Women have become increasingly involved in sporting activity over the past 30 years. In 1972, Title IX—a federal antidiscrimination law—led to a significant increase in female sports participation. The Title IX amendment prohibits gender discrimination in secondary and postsecondary educational institutions receiving federal funds. This has led to more women competing at the high school, college, and professional levels. Women also participate in a greater variety of sports, including traditionally male-dominated sports. For example, women not only compete in gymnastics, figure skating, and softball, but also in soccer, lacrosse, hockey, and American football.
As a result of increased female sports participation, orthopedic injuries are emerging that are more common and unique to female athletes. Anatomic differences and poor training regimens have contributed to the increase in sports injuries for women.
Anatomic and physiologic differences between men and women play a role in the incidence and type of sports injury. The three most common injuries are the knee, shoulder, and foot.
Patellofemoral disorders and anterior cruciate ligament (ACL) injuries of the knee have a higher incidence in female athletes than in males. Patellofemoral disorder refers to a group of syndromes that arise from the knee extensor mechanism and the surrounding soft tissue attachments. The knee extensor mechanism consists of the quadriceps muscle (commonly known as the anterior thigh), patella (or kneecap), and patellar tendon. Several anatomic differences contribute to the increased incidence of patellofemoral disorders in female athletes. These anatomic differences include underdeveloped quadriceps and hamstring muscles, knee recurvatum (hyperextension), and patellar misalignment. Patellofemoral injuries cause an irritation and inflammation of the undersurface of the patella. Women often report pain behind the patella, buckling knees, and stiffness after prolonged sitting. Treatment for these conditions ranges from conservative therapy and exercise to surgical procedures.
Anterior cruciate ligament injuries are more common in females participating in sports that involve jumping and pivoting, such as basketball, soccer, and volleyball. The Anterior cruciate ligament provides knee stability and prevents forward movement of the femur (thigh bone). Theories suggest that ligament laxity, intercondylar notch dimensions and limb alignment, and low ratios of hamstring-to-quadriceps strength contribute to the higher incidence of Anterior cruciate ligament injuries in women. Ligament laxity refers to decreased tensor strength of the Anterior cruciate ligament and may be hormone dependent. For example, the hormone relaxin, secreted during the luteal phase of the menstrual cycle (the time between ovulation and the onset of the next menses), is postulated to cause greater Anterior cruciate ligament laxity in women, leading to more frequent Anterior cruciate ligament injury. Additionally, women generally have wider pelvises than men, which increase the angle that the femur connects to the knee joint and may result in increased force transmission to the Anterior cruciate ligament. A related biomechanical factor is the narrower intercondylar notch dimensions in women. The Anterior cruciate ligament passes through the intercondylar notch of the femur before fanning out and connecting to the tibia (shin bone). It is postulated that cutting and jumping movements in athletes with narrow femoral notches may weaken and fray the Anterior cruciate ligament. Finally, women generally have a lower ratio of hamstring-to-quadriceps strength, indicating a relative deficit in hamstring strength. Jumping and pivoting motions require that the quadriceps and hamstring muscles oppose and act in concert with each other. For example, landing from a jump and bending the knees involves eccentric contraction of the quadriceps (lengthening of muscle fibers) and concentric contraction of the hamstrings (shortening), whereas recovery requires the opposite action. Female athletes with low ratios of hamstring-to-quadriceps strength, rely on quadriceps activation for both landing and recovery, creating a high probability for Anterior cruciate ligament injury.
Anterior cruciate ligament injuries most often involve a partial or full-thickness tear of the ligament. Women who sustain these injuries develop pain, swelling, and instability of their knee. Most often surgical intervention is necessary to repair the damaged ligament.
The shoulder joint is another common area of injury in female athletes. Sports that involve overhead movements such as swimming, racquet sports, and throwing sports frequently cause shoulder pain. Rotator cuff impingement syndrome commonly occurs in overhead sporting activity. Impingement syndrome occurs when the shoulder rotator cuff tendons become impinged underneath the acromion (the flat bone covering the rear of the shoulder) with overhead arm movement. This condition occurs because of less developed shoulder girdle musculature. As a result, the rotator cuff muscles and tendons must work harder to perform the demands placed on them. With rotator cuff impingement syndrome, the tendons become irritated and inflamed leading to bursitis, tendonitis, and potential tearing. Treatment primarily involves therapy to alleviate the inflammation and build strength in the shoulder and upper extremity muscles.
Increased shoulder capsular laxity is an anatomic difference between females and males that also causes shoulder pain. Capsular laxity refers to the movement, or translation, of the head of the humerus (upper arm bone) with respect to the socket, or glenoid. With cap-sular laxity, the shoulder joint is unstable causing pain in the shoulder and upper arm. Thus, laxity in the shoulder capsule may become a problem in repetitive overhead arm movements. Similar to rotator cuff impingement syndrome, a progressive strengthening program improves stability, thereby alleviating pain.
Anatomic foot differences are also a common problem area in female athletes. Studies suggest that women’s foot problems, particularly bunions and other toe deformities, may be inherited but often arise from poor footwear. Athletic footwear has traditionally been designed for the male population with smaller versions available for females. However, the female foot is not simply a smaller version of the male foot. A female’s wider forefoot and narrow hindfoot need a shoe design to properly accommodate these differences. Improperly fitted athletic shoes can cause hallux valgus (bunion) deformity, hammertoe, and plantar calluses. These problems typically cause foot discomfort and hinder athletic performance.
A major contributor to sports injury in female athletes is a lack of proper training. Coaching has focused on winning the game rather than training and proper conditioning for a particular sport. Sport-specific conditioning strengthens muscles that prevent fatigue and overuse-type injuries such as patellofemoral and shoulder impingement syndromes. Teaching proper jumping and landing techniques reduces the risk of twisting injuries that cause ligament damage. Studies show that a decreased injury rate is directly correlated with proper training and conditioning. In fact, the primary treatment for many nonsurgical athletic injuries starts with a rehabilitation program that focuses on conditioning the injured joint to meet the demands of sports activity.
The significant increase in women’s sports participation the past 30 years has led to female injury patterns not previously recognized or studied. Recognizing female anatomic differences and the necessity of proper training will provide a better understanding for treating and preventing injuries.
See Also: Arthritis, Exercise, Foot care, Menstruation, Osteoarthritis, Tendonitis, Women’s Health Initiative
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