The Journal of Women's Sports Medicine (ISSN 2769-4895) is a peer-reviewed multidisciplinary journal featuring cross-disciplinary research that furthers the understanding of sports injuries/conditions, treatments and outcomes that are specific to female athletes. All articles must undergo a double-blinded peer review process guided by a multidisciplinary editorial board. Articles are published open access without publication fees, to encourage patient-centered research that supports female athletes and the advancement of women's sports. The journal encourages submission of original scientific articles, review papers, and case reports, that have taken a cross-disciplinary approach to address the topic of issues in female athletes, not limited to the following disciplines: Sports medicine Orthopaedic surgery Pregnancy and obstetrics Hormones and endocrinology Nutrition and disordered eating Sports psychology Sports rehabilitation Injury prevention, education, and access to care For questions regarding topics and submissions, please contact editor@jwomenssportsmed.org. For all other questions, including opportunities for sponsorship or advertisements, please contact info@jwomenssportsmed.org.
EQUAL PAY, EQUAL HEALTH: Player Voices from The Women’s Soccer Health Study
The concept of Equal Pay, Equal Health is motivated by the fact that women’s soccer players not only receive less pay than male players but are also under-represented in sports health research. The Women’s Soccer Health Study: From Head to Toe has collected data on 560 retired elite women’s soccer players in 5 health domains: General, Musculoskeletal, Reproductive, Post-Concussion, and Mental. Previous publications have reported on the high number of musculoskeletal injuries and post-concussion symptoms. Another key finding has been that players with ACL reconstruction have lower post-career satisfaction. To incorporate athlete voices, the players were asked to rank the 5 health domains in order of importance and to report other topics that were missing from the study. The top-ranked area was mental health, and nutrition topped the list of other health issues. Among the 99 written comments, 30% expressed appreciation for this research on female athlete health.
Concussion, Epidemiology research, Nutrition, Soccer
Copyright (c) 2025 Daphne I. Ling, Jo A. Hannafin, Heidi Prather, Heidi Skolnik, Rachel Vanderkruik, Theresa A. Chiaia, Polly de Mille, Cara L. Lewis, Ellen Casey https://creativecommons.org/licenses/by-nc-nd/4.0
Safety and efficacy of a video-based physical education program during pregnancy: A pilot study
BACKGROUND: The objective of this study is to report on the safety and efficacy of once-per-week instructional exercises videos during pregnancy in a pilot study. METHODS: Pregnant women in their second trimester under the care of obstetricians in an academic hospital were enrolled in the exercise group. Participants in the exercise arm received an instructional video and explanation on each physical exercise beginning at 12 weeks gestation, once a week for the following 12 weeks. Each video focused on a clinically recommended exercise to aid musculoskeletal health. Participants were surveyed regarding physical activity, mental health, and general well-being using the PROMIS-10 and Pregnancy Physical Activity Questionnaire [PPAQ] at 0-, 6-, and 12-week time points. A control group of patients was surveyed for comparison at the 6- and 12-week time points. Differences of means between exercise and control groups, and multivariate regressions of the PROMIS-10 and PPAQ outcomes on treatment status, controlling for BMI at 8 weeks gestation and age, were performed to assess the relationship between physical activity education and well-being and exercise indices. RESULTS: 22 pregnant women were enrolled in the exercise arm and 34 were enrolled in the control groups. Of the 22 women that began the exercise program, 72.7% (16) completed 6 weeks and 45.5% (10) completed all 12 weeks. No adverse events were noted. No significant differences were established between the exercise and control groups for either the PROMIS-10 or PPAQ measures in this pilot study. Compliance was greater for a shorter duration and among women ≥35 years. CONCLUSION: We found that a weekly instructional exercise videos during pregnancy could be safely administered, with low to moderate compliance amongst participants. This pilot study suggests the potential of pursuing exercise education interventions with a greater number of participants to better understand the role of exercise education during pregnancy.
Copyright (c) 2026 Ally Scheve, Maria Velasquez Hammerle, MD, Lisa Baute, MD, Jamie Preszler, PT, DPT, ATC, Miho J. Tanaka, MD, PhD https://creativecommons.org/licenses/by-nc-nd/4.0
Implementation of an Anterior Cruciate Ligament (ACL) Injury Risk Reduction Program in NCAA Division II Women's Soccer
BACKGROUND: Anterior cruciate ligament (ACL) injuries are a significant cause of performance limitation among female collegiate athletes, often resulting in lengthy rehabilitation and increased risk for long-term complications such as osteoarthritis. While multi-component injury risk reduction (IRR) programs incorporating plyometric, neuromuscular, balance, and strengthening exercises have shown promise, their efficacy in broad competitive populations remains unstudied. This study evaluated the effectiveness and feasibility of a six-week injury risk reduction program among NCAA Division II women's soccer players. METHODS: A single-group pretest-posttest design was applied to 27 participants aged 18-21 from Nova Southeastern University during the Fall 2024 season. Baseline and post-intervention assessments included functional knee testing via the Single-Leg Squat, Lachman, and Lever sign, alongside injury tracking throughout the season. The program consisted of biweekly, supervised 15-minute sessions targeting specific muscles associated with knee stability through equipment-free exercises. RESULTS: Results showed no statistically significant group-level improvements in squat test outcomes post-intervention; however, some individual athletes exhibited function gains in lower extremity control. Injury data revealed no ACL injuries during the season. Participant adherence was high, with 78% completing the program as planned, and the protocol was well tolerated with no adverse events. Analysis found no association between injury history and demographic or screening variables. CONCLUSION: The findings demonstrated the feasibility and the potential for short, standardized IRR protocols to be integrated into collegiate athletic training, particularly in resource-limited areas. The program's equipment-free design and supervised delivery suggest scalability for teams without dedicated athletic trainers. Although further research with larger, controlled samples is warranted to optimize dosage and long-term outcomes, this study supports the implementation of complex ACL injury prevention programs as practical and promising strategies in women's collegiate soccer.
Copyright (c) 2025 Roody Joseph, Nicole Schneider, Dylan Sehgal, Evelyn Echevarria Cruz, Hemangi Patel, Zachary Morcos, Alicia Graubard, Ambika Singh, Vivian Calderon https://creativecommons.org/licenses/by-nc-nd/4.0
Auditing the Representation of Active Girls, Women, and Female Athletes in Low Energy Availability Research: A Decade-Long Review of the Literature
BACKGROUND: Low energy availability (LEA), or a mismatch between energy intake and exercise energy expenditure, is a major concern for physically active individuals, particularly females. Although more female athletes are participating in sport today than ever before, they remain underrepresented in sport and exercise science research. However, it remains unclear how well physically active females are considered in research on LEA and LEA-related conditions. This study aimed to (a) evaluate the representation of physically active female in LEA research, and (b) explore the methodological characteristics underpinning LEA research. METHODS: This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three databases were searched for publications that investigated LEA in active individuals and athletes from 2014-2024. The number of total participants (male/female), title, topic/focus, and methodological characteristics were recorded for each publication. Data were expressed in frequencies and percentages. Chi-square goodness-of-fit tests, independent t-tests, and Chi-square tests of homogeneity (χ2) were used to compare sex counts across studies, sex-specific studies, and proportions of study population based on methodological characteristics, respectively. Across 296 publications, 34,818 participants were included in analyses. RESULTS: There was a significant imbalance between the total number of female (n = 28,738; 82.5%) and male participants (n = 6,080; 17.5%) (χ²(1, n = 34,818) = 14,744.81, p < .001). Overall, 56% of studies included females-only, 22% included males-only, and 22% included both sexes, demonstrating female bias (t(229) = 2.196, p < .001, d = .321). Between 2015 and 2023, mixed-sex cohort publications increased by 800%, female-only cohort publications increased by 420%, and male-only cohort publications rose from 0 to 10, demonstrating substantial growth across all cohorts during this period. CONCLUSION: A majority of research on LEA is conducted on physically active females, which contrasts with other areas of sports science research.
Copyright (c) 2026 Ahnna E. Faust, Alexis V. Viehl, Melissa T. Lodge https://creativecommons.org/licenses/by-nc-nd/4.0
Beyond "Users" and "Non-Users": Insights from a Murine Model of Oral Contraceptive Formulations
Oral contraceptive pills (OCP) are a commonly prescribed medication in the United States and worldwide for female individuals in the athletic and general populations. Research often compares female participants as oral contraceptive pill “users” or “non-users.” However, there are distinct types of oral contraceptives with differences in synthetic hormones and doses. The heterogeneity in hormone type and dosage composition represents a critical variable when investigating the impact of oral contraceptive pills on musculoskeletal health and athletic performance. Many athletes are opting to use OCPs to manipulate their menstrual cycles in coordination with training and competition schedules. Just as it is important to understand how different OCPs affect menstrual patterns to guide individualized prescribing, so too should we strive to understand their musculoskeletal effects. Improved knowledge in this area will allow clinicians to optimize OCP prescription to further support musculoskeletal health and performance.
Copyright (c) 2025 Nicole B. Katz, MD, Fabrisia Ambrosio, PhD, MPT https://creativecommons.org/licenses/by-nc-nd/4.0
Injury Patterns and Specialization Age in Elite Female Ice-Hockey Athletes
BACKGROUND: Amongst youth athletes, a trend towards earlier specialization in a single sport has been observed and may be associated with increased injury rates and burnout. In elite women’s ice-hockey, neither the implications of early sport specialization nor generalized injury patterns have been well described. This study investigates the association of early specialization in elite female ice-hockey players with injury prevalence and highest level of play attained, and characterizes injury location in elite female ice-hockey players. METHODS: An online survey was distributed to elite female ice-hockey players including current and retired high school, collegiate, professional, and Olympic/ World Championship players. Athletes reported date of birth, height, weight, handedness, highest level of play, and ice-hockey related injury data. Injury data included specific diagnoses, laterality, and if it required time out of sport. RESULTS: 259 athletes completed the survey. Older age at specialization was associated with higher levels of play, with 12.9 (± 2.4) years for high school up to 15.0 (± 3.0) years for senior national team level. There was no association between the age at specialization and professional level play, total injuries, concussions, or fractures sustained during ice-hockey (p > 0.05). 49.0% of players reported ice-hockey related concussions, with mean number of concussions per player of 0.9 (± 1.1). Laterality of injury was associated with shooting side dominance. 71.8% of retired players reported ongoing physical and/or mental health issues. CONCLUSION: No significant association was found between age at specialization in ice-hockey and professional level play or number of injuries, paralleling findings in elite men’s ice-hockey players. Concussion was the most common injury reported, emphasizing the significant prevalence of head injuries on women’s sports. A significant proportion of retired players reported ongoing issues secondary to ice-hockey injuries.
Copyright (c) 2025 Claire Margaret Thompson, Isabel Wolfe, Caroline A. Dannacher, Raven Hollis, Guillem Gonzalez-Lomas, Abigail L. Campbell https://creativecommons.org/licenses/by-nc-nd/4.0
Injuries in Female American Football Players from 2015 to 2024: An Age-stratified Epidemiological Analysis
BACKGROUND: American football has seen growing participation by women. In 2023, 474,000 females aged 6–17 participated in flag football, and the number of high school-aged females registering for tackle football rose by 5.6% compared to 2022. Unfortunately, female football players remain understudied in the injury prevention literature, limiting our understanding of the potentially unique risks that they may face. This study sought to describe injury patterns among female football players, with a particular emphasis on characterizing the relationship between player age and injury. METHODS: The National Electronic Injury Surveillance System database was queried for football-associated injuries in female patients from 2015 to 2024. Patients were stratified into three groups—those aged 6–13 (“youth”), 14–18 (“high school”), and 19+ (“adult”). National estimates were calculated for injuries by location and by diagnosis for each age group. Chi-square tests assessed for differences in injury location and diagnosis between groups. RESULTS: Between 2015 and 2024, an estimated 176,831 football-related injuries were treated in U.S. emergency departments. The hand was the most common site of injury, comprising 48.2% of injuries in youth, 35.8% in high school, and 31.6% in adult athletes. Sprains/strains were the most common injury diagnosis across all age groups, accounting for 30.3%, 33.5%, and 29.6% of injuries in youth, high school, and adult female football players, respectively. Fractures and injuries to the hand, elbow, and upper extremity made up a greater proportion of injuries in youth athletes compared to high school and adult athletes. However, injuries to the knee and lower extremity were proportionally less common in youths. Concussions and strains/sprains were proportionally most common in high school athletes. Dislocations, shoulder injuries, and trunk injuries were most common in adults. CONCLUSION: : Female football players experience differing injury patterns by age group. Notably, these patterns frequently differed in direction and/or magnitude from those reported in mixed-sex populations, where risk profiles specific to female football players may have been obscured by the larger number of males. Future studies should utilize these results to inform the development of age- and sex- specific injury prevention protocols and clinical guidelines.
Copyright (c) 2025 Eric Mao, Brandon Chen, Eve Glenn, Pranav Dewan, Dawn LaPorte https://creativecommons.org/licenses/by-nc-nd/4.0
Mouse Model for Combined Oral Contraceptive Administration in Diet
BACKGROUND: Combined oral contraceptives (COCs), containing synthetic estrogen and progestin, are widely used for birth control and managing various conditions. A wide variety of COC formulations are prescribed, yet formulation-specific effects on health remain poorly understood. This study investigated the impacts of two COC formulations––low-dose ethinyl estradiol (EE) with high androgenicity progestin, levonorgestrel (LNG) and high-dose EE and low androgenicity progestin, desogestrel (DSG)––on estrous cycling and anthropometrics in a mouse model. METHODS: Eighteen female C57Bl/6J mice (12 weeks old) were randomized into three groups: low-dose EE + LNG (2mg/kg EE, 200 mg/kg DSG), high-dose EE + DSG (5mg/kg EE, 200 mg/kg DSG) and a control group. Hormones were administered via diet over 8 weeks. Body weight, food intake and estrous cycle stages were monitored, and serum hormone levels were measured at the time of euthanasia. RESULTS: Both COC formulations disrupted estrous cycling, with the EE + LNG group spending more time in diestrus and the EE + DSG group in metestrus, compared to the controls. No significant differences in body weight change or serum progesterone levels were observed, though serum estradiol levels were lower in both experimental groups compared to the control group. CONCLUSION: These findings contribute to the refinement of translational rodent models for COC research and provide insight into the differential effect of the composition of different COC’s.
Copyright (c) 2025 Olivia R. Rau, BA, Arielle J. Hall, MD, Jennifer Cheng, PhD, Audrey C. Wimberly, MPH , Camila B. Carballo, PT, PhD, Scott A. Rodeo, MD, Ellen K. Casey, MD https://creativecommons.org/licenses/by-nc-nd/4.0
Case Study: Psychoneuroendocrinology of Mild Traumatic Brain Injury Recovery
BACKGROUND: The correlation between the endocrine system and cognitive functioning has been increasingly discussed in the literature in recent years, as a growing number of studies in this field emerge. Despite this growth in interest in this correlation, however, the topic still remains heavily under-explored especially in the case of female athletes who have sustained traumatic brain injuries. There exist many obstacles in acquiring relevant data to enrich this field of research, including, but not limited to, current medical approaches, difficulty in isolating neurological and psychological symptoms stemming from mild traumatic brain injury (mTBI), the dismissal of multidisciplinary and holistic approaches, as well as limited resources such as time and funding. Although interest has increased and been popularized in the last decade, limited research has been conducted and/or published to specifically explore, clarify, and connect mTBI recovery with endocrine (dys)function. METHODS: The current case study contributes to this topic and offers empirical data gathered through work with an mTBI participant with preexisting hormonal dysfunction. It describes the hormonal changes that precede and follow mTBI recovery in a female athlete, as well as her atypical recovery and long-term post-concussion symptoms. Data gathered includes hormonal charts, neurocognitive assessments, and quantitative electroencephalography (qEEG) assessments administered over a period of six years. RESULTS: Possible interaction of the hormonal changes and their importance in mTBI recovery are theorized in this study, as well as the possible impact that mTBI can have on endocrine functioning. CONCLUSION: The current report suggests a need for further research in the area of hormone function in females who have sustained a traumatic brain injury, even if mild in nature. On a case-by-case basis, there is clinical validity in assessing women who fail to recover from concussion in a timely manner via comprehensive hormonal evaluation and treatment combined with psychological, nutritional, and exercise interventions.
Copyright (c) 2025 Biljana Damevski, MA, Malini Ondrovcik, MA, Henry J. Svec, PhD https://creativecommons.org/licenses/by-nc-nd/4.0
Utilizing the Low Energy Availability in Females Questionnaire (LEAF-Q) to Assess Female Athlete Triad in Collegiate Athletes
BACKGROUND: The female athlete triad has a high prevalence in female athletes and is made up of three components: low energy availability, decreased bone mineral density and menstrual dysfunction. The triad is often recognized in the later stages in endurance sports such as cross country, track, and rowing, which causes significant health issues. The focus of this study is to use the Low Energy Availability in Females Questionnaire (LEAF-Q) to assess risk for the triad amongst all female collegiate endurance and non-endurance athletes, as previous studies have focused solely on endurance athletes. METHODS: A total of 51 female collegiate athletes attending Nova Southeastern University who compete in basketball, cross country, golf, soccer, softball, swimming, tennis, rowing, and volleyball filled out the LEAF-Q on REDCap in a self-reported format. Athletes who completed the survey were divided into endurance or non-endurance groups. Independent t-tests were utilized to examine differences between endurance and non-endurance athletes for injuries, GI issues, and menstrual scores. RESULTS: An average score of 8.36 was obtained from the LEAF-Q, with a value greater than or equal to 8 meaning an individual is at risk for the triad. Between the non-endurance athletes versus the endurance athletes, 60.0% of the non-endurance athletes and 58.3% of the endurance athletes were found to be at risk of the triad. No significant differences in injuries per athlete (p = 0.135), GI issues (p = 0.352), and menstrual (p = 0.738) scores were found which means both types of athletes had similar results of being at risk of the triad. CONCLUSION: According to our findings, non-endurance athletes are at a similar risk of the triad compared to endurance athletes. Further research should be conducted on a larger number of female athletes from a variety of universities to increase the significance of the findings and to further the knowledge of the female athlete triad for athletes, coaches, and parents.
Copyright (c) 2025 Nicole Schneider, OMS-3, Sydney Schneider, MS-1, Pradeep Vanguri, PhD, LAT, ATC1 https://creativecommons.org/licenses/by-nc-nd/4.0
SLAP Repair or Isolated Biceps Tenodesis May Yield Similar Outcomes for SLAP Lesions in Females
BACKGROUND: The purpose of this study was to report outcomes following Superior Labral Anterior to Posterior (SLAP) repair and biceps tenodesis (BT) for SLAP tears in females. METHODS: Female patients who underwent SLAP repair or BT for treatment of isolated SLAP tears between 1/1/2014 and 9/1/2019 were retrospectively reviewed. Patients undergoing a concomitant procedure were excluded. Patients completed American Shoulder and Elbow Surgeons (ASES), single assessment numerical evaluation (SANE), and visual analog scale (VAS), and a custom return to activity surveys at a minimum 2 years post-operatively. RESULTS: The study included 65 female patients; 38 (58.4%) underwent arthroscopic SLAP repair and 27 (41.5%) underwent open- or arthroscopic BT. There was no significant difference in laterality of procedure but patients in the repair group were significantly younger (36.7±8.44 years versus 44.4±10.4 years, P = .003). At minimum 2-year follow-up, both cohorts experienced ASES scores (SLAP: 78.3 versus BT: 80.0, P = .591), SANE scores (77.0 versus 80.1, P = .722) and VAS scores (26.4 versus 24.4, P = .530). Rates of participation in sports prior to surgery were higher for patients undergoing SLAP repair compared to BT (58.8% versus 37.0%, P = .152) and reported rates of return-to-sport after surgery (75.0% versus 80.0%, P = 1.000) were similar. CONCLUSION: The findings of this study indicate that female patients undergoing surgical treatment of SLAP lesions with either SLAP repair or BT show acceptable patient-reported outcomes and return to sport at a minimum 2 years. However, due to the potential for selection bias and surgeon preference towards SLAP repair for patients of younger age and greater activity level, further controlled research is necessary in order to draw definitive conclusions regarding optimal surgical management of SLAP lesions in females.
Copyright (c) 2025 Nathaniel Tchangou, BS, Adeeb J. Hanna, BS, William L. Johns, MD, Matthew Wallingford, BS, Emma E. Johnson, BA, John Hayden Sonnier, MS, Sommer Hammoud, MD, Brandon J. Erickson, MD, Steven B. Cohen, MD, Michael G. Ciccotti, MD, Meghan Bishop, MD https://creativecommons.org/licenses/by-nc-nd/4.0
The Association of Low Energy Availability Knowledge and Risk in Female Track and Field Athletes
BACKGROUND: Under fueling is associated with a number of negative health and performance consequences, and strategies are needed to improve outcomes. Few studies have explored the associations among LEA knowledge and risk of low energy availability (LEA) conditions (i.e., Relative Energy Deficiency in Sport (REDs), eating disorder/disordered eating (ED/DE)). The purpose of this study was to examine associations between LEA knowledge and LEA and ED/DE risk. METHODS: Female track and field athletes (n = 368) completed an anonymous online survey consisting of demographic information, Low Energy Availability in Females Questionnaire (LEAF-Q), Female Athlete Screening Tool (FAST), Eating Disorder Examination Questionnaire (EDE-Q)], and LEA knowledge (LEA-KQ). A one-way ANOVA examined differences between LEA-KQ scores and low- vs. high-risk groups for LEA, DE, and ED. Pearson’s partial correlations, controlled for bone stress injury (BSI) and peak training mileage, were used to assess associations between LEA-KQ and LEAF-Q, FAST, and EDE-Q scores. RESULTS: Of the total sample (n = 368; age 29 ± 8 years), 49% were at high risk for LEA based on the LEAF-Q, 35% were at subclinical DE risk and 13% were at clinical ED risk based on the FAST. Scores on the EDE-Q demonstrated 22% of the sample were at high risk for ED. There was a significant difference in mean LEA-KQ scores in athletes at risk for DE based on the FAST [F (2, 365) = 4.078, p = 0.018, η = 0.022]. There were no significant associations between LEA-KQ and LEAF-Q, FAST, and EDE-Q (p = 0.534, p = 0.051, and p = 0.934, respectively) while controlling for BSI and peak weekly mileage. CONCLUSION: There was no significant association between LEA knowledge and risk. This warrants further exploration, as it is important to understand the direction of the relationship to employ effective education-based programs to prevent the negative health and performance consequences associated with under fueling.
Copyright (c) 2025 Melissa T. Lodge, MS, Stephen M. Cirella, MA, MS, Mark E. Hartman, PhD, Nicole E. Logan, PhD, Christie L. Ward-Ritacco, PhD https://creativecommons.org/licenses/by-nc-nd/4.0
Factors Influencing Female Patients’ Selection of Care Through Women’s Sports Medicine Programs
BACKGROUND: To describe physician- and clinic-specific factors that may influence female patients’ selection of care in a multidisciplinary women’s sports medicine program. METHODS: A cross-sectional anonymous survey was distributed to female patients evaluated by female physicians in a women’s sports medicine clinic over a 2-month time period. Patient demographics, referral sources, influence of physician gender on selection of physician (1-7 Likert scale), and potential contributing factors (binary scale) were recorded. Patient interest in various ancillary multidisciplinary services (each on a binary scale, as below) were recorded and analyzed. RESULTS: A total of 178 female patients (mean age 44.3 +/- 16.6 years) were included in this study. Patients reported 5.4 +/- 4.8 hours of weekly exercise. Physician selection was moderately influenced by a physician’s female sex (4.2 +/- 2.2; 1 being “not influential”, 7 being “most influential”). 75.3% noted some preference (> 1), and 35.3% noted strong preference (6 or 7) for a female physician, with 20.6% reporting female physician sex as the most influential factor in their selection (7). Among self-referred patients, female physician sex played a stronger influence on selection than those referred from other sources (5.3 vs 3.9, p<0.001) with 59.5% reporting strong preference. The most frequently cited reason was “I feel more comfortable with a female physician” (52.0%). Nearly 80% of patients requested access ancillary services, including injury prevention training (50.0%), exercise counseling (48.9%), nutrition counseling (35.4%), sleep specialists (16.9%), hormonal specialists (16.3%), sports psychology (7.3%), and sports cardiology (4.5%). Younger patients (< 40 years) more frequently requested sports psychology compared to older patients (40+ years) (12.2% vs 3.1%, respectively; p=0.020). CONCLUSION: Female patients who were evaluated by female sports medicine physicians in the women’s sports medicine program frequently cited physician sex as a contributing factor in their selection, more so among patients who were self-referred. The majority of patients were interested in access to at least one ancillary service, highlighting the need for multidisciplinary sports medicine care in women’s sports medicine programs.
Copyright (c) 2025 Haylee Borgstrom MD, MS, Stephanie DeLuca, MD, Kelly C. McInnis, DO, Miho J. Tanaka, MD, PhD https://creativecommons.org/licenses/by-nc-nd/4.0
Risk Factors and Injury Prevention Among Female Rock Climbers
BACKGROUND: Female climbers are underrepresented in the literature on rock climbing injuries despite their increasing participation in the sport and higher risk for certain health conditions, especially those related to menstrual dysfunction and bone mineral density. We aimed to investigate potential risk factors for injury as well as possible protective behaviors among recreational female climbers. METHODS: We designed and distributed a 31-question survey on health and demographic characteristics, rock-climbing experience, training behaviors, and injury in the past 12 months. The survey was distributed via 6 online rock-climbing forums and 2 physical locations at rock-climbing gyms in Baltimore County, MD. Female climbers >18 years were invited to participate. Analyses were conducted to compare basic demographic characteristics of climbers with and without injury in the past year as well as to investigate associations between injury and potential risk factors. RESULTS: Nine hundred ninety-seven female climbers completed the survey. In bivariate analysis, warming up with activities other than climbing was significantly associated with injury in the past year compared to warming up with climbing only. After adjusting for hours per week climbing and relevant health conditions and training behaviors, climbers who participated in bouldering were more likely to have experienced injury in the past year (odds ratio [OR] = 1.69; 95% confidence interval [CI] 1.10–2.64; p = 0.018), whereas climbers who regularly participated in other sports were less likely to have experienced injury (OR = 0.65; 95% CI 0.48–0.87; p = 0.005). History of an eating disorder was associated with injury when adjusting for age, diagnosis of amenorrhea, and diagnosis of another physical health condition (OR = 1.53; 95% CI 1.02–2.33; p = 0.043). CONCLUSION: Cross-training and climbing-specific warm-up routines may be protective against injury among female climbers, but bouldering may have a higher risk of injury compared to other climbing disciplines. Clinicians should be aware that climbers with eating disorders may be at particularly high injury risk. Continued investigation into safe training practices is essential to ensure the long-term health and performance of recreational female climbers.
Copyright (c) 2025 Grace Q. Chen, BS, Dawn M. LaPorte, MD https://creativecommons.org/licenses/by-nc-nd/4.0
The Female Athlete Triad in Swimmers: a Review of Current Literature
BACKGROUND: The female athlete triad, including low energy availability, low bone mineral density, and menstrual dysfunction, has serious implications for female athletes, with extreme cases leading to potentially irreversible consequences. It is unclear how or if the female athlete triad uniquely affects swimmers, for whom weightbearing is not part of their sport. The goal of this systematic review was to analyze studies of the triad pertaining to female swimmers with an emphasis on the volume of literature and the prevalence of individual components of the triad. METHODS: A literature search was conducted on November 8, 2023, through PubMed and Google Scholar using the terms “female athlete triad” and “swimmer” or “swimming.” Of the 259 studies extracted, 17 were selected for inclusion after abstract and full-text screening. Outcomes involving each component of the triad, as well as overall prevalence and risk of the triad, were aggregated to derive means. Quantitative reporting of triad components varied across studies; thus, reported mean percentages were calculated using only the studies that reported the relevant statistics. “Female” was defined in reference to cis-gender females based on self-identified gender identity. RESULTS: The 17 studies varied widely in terms of reported metrics. The 11 studies that reported the number of female swimmers included a total of 478 female swimmers. Menstrual dysfunction was the most frequently documented symptom, with a mean of 41% of swimmers experiencing menstrual irregularity. A mean of nearly 12% of swimmers were found to have low bone mineral density, and 51% were found to have low energy availability. Overall, 41% of female swimmers were estimated to be at risk for the triad. CONCLUSION: With an estimated 4 in 10 female swimmers at risk of the triad, early identification through screening, awareness, and special attention to the most reported symptom, menstrual irregularity, is key to maintaining health of athletes. The overall small number of studies on the triad/REDs in female swimmers, along with the wide heterogeneity of quantitative data point to the need for further research on the female athlete triad to better understand the interplay of each symptom in this unique athletic population.
Copyright (c) 2025 Brienna K. Buchanan, BA, Victoria E. Bergstein, BA, Evin F. Rothschild, BS, Alexis Coslick, DO https://creativecommons.org/licenses/by-nc-nd/4.0
A Systematic Literature Review on Menstruation Management and Suppression in Female Athletes Including Performance in Remote Environments
BACKGROUND: This review aims to analyze general principles, current evidence and management options of menstrual management and suppression. It is aimed at those who are involved in sports participation with an additional focus on endurance events within remote environments and wish to further educate themselves on menstruation management, regardless of sex and/or gender. METHODS: A systematic search was conducted using the Boolean method through the Scopus database and Google Scholar. A list of inclusion and exclusion criteria was formed along with a parallel search of resources. Results regarding the suppression or manipulation of menstruation were synthesized. RESULTS: This review demonstrates that there is no ‘correct way’ to manipulate menstrual cycles. The information has been collated and presented with considerations given to the challenges female athletes face. CONCLUSION: Several challenges unique to female athletes, especially in remote environments, have been identified in this review. It is the responsibility of everyone involved in performing and managing female athletes to educate themselves and abolish the taboo of menstruation in sports performance. In doing so, we can encourage more females to participate, including adventurous activities in extreme environment.
Copyright (c) 2024 Mabli Wyn Davies, MBBCh, PGDip, MSc, Karl J. New BSc, PGCE, PhD https://creativecommons.org/licenses/by-nc-nd/4.0
Breast Impact Discomfort Reduced with Customised Breast Protection for Amateur Female Soccer and Rugby League Players in New Zealand
BACKGROUND: The aims of this study were to survey amateur female domestic soccer and rugby league players on their sports bra use, to compare prior use of sports bra to wearing a custom fitted sports bra with polymer inserts over a competition season in New Zealand, and to compare breast injuries with different sports bra utilization over a competition season. METHODS: Players were invited to participate in a baseline survey of sports bra use. Players who completed the survey were provided with the opportunity to wear a sports protection bra and inserts and to complete post-match surveys reporting any breast injuries. The study duration was one competition season in 2023. RESULTS: 93 players (41 soccer open, 29 soccer U16, 23 league) completed the baseline survey. Of these 79 players (32 soccer open, 24 soccer U16, 23 league) utilised the sports breast protector during the season. There were 25 breast injuries over the study resulting in a pooled breast injury incidence of 41.3 (95% CI: 26.7 to 61.1) per 1,000 match-hrs. Eight of 25 injuries (32%) occurred to players wearing the sports protection bra (i.e., 5/79 =10% sports breast protector players; 9/14 = 64% other players; 14/93 = 15% all players). Of the 34 participants who reported a previous breast injury, there were 2.6 ±1.4 breast injuries per player in the previous year and, more than a third (37.5%) reported either wearing a padded bra or did not use strategies to prevent breast injuries. CONCLUSION: It is important that players, coaches, and team medical support associated with female sports are educated on the injury risk to breasts in training and competition enabling these players to be encouraged to report and seek treatment if necessary.
Copyright (c) 2024 Doug King, PhD, Patricia A. Hume, PhD, Trevor N. Clark, PhD https://creativecommons.org/licenses/by-nc-nd/4.0
The Association of Salivary Estradiol Levels with Anterior Cruciate Ligament Stiffness and Laxity
BACKGROUND: Females are three to six times more likely to sustain an anterior cruciate ligament (ACL) injury than males. Researchers have previously identified hormonal fluctuations as a possible intrinsic factor related to the higher incidence of ACL injuries among female athletes. Whether hormonal levels, with or without use of oral contraceptives (OC), influence ligamentous mechanical properties resulting in increased ACL injury risk remains unclear. Furthermore, previous studies have mainly focused on anterior tibial translatory (ATT) laxity, with limited research on changes in ATT tissue compliance/stiffness. The purpose of this study is to investigate the influence of estradiol levels, menstrual cycle phases, with and without use of OC on ATT tissue compliance/stiffness and laxity. METHODS: Fifty-two female participants (age 24-30 years), divided into two groups of 26 each (Group OC using oral contraception, and Group NOC not using oral contraceptive). Data collection was performed on two different dates corresponding to two menstrual cycle phases: follicular or inactive phase (days 1-3) and the ovulation or active pill phase (days 12-14). Estradiol levels via saliva sampling, ATT tissue compliance/stiffness and laxity measures via the GNRB knee arthrometer were collected each testing session. Spearman’s rank-order correlation product-moment correlations were run to determine the relationship between follicular and ovulation phase estradiol and GNRB outputs related to translation and compliance. RESULTS: Estradiol levels showed a significant change between follicular and ovulation phases across both groups combined (p = 0.01). There were weak non-significant correlations between measured estradiol levels and GNRB measures of anterior translation and compliance, (p> 0.05). No significant relationships were found across subjects whether they were on oral contraceptive or not using hormone regulated birth control. CONCLUSION: Estradiol level changes in the follicular and ovulation phases and oral contraceptive use did not significantly influence ACL laxity (anterior tibial translation) or compliance/stiffness. Additional studies on hormonal fluctuations as a potential risk factor for higher female ACL injury are indicated.
Copyright (c) 2024 Kayla Smith, PT, DSc, Nicole Miller, PT, DPT, Steven Laslovich, PT, PhD, Yvonne Body, PT, DHSc https://creativecommons.org/licenses/by-nc-nd/4.0
Menstrual Cycle Phases and Elite Female Soccer During Training: Exercise Load Perception and External Workload Monitoring
BACKGROUND: Female soccer has grown exponentially in the last years, however studies on women soccer players are very few compared with male ones and several inconsistencies are reported in the literature for female players. Physiological hormonal fluctuations during the different moments of menstrual cycle could have important implications on soccer performance, therefore, the aim of the present study was to investigate the impact of menstrual cycle phases on external and internal loads in elite women’ soccer players during an in-season training period, and to describe the internal-external training load relationship, in relation to different menstrual cycle moments. METHODS: 16 elite players from Italian soccer first division were monitored for 12 weeks. The main internal parameter (rate of perceived exertion - RPE), external variables (total time, total distance, high speed running - HSR, numbers of accelerations/decelerations) and session-RPE were collected during training sessions and analyzed trough a repeated-measures ANOVA to identify differences in the MC weeks. Menstrual cycle was monitored through daily questionnaires and was divided into four phases: menstruation week, pre-ovulation, post-ovulation, and pre-cycle. RESULTS: HSR and total distance were significantly lower during menstruation week than post-ovulation week (18318.70 ±1802.04 m vs 20358.41 ± 1639.27 m, respectively; p=0.022). A significant correlation was found in pre-cycle week between RPE and total distance (r=0.545; p=0.029), and between session-RPE with total distance (r=0.514; p=0.042) and total time (r=0.502; p=0.048). When considering the whole menstrual cycle, weak and moderate correlations were found for RPE and session-RPE with total time, total distance and HSR. CONCLUSION: Appropriate menstrual cycle monitoring is required for better interpretation of players’ response in elite women’s soccer training, given that during menstruation week, external load variables could be impaired. RPE and session-RPE values do not change statistically with changes in external variables, and their relationship showed unclear results, highlighting caution when interpreting them, and suggesting their use in combination with other parameters, especially during early follicular phase.
Copyright (c) 2024 Chiara Groff, MSc, Cristian Ieno, PhD, Ruggero Romagnoli, PhD, Marco Lista, PhD, Paolo Sgrò, MD, Francesca Pittaccio, MSc, Luigi Di Luigi, MD, Luigi Fattorini https://creativecommons.org/licenses/by-nc-nd/4.0
Educational Intervention Improves Female Athlete Triad Awareness in Female Collegiate Swimmers
Introduction: The Female Athlete Triad (Triad) is characterized by high energy expenditure and low caloric intake, leading to dysregulation of menstruation and bone metabolism. Triad-associated relative energy deficiency in sport (REDs) adversely affects performance and mental health. Risk factors are underrecognized in swimmers, who are less likely to present with bone stress injuries because of swimming’s non-weightbearing nature. Our objective was to quantify knowledge about the Triad and REDs among collegiate swimmers and demonstrate the value of educational intervention. Methods: Members of two Division III women’s varsity swim teams completed a Qualtrics survey, consisting of 35 Triad and REDs questions, and 13 demographics questions. Participants then attended an in-person, 20-minute educational session focused on Triad risk factors and prevention, after which they completed a post-session survey. The post-session survey contained 13 additional questions using a Likert scale, where 1=Strongly Agree and 5=Strongly Disagree. Pre- and post-session data were analyzed using Microsoft Excel. Results: Thirty-one swimmers were included. Pre-session, 9.7% of respondents named one or more Triad components, compared to 96.8% after (p<0.0001). 9.7% could define the REDs acronym pre-session, compared to 87.1% after (p<0.0001). Participants better understood the Triad post-session (mean Likert score=1.23) and found the session helpful (mean=1.23), but in a hypothetical scenario, felt relatively uncomfortable contacting medical staff about Triad symptoms (mean=1.87, p=0.0002). Of the 35.5% who believed they may be experiencing Triad components, 72.7% indicated the session motivated them to seek help. Conclusions: Female collegiate swimmers’ low baseline Triad and REDs knowledge improved significantly after an educational intervention. Survey responses highlighted the importance of heightened Triad awareness, but also its continued stigmatization. The session encouraged swimmers with self-identified Triad symptoms to seek help, underscoring the importance of continued education efforts, especially in sports where the Triad is underrecognized.
Copyright (c) 2024 Victoria E. Bergstein, BA, Jessica Schmerler, BS, Andrew J. Cosgarea, MD, Ryan T. Roemmich, PhD, Dawn M. LaPorte, MD, Alexis M. Coslick, DO https://creativecommons.org/licenses/by-nc-nd/4.0
Many girls and young women begin participating and competing in sports at a very young age. These young athletes can present unique opportunities and challenges for the sports medicine physician. The authors in this issue, all members of the PRiSM Female Athlete Research Interest Group, showcase the expertise of this group, which will undoubtedly contribute to improving our understanding of ways to optimize orthopaedic care for the young female athlete.
Copyright (c) 2024 Corinna Franklin, MD, Miho J. Tanaka, MD, PhD https://creativecommons.org/licenses/by-nc-nd/4.0
Five-year Outcomes Following Anterior Cruciate Ligament Reconstruction: Does Sex Impact Patient-Reported Outcomes and Re-operation Rates?
BACKGROUND: Females have been shown to have a two to eight times higher risk of Anterior Cruciate Ligament (ACL) injury than their male counterparts. Despite the clear difference in risk, sex-based differences in outcomes following ACL reconstruction are less well understood. The purpose of this study was to compare 5-year outcomes between males and females who were under the age of 26 at the time of enrollment in an ACL registry. We hypothesize that male and female patients will have similar patient-reported outcome scores, but females will have a higher incidence of ACL graft re-injury. METHODS: Patients undergoing ACL reconstruction while under the age of 26 were included if they also had completed five-year follow-up questionnaires. Outcomes were compared between males and females, and the outcomes of interest included the International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Score (KOOS), ACL Return to Sport after Injury (ACL-RSI), and reoperation. RESULTS: Of the 159 patients enrolled in the registry, 35 had complete follow-up (22%). The average difference between postoperative and preoperative IKDC scores for males and females was 37.9 ± 21.6 and 33.2 ± 26.6, respectively (p=.600). The average difference between postoperative and preoperative KOOS scores for males and females was 31.6 ± 15.4 and 29.2 ± 23.0, respectively (p=0.731). The average ACL-RSI for males and females was 79.8 ± 47.0 and 56.5 ± 31.1, respectively (p=0.088). The incidence of reoperation and ACL re-tear for the entire cohort was 28.6% and 5.7%, respectively. CONCLUSION: Overall, males and females under the age of 26 who underwent ACLR had similar 5-year outcomes regarding outcomes scores after surgical intervention. The ACL-RSI was lower in women, however, failed to reach significance. The reoperation rate for males and females was not statistically significant. ACL reconstruction is a successful operation in young males and females with improvement in knee outcome scores and ability to return to sport.
Copyright (c) 2024 Henry A. Kuechly, BS, Sophia Le, BS, Sarah C. Kurkowski, MD, Michael Thimmesch, BS, Tyler Gardner, MD, Jonas Keller, BS, Brian M. Grawe, MD https://creativecommons.org/licenses/by-nc-nd/4.0
Prevalence of Iron Deficiency in Female Collegiate Athletes at a Division I Institution
BACKGROUND: Iron deficiency is widely underdiagnosed in female college athletes and may limit their athletic performance. Routine screening is necessary to identify potential female athletes who might benefit from iron supplementation. A retrospective study on the prevalence of iron deficiency in female collegiate division I athletes is imperative to bring awareness to the prevailing problem. The objective of this study is to determine the prevalence of iron deficiency in female athletes presenting to a Division 1 Athletic Training Room for initial health screening evaluation from January 2017 to July 2022. METHODS: A retrospective chart review was performed for female athletes who presented for initial pre-participation examination health screening to a Division 1 Athletic Training Room The data collected included the patients’ age, BMI, menstrual history, ferritin, and hemoglobin lab values. The primary sports analyzed was swim and dive, soccer, basketball, track and field/cross country, softball, lacrosse, volleyball, high tech, tennis, golf, and cheerleading. Descriptive statistics were used to describe the prevalence of iron deficiency among female athletes and the Student’s t-test and Pearson correlation analysis are used to identify any potential risk factors for iron deficiency. RESULTS: There was a total of 336 participants. The prevalence of athletes with low initial ferritin values under 40 ng/mL at pre-participation examination was 194 (57.74%, n=336). The mean ferritin value at pre-participation examination was 43.18 ng/mL (n=336). Statistical analysis of the other variables collected in this study including body mass index, menstrual history and primary sport showed no significant differences in relationship to initial ferritin levels. Female athletes with low ferritin levels were more likely to receive iron supplementation (p=8.089e-18, 95% CI= -31.33142, -20.19980). An increase in ferritin levels was correlated with iron supplementation (p=0.0217, 95% CI= 1.45825, 18.34014) and hemoglobin levels were higher in female athletes with higher ferritin levels (p-value=0.04971, 95% CI=0.00546, 0.14506). Initial ferritin levels were positively correlated with hemoglobin levels (p=2.402e-11, 95% CI=0.26962, 0.46399). Statistical analysis showed an increase in ferritin levels with usage of contraception (p=0.0073, 95% CI= 3.15448, 20.05362). CONCLUSION: This study’s findings represent the importance of screening ferritin levels in all female collegiate athletes regardless of sport, BMI, or menstrual history due to the high prevalence of low ferritin values. There was an increase in ferritin levels with usage of birth control suggesting the need to further evaluate the impact of menstrual history and contraception usage on ferritin and hemoglobin levels. In these authors experience, it is uncommon for institutions to incorporate routine screening measures in place for screening all female athletes with a ferritin value and complete blood count at initial pre-participation examination.
Copyright (c) 2024 Leah D. Dunn, OMS3, Cathleen Callahan, MD, MPH, Mark Rogers, DO, Mary Mitchell, DO, Ramu Anandakrishnan, PhD https://creativecommons.org/licenses/by-nc-nd/4.0
Increased Utilization of Pitchers in NCAA Women’s Softball Compared to Men’s Baseball
BACKGROUND: Pitch count and rest time guidelines are widely employed in youth baseball to mitigate injury risk among pitchers. Similar recommendations are lacking in youth softball, despite evidence of potential overuse injuries from the underhand windmill pitching motion. This disparity in regulation may heighten injury susceptibility. Additionally, the composition of collegiate softball and baseball rosters differs significantly, with softball teams typically featuring fewer pitchers. This discrepancy may lead to increased pitching demands for individual softball pitchers, potentially exacerbating injury risks. Therefore, understanding the relationship between the number of pitchers, game appearances, and injury incidence is crucial for informing injury prevention strategies in both baseball and softball. We hypothesize that individual softball pitchers will have significantly more game appearances per season and pitch more innings per game and season as compared to baseball pitchers, and that softball rosters will average significantly fewer pitchers per team than baseball rosters. METHODS: A retrospective analysis was conducted of National Collegiate Athletic Association Division I softball and baseball College World Series teams from 2016 to 2021. Individual data consisting of game appearances and season innings pitched facilitated calculations for innings per game. Team data included the number of athletes and pitchers per team. Statistical analysis comparing baseball and softball team continuous variables utilized Student’s t-test. Individual data, characterized by non-normal distribution, was evaluated with the Wilcoxon-Mann-Whitney Test. A significance level of p < 0.05 was applied to all analyses. RESULTS: Softball pitchers had a significantly greater number of innings pitched per season (median 84.1 (21.0-143.2) vs 29.2 (10.0-56.1) p<0.0001), game appearances per season (median 23.0 (10.0-32.0) vs 16.0 (9.0-21.0), p<0.0001), and innings pitched per game (median 3.6 (2.2-4.7) vs 1.6 (1.1-2.8), p<0.0001). Baseball rosters averaged significantly more total players (35.7 ± 3.9 vs 21.5 ± 2.8, p<0.0001), more pitchers (15.7 ± 2.3 vs 4.5 ± 1.1, p<0.0001), and a greater percentage of their roster was made up of pitchers (44.2% ± 6.4% vs 21.0% ± 4.4%, p<0.0001). CONCLUSION: This study highlights a notable difference in collegiate softball pitcher utilization compared to baseball pitchers. Fewer pitchers on softball teams led to a higher cumulative workload per pitcher, with increased innings pitched per season, per game, and more game appearances. While the relationship between pitch count and injury risk is established in baseball, further research is needed to understand its implications for softball pitchers.
Copyright (c) 2024 Taylor Freetly, MD, Patrick Albright, MD, Sonali E Feeley, Brian T Feeley, MD, Caitlin Chambers, MD https://creativecommons.org/licenses/by-nc-nd/4.0
The Role of Social Factors in Relative Energy Deficiency Risk for Female Collegiate Athletes
BACKGROUND: Relative Energy Deficiency in Sport (RED-S) refers to compromised functioning of one’s metabolism, reproductive system, immune system, cardiovascular system and more due to a relative energy deficiency. Most prevailing RED-S research has focused on its physiological symptoms, yet little data exists regarding the psychological and social aspects that might contribute to its development. The purpose of this study is to determine the role of psychosocial factors in RED-S risk for female collegiate athletes. METHODS: 105 female collegiate athletes under National Collegiate Athletic Association (NCAA) jurisdiction were surveyed representing a variety of varsity sports. All participants were assessed for low energy availability using the Low Energy Availability in Females Questionnaire (LEAF-Q) through an online survey battery, which also included sources of nutrition information scale (SONI scale), the revised group environment questionnaire (GEQ), and the revised exercise group social provisions scale (EXSPS questionnaire). The participants were sorted into an At Risk (AR) and Not At Risk (NAR) group based on their LEAF-Q scores. One-tailed independent t-tests and chi square tests were used to determine the difference between AR and NAR for dependent measures, and multiple linear regression determined the relationship between risk of LEA and GEQ, EXSPS, and SONI. RESULTS: Overall, 66 participants (62.8%) were at risk for LEA based on LEAF-Q scores. Significant differences were identified between the AR (11.5%; 66.7%) and NAR (40.0%; 37.0%) groups regarding comfort with discussing nutrition with coaches or teammates, respectively (p = 0.034, p = 0.035). However, none of the social measures predicted LEA risk (group cohesion: R = 0.04, p = 0.92; social support: R = 1.85, p = 0.09; SONI: p = 0.136) Awareness of RED-S (using a Yes (1) or No (0) question) was also found to be not significantly different between the AR (0.28 ± 0.45, 29%) and NAR (0.39 ± 0.50, 41%) groups (p = 0.12). CONCLUSION: Overall, risk for RED-S is high in female collegiate athletes, however group cohesion, social support, and the athletes’ sources of nutrition information did not predict RED-S incidence.
Copyright (c) 2023 Journal of Women's Sports Medicine https://creativecommons.org/licenses/by-nc-nd/4.0
Returning to Sport: A Level-Based Guide for Women’s Artistic Developmental Program Gymnasts
Female artistic gymnasts, defined as gymnasts who compete in the vault, uneven parallel bars, balance beam, and floor events, may be affected by a wide variety of acute and overuse injuries throughout their athletic careers. Returning these athletes to their sport safely after an injury requires detailed knowledge of the various events in which they compete as well as a familiarity with what is expected of these gymnasts at the various levels of training and competition. Despite the complexity described above, there are few published resources to help providers guide the female artistic gymnast back to sport after injury. Therefore, we developed two purposes for this paper: (1) to review important concepts regarding return to play (RTP) in women’s artistic gymnastics and (2) to add to the existing literature on RTP in women’s gymnastics by providing RTP protocols that consider a gymnast’s training level as well as injured body area.
Copyright (c) 2024 Tatiana Patsimas, MD, David Tilley, DPT, Darby Glackin, ATC, Emily Sweeney, MD https://creativecommons.org/licenses/by-nc-nd/4.0
Screening for Relative Energy Deficiency in Sport and Female Athlete Triad: A Survey of Pediatric Sports Medicine Professionals
BACKGROUND: Relative Energy Deficiency in Sport, or RED-S, is a multi-scale physiological response to a mismatch between energy intake and exercise energy expenditure that affects up to 50% of adolescent athletes. RED-S symptomology was first described as the Female Athlete Triad (the Triad) and includes specifically low energy availability with or without disordered eating, menstrual dysfunction, and low bone mineral density. Despite the wide impact of RED-S/the Triad, there is a lack of standardization of screening in adolescent athletes. Therefore, the purpose of this study was to assess if there are differences in practitioner demographics when screening for RED-S/the Triad in adolescent athletes. In addition, we sought to assess if providers’ screening habits differ based on specific patient characteristics. METHODS: We conducted a cross-sectional online questionnaire of members of the Pediatric Research in Sports Medicine (PRiSM) Society. PRiSM is an interdisciplinary group of professionals who are dedicated to advancing the research and medical care of young athletes. The questionnaire assessed screening tools that members used to assess for RED-S/the Triad, practices implemented when providers were concerned for RED-S/the Triad, demographic data, and type of training. RESULTS: Of 389 PRiSM members, 60 completed the survey and were included in subsequent analyses (15% response rate). Most participants were primary care sports medicine physicians (37%), orthopaedic surgeons (27%), or physical therapists (23%), and about half of respondents identified as a cis gender woman (55%). There was a trend toward more women screening for RED-S routinely than men (55% vs. 33%: p=0.10), and orthopaedic surgeons were less likely to screen than other specialties (25% vs. 52%, p = 0.06). Eating disorders (88%), menstrual dysfunction (76%), and bone stress injury (74%) were reported as specific red flags that make providers screen for RED-S/the Triad. Participants reported that lack of time (57%) and lack of resources (37%) were barriers to screen for RED-S/the Triad. The most commonly utilized tools to screen for RED-S/the Triad were the Female Athlete Screening Tool (FAST), Female Athlete Triad Risk Scale, Female Athlete Triad Consensus Panel Screening questions, and RED-S Specific Screening Tool (RST). CONCLUSION: Orthopaedic surgeons were less likely than other health care professionals to screen for RED-S/the Triad. Barriers that prevent healthcare providers from screening for RED-S/the Triad included limited time and resources. By describing current practices, we have identified gaps and areas of need to enhance screening for RED-S/the Triad across multiple sports medicine disciplines.
Copyright (c) 2024 Emily A. Sweeney, MD, Madison Brna, BS, David Howell, PhD, Aubrey Armento, MD, Gabrielle Gilmer, BChE, Corinna Franklin, MD https://creativecommons.org/licenses/by-nc-nd/4.0
The Impact of Breasts and Bras on Physical Activity Amongst Women and Girls: A Systematic Review and Meta-Analysis
BACKGROUND: Breast motion may cause breast pain in active women, which can negatively impact physical activity. Sports bras are essential pieces of sporting equipment and were designed to help women comfortably participate in sports and engage in physical activity. Thus, the purpose of this systematic review was to summarize how breasts and bras influence physical activity in women and girls. METHODS: A systematic review was conducted by performing electronic searches of PubMed, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials. Title, abstract, and full text screening were performed by two independent reviewers to identify articles investigating how breasts or bras impact physical activity related outcomes in women or girls. We performed meta-analyses to evaluate the effect of (i) breast size, (ii) bra type, and (iii) breast reduction on (i) breast pain, (ii) physical activity level, and (iii) breast biomechanics. Standardized mean differences and pooled standard deviations of outcome measures were calculated using the DerSimonian-Laird method. All meta-analyses were performed using SPSS Statistics Software. RESULTS: Of the 323 articles identified, 77 were included in the final analysis. The majority of articles studied participants who were 20-29 years old, identified as white, lived in Western countries, were non-athletes, and weighed between 45-65 kg (BMI: 18.5-29.9), while they were performing a running movement. Very few articles reported household income and ethnicity/race. Key themes investigated by this body of literature were breast biomechanics, breast pain, and physical activity levels. Meta-analyses revealed that women and girls with larger breasts reported more exercise-induced breast pain and experienced greater breast mediolateral velocity and anterior/poster acceleration during physical activity than women and girls with smaller breasts. Meta-analyses revealed that sports bras were associated with less breast pain during physical activity than standard bras. CONCLUSION: This body of literature largely studied a homogenous population, and there is a need for greater inclusion of women and girls who identify with under-represented minorities, with disability, who are post-menopausal, and who are overweight. Factors such as ethnicity/race and household income, were underreported in the literature, and studies of movement patterns beyond running are needed. Mediolateral breast velocity and anterior/posterior breast acceleration may be contributors to breast pain in women and girls with larger breasts, thus these biomechanical outcomes are of particular interest for future research and for consideration in sports bra optimization.
Copyright (c) 2024 Gabrielle Gilmer, BChE, Elaine Xu, BS, Corinna Franklin, MD, AB, FAOA, Nailah Adams, MD, MS, CAQSM, FAAFP, Katherine Rizzone, MD, MPH https://creativecommons.org/licenses/by-nc-nd/4.0
Patients’ Comfort with Opioid Use and Disposal Post-Operatively After Outpatient Anterior Cruciate Ligament Reconstruction: A Gender-Based Analysis
BACKGROUND: Despite legislative efforts to curb inappropriate prescribing, opioid-related adverse events and deaths persist. Prior research has demonstrated that pain perception and response to analgesic medications may vary between genders, underlining the importance of a gender-based analysis in postoperative opioid management. Furthermore, orthopedic surgery remains a significant contributor to opioid prescriptions, however, little is known about patient-specific perspectives regarding opioid usage after knee surgery. This study aimed to assess patients' comfort with postoperative opioid use and explore pre-existing knowledge of opioid disposal, with a specific focus on analyzing differences between genders. METHODS: All patients scheduled for outpatient anterior cruciate ligament (ACL) reconstruction by the senior author between August 2018 and July 2019 were identified and enrolled in the study. At ten days postoperatively a 7-question, multiple choice paper survey created by the authors was administered in person to each patient. The survey inquired about their use of the medications, any concerns, alternative pain control modalities, and their method of disposal of any remaining prescription pain medication. Patient survey responses were collected, and descriptive and inferential statistics of responses were performed for the overall cohort and per gender. RESULTS: A total of 47 patients (15 males and 32 females) were included in the final study cohort with a 100% response rate. 100% of respondents reported having remaining medication 10 days after surgery. There were no significant differences in responses based on gender. The primary concern with opioid use was addiction risk (43%) while the second most common response was that they had no concerns (28%). Females reported an increased frequency of concern about disposal methods. 72% of patients discontinued medication due to no longer being in pain. Females more frequently discontinued use because they were no longer in pain while males more frequently discontinued due to other concerns. Various disposal methods were used with 40% of males and 13% of females keeping medications in the house most commonly “just in case” they needed it. CONCLUSION: Both males and females exhibited similar concerns and preferences regarding postoperative pain management, with observed but non-significant differences in medication use and disposal practices. These findings emphasize the value of gender-aware education in opioid misuse prevention efforts.
Copyright (c) 2024 Sean Hazzard, PA, MBA, Blake Bacevich, BS, Nasir Stovall, BA, Varun Nukala, BS, Peter Asnis, MD https://creativecommons.org/licenses/by-nc-nd/4.0
Biomechanical Comparison of Pediatric Female Ballet Dancers With and Without Pain
BACKGROUND: Across all genres of dance, studies have reported musculoskeletal injury in 20-84% of dancers with 95% reporting a history of musculoskeletal pain. Compared to other dance styles, ballet dancers specifically are most affected by musculoskeletal injuries. The purpose of this study is to compare movement patterns and muscle activity in pediatric female pre-professional dancers with and without self- reported pain, using the Patient-Reported Outcomes Measurement Information System pediatric numeric rating scale. We hypothesize dancers reporting pain will exhibit compensatory strategies, such as asymmetrical movement patterns and muscle activity, across a series of ballet movements. METHODS: A total of 55 female ballet dancers who train en pointe were seen for testing (age 14.4±1.9 years), with 34 dancers (62%) self-reported pain in the 7 days preceding testing. Biomechanical testing, performed in pointe shoes, included performance of static (5 classical ballet positions) and dynamic ballet movements (développé, arabesqué and grand jeté) while instrumented with surface electromyography (EMG) to capture muscle activity and inertial measurement (IMU) dual sensors on the trunk and lower extremities to capture movement patterns. The experimental setup allowed for measurement of trunk and lower extremity muscle activity, as well as trunk, hip, knee, and ankle joint angles in the sagittal, coronal, and transverse planes. Student’s t-test was used to compare the pain and no pain groups across all variables with statistical significance set to α=0.05. RESULTS: Movement patterns and EMG differences were seen between groups. During first and third positions, the right (non-barre sided) leg demonstrated less external knee rotation in the pain group (p≤0.05). In fifth position, the left (barre-sided) leg exhibited increased ankle flexion (p=0.048), reduced hip abduction (p=0.027), and reduced knee adduction (p=0.026) in the pain group. The pain group exhibited decreased trunk flexion/extension range-of-motion during the grand jeté (p=0.004), and increased trunk rotation range-of-motion when performing the arabesqué en pointe (p=0.034). Rectus femoris activation was reduced for the pain group on the left leg in fifth position (p<0.03). The up leg in the pain group during the développé (flat) showed increased hamstring activation (p=0.04). CONCLUSION: Ballet dancers with pain exhibited differences in movement patterns while performing certain ballet movements, notably during fifth position, grand jeté, and arabesqué (en pointe). Additionally, dancers with pain exhibited reduced rectus femoris activation in fifth position and increased hamstring activation on the working leg during the développé (flat). Future work should investigate how movement patterns and muscle activation in ballet dancers vary by location and severity of reported pain.
Copyright (c) 2024 Ashley L. Erdman, BS, MBA, Sophia Ulman, PhD, Jessica Dabis, DPT, Shane M. Miller, MD, Jacob C. Jones, MD, Henry B. Ellis, MD, Jane S. Chung, MD, FAAP https://creativecommons.org/licenses/by-nc-nd/4.0