Basketball Players

For an Afternoon Game


  • Ham, egg, and cheese bagel sandwich

  • Vanilla low-fat yogurt topped with berries

  • 100% apple juice

For an Evening Game


  • Vegetable soup

  • Grilled chicken sandwich

  • Baked potato

  • Green beans

  • Dinner roll

  • Lemonade

  • Low-fat milk

The importance of adequate hydration cannot be minimized. Athletes who are even minimally dehydrated can experience increased core temperatures. Women inherently have a higher thermoregulatory threshold compared with men and thus begin sweating at a higher core temperature than do men. This mechanism may make it more difficult for females to cool themselves during times of intense training, and nonreplaced sweat loss of 1% to 2% of body mass can impair performance. The degree of a person’s hydration status can be gleaned by measuring the urine-specific gravity or by computing differences between preexercise and post­exercise weight. Water is adequate replacement for fluid losses unless excessive sweat losses occur, as is the case during endurance events. In these instances, adding electrolytes to water or consuming a sports drink with added electrolytes is recommended. A sports medicine care provider and a sports nutritionist are valuable resources for helping the female athlete devise a meaningful, sport-specific nutritional plan.

Female Athlete Triad

The female athlete triad (referred to in this chapter as the triad ) was first described in 1992 and was reported as an association between disordered eating, amenorrhea, and osteoporosis. The American College of Sports Medicine published the most recent position statement on this subject in 2007. In this position statement, the triad is described as the association of low energy availability (with or without eating disorders), amenorrhea, and osteoporosis ( Box 32-4 ). The most recent position statement emphasizes the aspect of energy availability to a greater degree than prior position statements.

Box 32-4

Components of the Female Athlete Triad

  • 1.

    Low energy availability (with or without an eating disorder)

  • 2.


  • 3.


Low energy availability may be a result of either excessive exercise or reduced energy intake. An eating disorder (either anorexia nervosa or bulimia nervosa) may be tied in with low energy availability. Anorexia nervosa is an eating disorder characterized by restrictive eating, perceptions of being overweight, and fear of gaining weight even though the affected person is at least 15% below the expected weight for age and height. The two subtypes of anorexia are restricting and purging. Persons with bulimia nervosa usually have ideal body weights but engage in cyclic overeating or binge eating followed by purging or other compensatory behaviors such as fasting or excessive exercise. Female athletes who do not meet all the criteria for anorexia or bulimia are classified as having an “eating disorder–not otherwise specified.”

Although amenorrhea (i.e., the absence of a menstrual cycle for more than 3 months) is the most serious menstrual abnormality associated with the triad, oligomenorrhea (i.e., a menstrual cycle occurring at intervals longer than 35 days) may manifest as well. Low energy availability can induce amenorrhea, which has a negative impact on bone density by modifying estrogen availability and suppressing hormones that stimulate bone growth.

Osteoporosis (i.e., a decrease in bone mineral density) increases fracture risk in the female athlete. It is typically defined as a measure of two standard deviations (SDs) below mean bone density. Two scores are commonly assessed, depending on the age of the individual. The T score measures bone mineral density (BMD) in a postmenopausal woman by comparing her BMD with the average BMD of a young adult. The Z score is used to compare BMDs of younger women to age-matched control subjects; a Z score less than 1.0 SD below the average warrants further investigation for potential causes of low BMD. Further details are provided in the “Osteoporosis and Osteopenia” section in this chapter.

Athletes in certain sports are at increased risk for the triad. These sports include those in which body image, especially a thin appearance, is important. Athletes participating in gymnastics, sports with weight classes, distance running, and dancing have the highest risk for the triad. These athletes may exercise excessively while restricting caloric intake (via the amount and/or types of food). Thus they may require special attention and early screening to identify the triad expeditiously, because treatment may be more successful when commenced early in the disease process. Nutritional screening should therefore be a vital component of the preparticipation screening for all athletes.

Treatment of the triad focuses on a team approach. Sports medicine providers, sports nutritionists, and mental health providers should all be involved in the evaluation process and develop specific, individually tailored treatment plans. Obviously, any medical complication that is life threatening should be treated first and without delay. For example, electrolyte or cardiac abnormalities must be addressed immediately. Subsequently, the initial goal of therapy is to increase energy availability, which may consist of diet modification or limiting excessive exercise. For an athlete with an eating disorder, behaviors need to be normalized, emotional issues need to be addressed, and psychological counseling needs to be initiated and sustained during healing. Physically, the menstrual cycle needs to be normalized, which in turn will ultimately help improve BMD. Vitamin D and calcium supplementation should be implemented to help optimize bone architecture and maintain normalcy. In the past it was believed that use of oral contraceptives helps restore menses and thus improve BMD. However, recent studies have shown varied results pertaining to improved BMD, and thus the precise role of oral contraceptives with regard to BMD remains to be delineated. A study of female adolescents with either anorexia or an eating disorder–not otherwise specified who took a triphasic oral contraceptive pill for longer than 1 year did not demonstrate a statistically significant effect of “the pill” on lumbar spine BMD. The present opinion is that oral contraceptives restore menstrual cycles but not necessarily low BMD. In conclusion, the triad is a well-recognized entity that needs to be identified early in its course so that prompt treatment can be initiated before the development of serious, potentially fatal consequences.

Osteoporosis and Osteopenia

Many women enjoy continuation of their athletic careers as they age. Senior- or masters-level competitions are common in a variety of sports. Athletes who participate in these competitions exercise and train at a high level of intensity to maintain peak athletic performance levels. A consequence of menopause is a decrease in bone density as a result of waning estrogen levels, which enhances fracture risk. BMD is commonly measured by bone densitometry (typically using dual-energy x-ray absorptiometry [DEXA]). As previously discussed, scores obtained are compared with a healthy young adult population to yield a T score. According to the World Health Organization, “osteopenia” is defined as a T score of −1.0 to −2.5 SD below normal average age-matched BMD and “osteoporosis” is defined as a T score lower than −2.5 SD below average age-matched BMD as measured by the DEXA scan ( Table 32-7 ; Fig. 32-3 ).

TABLE 32-7


Condition Definition
Normal BMD BMD ≤1 SD below the mean depth bone mass in normal women (T score >−1)
Osteopenia BMD >1 but <2.5 SD below the mean peak bone mass (T score >−1 to 2.3)
Osteoporosis BMD ≥2.5 SD below the mean peak bone mass (T score >−2.5)

BMD, Bone mineral density; SD, standard deviation.


Example of a dual-energy x-ray absorptiometry scan. BMD, Bone mineral density; YA, young adult.

Specific indications for DEXA testing include women older than 65 years or women aged 50 to 65 years who have a suspected secondary cause of osteoporosis such as hyperthyroidism, inflammatory bowel disease, chemotherapy, and hyperparathyroidism. Women 60 to 64 years of age should be screened if they have a history of alcoholism, tobacco use, low weight (<125 lb), a sedentary lifestyle, or estrogen deficiency induced by premature menopause, either primary (natural) or as a result of a hysterectomy and oophorectomy. Other risk factors that may merit early DEXA testing include a family history of osteoporotic fractures in first-degree relatives, a personal history of fracture at more than 40 years of age, Caucasian or Asian heritage, and an anovulatory state for more than 5 years without estrogen replacement.

Treatment should commence prior to or early in the osteopenic phase to help curtail the rate of bone loss. Therapy includes nonpharmacologic and pharmacologic methods. The primary nonpharmacologic treatment is weight-bearing exercise. Women should also stop smoking and avoid excessive weight loss. BMD is higher in postmenopausal women who exercise. Runners who performed weight-bearing exercise had a higher BMD than did swimmers (swimming is a non–weight-bearing exercise), and notably, athletes in this study had a higher BMD of the femoral neck compared with sedentary women. Pharmacologic treatment for persons at risk of low BMD includes 1000 to 1500 mg of calcium and 400 to 800 IU of vitamin D supplementation daily. The most controversial treatment may be hormone replacement therapy. The U.S. Preventive Services Task Force, the American Academy of Family Physicians, and other groups do not recommend hormone replacement therapy (including combination estrogen and progestin or isolated estrogen therapy ). In summary, optimal therapy for the female athlete with osteopenia and osteoporosis is indeterminate. It is known that weight-bearing exercise, calcium and vitamin D supplementation, and smoking cessation are important. Athletes should consult their health care providers to make an informed decision regarding the best approach to meaningful therapy.

Birth Control

Many contraceptive choices are available to women. Between 2006 and 2008, 7.3% of women who were at risk for an unintended pregnancy were not using contraception. If contraceptive use is desired, sexually active athletes should have an annual gynecologic examination and review their contraceptive choices. Choices for contraception include intrauterine devices, spermicidal products, diaphragms, cervical caps, female and male condoms, injectable progestin, a vaginal ring (e.g., NuvaRing), and oral contraceptives ( Box 32-5 ). A review of major risks and benefits for each method of contraception is detailed in Table 32-8 .

Box 32-5

Classes of Contraceptive Methods

  • Intrauterine devices

  • Spermicidal products

  • Condoms

  • Diaphragms

  • Progestin

  • Vaginal ring

  • Oral contraceptives

TABLE 32-8


Method Risks/Benefits
Intrauterine device Perforation of the uterus
Length of time it can be used
May increase risk of pelvic inflammatory disease
Spermicidal products Low effectiveness when used alone
Improves effectiveness in preventing pregnancy when used with diaphragm, cervical cap, or condoms
Diaphragm Low effectiveness, user error
Nonhormonal contraceptive
Cervical cap Low effectiveness, user error
Nonhormonal contraceptive
Condoms (male/female) Allergic reaction to latex
Low cost, may reduce incidence of STI
Injectable progestin Variation of menstrual bleeding
Only has to be administered every 3 mo
Injection site reaction
Vaginal ring Blood clots from hormone
Does not need to be taken or changed daily
Oral contraceptives Blood clots, migraines
Most effective method if used correctly

STI, Sexually transmitted infection.

Presently, the most popular form of contraception is the oral contraceptive pill (OCP), which is 91% to 99% effective in preventing pregnancy. Two types of OCPs include the progestin-only pill and the combination estrogen and progestin pill. The mechanism of action is via the action of exogenous hormone in the OCP, which suppresses pituitary function, thereby decreasing production of follicle-stimulating hormone and luteinizing hormone, with resultant inhibition of ovulation. Female athletes who have heavy or painful cycles may experience decreased menstrual flow and analgesia, which may be the most significant noncontraceptive effects of OCP use. Contraindications for use include a personal history of blood clots, abnormal liver function, breast cancer, migraines, and specific cardiac conditions. Many female athletes defer use of OCPs because of a fear of weight gain. Two well-performed studies have shown that OCPs do not induce weight gain. Furthermore, in another study, compared with nonathlete control subjects, runners did not increase weight, fat mass, or body fat.

Lastly, the decision to begin using contraception and the method used is solely the woman’s choice. The goal of sports medicine providers should be to provide accurate information about various contraceptive methods and address concerns or questions to help the female athlete choose a safe and effective method of birth control that does not interfere with an athletic lifestyle or jeopardize health.


Previous concerns that exercise might result in preterm labor are unproven. It is currently recognized that exercise during pregnancy is not only safe but clearly advantageous. Benefits of regular exercise include:

  • Improving self-image

  • Avoiding excessive weight gain during pregnancy

  • Aiding in the management of gestational diabetes

  • Decreasing musculoskeletal ailments of pregnancy (e.g., increasing core strength results in fewer low back pain complaints)

To ensure safety, a preexercise program evaluation with an obstetrician is recommended to review the specific physical activities and the intensity and length of workouts. Contraindications to exercise during pregnancy are listed in Box 32-6 . Safe sports and those best avoided during pregnancy are listed in Box 32-7 . A healthy pregnancy and safe delivery should be the ultimate goal, and a well-structured exercise program can help attain that goal.

Box 32-6

Contraindications to Exercise During Pregnancy


  • Poorly controlled maternal hypertension

  • Poorly controlled maternal diabetes

  • Previous spontaneous abortion

  • Severe anemia

  • Underweight or maternal eating disorder


  • Preeclampsia/eclampsia

  • Premature rupture of membranes

  • Placenta previa

  • Persistent second- or third-trimester bleeding

  • Preterm labor

  • Incompetent cervix

  • Growth-restricted fetus

Box 32-7

Athletic Activity During Pregnancy

Safe Sports

  • Walking is a good exercise for anyone.

  • Swimming is great because it works so many muscles.

  • Cycling provides a good aerobic workout.

  • Aerobics is a good way to keep the heart and lungs strong.

  • Women who were runners before becoming pregnant often can keep running during pregnancy, although their routine may have to be modified.

Sports to Avoid

  • Downhill snow skiing. A pregnant woman’s change in balance may put her at a greater risk of injuries and falls; also, she may be at risk of altitude sickness, an illness caused by breathing air that contains less oxygen.

  • Contact sports, such as hockey, basketball, and soccer. These sports can result in harm to a pregnant woman and her baby.

  • Scuba diving. Scuba diving can put the baby at risk of decompression sickness, a serious illness that results from changes in the pressure surrounding the body.

Nonetheless, several exercise precautions are recommended for pregnant women. They need to avoid substantial or sudden increases in temperature. Avoiding exercise in extreme heat and humidity, planning workouts early in the morning or later in the day when temperatures are cooler, decreasing the intensity of training (especially in hot environments), and ensuring adequate fluid intake are all vital for safety. Furthermore, expected weight gain during pregnancy causes a shift in the center of gravity and weight distribution. Being cognizant of these changes may help guard against loss of balance during exercise. Alarm signs that should be an impetus to refrain from or discontinue exercise instantly include vaginal bleeding, leakage of amniotic fluid, decreased fetal movement, chest pain, shortness of breath (before or during exercise), and dizziness.

The National Collegiate Athletic Association (NCAA) has recommended guidelines for pregnant student athletes that focus on both the safety of the athlete and the unborn fetus. The athlete can be granted a 1-year extension (of the standard 5-year period of eligibility) to account for “lost time” during pregnancy. The NCAA guidelines on pregnancy state that the ability to participate in athletics is determined by the pregnant athlete, an obstetrical care provider in coordination with the team physician, and the policy of the institution. The medical care provided is not dictated by the institution.

Typically, 6 to 8 weeks after delivery, exercise does not have an adverse effect on lactation (volume or composition). Thus a woman who has given birth can continue or resume an exercise program and breastfeed without fear of negatively affecting the numerous benefits and critical aspects of the bond between the mother and child.

Psychological Issues in Women Sports

It is important to encourage adolescent girls to participate in a sport, because sport participation has been shown to increase self-esteem and decrease the incidence of depression. Teenagers who are active in sports are less likely to get pregnant or abuse drugs and are more likely to graduate from high school. The Women’s Sport Foundation also emphasizes that sports participation in women decreases shyness and increases social skills, thereby decreasing social anxiety; it also helps young women cope better with success and failure. Father/daughter bonding frequently develops through sport participation.

Opinions are varied regarding the development of muscular bodies in women who exercise, from a perception of “increased sexuality” to “less feminine” in sports such as rugby that inherently require an increase in muscle mass. More than half a century ago, Gottman suggested that body image is a combination of several factors including clothing, “carrying oneself,” and speech. As women pursue characteristics associated with peak athletic performance such as competitiveness, independence, and the development of bodies that are stronger and more muscular, they may feel that they are becoming more masculine and may struggle to accept these characteristics that could be seen as a threat to their femininity. Admittedly, during the past 20 years a greater acceptance of “more muscular bodies” in women has evolved, and generally, stronger physiques have become desirable. Conversely, a lean build is desirable by athletes participating in sports such as cross country, figure skating, and ballet. Persons involved in these activities are at risk for eating disorders because they may have an altered body image and falsely perceive themselves as being “too heavy.” Medical providers involved in women sports must recognize and be sensitive to these body image dilemmas that young athletic women may encounter.

Most coaches at the junior high, high school, or collegiate level will readily admit that the nuances of coaching women necessitates a different approach compared with coaching men. Generally, male players respond better to intimidation and encouragement to demolish the opposition, whereas these tactics are typically not effective for female athletes. Appealing to emotional aspects may be more effective for female athletes; for them, the desire to work harder often stems from loyalty to their teams and coaches. Boys and young men often believe that proof of masculinity is rooted in sport participation, whereas girls and young women may receive no secondary gain from competitive sports; in fact, superb female athletes have been known to “drop out” of sports to explore other activities. This phenomenon of “burn-out” or “change of focus” can be challenging for coaches and parents to accept. Moreover, the young athlete may find it difficult to explain to parents and her coaches that she no longer wishes to participate in a sport and may actually find it more socially acceptable to have an “injury” that sidelines her. In this scenario, being cognizant of the fact that injury is merely a superficial expression of a deeper emotional issue and helping the young athlete recognize the reality is an important responsibility of sports physicians. To retain strong female players during their teenage years, coaches often must be creative to make their sport enjoyable as well as competitive for participants. As women progress through higher levels of sports, their desire and motivation become more similar to those of their male counterparts.

Degenerative Arthritis

The following two important questions are frequently posed by older athletic women:

  • 1.

    Will exercise improve symptoms of osteoarthritis (OA)?

  • 2.

    Does regular exercise enhance risk for OA?

Twenty-seven million persons in the United States are reported to have OA, and in persons older than 45 years, OA is more common in women than in men. OA occurs both in athletic persons and in persons who are sedentary, yet either possess a genetic tendency to OA or have other risk factors (e.g., age, ethnicity, or obesity). In the past when arthritis developed in athletes, they were often discouraged from exercising. On the contrary, Healthy People 2010 recommendations include educating persons with arthritis about their disease process and recognizing the significance of obesity as a risk factor for OA and the value of a maintenance exercise program.

Sports medicine professionals encourage athletes and sedentary persons with arthritis to exercise. Recommendations include strengthening, stretching, balance and agility drills, and decreasing weight-bearing exercise while increasing non–weight-bearing exercise (e.g., swimming, water exercise, biking, use of an elliptical machine, or using light weights with multiple repetitions). Although water exercise has been recommended, especially for persons with severe arthritis, land exercise is also effective in increasing mobility and decreasing the pain of arthritis. The premise is that strong muscles help protect arthritic joints. Moreover, exercise has been found to increase mood and decrease depression. Flexibility exercises decrease stiffness, and the combination of enhancing balance and decreasing stiffness helps to minimize falls in the arthritic population. Furthermore, Kushi et al. have reported an association between increased physical activity and decreased risk of mortality. Exercise also helps to maintain or decrease body weight, and because obesity is associated with an increased risk of developing arthritis, controlling weight helps decrease the incidence of OA. Curl reported that the risk of cardiovascular disease across all age groups in women decreased as a result of increased fitness.

To answer the question of whether persons who exercise have an increased risk of developing OA, Hannan et al., Panush et al., and Chajravarty et al. conducted studies that have demonstrated that the incidence of OA is not increased in an exercising population when compared with age-matched control subjects. Although sports that subject joints to repetitive high levels of impact and horizontal loading may increase the risk of articular cartilage degeneration, moderate-intensity exercise has not been found to enhance the risk of OA.


A “concussion” is defined as a complex pathophysiologic process affecting the brain that is induced by traumatic biochemical forces. The diagnosis and management of concussions, especially in the athletic population, has changed dramatically during the past decade. The International Conference on Concussion in Sport was held in Zurich in 2008, after which an updated consensus statement on concussion was issued to better define and comprehend the various nuances of concussion evaluation, investigation, and management. To define the features of a concussive event, a clinician must consider the clinical, pathologic, and biochemical facets of the injury. It is beyond the scope of this chapter to fully detail all facets of concussion care. Instead, this section exclusively discusses the particulars of concussions specific to the female athlete.

Analyses of injury data from the NCAA data bank reveal that compared with male athletes, female athletes sustain more concussions in games than in practice. Female soccer players have the most concussions, followed by female basketball, lacrosse, and softball players and gymnasts. Female soccer and basketball players sustain significantly more concussions than their male counterparts in their respective sports. This trend was recently confirmed in a study involving high school athletes. In gender-comparable sports (i.e., soccer, basketball, and baseball/softball), high school girls had higher rates of concussions (new and recurrent concussions) compared with high school boys. Concussions in high school girls are more frequent from contact with playing surfaces compared with boys, whose concussions occur after player-to-player contact.

In addition to sustaining a higher number of concussions in certain sports compared with male athletes, female athletes tend to have more severe concussions than do male athletes. A metaanalysis review concluded that traumatic brain injury outcomes in female athletes are worse than in male athletes and are primarily manifested by somatic symptoms, including poor memory, dizziness, fatigue, irritability in response to light and noise, impaired concentration, headache, anxiety, and depression. Additionally, concussed female athletes are reported to be more cognitively impaired than concussed male athletes and have demonstrated significantly lower visual memory composite scores compared with male athletes. Without the use of helmets, female athletes are twice as likely as male athletes to experience cognitive impairment after sustaining a concussion.

Compared with new concussions, recurrent concussions tend to be more serious, with delayed symptom resolution and “lost athletic time.” Recurrent concussions also have the potential for unfavorable long-term consequences. In the high school population involved in “gender-comparable sports,” although girls had higher rates of recurrent concussions, the number was not statistically significant, which may indicate that in this age group, gender differences equalize after the initial concussion. Some concussed athletes experience lingering postconcussive symptoms, including chronic headaches. Female athletes also report a greater incidence of symptoms from postconcussion syndrome, along with depression.

Various theories have been proposed to explain the differences between female and male concussions. Suggested mechanisms include biomechanical differences in head and neck acceleration forces, hormonal variances, or a perception that boys are “tougher” than girls and continue to play after they are injured. Concussed female athletes need to be evaluated and treated in a manner akin to male athletes, and more research is needed to delineate gender variations in terms of symptoms, treatment, and recovery after a concussion.

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Feb 25, 2019 | Posted by in SPORT MEDICINE | Comments Off on The Female Athlete

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