 Though
males and females have the same musculoskeletal structures,
there are some unique differences that actually make female
athletes more prone to injury. In regard to skeletal
differences, males usually have wide shoulders and narrow hips,
whereas a female generally has a wide pelvis in relation to the
width of her shoulders. This wider pelvis is necessary for
childbirth. This wider pelvis is stabilized by the sacroiliac
ligaments in the back and the pubic symphysis and pubic
ligaments in the front. It is these ligament structures that are
stressed and account for the significant back pain that occurs
in 50 percent of women who are pregnant.
This wider pelvis in females leads to an increased inward slant
of the thigh and, therefore, an increased Q-angle of the knee.
The Q-angle, a measurement of the angle created by the line from
the anterior superior iliac spine and the patella, and the line
from the patella to the tibial tubercle, is normally less than
12 degrees. An increased Q-angle produces excessive lateral
forces on the quadricep's mechanism and abnormal tracking of the
patella. This is one of the reasons why chondromalacia patella
or patellofemoral syndrome is more common in women. (Hutchinson,
M. Knee injuries in female athletes. Sports Medicine. 1995;
19:288-302.)
As stated above, a female's thighs tend to slant inward towards
the knees more than a male's. This puts additional strain on a
woman's hips and their ligamentous support. This is one of the
reasons that the majority of the 120,000 hip replacements done
each year are in women. Females also have a wider carrying angle
of the elbows. This is similar to the Q-angle of the knee. This
wider angle places additional stress on the medial elbow
stabilizers, namely the ulnar collateral ligaments, which are
usually the culprits when a female athlete has medial elbow
pain.
 Body composition is also different between males and females.
The average body fat content of the female is approximately 26
per-cent, compared with that of the male at 14 percent. The
female has a lower lean body mass indicating less muscle mass.
The greater muscle mass in males is due to the predominant
effect of the androgen hormones, whereas estrogen, predominant
in females, results in increased body fat. As it turns out, this
difference in hormones is key to understanding why female
athletes are more easily injured and repair more slowly than
their male counterparts. Testosterone stimulates fibroblastic
proliferation, whereas estrogen, especially estradiol, inhibits
it.(Liu, S. Estrogen affects the cellular metabolism of the
anterior cruciate ligament. A potential explanation for female
athletic injury. American Journal of Sports Medicine. 1997;
25:704-709.)
It is for this primary reason that female athletes can benefit
from Prolotherapy for their sports injuries. Estrogen makes a
woman a woman, but they have a definite negative effect when it
comes to healing sports injuries.
Females also have a smaller proportion of muscle in relation to
body size because of the hormonal differences. Having less
muscle tissue means there is less muscle to stabilize the joints
if the ligaments are injured. This causes more stress to be
placed on injured ligaments in women than in men, because women
do not have as much muscle back-up. This is another reason for
female athletes to become familiar with the local Prolotherapist.
Females, compared to males, have a lower metabolic rate, the
rate of conversion of food to energy under conditions of total
rest. This appears to be related to the greater lean body mass
of the male and the greater proportion of adipose tissue in the
female. This could be one explanation why females heal sports
injuries slower than men and why more of them develop chronic
pain, and need operations such as hip replacements.
The Hormone Factors
Walk into any chronic pain clinic and who do you see? You see
women. Caring Medical and Rehabilitation Services in Oak Park is
no different. About three out of every four patients coming for
Prolotherapy are woman. Why are the women getting most of the
arthritis and needing the majority of the artificial joint
replacements? It is easy to explain when you take into account
the hormone factor.
The dominant hormone in males is testosterone. Testosterone is
very anabolic, which means that it stimulates the growth or
repair of tissues. Men have about 10 times the amount of
testosterone as women. This is why they have a sex drive that is
about 10 times as strong as women do. It is also the reason why,
on average, men are 33 percent stronger than women. Males are
stronger because of their increased muscle mass due to
testosterone. When males perform strength training, they develop
increased strength and increased muscle size due to hypertrophy
of the muscles. This hypertrophy is due to the effect of
testosterone. Females performing strength training gain
increased strength with relatively less muscle hypertrophy. This
is because females have significantly less testosterone. If a
woman shows up at the Olympics looking like a man, the other
athletes will accuse her of using anabolic hormones like
testosterone. The complaint is justified. When a woman does
weight strength training, she will get stronger, but she cannot
turn herself into a body shaped like a man because the hormones
are just not there.
Recent epidemiological studies have recognized a significantly
higher anterior cruciate ligament (ACL) injury rate in female
athletes as compared with male athletes in sports such as
basketball, hand-ball, gymnastics, and soccer. (Gray, J. A
survey of injuries to the anterior cruciate ligament of the knee
in female basketball players. International Journal of Sports
Medicine. 1985; 6:314-316.; Nilsson, S. Soccer injuries in
adolescents. American Journal of Sports Medicine. 1978;
6:358-361.; Slauterbeck, J. The incidence of anterior cruciate
ligament tears in men and women collegiate soccer players Orthop.
Trans. 1996; 20:259.; Whiteside, P. MenĘs and women's injuries
in comparable sports. Physician and Sports Medicine. 1980;
8:130-136.) Although various causes of this phenomenon have been
postulated, including differences in ligament or muscle
strength, conditioning, endurance, anatomy, and training
techniques, the most plausible appears to be the hormone factor.
Unique to the female athlete is her exposure to a constantly
changing hormonal milieu throughout her reproductive years. For
most of her life, the female athlete is exposed to rhythmic
variation in either endogenous hormones during a regular
menstrual cycle or exogenous hormones via oral contraceptives.
It has been only recently that it was discovered that there are
estrogen receptors on the fibro-blasts of the human ACL,
suggesting that female sex hormones may have an effect on the
structure and composition of this ligament. Dr. Stephen Liu and
associates, at the UCLA School of Medicine, made this discovery
and went the next step to find out exactly how estrogen affects
ligament growth. They investigated the effects of 17B-estradiol
on the cellular proliferation and collagen synthesis of
fibroblasts derived from the rabbit anterior cruciate ligament.
Measuring 3H-thymidine and 14C-hydroxyproline incorporation
assessed fibroblast proliferation and collagen synthesis,
respectively. They found that collagen synthesis was
significantly reduced with increasing local estradiol
concentration. Declining collagen synthesis was first noted at a
17B-estradiol concentration of 0.025 ng/ml. Within physiologic
levels of estrogen (0.025 to 0.25 ng/ml), collagen synthesis was
reduced by more than 40 percent of control, and at
pharmacological levels of 2.5 and 25 ng/ml, as typically occurs
in female atheletes taking birth control pills or estrogen
replacement therapy, by more than 50 percent of control. A
significant reduction of fibroblast proliferation was also
observed with increasing estradiol concentrations.
These results are startling. Estrogen, the female hormone,
dramatically inhibits fibroblasts. These fibroblasts are what
make the collagen that makes up the ligaments and tendons, which
are injured during sports. Estrogen was shown in the above study
to inhibit the fibroblastic growth and thus collagen formation
in a dose-dependent manner.
The more estrogen a woman has, the more inhibition will occur.
This has direct effects for all women taking birth control
pills. Birth control pills have pharmacological levels of
estrogen, which are far in excess of a woman's normal
production. The simplest way for a female athlete, who is on
artificial estrogen, to overcome sports injuries, is to stop
taking them. Inevitably, women are placed on birth control pills
because of menstrual irregularities, which are easily treated
with natural medicine techniques including diet manipulation and
nutritional supplements. At Caring Medical and Rehabilitation
Services in Oak Park, we perform Diet Typing and hormonal
testing on our patients. The female athletes inevitably come up
essential fatty acids deficient. This means they need to injest
more good fats in their diets in the form of omega-3 fatty acids
as is found in fish oils. They are encouraged to drink cod liver
oil and eat more fish. Better kinds of fats are also found in
nuts and seeds, flaxseed oil, and olive oil. Just this mild
change in diet is typically all that is needed to get rid of
menstrual cramps and other menstrual irregularities. Sometimes,
however, more sophisticated dietary manipulation, herbal
supplementation, or other natural medicine techniques may be
needed.
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