Published: Oct. 17, 2006
Updated: May 31, 2011
Open a yearbook from any high school across the country, and you'll see basketball, volleyball, and soccer teams full of young female athletes bursting with health -- or so it would appear. But appearances can be deceiving, as Alison Toth, MD, knows all too well.
"More than a few of these teenagers could be developing bones as porous and brittle as a 50-year-old woman's," says Toth, director of the Duke Women's Sports Medicine program. Such young women, she explains, are often victims of the 'female athlete triad' -- a syndrome in which young women don't eat enough to make up for the calories they expend.
The result: Menstrual periods cease, bones lose mass, and those strong-looking young women become alarmingly vulnerable to stress fractures and cardiovascular problems, as well as osteoporosis that can never be completely reversed.
"With more women participating in sports and exercise these days, we're seeing a rash of problems that are unique to women or more common in women," says Toth, an orthopaedic surgeon. "Unfortunately, they don't always get the attention from the health care community that they should."
Thanks to the efforts of people like Toth, that's changing. As director of Duke's Women's Sports Medicine Program, she supervises a range of services designed to both treat the injuries and meet the medical needs of active women.
More than a clinic, the program is also a command center for the growing movement to teach women and doctors alike to recognize and prevent the problems that plague active females -- whether they're teenage Olympic hopefuls or sixty-somethings seeking to resume a walking program after a fracture.
The Duke clinic, one of the first three of its kind in the U.S., is at the tip of a wave of such programs cresting nationwide. Part of the reason for the boom is the sheer number of active women, which has exploded in recent decades.
Since the 1972 passage of Title IX -- a constitutional amendment that banned sex discrimination in public school athletics -- the number of high school girls playing sports has jumped from 300,000 to 2.5 million.
Swelling numbers of middle-aged baby boomers determined to stay active and fit form another significant component. In all, it's estimated that more than 20 million women engage in some regular form of physical activity, whether it be workouts, walking, or participation in a sport.
They have a passionate advocate in Toth, who believes a multidisciplinary approach is key to meeting active women's needs. "Treating the whole patient is critical because musculoskeletal problems in women are often linked to other issues -- for example, a stress fracture may be caused by low estrogen levels," she says.
"At Duke, we have a team of specialists who offer multiple services for active women, such as orthopaedic surgery, bone density testing, disordered eating management, and integrative medicine services such as acupuncture. We need to bring all the pieces together to help women avoid future injuries and return to their activities as soon as possible."
Toth is one of only 2.5 percent of all practicing orthopaedic surgeons who are women, and the first female orthopaedic surgeon on faculty at Duke. The Duke Women's Sports Medicine team she has assembled includes Deborah Squire, MD, who provides non-operative musculoskeletal care, as well as Duke consultants in disciplines such as cardiology, endocrinology, obstetrics, gynecology, nutrition, mental health, and physical therapy.
While the clinic offers the full spectrum of treatments, helping women avoid injury in the first place is one of its main goals. "The anatomic, biomechanical, and hormonal makeup of women can make them more prone to certain injuries than male athletes," Toth points out.
"We can help women avoid problems by raising awareness of their risks and teaching them how to use their bodies properly. Injuries are often due to overuse, and women tend to have lower extremity alignment problems that men do not."
A classic example is the tear of the anterior cruciate ligament (ACL) of the knee. "We hear about ACL injuries in male football and basketball players," Toth says. "However, when women participate in sports that require pivoting or jumping, they injure their ACL much more often than men playing the same sports -- up to nine times more frequently. That is a frightening statistic."
There may be several reasons for this discrepancy, including basic differences in anatomy, muscle firing patterns, and muscle strength, Toth says. "The relative power of the hamstrings compared to the quadriceps can be less than 50 percent in females, compared to 70 percent for males. In addition, male athletes use the hamstrings to decelerate more than women do, an action than protects the ACL from injury. Women tend to depend more on the quadriceps to decelerate, putting extra stress on the ACL."
Women are also more prone to elbow and wrist injuries when participating in sports such as golf or tennis, due both to their lower muscle mass in the upper body and their joint laxity. This may stress ligaments and tendons, since the surrounding muscles and ligaments have to compensate to keep the joint stable.
Toth emphasizes, however, that women can take steps to protect themselves. "Like many sports injuries, most golf injuries are due to overuse, especially the use of muscles that are untrained for the great stresses of this sport," she says. Simple hand-and-wrist strengthening exercises can help prevent problems, while early recognition of injury symptoms could speed rehabilitation.
Lateral epicondylitis -- colloquially known as tennis elbow -- is another common injury. "If tennis elbow is treated promptly and properly, the player will likely be out of the game for only a few weeks," Toth says. "But, without rest and subsequent strengthening of the forearm muscles, the pain progressively gets worse until even minimal activity hurts. The same holds true for wrist and back injuries."
Rest, ice, and non-steroidal anti-inflammatory medications or acetaminophen can often ease the pain; a corticosteroid injection or surgery may be needed in severe cases. Toth points out that the condition is not an inflammation, but micro-tearing or degeneration of tendon tissues. That means easing symptoms will not correct what caused it in the first place.
"If you simply resume your bad habits, the injury will likely return," she says. "For lasting improvement, you need to learn better ways to do things."
While the Women's Sports Medicine program conducts formal research designed to analyze how effectively injury-causing habits can be "trained out" of female athletes, much of its injury prevention training occurs during day-to-day clinic visits from women of all ages and fitness levels -- including young girls.
"Just as in the young pitcher's shoulder and elbow, active girls may develop pain in the hip, knee, and foot related to jumping and running," Toth says. "Fortunately, most of these conditions can be treated non-operatively and kids can return to their sports."
As female children grow, they also experience societal pressures that create a unique class of health concerns. "Our society puts a great deal of emphasis on body image," Toth says. "Many young girls respond to these pressures by combining excessive exercise with disordered eating. We would like to raise awareness about issues specific to girls and women such as the ‘female athlete triad,' so that parents and young, active girls can identify the problem and seek expert help."
Another group that Toth believes could benefit from injury-prevention training are "mid-life" women. Such women, who came of age before the Title IX amendment became law, are eager to stay active and fit, but often haven't had the opportunity to be trained in weight-lifting, running, or organized sports.
"The mid-life woman is interested in exercising for her general good health, but may not know how to do so safely," Toth says. "She may be unsure how to choose the right running shoe or how to strengthen her muscles so that she can play golf or tennis without injury. I think we can play a great role in preventing injury in this group.
"It's wonderful that so many women are participating in sports these days, and they should know that there are resources available to help them," Toth sums up. "We're here to provide leadership in women's sports medicine and a total approach to helping healthy, active women stay that way."
Toth and the Duke Othopaedics team provide expert care to women -- and men -- of all ages. For more information, visit the Duke Sports Medicine Web site.