1. Physical Preparation and the Female Athlete

2. Female Athlete Less well understood than male Less studied
Relatively new high profile of elite female athletes compared to men
Fewer female coaches, doctors in sports medicine, strength and conditioning specialists
Limited youth sports historically (gymnastics, swimming)
Less studied
Performance factors
Repetitive stress
Acute injuries

3. Growth Rate Profile

4. PEAK HEIGHT VELOCITY & PEAK BONE MASS GROWTH
Males
Females
Relative increase per year
Age (years)
(Adapted from Tanner, 1978 & Kahn, 1999)

5. Developmental Events
Borrowed from Carmen Quatman

6. Rapid Growth Significantly Affects
Height
Weight
Length and mass of levers (tibia, femur)
Center of mass
Muscle strength, activation & stiffness
Difficulty controlling trunk & increased forces at the knee joint
(Myer, 2007)
Changes in coordination, balance, control and force expression

7. Growth Monitoring during Adolescence

8. Equality Prepubertal Female equal to male: Female sex hormones affect:
Strength
Aerobic power
Heart size
Weight
Female sex hormones affect:
Bone mass
Lean muscle mass
Circulation
Metabolism

9. Gender Differences Puberty Adult women 10% > fat
Males gain LMM and lose BF (testosterone)
Females gain LMM and BF
Adult women 10% > fat
Teenage women 20-25% BF, athlete 10%
Female BMR 10% lower (nutrition)
metabolic activity of fat vs muscle tissue
Oestrogen & progesterone
Greater reliance on fat metabolism at relative exercise intensity
Enhances glycogen uptake, storage and utilisation

10. Sexual Changes in Fat Distribution

11. Gender Differences
Testosterone leads to male hypertrophy of cardiac and skeletal muscle
Females 23% LMM, males 40%
Female muscle cross sectional area 60-85% males
Female muscle fibre size lower
Fast twitch : slow twitch ratio (?)
Higher levels of intramuscular fat and connective tissue
Slower time to maximal force
Lower RFD
Training does not lead to bulk, rather increased x sectional areas offset by reduced body fat

12. Gender Differences
Post puberty males have higher haemoglobin and hematocrit concentrations = greater O2 carrying capacity
Women have smaller heart and lung mass, stroke volume and maximal cardiac output (base lined for weight)
Corresponds to lower performance in aerobic and anaerobic activities

13. Anatomy Typical female athlete presents with: Wider pelvis
Internal rotation of femur
‘Knock knees’ (valgus knees)
External tibial torsion
Pronation of feet
Shorter, smaller bones
Smaller articular surfaces
Shorter leg length as proportion of height
Shorter bone lengths = shorter levers = lower achievable force

14. Gender Risk Factors
Anatomical
Biomechanical
Neuromuscular
Hormonal

15. Neuromuscular Risk Factors
Altered muscle activation patterns
Quad dominant:
High levels of quadriceps activity
Low levels of hamstring activity
Decreased normalised strength
Altered muscle stiffness patterns
Muscle activation response time to movement or perturbation

16. Q angle

18. Altered Movement Patterns
Consistent movement differences found between adult and adolescent males and females during laboratory based landing tasks (Ford, 2003; Hanson, in press; Hewett, 2005; Padua, 2002)
Females display:
Increased load on ACL:
Decreased hip and knee flexion
Increased hip internal rotation
Increased knee valgus
Increased anterior tibial shear

19. Altered Muscle Activation
Adult females of all levels exhibit quadriceps dominance during landing and cutting (Huston, 1996; Malinzak, 2001; White, 2003)
Eccentric contraction coupled with decreased knee flexion  greater anterior tibial shear
Decreased knee flexion minimizes posterior shear forces of the hamstrings
Borrowed from Darin Padua

20. Altered Muscle Stiffness
Adult females have decreased stiffness of the hamstrings and quadriceps (Padua, 2002; Wojtys, 2002; Blackburn, 2008)
Decreased ability to dissipate external forces
Increased joint motion
Greater load placed on static restraints (ligament dominance)
Increased risk for ACL injury
No known studies investigating muscle stiffness in youth population

21. ACLs
Onset of ACL injury incidence coincides with onset of puberty (Michaud, 2001; Shea, 2004)
No difference in ACL rates between genders before onset of puberty Age 12 distinct shift in increased female sprain rates
Gender bias in ACL injuries present after age 12

22. ACL: Intrinsic Risk Factors
Anatomy and Alignment - Static
Increased femoral anteversion (IR)
Increased Q angle
Excessive tibial torsion (ER)
Subtalar pronation
Narrower intercondylar notch
Smaller ACL
NO anatomical risk factor itself
correlates with inc risk ACL injury

23. ACL: Intrinsic Risk Factors
Hormonal
Appears to be a predisposition for ACL injuries during pre- ovulatory phase
Wojtys et al, American Journal of Sports Medicine, 2002

24. Neck and Spine Injuries
Females athletes sustain more cervical neck strains vs males
Scoliosis and Spondys have a female predominance
Delayed puberty/menarche are risk factors for scoliosis
Broshek et al, Journal of Neurosurgery, 2005

25. Shoulder Issues in Female Athletes
In general, females have increased joint laxity vs males
Laxity = Instability (symptomatic)
Generalized Ligamentous Laxity Screen: 9 point
Thumb apposition to forearm
Little finger hyperextension > 900
Knee recurvatum > 100
Elbow recurvatum > 100
Bend at waist, palms to floor
Beighton et al, Annals of Rheumatologic Disorders, 1973

26. What We Should Do
Proposed females do not go through neuromuscular spurt similar to males
Negatively affects trunk & hip neuromuscular control
(Myer, 2008)

27. Identify The Risk Strategy How?
Identify “at risk” individuals and intervene
The Risk
Strategy
How?
Extended knee
Flexed knee
Soft landing
Extended hip
Flexed hip
Knee valgus
Minimize valgus
Control landing, strengthen hip Abd & IR
Loss of balance
Improve balance
Dynamic balance training
Lateral trunk lean
Neutral trunk
Core stability training and landing posture
Garret & Griffin, 2006

28. Female Athletic Triad High risk sports
Emphasis on prepubertal body type, perfectionism, thinnness, revealing clothing, judged subjectively
Low body fat is beneficial
Dance, gymnastics,
figure skating, distance running

29. Menstrual Cycle

30. Menstrual Cycle Oestrogen Progesterone Luteinising hormone
Promotes secondary sex characteristics
Stimulates endometrial growth
Progesterone
Effects amplified in presence of Oestrogen
Preparation of uterus for
Falling levels result in menstruation
Luteinising hormone
Stimulates ovulation
Follicular Stimulating Hormone
Initiates follicular growth (ovulation)

31. Menstrual Cycle Oestrogen Progesterone has opposite effect Relaxin
decreases collagen content
Reduces ligament tensile force
Increases joint elasticity
Progesterone has opposite effect
Relaxin
Slows collagen synthesis
Stimulates collagenase activity
Receptors for oestrogen, progesterone, relaxin found on ACL

32. Female Athletic Triad
Harmful effect of excessive energy deficits on the reproductive and skeletal health of physically active women
More females than males practice diet and exercise behaviours that cause excessive energy deficits

33. Female Athletic Triad
1993 Criteria
Previous definition
Disordered eating
Amenorrhea
osteoporosis
2007 ACSM Position Stand
Revised definition
Energy availability
Menstrual fluctuations
Bone mineral density
KEY POINT:
Energy availability = Energy intake – Energy expenditure
Nattie et al, Medicine & Science in Sports & Exercise, 2007

34. Female Athletic Triad
Goal: every female’s physical condition to be at upper right end of spectrum

35. Energy Availability
Spectrum from optimal to low energy availability—with or without eating disorder
Inadequate caloric intake predisposes athlete to menstrual dysfunction and detrimental bone effects

36. Endocrine impact of Low Energy
On menstrual function
Through LH (luteinising hormone) – regulates ovarian cycle
On Bone Mineral Density (BMD)
Through influence of oestrogens on bone resorption
Through influence of Insulin, T3 and IGF-1 factors on bone formation

37. TRIAD Amenorrhea Osteoporosis Eating Disorder
Cessation of menstruation
Osteoporosis
Reduced bone density (irrecoverable)
Eating Disorder
Anorexia, Bulimia
NEGATIVE ENERGY BALANCE
Energy availability = Energy intake – Energy expenditure
Nattie et al, Medicine & Science in Sports & Exercise, 2007

38. Eating Disorders a) Anorexia Nervosa
Females aged are at greatest risk.
SYMPTOMS
INTENSE FEAR OF FATNESS, DISTORTED BODY IMAGE, REFUSAL OF MEALS, AMENORRHEA
Higher Risk Sports - appearance sports (figure skating, gymnastics, ballet), endurance sports (distance running), weight classification sports (horse racing)

39. Eating Disorders b) Bulimia Nervosa
Episodes of binge eating (large amount of food in a discrete period of time), feeling lack of control over eating, purging behavior (self-induced vomiting, laxative use, diuretic use)
Persistent overconcern with body shape and weight
PREVALENCE in female athletes estimated as high as 50  for elite athletes in certain sports
Female Triad - disordered eating, secondary amenorrhea, bone mineral disorders.

40. BMD & Osteoporosis
Result of accelerated bone loss in adulthood OR lack of optimal accumulation during childhood / adolescence
Decreased bone mineral content - increased bone porosity - greater risk of fractures - increase 2 - 5x starting with onset of menopause
CONTRIBUTING FACTORS in postmenopausal women: Oestrogen deficiency, inadequate calcium intake, inadequate physical activity.

41. Menstrual Function
Spectrum for eumenorrhea to amenorrhea (absence of menses > 3 months)
Consequences of hypoestrogenism:
Impaired vasodilation  reduced muscle perfusion/oxidative metabolism
Dec bone mineral density/inc risk of fracture
Scoliosis
Infertility

42. Menstrual Dysfunction
Disruption of normal menstrual cycle.
A high percentage of female athletes in endurance and appearance sports experience SECONDARY AMENORRHEA - normal menstrual function lost for months or years.
REVERSIBLE - reduction in intensity and volume of training, increase in caloric intake

43. Menstruation and Performance
Considerable INDIVIDUAL VARIABILITY in performance during different phases of menstrual cycle (no change x noticeable), no general pattern in achieving BEST PERFORMANCE during any specific phase. Women experiencing PREMENSTRUAL SYNDROM or DYSMENORRHEA - performance decrease.
MENARCHE - coming later in highly trained athletes - not as a rule

44. Menstrual Cycle Most Studies show: Consider
Strength not different over different periods of the menstrual cycle
Olympic medal performances during menstrual cycle
Some reports suggest stronger physical performance immediately post menstruation until day 15 of cycle
Consider
Premenstrual symptoms & Dysmenorrhea (severe pain)
Psychological outlook and attitude towards competition

45. Psychology
Unproven link between adverse effects on performance and premenstrual syndrome
Existence of premenstrual syndrome not in doubt
BUT: not all athletes are the same.....
Understand your athlete
Timing
Role of OCPs in regulation
Medical Support

46. PREGNANCY Fundamental postural changes Relaxin Hormone
Anterior pelvic tilt
Lumbar lordosis
Relaxin Hormone
Ligament softening
Reduced joint stability
1 year + after birth
Abdominal muscles
Abdominal separation
Rectus abdominis – linea alba
Loss of dynamic stability
Transversus abdominus

47. STRENGTH & POWER TRAINING
No difference in abilities until puberty
Males produce more testosterone
Aids muscle lean muscle mass development
Females produce more oestrogen
Aids adipose tissue deposition
Adults
Testosterone 10-30x greater in man
Women rely on Growth Hormone
Women typically smaller muscle fibres and fewer(?)
Women high levels of body fat

48. STRENGTH & POWER TRAINING
Absolute strength is 60-60% of males
Upper body strength is 20-55% of males
Lower body strength is 70-75% of males
Max vertical jump is 54-75% of males
Max broad jump is 75% of males

49. And Relatively Relative to LMM Fibre cross sectional area
Strength differences are substantially reduced
Fibre cross sectional area
Sex differences completely eliminated
Males & Females respond similarly to training
Males exhibit greater hypertrophy due to testosterone concentrations

50. Training Females typically exhibit greater body fat
Per unit of body mass with greater amount of non-functional tissue
Upper body strength biggest differences
Body Weight strength
Ability to handle total body weight in various

51. Strength Training Enhanced BMD
Stronger connective tissues & joint stability
Increased LMM and non functional body fat
Higher metabolic rate
Increased functional strength

52. Training Age Need for strength & Power training in females overlooked
From child to adolescent to adult, females typically express less interest to train (strength)
Females tend to have a shorter training age

53. Implications
Many young adult female athletes can make large gains with basic training programmes
Prolonged periods of inactivity can be detrimental
Relevance to off-season
Relevance to injury