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“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Female Athletic
Injuries and Issues
Jessica Huerta, DO, MS
LECOM Erie Sports Medicine Fellow
May 2, 2014
Sports Medicine Fellowship
Dr. Leary
Dr. Coppola
Goal

Provide optimal care to female athletes
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
1
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Objectives
Review History of Women’s Participation
Review and discuss Gender Differences
 Review Specific Sports Injuries & Issues
 Discuss current literature
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Benefits to Physical Activity
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Emotional well being
Enhanced cognitive
function
Better perceived
quality of life
Heart Disease
Diabetes
Cancer
Walking
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JAMA: Holmes, May 2005, 3-5 hours/week
Clinics Sports Med: Macera, 2005, 1h/day
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
2
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Benefits of Walking

20-30% Decrease Mortality
– 30 min walk most days of the week
Reduction in BP  11 hours after ten
minute walk
 Three 10min may be better than one
30min
 Breast Cancer Survival with 3-5 Hours
of Walking per week
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Predisposing Conditions
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Previous Injury
Previous Surgery
Obesity: BMI & Pain UP ~ Activity Down
Osteoarthritis
Osteoporosis
Cardiovascular Disease
Poor Sleep
Addictions
Cancer
Diabetes Mellitus
Result of Participation
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Decrease unwanted
pregnancy
Decrease drug
involvement
Increase high school
graduation rates
Increase self esteem
Decrease depression
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Value of competition
Self image
Self confidence
Reduced tension
(Lopiano)
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
3
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Title IX Amendment

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Patsy Mink
Education Act 1972
Common Women’s Sports
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Cheerleading
Gymnastics
Basketball
Soccer
Running
Hockey
Swimming
Crew
Lacrosse
Volleyball
Issues
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ACL Injury/Prevention
Patellofemoral Pain
Osteoporosis
Concussion
Iron Deficiency (Anemia)
Shoulder
Stress Fractures
Female Triad
Pregnancy
Depression/self esteem
Cancer
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
4
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Sports Specific Injuries
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Basketball  ACL
Soccer  Concussion
Crew  Sacral Stress
Fracture
Volleyball  Pars
Defect
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Lacrosse  Wrist
Swimming Shoulder
Diving  Triad
Cross Country 
Stress Fractures
Anterior Cruciate Ligament Injuries
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Track and field 31%
crew 8%
Basketball 4%
Lacrosse 3%
Soccer 3%
15% of athletic
injuries
Anterior Cruciate Ligament
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~ 250,000 ACL
ruptures per year
Sixth most common
orthopedic surgery
Most expense in
soccer
Cause of OA
Repair can prevent
meniscal tears and
reduce instability
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
5
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Anterior Cruciate Ligament

Functionally the ACL is two ligaments.
– the posterolateral and anteromedial are
intimately spiraled around each other a full
90 degrees.
– spiraling along with broad insertions keeps
some of the fibers taut throughout the
range of motion.
Anterior Cruciate Ligament Injuries
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Anterior Cruciate Ligament prevents anterior
femoral translation on shin bone (tibia)
Pivot and twisting movement at less than 21° of
flexion.
– 66-93% non contact
Lateral meniscus = acute ACL
Medial meniscus = chronic ACL
Muscle Imbalance = Quadriceps > Hamstrings
Rapid growth in skeletal immaturity
Neuromuscular Imbalance
ACL Demographics

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Women have more
ACL ruptures than
men; 2-8 times
2x Soccer
3x Baskbetball
(Arendt & Dick)
Women have more
stress fractures than
men; 2-12 times
(NCAA)
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One in ten will
sustain serious knee
injury
2/3 ball possessor
(JM Bjordal)
75% Game
Situations
4 of 5: non contact
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
6
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Demographics

Sports
Participation:
– 1 in 27 girls in
High School sports
in 1971
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$37 million per
year
~100,000 repairs
per year
$25,000 to repair
– 1 in 3 in 1998
ACL intact
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15 mm wide
Ligamentous laxity
via KT-1000
> AP
translation(Rozzi)
38,000 repaired in
women per year
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
7
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Anterior Cruciate Ligament


Notch size and
ligament size
controversial
(Barret)
ACL laxity does not
vary with menstrual
cycle
Factors

INTRINSIC

EXTRINSIC

laxity
hormones
alignment
notch width
muscle recruitment
pattern
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conditioning
experience
skill
muscle strength
training
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Intrinsic (Host)
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Q Angle <17
degrees
(LH Woodland)
Factor in
patellofemoral
disorders
Likely not a factor in
ACL rupture risk
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
8
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Extrinsic (Environment)
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Muscle strength and
conditioning
Technique
Coaching
Shoes
Surface
Bracing/taping
OUTCOME
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3:1 Women : Men
All offensive
All ball possessors
Q angle < 17
degrees
All non contact,
pivot or sudden stop
Quadruple
hamstring grafts
ACL Prevention
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
9
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Knee Pain
KOOS Survey
 Rosenburg Views Demonstrating
Fairbanks changes

Gender Bias
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Total Knee Replacement:

12 years after ACL-Fairbanks Changes;
– 2/1  Male/Female
(Lohmander, 2004, Arthritis and Rheumatism)
> 600,000 TKR in the United States per
year
 $20,000 - $40,000 per knee

– Surgery
– Rehabilitation
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
10
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Escalating Burden of Arthritis
57% increase
Millions of Cases*
Arthritis prevalence
59.4
60
Arthritis causing
activity
limitation
50
40
37.9
30
66%
increase
20
10
0
11.6
7.0
1990
2020†
Year
*United States population (estimated)
†Projected
Lawrence RC et al. Arthritis Rheum. 1998;41:778–799.
Remember

ACL>MCL>ACL-MCL>PCL>LCL
– ACL half
– MCL fourth
– Acute ACL-Lateral Meniscus
– Chronic ACL-Medial Meniscus
Osteoporosis
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
11
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Concussion

Women and younger athletes tend to
do worse
– Younger athletes at higher risk

High School and College
– Higher rates in women
#1 Sport – Soccer
 Need for more research

Iron Deficiency
3% Iron Deficiency
Heavy and frequent menstruation
Nutritional Deficits
Hydration
Over usage
Controversy over Low Serum Ferritin
without anemia.
Pseudoanemia
Older Shoulder and Sick Scapula
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
12
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Stress Fracture

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Too
Too
Too
Too
Too
Much
Often
Hard
Fast
Soon
Incidence
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Track and field 31%
Crew 8%
Basketball 4%
Lacrosse 3%
Soccer 3%
15% of athletic
injuries
Stess Fractures
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Year around athlete
with repetitive
mechanical loading
California, Florida,
Texas
3.5 times
women>men
white > black 2x
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Tibia 50%
Metatarsals 14%
Fibula 7%
Tarsal 3%
1/4 exercise induced
leg pain.
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
13
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Stress Injury
Tarsal Navicular (N Spot)
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7 months: symptoms dx
Poor dorsiflexion
Insidious pain in archincrease with activity
Limited subtaler motion
Point of maximal
tenderness-ant tibial
tendon—extensor
hallucis longus
73% from Track
Diagnosis
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A change in training
2-3 weeks prior
Minimal swelling
Pain becomes
incapacitating
Plain films normal
Stress response with
stir images
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
14
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
The Female Athlete Triad

Disordered Eating
15-62%

Amenorrhea
(Secondary)
3.4-66%

Osteoporosis
0-13%
The Female Athlete Tetrad?
Secondary
Amenorrhea
Disordered
Eating
Osteoporosis
Endothelial
Dysfunction
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
15
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
The Female Athlete Triad

Risk Factors:
– Sports emphasizing leanness
– Individual sports
– Early sport-specific training
– Social isolation
– Poor body self-image
– Unreasonable performance expectations
– Punitive measures for weight gain
Exercise in Pregnancy

Recommendations:
– Uncomplicated pregnancy: 30 minutes or
more of moderate exercise on most days
of the week
– Avoid: activities with high risk of falling or
abdominal trauma, scuba diving
– Avoid supine activities after the first
trimester
– Can reduce incidence of gestational
diabetes
Exercise Post-Partum
Resumption of activities post-partum
should be gradual
 Can decrease incidence of post-partum
depression
 Moderate weight reduction while
nursing is safe

POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
16
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
Conclusion
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More women more
injuries
More ACLs, more
stress fractures
Training, nutrition,
hormones
Coaching, education,
experience
Prevention
Hydration

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Women 2.2 liters / Day
Men
3 Liters / Day
Exercise
Ideal For
Benefit Desired
Intensity Level (% Maximum
heart rate)
Light Exercise
Maintain Healthy Heart/Get Fit
50% - 60%
Weight Management
Lose Weight/ Burn Fat
60% - 70%
Aerobic Base Building
Increase Stamina Aerobic
Endurance
70% - 80%
Optimal Conditioning
Maintain Excellent Fitness
Condition
80% - 90%
Elite Athlete
Maintain Superb Athletic
Condition
90% - 100%
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
17
“Women’s Sports Injuries”
Jessica R. Toler Huerta, D.O.
References
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1. Brukner Peter, Khan Karim: Clinical Sports Medicine 3rd Edition. 472-493
2. Frank CB, Jackson DW. The Science of Reconstruction of the Anterior Cruciate Ligament. J
Bone Joint Surg Am. 1997;79:1556-1576
3. Gregory D. Myer, Kevin R. Ford, Timothy E. Hewett. Rationale and Clinical Techniques for
Anterior Cruciate Ligament Injury Prevention Among Female Athletes. Journal of Athletic
Training. 2004;39(4):352-364
4. “Title IX”. Wikipedia, the free online encyclopedia. http://en.wikipedia.org/wiki/Title_IX
5. Lopiano, DA. Modern History of Women in Sports. 25 years of Title IX. Clinical Sports Med
2000;19(2):163-173
6. Jesse C. DeLee, David Drez, Jr., Mark D. Miller: DeLee & Drez’s Orthopaedic Sports Medicine
3rd Edition. 1645-1655
7. Timothy E. Hewett, Gregory D. Myer, Kevin R. Ford. Prevention of Anterior Cruciate
Ligament Injuries. Current Women’s Health Reports 2001, I:218-224. Current Science Inc.
ISSN # 1534-5874
8. L.S. Lohmander, A. Ostenberg, M. Englund, H. Roos. High Prevalence of knee
Osteoarthritis, Pain, Functional Limitations in Female Soccer Players Twelve Years After Anterior
Cruciate Ligament Injury. Arthritis & Rheumatism. Vol. 50, No. 10, Oct 2004, pp 3145-3152
9. Bracker, Mark D. Editor. The 5-Minute Sports Medicine Consult. 2nd Ed. 2011. Lippincott
Williams & Wilkins.
10. http://www.rothmaninstitute.com/specialties/conditions/womens-sports-injuries.
11. Griffin LY, et al. “Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and
Prevention Strategies” J. Am. Acad. Ortho. Surg., May/June 2000; 8: 141-150.
12. https://www.womenssportsfoundation.org/en/home/research/articles-and-reports/mentaland-physical-health/female-athlete-and-concussions
POMA 106th Annual Clinical Assembly
April 30 – May 3, 2014
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