Transcription:
Keeping Female Athletes Healthy

Scott Webb: Young female athletes are at higher risk for certain types of sports injuries, like bone stress and ACL injuries. And it's important for those of us who have active daughters to know the warning signs, preventative measures and treatment options. And joining me today are Dr. Emily Kraus, she's a Pediatric Sports Medicine Specialist at Stanford Children's Health, and I'm also joined by Dr. Kevin Shea, he's the Director of the Sports Medicine Program at Stanford Children's Health.

This is Health Talks from Stanford Children's Health. I'm Scott Webb. So first off, I want to thank you both for joining me today. I have a 13-year-old daughter who plays a bunch of sports, and I worry about her health. I worry about her knees. And this is the first in a series with the two of you. So I'm glad to have you on not only for me, but for other listeners as well. And Dr. Kraus, as we get rolling here, what are some of the unique health issues that female athletes face?

Dr. Emily Kraus: There are number of injuries that female athletes suffer from at a greater incidence or greater degree than male athletes. And for one, I'll start with bone stress injuries, which is an area of research of mine. I see a lot of athletes who come into my clinic, suffering from bone stress injuries, especially runners. And these are a type of injury, it's an overuse injury to the bone, from cumulative or overuse of the bone. So this occurs on a spectrum of severity from you may have heard of a stress reaction all the way to an actual stress fracture of the bone. And we see this at a pretty high rate in the high school athlete population, as well as the collegiate population. And we see kind of longer time for return to play certain risk factors, which we'll dive into a little bit later, especially as it relates to the female athlete.

Another big health issue is ACL or anterior cruciate ligament injuries. We see a greater incidence in females compared to males in both high school and collegiate athlete. And then also another big one probably talked about is sports-related concussions. And the research shows that females report symptoms post-injury and have higher rates of post-concussive syndrome compared to male athletes.

So those are the three big heavy hitters that we talk about a lot. And far as education, we're seeing them a lot in our clinic, both Dr. Shea and myself. And, really, it's important to just understand those injuries, understand the best ways that we can prevent them and optimize their return to sports.

Dr. Kevin Shea: Yeah, Dr. Kraus, a really great list of topics. The one thing I might add is there's been a growing interest in recognition that kneecap instability, kneecap dislocations may also unfortunately preferentially impact the female athlete, especially recurrent patella instability events. So that group of three plus maybe patellar instability, I think, are things that the families and parents really need to be focused on in the future.

Scott Webb: Yeah. And as I preface saying that I have a 13-year-old who plays a lot of sports. These are all things that I worry about and I think about constantly. And as you mentioned, Dr. Kraus, you know, that return to play is something that athletes and parents wonder. So when my child is injured, how quickly, you know, can they get back on the field, can they get back on the court? I also wanted to ask you, what's the female athlete triad?

Dr. Emily Kraus: Great question. And this is an important topic. I wanted to take a step back and actually talk about low energy availability, which is one of the components of the female athlete triad and then get into the definition of female athlete triad. So, low energy availability actually occurs when an athlete don't consume enough energy or food or fuel to account for the exercise that they're doing. And that also includes the body's natural processes, such as metabolism, growth and development, which is super important in adolescence.

And we actually often see this chronic low energy availability state in two particular conditions. One of which is the female athlete triad. So the triad is comprised of three components, low energy availability. And this could include an eating disorder or disordered eating. Number two is some degree of impaired bone health. So I'd mentioned bone stress injuries or overuse injuries to the bone. Sometimes we actually also see low bone mineral density as a consequence. And then, menstrual irregularities, so this is irregular periods, whether this is the delay in the first period that a female athlete gets, kind of after the age of 15 or this is missed periods. So maybe the increase in training volume or the underfueling gets to a point where that female actually has hormonal suppression that leads to a loss of period.

And so it's an important area that sometimes there's the misconceptions around with a female athlete that it's normal or a right of passage to lose their period during heavy bouts of training. And unfortunately, this is very harmful for overall bone health, as well as just performance. So it's an important concept that the females, we're trying to really just disseminate that information and educate both athletes and coaches and parents on.

Scott Webb: Yeah, education is so key. And I know that a lot of times with my daughter in particular, we play sports early in the morning. You know, she's not always hungry at 6:30 in the morning. I mean, a lot of people aren't hungry at 6:30 in the morning. So I'm wondering how that feeds into, no pun intended, the RED-S. You know, that athletes are up early, they're not hungry, they don't eat. And then is that maybe one of the reasons why they suffer from RED-S?

Dr. Emily Kraus: Yeah. So, first of all, define RED-S or REDS, both of them are used. So that stands for relative energy deficiency in sports. And this actually includes the triad symptoms. So the RED-S is the expansion of the female athlete triad, but also describes potential effects on an athlete's heart health, mental health, hormonal balance, and other processes.

And so when an athlete skips breakfast, that's putting them in this low-energy state as they get into their practice or training. And maybe that's even just going to school, they skip breakfast, they go to school and then, they maybe they have a snack or lunch later and maybe some snack before practice, but they're putting themselves at an energy deficit before they even start their day. And if they do an early morning practice, their tanks are already empty. And how are they going to be able to sprint up that hill or execute that workout or that practice to the potential if their tanks are empty?

I am on team breakfast and I recommend planning ahead, whether that's just getting some juice and toast and/or a bar or there's really easy oatmeal packets that can be used, but there are ways to really work around that. And, even though sometimes those hunger cues maybe haven't woken up yet for that athlete, it's still really important to start off with a breakfast before that first practice,

Scott Webb: Yeah, I think you're so right. And one of the effective things that I offer my daughter is a peanut butter toast with sliced banana, à la Elvis, you know.

Dr. Emily Kraus: Big fan. Big fan.

Scott Webb: She loves it. And I figure she's getting, you know, carbs and protein and everything that she needs to get out there and, you know, kick butt on the field. Why are some of these conditions that we're discussing here more likely to occur in young female athletes versus young male athletes?

Dr. Emily Kraus: You know, we are seeing more often and more frequently, both disordered eating and eating disorders in female athletes compared to male athletes. And a lot of times, even just this underfueling can be what we call inadvertent or unintentional. And that could be just from a change in training. So I see this when an athlete goes from like junior varsity to varsity or from middle school to high school where the training intensity and volume and number of hours per week really increase. Or maybe they're doing kind of double-dipping in two different practices or on two different teams, which I don't advise. And over time, that can lead to this energy deficit. And sometimes that athlete thinks that they're getting this gain from this. And we're seeing this more often in female athletes than male athletes, these disordered eating behaviors. Especially as we're coming out of the pandemic and return to sport, we're really seeing a greater degree of this coming into our clinic.

And over time, this leads to this hormonal suppression that we see in the triad resulting in these missed periods, these other bone health consequences and we're seeing it just at a greater rate in female athletes. And we do see this in male athletes as well, but it is harder to detect because males aren't having periods. And so there's other degrees of hormonal suppression that are a little more difficult to ask about or screen for in an annual physical, for example.

Scott Webb: And I'm guessing that leaving these conditions untreated or not, you know, paying attention to the energy deficit and so on is never going to be good for the young female athletes. But maybe you can discuss that a little bit. What can really happen if these things go untreated?

Dr. Emily Kraus: Yeah. So I touched upon bone stress injuries earlier, so that's overused injuries to the bone. And we're seeing a greater number of triad risk factors. There is a greater severity and a longer duration of being out of sport from a bone stress injury. But we can also see long-term bone health consequences, and super important in the adolescent athlete population, because this is peak bone building time. Most of the bone mass is created before athletes turn 18 years old. So this is that time to really optimize the nutrition. And another thing is just engage in different types of sports and we really encourage multi-directional sports such as soccer and that involved cutting and kind of different types of bone loading or things that can actually help improve and optimize bone health in the developing athlete.

But we're also seeing performance effects. We see impaired recovery, greater fatigue and a reduction in both physical, psychological and kind of mental wellness and kind of that aptitude to really execute and perform at an athlete's best on a field or court.

Scott Webb: And what can young athletes and their parents do to keep our daughters healthy? What can we do to keep them playing sports to keep them on the fields and courts?

Dr. Emily Kraus: I think step one is to have the conversation. Keep that dialogue open. Encourage optimal fueling. Fueling, sleep, recovery days, those are just as important as the actual training. And so I think that's a great start. I also think it's important to create an environment that's conducive to these conversations that we're not just thinking about the fastest runner and the most shots taken, but really kind of creating this well-balanced athlete for life, not just for that season.

I encourage for female athletes that, you know, periods are cool. It's great to have your period every month and you should. And if that isn't happening, that should be the check engine light, where you got to see what's under the hood and see might be the problem and really address that early.

And one thing that I think is really being talked about more, which I am so happy about is I'm talking about mental health and mental health is part of the health process and part of training. So really I'm thinking about all those stressors, both sport stressors and non-sport stressors and how that may influence a week and just really respecting some of that anxiety and stress around school can continually trickle into those training days. And I think the awareness of that is a really good starting point and may help explain some different like risk factors, that we just need to explore more.

So those are, I think, a good starting point. And really kind of having these conversations with the coaches, the parents, so that we're all on the same page about all of these topics. So I'm making sure that you find ways to share this information and disseminate the good information, so everyone's on the same page.

Scott Webb: Dr. Kraus, this has been great and really educational. As we wrap up here, you know, you're a nationally recognized doctor, you know, for your work on injury prevention in young female athletes, which is why we're having you on. Can you give us some highlights of your current research?

Dr. Emily Kraus: Well, I've been super fortunate to be given the role as director of a new female athlete program focused on translational research for the female athletes. And I've titled it FASTER, which stands for Female Athletes Science and Translational Research, has a kind of a nice catchy acronym, which makes it fun.

We're really focused on translating this research. There's a lot of incredible research happening all over the world on female athletes. And we're really trying to close that gap and better understand some of those sex-related differences. That's great, but I think the other big piece of that is to find a way to get that information to the coaches, the parents, the athletes, so that they can really take that information and learn and grow and really be empowered and kind of be an advocate for their own health and for their daughter's health or the athlete's health on their team.

So one of our big goals as part of FASTER is to develop a platform of education. So, videos and other infographics and material that's easily accessible for coaches and female athletes to really access. I think knowledge is power and finding ways to really increase the access to that is a big goal of ours.

Scott Webb: Yeah. I think you're so right. Knowledge is power. And we'll add in terms of, you know, what we're hoping whether it's videos or whatever materials are out there, we'll add this podcast. You know, another tool in the tool belt for coaches and parents and athletes. So I thank you both so much for your time. I look forward to our next podcast on ACLs and meniscus injuries. And in the meantime, stay well.

Dr. Emily Kraus: Thank you.

Scott Webb: Call (844) 416-7846 to make an appointment or go to stanfordchildren.org for more information. And if you found this podcast to be helpful, please be sure to tell a friend and subscribe, rate, and review this podcast and check out the entire podcast library for additional topics of interest.

This is Health Talks from Stanford Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.