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Unique Considerations for Female Athletes

Unique Considerations for Female Athletes

by | Jun 13, 2022 | Sports Medicine

These are highlights from a lecture provided as part of, Coffee, Kids and Sports Medicine, a monthly lecture series for medical professionals. Using example cases and detailed visuals, sports medicine physician Jane S. Chung, M.D., discussed the evaluation and treatment of the female athlete.

Watch recording.

Download PDF.

What are the unique benefits for girls participating in sports?
Known benefits of physical activity include cardiovascular fitness, cognitive function, strength and many more. Female athletes have also shown to have these benefits:

  • Higher self-esteem
  • Better grades
  • Higher graduation rates
  • Lower rates of teen pregnancy
  • Lower rates of smoking and drug use
  • Lower rates of depression and anxiety
  • As much as 30% greater bone mineral density than nonathlete counterparts

What are some sport-related physiological and anatomical characteristics of females compared to males?

  • Higher percent body fat (average 26% vs. 14%)
  • Less lean muscle mass
  • More oxygen consumption with weightbearing exercise
  • Total cross-sectional area of muscle (60% vs. 80%)
  • Smaller heart and faster heart rate
  • Smaller thorax and lungs
  • Lower blood volume and VO2 max
  • Fewer red blood cells and 10% less hemoglobin

What has changed in the definition of the female athlete triad?
Female athlete triad was a medical condition initially described as involving these three components: osteoporosis, amenorrhea and eating disorder. Now, the updated definition recognizes that the central cause of female athlete triad is due to low energy availability with the three components being interrelated and each lying on a spectrum.

Spectra of the Female Athlete Triad

  • Low energy availability
  • Impaired bone health
  • Menstrual dysfunction

Triad occurs when energy intake does not adequately compensate for exercise related energy expenditure. This is referred to as under-fueling which then can adversely affects reproductive, bone and possibly cardiovascular health.

What are Risk Factors for the Athlete Triad?

  • Sports that emphasize aesthetics and leanness such as dance, cheerleading, figure skating, gymnastics, long- and middle-distance running, pole vaulting, cycling, wrestling, light-weight rowing (coxswain) and horse jockeying.
  • Early age of sport specialization
  • Family dysfunction, abuse, dieting, stressors from family/coaches

What is Energy Availability?
Amount of dietary energy left to support other physiologic functions after subtracting energy used in exercise.

Energy availability is described using a spectrum:

  • Optimal energy availability
  • Reduced energy availability
    • Unintentional: inadequate dietary intake and/or excessive exercise
    • Intentional: disordered eating behaviors
  • Low energy availability
    • Eating Disorder: clinical mental disorder defined by DSM-V
    • Disordered Eating: various abnormal eating behaviors including restrictive eating, fasting, frequently skipped meals, diet pills, laxatives, diuretics, enemas, overeating and binging and purging

How much dietary intake is normal?
Optimal energy availability is 45 kcal/kg fat free mass per day. This is known to support physically active women. Anything less than 30 kcal/kg fat free mass per day contributes to negative metabolic, reproductive and bone health related changes are seen below this level.

  • An athlete’s weight should be >90% of expected body weight.
  • Low BMI is a strong predictor of low bone mineral density and stress fractures.

What are normal and abnormal menstrual cycles?
Also called eumenorrhea, the typical cycle occurs every 28 days and lasts about 7 days. In cases where the cycle occurs less frequently, specifically more than 35 days apart, it is called oligomenorrhea. The absence of the cycle, amenorrhea, may be primary or secondary. In cases of low energy availability, the absence is further defined as functional hypothalamic amenorrhea.

How are estrogen and progesterone associated with musculoskeletal health? 

Beyond the reproductive cycle, these hormones are also important in bone health.

  • Stimulates osteoblasts
  • Inhibits osteoclasts
  • Muscle activation
  • Ligament and tendon stiffness
  • Suppresses hormones that cause articular cartilage breakdown

What is peak bone mass and what can positively influence it in female athletes?
Peak bone mass is a measure of bone mineral density that is used to assess bone health and risk for injury such as fracture, stress fracture and osteoporosis later in life. Ninety percent of peak bone mass is obtained by age 18 in females and age 20 in males. In young adults, bone mineral density 10% higher than the mean may reduce risk of fractures as well as delay the onset osteoporosis as much as 13 years. Therefore, attention to bone mass during childhood and adolescence is of utmost importance.

Genetics is the main determinant of peak bone mass. The following items also impact peak bone mass:

  • Mechanical forces
  • Gender
  • Hormones
  • Nutrition
  • Physical activity or other outside risk factors.

Early puberty is the most crucial time to positively influence peak bone mass with weightbearing sports and high-impact exercises. Studies have found that participation in sports can increase bone mass by as much as 10%.

What problems occur from low energy availability?
Several systems are affected, and the consequences compound in a cascade. Here are some key messages to keep in mind.

Bone Health

  • A reduction in bone formation caused by suppression in hormones is possible.
  • Low bone mineral density is known to increase the risk of stress fractures.
  • Changes from low bone mineral density may be irreversible.
  • DXA scans are recommended based on the presence of specific high and or moderate risk factors.

Reproductive System

  • Functional hypothalamic amenorrhea is a diagnosis of exclusion.
  • Other causes of abnormal menstrual cycles should be considered.
  • Young athletes believe it is a normal response to training, but it is not.

Tip for young athletes: encourage females to be prepared for their period with supplies (feminine hygiene products, clean clothes, plastic bag) and to monitor their menstrual cycle to adjust training as needed.

Cardiovascular Health

Studies have shown that history of prolonged irregular menstrual cycles may negatively affect cardiovascular health and has shown possible association with:

  • Coronary artery disease
  • Endothelial dysfunction
  • Unfavorable lipid profiles and increased LDL

Performance

  • Triad may reduce performance and training responses, delay or extend healing and cause fatigue.

What is Relative Energy Deficiency in Sports?
Also referred to as RED-S, this is an evolution of the concept recognizing impaired physiological functioning caused by relative energy deficiency. This includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis and cardiovascular health.

How is male athlete triad different than female athlete triad?

Reproductive suppression is seen in males in these forms:

  • Low testosterone (T)
  • Oligospermia
  • Decreased libido

When is screening for triad or RED-S most appropriate? 
Well visits such as during a pre-participation physical evaluation (PPE) or the yearly check-up and any time an athlete presents for a recurrent injury, bone stress injury or other illness. To diagnose the condition, only one of the three components must be present. Evaluate further with any positive finding.

What are appropriate screening questions?
The Female and Male Athlete Triad Coalition provides a list of 15 screening questions. These are consistent with the American Academy of Pediatrics 2019 Preparticipation Physical Evaluation recommendations and can help to guide further discussion and assessment.

  • Do you worry about your weight or body composition?
  • Do you limit or carefully control the foods that you eat?
  • Do you try to lose weight to meet weight or image/appearance requirements in your sport?
    • Does your weight affect the way you feel about yourself?
    • Do you worry that you have lost control over how much you eat?
    • Do you cause yourself to vomit or use diuretics or laxatives after you eat?
  • Do you currently or have you ever suffered from an eating disorder?
    • Do you ever eat in secret?
  • What age was your first menstrual period?
  • Do you have monthly menstrual cycles?
  • How many menstrual cycles have you had in the last year?
  • Have you ever had a stress fracture?

What are other risk factors of RED-S?

  • History of menstrual irregularities
  • History of stress fractures, family history of osteoporosis
  • Depression
  • Perfectionistic or obsessive personalities
  • Overtraining
  • Non-healing injuries
  • Inappropriate coaching
  • Early sports specialization

What are the treatment and recovery expectations for athletes with female athlete triad?
The primary goal is restoration and normalization of body weight, to restore menses and to improve bone health. Rest or modified training may be recommended depending on the risk of injury or presence of concerning symptoms. A collaborative treatment approach includes a physician with experience treating athletes with triad, a dietitian, a psychologist and sometimes other specialists. Treatment with a birth control pill may lead to the false belief that the natural process has been restored, however, these do not cause the return of normal menses.

Returning to sports should be considered using a cumulative risk assessment. Recovery occurs first with energy status, then menstrual status and then bone health. Earlier diagnosis reduces the length of recovery and hopefully prevents irreversible changes. Resumption of normal menses can sometimes take months or longer, reversal of low bone mineral density can sometimes take year or longer, and sometimes may be irreversible.

What are strategies to optimize bone health in young athletes?

  • Focus on risk factors to address biological risk factors for low bone mineral density
  • Ensure adequate calcium and vitamin D, nutrition and overall energy availability
  • Encourage adequate sleep as it may promote bone health
  • Appropriate loading activities during the “critical period” of youth (early puberty)

About the Speaker
Jane S. Chung, M.D., is a pediatric sports medicine physician at Scottish Rite for Children Orthopedics and Sports Medicine Center in Frisco, Texas. She is passionate about the health and safety of young athletes and cares for pediatric sport-related medical and musculoskeletal conditions. Chung loves to teach other provider, parents and athletes about the unique needs of female athletes during crucial growing years.

Preventing Hip Problems for Your Baby

Preventing Hip Problems for Your Baby

by | Jun 8, 2022 | Hip Disorders

Newborns need a lot of care, and that means plenty of visits to the pediatrician during the early months. One thing your pediatrician will carefully screen for is developmental dysplasia of the hip (DDH), a common condition that young babies are especially susceptible to. Learn more about DDH, its risk factors, tips on how to prevent the condition and guidelines on how to spot hip-safe baby accessories from our experts.

Could my baby have DDH?
DDH occurs when there is inadequate coverage of the ball by the socket or there is a dislocation of the hip (the ball is completely outside the socket). The cause of the shallow socket is complex, but it’s a gradual process that occurs during infancy and does not happen at a specific moment.

  •  Many different factors contribute to DDH, including genetics, as children with a family history of the hip condition are more likely to have DDH than children who do not have a family history.
  • Babies who were breech during the third trimester and girls are also more likely to be diagnosed with DDH.
  • Studies have shown that if a baby is swaddled incorrectly, it could cause DDH.

At the Center for Excellence in Hip at Scottish Rite for Children, we typically treat DDH using a Pavlik harness, which keeps the hips gently flexed and separated in the right position for encourage normal development of the hip joint. After treatment with a Pavlik harness, we use physical exams, ultrasound and X-rays to monitor growth and confirm the hip joint is developing properly. Even when starting with a dislocated hip, most infants require no further orthopedic treatment after wearing a Pavlik harness.

What other factors could cause my baby to have DDH?
While developmental dysplasia of the hip (DDH) cannot always be prevented, there are some things to look out for as you care for your baby to avoid causing abnormal stress and pressures to the hip that could lead to future problems.

Swaddle Safely
Many parents choose to swaddle their newborn infants. Swaddling involves wrapping a blanket around the upper body of the baby to create a snug fit so that the baby feels secure, but if done improperly, swaddling may lead to DDH. When swaddling your baby, be sure of the following to prevent hip dysplasia and other hip issues:

  • A parent/guardian should wrap the blanket around the upper part of the body while keeping the legs free to move and kick.  The baby should be able to flex their hips freely.
  • If the legs are wrapped tightly with the hips in an extended position, it could affect hip development and increase the risk of dysplasia.
  • In young babies, developing hips are very moldable and growing rapidly. Keeping the legs free while in a swaddle allows the baby’s hips to develop normally.
  • To avoid swaddling incorrectly, consider using a certified hip-safe swaddle that does not restrict the baby’s legs.

Watch our Proper Swaddling video:

Babywear Properly
Babywearing has been practiced for generations, but a baby’s improper hip position when babywearing could cause problems, while proper placement can contribute to natural hip development. 

  • The “M-position” is a natural clinging position for infants. In this position, the baby’s thighs spread around the parent’s torso with the hips flexed and the knees slightly higher than the buttocks with the thighs supported.
  • Babywearing with your baby facing inwards toward your chest may be better for hip development, especially in babies under six months of age.
  • By babywearing your infant in the correct position, you can promote healthy hip development.
  • Purchase a hip-healthy baby carrier that has been recognized as hip-safe for babywearing.

Shop Smart
When shopping for baby products such as baby carriers for babywearing or swaddles for sleeping, look for products that have been recognized as hip-safe by the International Hip Dysplasia Institute. Products that have been recognized by the organization promote proper hip placement. View the list of hip-healthy products: https://hipdysplasia.org/hip-healthy-products/.

  • Look for recognized hip-safe products.
  • Discuss best practices and recommended products with your pediatrician.
  • Always use products as instructed and ask your pediatrician for guidance if needed.
  • Do not use products that have been altered or damaged, as they may not work properly and could promote poor hip placement.
  • Limit time in baby seats that hold the legs in a fixed position.

“We know that the position of baby’s hips are held in infancy can have a dramatic impact on early hip development. We want to ensure they are not positioned in forced hip extension.”

– William Z. Morris, M.D.

 

At Scottish Rite for Children, our Center for Excellence in Hip has hips covered. We treat a wide array of hip conditions and disorders in patients of all ages. Hip health is important throughout your child’s life, and we’re here to help every step of the way. Learn more about our Center for Excellence in Hip and all of the conditions we treat.

Learn more about our Center for Excellence in Hip and all of the conditions we treat.

Scottish Rite for Children Awarded Department of Defense Research Grant

Scottish Rite for Children Awarded Department of Defense Research Grant

by | Jun 7, 2022 | Press Coverage, Research & Innovation

Researchers at Scottish Rite for Children were awarded a $100,000 grant from the Department of Defense’s Neurofibromatosis Research Program. This grant will fund efforts to investigate new treatments for bone fractures in children with Neurofibromatosis Type 1 (NF1).
 
NF1 is an uncommon genetic disorder associated with pediatric and adult tumors. Some children with NF1 develop orthopedic conditions requiring treatment, such as scoliosis and persistent bone fractures. For many years, Scottish Rite has been recognized as an international leader in the care of children with NF1. Recently researchers at Scottish Rite, led by former Assistant Chief of Staff B. Stephens Richards, M.D., co-led a clinical trial testing the INFUSE graft to treat persistent fractures in children with NF1. Surgery is currently the best option for children with NF1, but a team of Scottish Rite researchers is dedicated to developing new, less invasive treatment methods.
 
“Our team has dedicated years of research to understand why these persistent fractures occur in children with NF1,” says Jonathan Rios, Ph.D., assistant director of Molecular Genetics and lead investigator of the study. While several drugs are either approved by the FDA or currently in clinical trials to treat tumor manifestations of NF1, no such treatments exist for orthopedic conditions associated with NF1. “All of our team’s efforts have led to this moment, where we can now test new therapies in the lab. And by evaluating therapies already in clinical trials for other aspects of NF1, we hope to rapidly translate the most promising of these therapies to treat fractures in children with NF1,” Rios says.
 
“Dr. Rios’ research will allow us to advance how we care for children with NF1 suffering from persistent fractures and will improve the lives of children with NF1 at Scottish Rite and around the world,” Chief of Staff for Scottish Rite for Children Daniel J. Sucato, M.D., M.S., says. “Dr. Rios’ research exemplifies Scottish Rite’s reputation as an international leader in translational research that will bring new treatments to children for years to come,” Director of Basic Research Carol Wise says.
 
search about our leading-edge research.
 
Jonathan J. Rios, Ph.D., is the assistant director of Molecular Genetics at Scottish Rite, as well as an associate professor in the McDermott Center for Human Growth and Development and the Departments of Orthopaedic Surgery and Pediatrics and is a member of the Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center (UTSW). Carol Wise, Ph.D., is the Director of Basic Research at Scottish Rite and is a professor in the McDermott Center for Human Growth and Development and the Departments of Orthopaedic Surgery and Pediatrics at UTSW. Dr. Sucato is the Chief of Staff at Scottish Rite and is a Professor in the Department of Orthopaedic Surgery at UTSW.
Scottish Rite for Children and The University of Texas at Dallas Collaborate to 
Improve Education for Children with Dyslexia

Scottish Rite for Children and The University of Texas at Dallas Collaborate to 
Improve Education for Children with Dyslexia

by | Jun 7, 2022 | Dyslexia & Learning Disorders, Press Coverage

The Luke Waites Center for Dyslexia and Learning Disorders at Scottish Rite for Children and The Center for Simulation and Synthetic Humans at The University of Texas at Dallas have joined forces on an innovative project to break down educational barriers. Dyslexia affects 20% of the population and represents 80 – 90% of all those with learning disabilities. It is the most common reading difference.
 
Since 1968, Scottish Rite has been a pioneer and international leader in the evaluation and treatment of dyslexia. Dyslexia is a specific learning disorder that is neurological in origin, affecting a child’s ability to decode words (break them down into sounds) and then sound out new words. Additional problems can include reading comprehension, reduced reading experience and impeded growth of vocabulary and background knowledge. 
 
Innovators at Scottish Rite approached Marjorie Zielke, Ph.D., Director of the Center for Simulation and Synthetic Humans UTD to develop a program that would make dyslexia intervention possible for more children. Using motion capture recording technology, Zielke’s team of researchers, artists and developers worked with Karen J. Avrit, M.Ed., LDT, CALT-QI, Director of Dyslexia Education at the Luke Waites Center for Dyslexia & Learning Disorders to create Ms. Hallie, a virtual human. By recording Avrit’s precise facial movements, dictation and vocal tones, her expert teaching methods have been captured and preserved, allowing her expertise to be shared in classrooms across the country. Alongside a certified teacher, Ms. Hallie will help instruct students while using the dyslexia intervention curriculum created by Scottish Rite, Bridges: A Dyslexia Intervention Connecting Avatar, Teacher and Student. Avrit has more than 30 years of dyslexia education experience and serves as the lead author of both the Take Flight and Bridges curriculum.
 
Scottish Rite’s expertise in dyslexia education and therapist training, combined with UT Dallas’s futuristic synthetic human and simulation technology, allows Bridges to knock down barriers. Districts and schools who do not have access to specialized education or enough certified dyslexia therapists can now provide more services to those in need. Together, Avrit, Zielke and their teams are excited about the possibilities. “Bridges was the carefully considered response to the discrepancy between the number of students who need services and the number of trained therapists available to provide services,” Avrit states. “It was designed to maintain high-quality and effective research-backed dyslexia instruction.”
 
While there is no replacement for a fully trained dyslexia therapist, “this program integrates the human expert (teacher), alongside the virtual human (Ms. Hallie), ensuring that the child receives the education they deserve,” Zielke said. “This important triad is built into the name, and this technology is successful due to all three components working together.”

Learn more about our Luke Waites Center for Dyslexia and Learning Disorders.

Empowering Women To Become Engineers and Surgeons

Empowering Women To Become Engineers and Surgeons

by | May 20, 2022 | Research & Innovation

Article previously published in Rite Up, 2022 – Issue 1.

Sounds of whirring drills, buzzing bone saws and clattering trays of suture and casting materials filled the room at Scottish Rite for Children Orthopedic and Sports Medicine Center in Frisco during the recent Perry Outreach Program (POP) course. The daylong course, created by The Perry Initiative, features mentorship as well as hands-on workshops and training designed to introduce young women to aspects of orthopedic surgery and engineering careers, two fields in which women are drastically underrepresented.
 
Jasmine, former Scottish Rite for Children patient, experienced a light-bulb moment during her POP participation, leading her to study bioinformatics, statistics and biomedical sciences in college. Now a junior at Texas A&M University, Jasmine came back to this year’s POP to help others feel what she felt.
 
“The empowerment I found through the program encouraged me to continue pursuing my interest in orthopedics rather than being deterred by the underrepresentation of females in the field,” she says. Her POP mentors, Scottish Rite medical director of clinical safety and pediatric orthopedic surgeon Amy L. McIntosh, M.D., along with Kirsten Tulchin-Francis, Ph.D., former division director of Movement Science, led the event in Frisco as local hosts providing guidance and education for 30 young women.
 
“There are very few women in engineering and orthopedic surgery, so it is essential that young women like these bring their creativity and diversity of thought to these fields,” Tulchin-Francis says. Participants performed mock orthopedic surgeries and conducted biomechanical engineering experiments, while also hearing from prominent women engineers and surgeons in the field.
 
This course featured suture training on bananas, sawing and drilling synthetic bones and repairing them with plates, screws and surgical devices, and how-tos about applying a cast.
 
“If I feel intimidated being one of the few females in the field, I remember the joy and empowerment I felt holding that drill,” Jasmine says. “I remind myself daily of the lessons I learned from my mentors to not be afraid to be bold.”
 
McIntosh encouraged all the young women in attendance. “Be great!” she says. “When you’re the only woman in a room full of men, you shouldn’t try to hide. Instead, use the situation as an opportunity to shine. Be memorable for your hard work, dedication, determination and poise. Speak up with intelligence and confidence.”
 
“One of my greatest takeaways from the program is to not be afraid to take up the space and make your presence known,” Jasmine says. “You are as deserving to learn as anyone else in the room.” Jasmine was accepted into the Joint Admissions Medical Program (JAMP) in 2021, where she received early provisional acceptance to 11 medical schools in Texas and plans to take the MCAT in April 2022.