Women's Health

THE FEMALE ATHLETE TRIAD

The "female athlete triad" is a term used to describe three distinct but interrelated conditions, including, low energy availability, menstrual dysfunction and low bone mineral density. Low energy availability is a term that is used to describe the condition that occurs if a female has low stored energy (low body weight for height), and/or low energy intake (insufficient calorie intake) and/or high levels of energy expenditure (lots of physical activity and/or exercise). The state of low energy availability can result in disruption of the normal menstrual cycle or delay the onset of a female’s first menstrual period. This is referred to as delayed menarche. Delayed menarche is defined as not having had your first menstrual period by age 15. In those females who have had their first period, but have low energy availability, their periods may get farther apart, or they may go away completely. Periods that occur every 35-90 days are referred to as “oligomenorrhea”. Periods that are farther than 90 days apart, or completely absent, are referred to as “amenorrhea”.

Low energy availability may occur unintentionally as a result of inadequate dietary intake relative to very high levels of exercise training. More often, it occurs as a result of intentional dietary restriction in the setting of disordered eating or an eating disorder such as anorexia nervosa or bulimia nervosa. A number of health problems can occur as a result of low energy availability leading to disrupted menstrual function. Infrequent or absent menstrual periods can result in low estrogen levels in the blood, which in turn leads to lower than expected bone mineral density. Amongst athletes, especially those that perform a weight bearing and/or impact sport like long distance running or basketball, the combination of these activities and low bone mineral density increases the likelihood of getting bone stress fractures. Stress fractures are serious injuries and can be a season ending and in some, a career ending injury.

Any female athlete is at risk for the female athlete triad. However, athletes who participate in aesthetic sports like gymnastics, figure skating, diving and dance, or in sports where leanness confers a competitive advantage like long distance running, are more likely to be affected by any component of the triad. We recommend that female athletes in high school and college undergo yearly preparticipation screening with a team physician or sports medicine physician who screens for the triad with the questions listed in Table 1.

Table 1: Female Athlete Triad Preparticipation Physical Evaluation Questions

  • Have you ever had a menstrual period?
  • How old were you when you had your “first menstrual period ?"
  • When was your most recent menstrual period?
  • How many periods have you had in the past 12 months?
  • Are you presently taking any female hormones (estrogen, progesterone, birth control pills)?
  • Do you worry about your weight?
  • Are you trying to or has anyone recommended that you gain or lose weight?
  • Are you on a special diet or do you avoid certain types of foods or food groups?
  • Have you ever had an eating disorder?
  • Have you ever had a stress fracture?
  • Have you ever been told you have low bone density (osteopenia or osteoporosis)?

Athletes identified as having any one component of the triad, should be carefully screened for the other aspects. While disruption of the menstrual cycle is a relatively common consequence of low energy availability, it’s important to make sure that other conditions are not resulting in menstrual disruption, specifically pregnancy and thyroid disease. Similarly, there are other conditions that can result in lower than expected bone mineral density. These conditions should be considered by a healthcare provider when evaluating an athlete with low bone mineral density.

Comprehensive evaluation of the athlete affected by the triad includes a physical and laboratory evaluation by a healthcare provider. Usually, an evaluation of dietary intake by a registered sports dietitian, and oftentimes an evaluation by a mental health professional, is done, especially if there is evidence of disordered eating or an eating disorder. Bone mineral density is often assessed using a tool called a dual-energy x-ray absorptiometry (DEXA)scan. The DEXA scan provides a number of scores. In the high school, college and young adult female, the “Z-Score” is used to make clinical decisions and NOT the “T-Score”. A Z-Score greater than 0 is normal. A Z-Score between -1 and 0 is still considered normal, but in the setting CONTINUED FROM PAGE 1 of the Triad should prompt discussion about the relationship between low energy availability, menstrual function and bone health – this is especially true if a prior DEXA is available for comparison and was previously greater than 0. A Z-Score between -1 and -2 in a weight bearing athlete is concerning and would indicate that bone health has been negatively affected. A Z-Score less than -2 indicates significant bone loss. Treatment of the triad should be focused on establishing adequate energy availability to meet energy demands of exercise, activities of daily living and in the younger athlete, growth. Although every person’s energy (or calorie) needs are different, research has found that achieving energy availability of 45 kilocalories per kilogram of fat free mass per day is associated with regular menstrual cycles. Fat free mass can be calculated (by measuring body fat percentage) or estimated. An example of this is provided in Figure 1.

Figure 1 : Calculating Energy Availability to Achieve Menstrual Regulation

18 years old
120 lb female
120 lb ÷ 2.2 = 54.5 kg
18% body fat
Fat Mass = 54.5 X 0.18 = 9.8 kg
Fat Free Mass = 54.5 – 9.8 = 44.7 kg
45 kcal X 44.7 kg = 2011 kcal/day

In this example of a 120-lb 18-year-old female, she would require 2011 kcal per day to support healthy reproductive function. A recent paper (2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad) written by members of the Female Athlete Triad Coalition, and published in the British Journal of Sports Medicine, Clinical Journal of Sports Medicine and Current Sports Medicine Reports, and endorsed by several medical professional societies also outlines the use of medications that may be considered in the treatment of women and girls who are affected by the Triad. However, it bears repeating that the primary treatment efforts should be focused on achieving adequate energy intake and adequate stored energy relative to energy expenditure. Medications such as birth control pills to initiate or regulate menstrual function should be used in those cases as outlined in the consensus statement.

The consensus statement also provides physicians with guidance regarding clearance and return to play for athletes affected by the triad. The paper developed a “Magnitude of Risk” tool that includes known risk factors that can be identified and scored leading to Risk Stratification and Recommendations. The risk factors included in this tool include: 1) presence or history of an eating disorder or disordered eating; 2) Current body mass index (BMI); 3) Age of first menstrual period; 4) Number of menstrual periods in the past 12 months; 5) Bone mineral density as measured by DXA scan; 6) History of bone stress fractures or stress reactions. Using the Magnitude of Risk and Risk Stratification tools, a physician can then inform the athlete where she lies on the continuum, and develop a plan to achieve health and guide safe participation in sports or exercise. In conclusion, exercise and sport participation improve health and quality of life for females of all ages.

The female athlete triad can be a consequence of participation, the same way that knee injuries can be a part of football participation. We should not discourage females from participating in sport, instead we should screen for risk factors and the conditions that make up the triad, and treat it appropriately.

WHY YOU SHOULDN'T EVER SKIP YOUR STRETCHES

Here at Champion Performance and Physical Therapy, we have a number of patients who, while they eat healthy, exercise consistently, and get plenty of nourishment and water, are in pain because they're missing one of the most under appreciated aspects of physical health in their daily lifestyles - stretching. 

It may seem like the most basic additive, but you must remember: the skeletal body is a lever system manipulated by musculature. In other words, your skeletal system will not move without the help of your muscular system, and each bone is almost entirely surrounded by muscles for this purpose.

During exercise (and after your warm up), your body is warm due to increased blood flow, the muscles are loose and firing.  Afterward, the muscles will cool, and if not properly stretched, will stiffen due to the biochemical aftereffects of exercise. While an effective fitness program should absolutely consist of cardiovascular training and strength training, the flexibility component is often overlooked. 

This is where skeletomuscular injuries come into play, specifically those relieved via physical therapy. When muscles tighten and stiffen, they pull just slightly on the bones in their direction. For example: runners often have tight hip flexors and quadriceps (the front of the thigh).  These muscles attach and originate along the anterior aspect (front) and inside of the pelvis. When they stiffen, they pull the pelvis slightly forward. Over a long period of time, the pelvis will shift so far forward that it will start to cause low back pain that can sometimes radiate into the hips, and SI - sacroiliac - joint, which is the point of attachment between the spine and pelvis. This can even radiate down the leg and into the knees, as the muscular insertion for the quadriceps are just below the knee on the tibia (shin bone).  Often times when patients come in with knee pain and all X-rays and MRI scans show no injury, it is because the muscles have pulled the skeletal system just out of sync enough for you to notice. 


Flexibility exercises are not only an essential part of recovering from aerobic activity, but can reduce your risk for further injury. The American Academy of Orthopaedic Surgeons (AAOS) encourages individuals to incorporate these exercises into their daily workouts.

EXPERT ADVICE
“Increasing your flexibility improves your ability to move easily,” said orthopaedic surgeon and AAOS spokesperson Raymond Rocco Monto, MD. “Some joints lose up to 50 percent of motion as we age. There are many ways to improve your joint flexibility including controlled stretches held for 10-30 seconds, stretches that rely on reflexes to produce deeper flexibility, as well as yoga and pilates.”

Before skipping flexibility exercises during your next workout, consider these five benefits of adding them to your workout regimen:

  • Less back and joint pain: A 2011 study in the Archives of Internal Medicine found that regular stretching was effective in relieving chronic back pain. Other research has shown quadriceps stretches helped decrease knee pain.
  • Better circulation: A 2009 study in the American Journal of Physiology discovered that torso stretches decreased stiffness and improved blood flow. This also may be why regular bedtime hamstring and calf stretches decrease the frequency and intensity of night-time leg cramps.
  • Improved joint motion: Flexibility naturally decreases with age. Stretching can help restore lost joint motion and improve function.
  • Better athletic performance: Like a good rubber band, muscles and tendons generate more force under tension when they are supple and compliant. 
  • Improved muscle health: Mobility exercises can increase the amount of stress muscles can handle in high tension activities that involve jumping and cutting movements.

Get the most out of your flexibility training by following these simple guidelines:

  • Always warm up before your stretch. Stretching cold muscles can cause injury.
  • Stretch slowly and gently. Breathe into your stretch to avoid muscle tension. Relax and hold each stretch 10 to 30 seconds.
  • Do not bounce your stretches. Ballistic (bouncy) stretching can cause injury.
  • Stretching should not hurt. If you feel pain, take the stretch easier, breathe deeply and relax into it.

    Stretching is important and can be tough to master to maximum efficiency. The trouble is, it takes some time to stretch muscles back out to a healthy length. A combination of stretching, manual therapy to help relieve some tension in the joints that are being pulled on, and strengthening the opposing muscles to those inflicting pain should easily solve the problem and have you pain free within weeks. Here at Champion Performance and Physical Therapy, this is probably the most common cause of injury we see, and we approach it with a unique, biomechanically-based mechanism meant to relieve pain and tension through multiple planes of your body. Why?  Because your body doesn't move in just one plane. 

    Talk to your doctor today about what physical therapy can help do for you. For more information, visit us on the SW corner of 75th and State Line Road in Prairie Village, or by phone at 913-291-2290.

Job Opening : Part-Time Women's Health Specialist in Pelvic Floor Dysfunction

JOB OPENING: Part Time Women's Health Specialist in Pelvic Floor Dysfunction

Champion is seeking someone who specializes with Pelvic Floor Dysfunction. This position specifically utilizes a variety of therapeutic techniques to assist in diagnosing and improving conditions. In support of our performance and mission, the Physical Therapist will help to provide more comprehensive healthcare and ensure that important patient needs are met. 

PHYSICAL THERAPIST RESPONSIBILITIES

Instruct patient in home exercise programs, transfer training, position, safety issues, modification and/or removal of architectural barriers and use of special devices, as necessary
Input of proper CPT and ICD codes for billing purposes regarding PFD treatments into EMR
Evaluation and assessment of pelvic floor dysfunction (PDF)
Treatment of pelvic floor dysfunction including but not limited to: Biofeedback, Connective Tissue Manipulation, Craniosacral Therapy, Electrical Stimulation, TENS (Transcutaneous Electrical Nerve Stimulation), Myofascial Release and Visceral Manipulation
Strictly adhere to HIPAA standards and regulations in managing or handling any patient information, patient inquiries and treatments

PHYSICAL THERAPIST QUALIFICATIONS

Graduate from an accredited Physical Therapy Education program and current KS licensure
Experience in treating Pelvic Floor Dysfunction
Knowledge of insurance policies and their coverage of PFD treatments
Experience with EMR, preferred
Embrace cultural differences and display sensitivity to them
Must be extremely dedicated to high quality patient care and maintain a positive attitude
Job Type: Part-time
Required experience: 2 years experience in treating Pelvic Floor Dysfunctions
Required license or certification: KS licensure