Medical Issues in Female Athletes Dr. Laleh Hakemi Internist Vice-President of Sports Medicine...
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Transcript of Medical Issues in Female Athletes Dr. Laleh Hakemi Internist Vice-President of Sports Medicine...
Medical Issues in Female Athletes
Dr. Laleh Hakemi
Internist
Vice-President of Sports Medicine Federation of Iran
In the Name of GOD
Physical benefits• Reduced risk of illnesses such as heart disease, hypertension, diabetes, and endometrial and breast ca.• Improved muscle-to-fat ratio-body composition• Stronger immune system with moderate physical activity• Less menstrual discomfort• Stronger bones and reduced risk of developing osteoporosis later in life
Micheli, Smith, Biosca, Sangenis
Psychosocial benefits• Improved self-esteem, self-confidence, and perception of competence; better performance in academic settings• Decreased risk of unwanted pregnancy• Decreased risk of drug and alcohol abuse
Micheli, Smith, Biosca, Sangenis
Performance differences
Running performance is related to max aerobic power
the slower running speed due to lower VO2 max
difference in VO2 max related to: body composition (fat F 20-25%/ M 10-14%) & Hb & lower blood volume (relative to lean body mass), lower stroke volume (relative to lean body mass)
if these corrected, no difference
Pre & Post pubertal differences
Strength
Age 20: 30%-50% difference in muscle CSA between men and women strength difference: upper > lower extremities
Upper: F= 40-75% M / Lower: F=60-80% MSimilar differences in bones
Endurance
6-15% lower in FLarger muscle fibers in men (both fast and slow
twitch)
the actual muscle fiber composition is similar in M & F
Athletic training (interval &
continuous) produce similar improvements in M & F
Nattiv, Ireland 1998
Musculoskeletal differences:
Muscle sizebone masswider pelvisknee valgus (QASIS (patella/patella-tibial tubercle)< 12o)ligamentous laxity
• Are girls/women at greater risk of certain types of injuries?
Gender-specific injuries are rare The female reproductive organs are better
protected Breast injuries are among the rarest of all
sports injuries
Micheli, Smith, Biosca, Sangenis
• Do girls/women get injured more often?
not at greater risk of “acute” injuries one exception is ACL injuries.
Overuse injuries
Micheli, Smith, Biosca, Sangenis
Anterior Cruciate Ligament in Female Athletes
A Meta-analysis of Neuromuscular Interventions Aimed at Injury Prevention
Female athletes have a 4 to 6 times higher incidence of anterior cruciate ligament injury than do male athletes participating in the same landing and pivoting sports.
A meta-analysis of 6 studies demonstrates a significant effect of neuromuscular training programs on anterior cruciate
ligament injury incidence in female athletes (test for overall
effect, Z = 4.31, P < .0001).
Timothy E. Hewett, PhD*, , , Kevin R. Ford,
MS and Gregory D. Myer, MS, CSCS ,2003
Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate
Ligament Injury Risk in Female Athletes A Prospective Study, Hewett et al
A cohort study205 female athletes(soccer, basketball,
volleyball)
Results: - In the 9 athletes with
ACL rupture - different knee posture &
loading- - 8 degrees greater knee
abduction angle at landing (p<.05)
- 2.5 times greater knee abduction moment (p< .001)
- 20% higher ground reaction force (p<.05)
- Stance time 16% shorter
- 73% specificity and 78% sensitivity of knee abduction moment for predicting ACL injury
Some measures to reduce ACL injuries:
1) strengthening muscles stabilizing the knee, especially hamstrings;2) improving aerobic conditioning to prevent fatigue-related missteps; 3) modifying the usual “cutting,” or “side-stepping,” maneuver from a
two-step to a three-step motion so the knee is never fully extended; 4) performing running and pivoting with the weight forward on the
ballsof the feet, emphasizing soft jump landings;5) educating coaches about the increased risk of ACL injuries in
female athletes and enhancing the ability of coaches to evaluate female athletes’ skills, conditioning, and readiness to participate.
Micheli, Smith, Biosca, Sangenis
In a case control study among female alpine skiers, the risk of suffering an ACL was significantly greater during the pre-ovulatory phase of the menstrual cycle compared with the postovulatory phase – therefore, phase of menstrual cycle may be a risk factor for knee ligament injury in female athletes
Am J Sports Med 2006; 34(5): 757-764
Association Between the Menstrual Cycle and Anterior Cruciate Ligament Injuries in Female Athletes
Edward M. Wojtys, MD et all
40 female athletes with less than 3 month ACL injury
significant statistical association was found between the stage of the menstrual cycle and the likelihood for an anterior cruciate ligament injury (P = 0.03). In particular, there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase.
Overuse injuries
Common overuse injuries include stress fractures, tendonitis, and bursitis.
Female athletes are more susceptible Two apparent reasons for this: a lack of long-term preparation for
vigorous sports and not beginning sports training until growth
spurt (typically 11-13), a time when musculoskeletal injury incidence is greater
Micheli, Smith, Biosca, Sangenis
Menstrual cycle & performance
No change in aerobic capacityNo change in anaerobic capacityNo change in performance
no reason to restrict activity
In a systematic review of risk factors for chronic pelvic pain in women, exercise was associated with a decreased risk of dysmenorrhoea
BMJ 2006; Apr 1;332 (7544):749-55
EVALUATION OF MENARCHE AGE AND RELEVANT FACTORS IN IRANIAN FEMALE ATHLETES
In 454 cases that were passed menarche age mean of age at menarche: 158.2+/- 0.7 m. (13.18 yr)Earlier menarche was reported in :1-lower height (p<0.001)2-lower age at beginning exercise (p=0.019)3-lesser number of sisters (p=0.007)4-lesser number of brothers (p=0.003)5-higher percent body fat (p=0.037)6-higher body mass index (p=0.002)
7-residing mountain side regions (p=0.001)
Hakemi L, Torkan F, Kabir A, 2002
Female Athlete Triad
Disordered eatingMenstrual dysfunctionBone mineral density
Amenorrhea EVALUATION
Most women with exercise-induced amenorrhea have hypothalamic amenorrhea: suppression of pulsatile GnRH from hypothalamus decreased FSH & LH loss of ovarian cyclicity and estrogen deficiency. are at risk for all complications of estrogen deficiency.
Exercise-induced amenorrhea is a Dx of exclusion. The characteristic history is that of a woman with previously normal cycles
irregular and then ceased after she began to exercise, especially if lost weight at the same time.
If PMHX of exercise-induced amenorrhea, which remitted after stopping exercise likely to recur if she resumes exercising.
hCG serum prolactin serum FSH premature ovarian failure Serum LH for PCOS or ovarian failure Androgen hormones
primary amenorrhea should be evaluated for anatomic abnormalities of the uterus and uterine outflow tract.
CONSIDER DIFFERENTAIL DIAGNOSES:
• THE MOST IMPORTANT:• PCOS• Drug use
Mean serum concentrations of testosterone (pg/mL), androstenedione (pg/mL), and DHEA-sulfate (ug/mL) in 10 normal women between day two to four of their menstrual cycle and 19 women with polycystic ovary syndrome (PCOS). The mean serum concentration of each androgen was high in the women with PCOS, but there was substantial overlap between the two groups and many women with PCOS had normal values for one or more androgens.
Data from DeVane, GW, Czekala, NM, Judd, HL, Yen, SS, Am J Obstet Gynecol 1975; 121:496
In female Olympic athletes from different sport disciplines, menstrualdisturbances were common (mainly endurance athletes) but these weremore frequently associated with polycystic ovarian syndrome (PCOS) ratherthan chronic energy deficiency or hypothalamic inhibition
Hyperandrogenism may explain reproductive dysfunction in Olympic athletes
Hagmar M, Berglund B, Brismar K, Hirschberg AL
Med Sci Sports Exerc 2009; 41(6: 1241-1248)
Asia Pac J Clin Nutr. 2009;18(2):200-8.The female athlete triad among elite Malaysian athletes: prevalence and associated factors.
Quah YV, Poh BK, Ng LO, Noor MI.
67 elite female athletes aged between 13-30 yearsPrevalence of all 3 components was low (1.9%), but the prevalence for individual triad component was high, especially in the leanness group.The prevalence of subjects who were at risk of menstrual irregularity, poor bone quality and eating disorders were 47.6%, 13.3% and 89.2%, respectively, in the leanness group; and 14.3%, 8.3% and 89.2%, respectively, in the non-leanness group.
Sports Med Arthrosc Rehabil Ther Technol. 2009 Jul 30;1(1):16.The relation between athletic sports and prevalence of amenorrhea and oligomenorrhea in Iranian female athletes.
Dadgostar H, Razi M, Aleyasin A, Alenabi T, Dahaghin S.
female athletes in national teams and medalists of TehranN= 788 (95% response rate)Post menarche (age range: 13- 37)There was also a positive association between amenorrhea/oligomenorrhea and the following:
age under 20, weight class sports, endurance sports, late onset of menarche, and use of oral contraceptive pills.Intensity of training sport or BMI were not risk factors.
Int J Sport Nutr Exerc Metab. 2002 Sep;12(3):281-93.Disorders of the female athlete triad among collegiate athletes.
Beals KA, Manore MM.
425 female collegiate athletes from 7 universities across the United States.The percentage of athletes reporting a clinical diagnosis of anorexia and bulimia nervosa was 3.3% and 2.3%, respectively. Menstrual irregularity was reported by 31% of the athletes not using oral contraceptives, and there were no group differences in the prevalence of self-reported menstrual irregularity.Muscle and bone injuries sustained during the collegiate career were reported by 65.9% and 34.3% of athletes, respectively, and more athletes in aesthetic versus endurance and team/anaerobic sports reported muscle (p =.005) and/or bone injuries (p <.001). Athletes "at risk" for eating disorders more frequently reported menstrual irregularity (p =.004) and sustained more bone injuries (p =.003) during their collegiate career.
Eating disorders.
The athlete with an eating disorder may also frequently abuse laxatives and diuretics, and is at increased risk for dehydration and electrolyte disturbances. The mortality rate in treated anorectic females reaches 18%.
(The Female Athlete Holschen, Jolie C. MD )
Med Sci Sports Exerc. 2005 Feb;37(2):184-93.The female athlete triad: are elite athletes at increased risk?
Female elite athletes in Norway ; national teams; 13-39 yr of age (N = 938) and non-athlete controls in the same age group (N = 900). After exclusion, a total of 669 athletes (88%) and 607 controls (70%)
A higher percentage of controls (69.2%) than athletes (60.4%) was classified as being at risk of the Triad (P < 0.01). A higher percentage of controls than athletes reported use of pathogenic weight-control methods and had high BD subscale scores (P<0.001). However, more athletes reported menstrual dysfunction and stress fractures compared with controls (P < 0.05). A higher percentage of both athletes competing in leanness sports (70.1%) and the non-athlete control group (69.2%) was classified as being at risk of the Triad compared with athletes competing in non-leanness sports (55.3%) (P < 0.001). Furthermore, a higher percentage of athletes competing in aesthetic sports (66.4%) than ball game sports (52.6%) was classified as being at risk of the Triad (P < 0.001).
Torstveit MK, Sundgot-Borgen J.
BONE HEALTH IN WOMEN
• Risk of hip fracture in older females can be reduced by nearly 20% if adolescent and teenage girls engage in regular physical activity
(healthlink 2004)
About 50% of men and 70% of women with age 50 or older suffer from osteoporosis or osteopenia in Iran.
Osteoporosis at L2-L4: 16.7% in M and 56.3% in F Osteopenia at L2-L4: 38.9% in M and 25% in F. PBM at L2-L4 at the age 29.3 years in women. Means of PBM (20-45 years) (gr/cm2):
◦for females 1.20+/-0.013 (lumbar spine) and 0.994+/-0.13 (hip)◦for males 1.18+/-0.14 (lumbar spine) and 1.05+/-0.16 (hip).
OSTEOPOROSIS IN IRAN & EFFECTS OF EXERCISEDr. Laleh Hakemi, Dr. Farzaneh Torkan, 2003
Peak bone mass in Iranian population seems to be 3.9% higher than Japanese and 5.6% lower than American population
Prevalence of vitamin D deficiency is significant in Iran, and one study showed that 80% of the population has at least mild vitamin deficiency.
Hip fracture is the most serious consequence of osteoporosis. The estimated incidence of osteoporotic fractures in the year 2001 in Iranian women was 417 fractures in spine, 4337 fractures in femur, and 1806 fractures in the forearm.
menopause
Calcium supplements protect against bone loss post menopause
Reid, IR, Ames, RW, Evans, MC, et al, N Engl J Med 1993; 328:460.
pregnancy
Benefits:Enhances maternal
fitnessenhance physiologic
reserveno difference in
premature labor
Safety: good nutrition hydration rest exercise after 3 hr post meal snack after exercise avoid extreme hot & humid avoid extreme intensity
exercise avoid hyperthermia exercise should not cause
discomfort avoid abdominal trauma avoid exercise in high
altitude avoid exercise in deep water
Precautions:
multiple fetuses, bleeding, IUGR, premature cervix change, previous miscarriages
1st trimester:CrampBleedingAvoid abdominal traumaAvoid hyperthermia
After 1st trimester:Exercise performance is decreased:
PhysiologicPsychologic
Avoid supine positionAvoid prolonged standingAvoid upside downAvoid sudden movementsAvoid Valsalva maneuverAvoid unsteady conditions
Breast protection
Bra especially for large breastsbreast padding for contact sportspetroleum jelly abrasion likely
ANEMIA
Torkan, Kabir, Hakemi, 2001
Hemoglobin (g/dl)
percent
<=11.5 6.9
<12 17.3
<13 57.7
Percent of anemia according to different hemoglobin thresholds, national level Iranian female athletes
1412
13.511.5
1311
02468
101214
mean of Hb in different levels of physical activity
MF
Kordi
Thank You For Your Kind Attention