Sex matters: From sports to life

By: Carolyn Rogers

By Carolyn Rogers

More research, better training and prevention, and increased education are needed to protect women’s musculoskeletal health, according to a panel of physicians discussing “Sex matters: From sports to life, gender really makes a difference in musculoskeletal health.”

“It’s not a question of which sex is defined as normal or prototypical,” said moderator Kimberly J. Templeton, MD. “Men and women will always be two different variations on a theme; therefore, it is imperative we understand those differences and have distinctly different options for preventing disease and injury for each sex.”

The number of women athletes with orthopaedic injuries now reflects the numbers of women who are flooding into both amateur and professional sports.

Although orthopaedic surgeons are better able to fix those injuries today, Dr. Templeton noted, “these women will never be like they were before their injuries, and they are increasing their risk of becoming disabled at an earlier age.”

Laura L. Tosi, MD, answered reporters’ questions on the importance of sex and gender in musculoskeletal health during Wednesday’s media briefing.

Impact of sex on ACL injuries
Anterior cruciate ligament (ACL) injuries are four to eight times more likely to occur in females than males, according to panelist Letha Y. Griffin, MD.

Eighty-five percent of ACL injuries are noncontact and occur when the athlete is off balance while pivoting, cutting, landing a jump, or stopping.

About 1 of every 100 female high-school athletes playing high-risk sports such as soccer, basketball, handball, and tennis will injure an ACL before she graduates, Dr. Griffin reported. In college-level players, the risk rises to 1 in 10—a much higher rate than among male athletes.

“Although the ACL can be repaired, and the knee can be stabilized enough to get athletes back on the field within 6 months, 20 percent of those who continue to play sports for 3 years will reinjure the same knee or tear the ACL in their other knee,” Dr. Griffin said.

Even more troubling, she said, is that 90 percent of patients who have achieved excellent knee stability following reconstructive surgery will experience degenerative arthritis in the injured knee within 10 years.

“Typically, they come back in their early 30s because of increased pain in the knee and significant loss of function,” she said. “By the time I see them they’ve given up running and tennis. Sometimes they can’t even keep up with their kids.”

While researchers search for better surgical procedures, Griffin says, “clearly, this is an issue we have to attack with prevention.”

Train girls to mimic boys
What’s the best way to do that? Although studies are limited, the most successful approach thus far has been to train girls to mimic movements that male athletes seem to do naturally. “When boys play sports, they instinctively keep their knees and hips flexed and their upper bodies equally balanced over their lower extremities—positions that help protect them against ACL injury,” Dr Griffin explained.

Female athletes tend to maintain a more upright position and extend their legs farther while playing, she said. When they jump, they often land in an upright position and are less likely to land on both feet—actions that make them more vulnerable to ACL injuries.

“If you watch boys play basketball, you hear shoes squeaking on the floor,” Dr. Griffin pointed out. “With girls, you hear thumps.”

This problem has led to the development of ACL prevention strategies that focus on teaching girls how to land, cut, and stop with hips and knees bent, up on the balls of the feet, and with the body balanced over lower extremities.

Recent randomized controlled trials that employed such strategies have resulted in decreased injury rates, Dr. Griffin reported.

Weak at the knees
When women jump, the laxity in their knee ligaments cause their knees to “wiggle.” To counteract that, a jumping workout to strengthen the female knee has been developed.

The program teaches young women to jump on both feet, and then add twisting and turning in the air. All nine Cincinnati high schools that participated in the training program reduced their female ACL injury level to that of male students.

So what’s the new news?
Despite the widespread recognition that an emphasis on alternative conditioning methods will decrease injury rates, coaches, athletic trainers, and players have been slow to adopt these prevention strategies.

Therefore, many orthopedists are lobbying schools across the country to adopt injury prevention programs. Coaches, trainers, and parents who know firsthand how devastating an ACL injury can be are most responsive to these efforts, but getting the coaches of younger girls to pay attention is more difficult.

“Until we do a better job of getting the word out to younger players, we’re not going to see a decrease in the number of these injuries,” Dr. Griffin says. “We need to recognize that training girls is different than training boys and that they need different conditioning at all levels of play.”

Other panelists included Laura L. Tosi, MD, who spoke on the importance of sex and gender in musculoskeletal health; Jo A. Hannafin, MD, who addressed the role of shoulder instability and impingement syndrome; and Naomi N. Shields, MD, who discussed foot and ankle problems in the female athlete.

For more information on ACL injury prevention strategies for female athletes, see the February issue of AAOS Now, online at