Transcription:
How Sex-Related Differences Impact Sports Injuries

Scott Webb: There are anatomical and physiological differences between boys and girls, of course, and as a result, the same or similar. Sports injuries may present and be treated differently. And joining me today to help us understand sex related differences in sports injuries and the value of proper warmups and nutrition in preventing certain injuries is Dr. Arvin Balaji. He's a sports medicine physician with Stanford Medicine Children's Health. This is Health Docs from Stanford Medicine Children's Health. I'm Scott Webb. So doctor, I'm really excited about this topic today. I have two kids, a boy and a girl, and they've had lots of injuries and there's some sort of differences between the two. So really great to have you on today, have your expertise. What are some of the sex related differences in sports injuries?

Dr. Arvind Balaji: Yeah, this is a very important topic to me and I think, to all parents that have, young ones that are involved. When we talk about the sex differences in injury patterns for both of the sexes, we think about a couple of different things. In particular, one of the things that has been eluding our full understanding is that girls generally tend to develop injuries to their knee and particularly the ACL ligament. Much more frequently than boys, and this is true, even if they're playing the exact same sport with the exact same rules as boys, we generally tend to see girls playing soccer, developing a higher rate of injuries to their ACL more commonly than boys.

And when you get down to the granularity of this, which might be interesting for our listeners. The type of injury that we're talking about to the ACL is not a contact injury or a collision injury in particular. So I'm not talking about girls diving at each other's legs and causing an impact injury to the ACL at a higher rate than boys. It's actually what we call the non-contact ACL injury, which is where you plant your leg and you're trying to change direction really quickly in a pivoting or shifting sport such as soccer.

And in that mechanism, it seems that girls seem to tear through the ACL ligament at more frequent rate than boys do now. We've been doing a lot of research for many years from perhaps the nineties, trying to figure out why that is. And there are some things that we've discovered, although we don't fully understand exactly what makes up the differences. In particular, one of the things that we've learned is that when go through puberty compared to boys, they go through different physiologic changes, and this actually contributes to different anatomical.

Boys put on more muscle mass as they go through puberty in general when compared to girls. Girls obviously gain the height just like the boys do. They put on a little bit more muscle mass just like the boys do, but they have some different physiology and anatomy that leads to a larger pelvis and a wider hips. Now, this in particular creates a different angle between the hips and the knees and a wider angle for girls than it does for boys. And what we understand is that when we ask girls after they're going through this pubertal change to continue playing a sport where they're having to move around a lot, the different forces that go to the knee challenge the knee a little bit more in girls than it does in boys because of this change in this angle.

And that can sometimes be dangerous to the knee. And so when girls are playing soccer and trying to change directions quickly, these variable direction of forces to the knee can increase their risk of tearing their ACL or injury in their ACL when we compare it to the boys. Now, , the other sort of injury pattern we like to think about that seems to be quite different between boys and girls is concussion. We also don't fully understand this, but it appears that girls that are engaged in sports at the adolescent and young teenage level suffer injuries related to concussion more frequently than boys do.

This is also true in regards to, like I mentioned, for the ACL injuries, even if they're playing the same sport with the same rules. Girls seem to develop concussions at a more frequent rate than boys do. We don't exactly know why and we're working on that. And the other part about the concussion, topic to dis to discover and to discuss is that girls, when they recover from a concussion, it has been noted for quite some time that they seem to take a little bit longer than boys, but some brand new research that was published within the last several years seems to indicate that if we can get girls to provider attention and get them involved in the rehabilitation from their concussion as fast as we do for the boys.

Then the differences in their recovery doesn't really seem to last. Meaning we're not doing as good of a job as we should. Getting our concussed girls to a provider that can help them appropriately. If we can get them there just as fast as we're able to for boys, then the differences between the recovery rate seems to go away. They get better at about the same time. So that's really something I think we can all work on together as a community, as a medical community and as well as education for our parents, our school nurses, our school athletic trainers, all those sorts of people.

We should be coming together to work on that, recognizing concussion symptoms in our girls and trying to get them into the hands of somebody that can help them at a quick speed. And get them as quick as possible into that office because we can really do a lot of good, and we can be treating them just as well as we're able to treat our.

Scott Webb: Yeah, this is so interesting. You're speaking my language, doctor, and again, having two kids and a boy and a girl. The boy's a little bit older, so the girl's still playing sports. She just got into high. School and she's the basketball player. Does make me wonder, you're saying, you know, that we need to do a better job, getting treatment for girls, especially for concussions. I'm trying to understand the psychology of that. Why do you suspect, or maybe even if it's just purely anecdotal, why don't we seem to rush them to the ER or the emergency department to seek help the way we tend to do for our boys? I'm trying to understand that especially as not just as a host, but as a dad.

Dr. Arvind Balaji: Yeah, it's a phenomenal question, one that I think a lot of us in the medical community are really interested in answering. , the shortest answer is, We don't know all of the details about why there's a significant difference in our ability to get our girls to medical attention. But it is a pattern that we see throughout medicine. We know that, for example, older women who are suffering from heart attacks may present differently in terms of what they tell their physician their primary complaint is then men who suffer heart attacks are.

And so when you're taught in medical school to expect a certain presentation for a certain disease, You kind of make up your mind that that's how it's supposed to be. And so when someone comes in to seek medical attention for that disease and they describe it in a way that you're not used to hearing, we're not always the best at capturing that and appropriately providing the care that that person deserves. And I think that that pattern comes all the way back down towards our pediatric patients and our young adolescents.

Girls who suffer concussion, if they're particularly mild and not a terrible big injury where it's obvious that they've been hit, they may not provide the right, I don't wanna say it that way. They may not provide the. Same use to pattern that we expect to hear from a patient who's concussed. They may not come in and say, I've gotten my head hit. I'm feeling dizzy, I'm feeling nauseated. I have a headache. They might present much more inly where they might not complain of anything, and the next day they might have a little bit more moodiness or complain of a low level headache.

And no one really thinks that that's anything significant related to an injury. And it's not until you. Sit down and go through the pattern of events, do a good history, perform the right physical exam that you realize, oh, you know what, that injury four days ago. Likely contributed to these conditions that we're seeing, likely contributed to these symptoms that we're seeing. We actually think this is a concussion and we are gonna treat you the right way now. So if I had to pick anecdotally without being able to provide the exact data to completely support that, I would say that that's relatively common and we can see it in different disease types in addition to concussion.

Scott Webb: Yeah, and if my daughter were a part of this podcast today, doctor, she would just tell you that girls are tougher. They're just tougher. They're stronger, obviously, doctor, there are differences, many differences between boys and girls, anatomical, physiological, and otherwise. So I guess I'm wondering when they present similar injuries, same injuries, do you treat them differently?

Dr. Arvind Balaji: That's a great question. I think that by and large for pediatric patients, the treatment for the particular injury, if it's the same between, for example, a young female basketball player and a young male basketball player, if their injuries are about the same, then I would say the treatment that we provide is by and large, the same as well. So if they have an ACL injury, There are many different ways to reconstruct the ACL surgically. And me not being a surgeon, I don't want to go into the specifics, but we know that there's different choices that you can do in terms of a surgical repair.

But the ultimate treatment for this injury right now medically speaking, is to reconstruct the ACL using some form of graft, the differences that would exist in how this treatment applies to a boy. Girl is that when the surgeon is doing their evaluation and trying to figure out how best to treat this patient, the graph that they decide to use or the graph that they counsel the patients to pick may be different based on what they're seeing the patient anatomically looks like, and based on what the available resources are, as well as the sport that they're playing. But the ultimate treatment between the two will always be the same, which will be the ACL reconstruction.

So by and large, I would. Overuse injuries, traumatic injuries for our age group that we deal with. The treatment availability for both boys and girls is about the same. We expect the same sort of rehab approach. We expect the same, surgical approach, but there's some minor tiny differences when you get down to the details that may be a little bit different between the two.

Scott Webb: Yeah. So let's talk about warmups and training. And this is something that dad has been harping on with both kids for a very long time, that I find that kids don't warm up properly, long enough that they don't appreciate the value in warmups. So I'm wondering if you can take us through this. Are there some sex related differences? That maybe impact warmups and training, and then ultimately to the lack thereof, the the improper warmups. Can that be pointed to, can you look at that and say, Well, that may be one of the reasons that you didn't warm up properly, you didn't warm up enough, you didn't warm up the right muscles, whatever it might be? What is the impact, I guess, of warmups in training when we think about the sex related differences?

Dr. Arvind Balaji: Yeah. Warmups are boring, right? It's hard to convince people to be able to do it. It's.

Scott Webb: Let's just play.

Dr. Arvind Balaji: Yeah, we've gotta get out there and play. And I empathize a little bit because I do have a similar mentality. But as you appropriately pointed out, warmups are incredibly important to prevent injury. And when we think about the differences, one of the nice things in our field is when we notice a pattern causing a difference in injuries, we can use that information to figure out how best to rehab as well as, prehab or prevent an injury. So when we think about warmups and we know that, for example, girls may have a higher risk of an ACL injury compared to boys, there are now many different sort of knee injury prevention programs that people can look up online.

They can basically just search that into any internet search engine and they'll find lots of resources about preseason conditioning, specific hip and knee and core exercises, that can help people figure out exactly how to strengthen different components of those muscle groups. To be better prepared for whatever sport they're gonna play once the season starts. These programs are designed to help you do something before your competitive season starts, and they have a version that you're supposed to keep doing during your competitive season as part of your general training, conditioning and warmup.

And this has really been proven to have a profound impact in decreasing the risk of injuries during your competitive season. So this has really helpful of course for our girls where we they're the group that we should target a little bit more closely than our boys because there is that disparity in injuries, but certainly boys should be doing this as well. They should be decreasing their risk as much as possible for any sort of bad outcome related to a lower extremity or knee injury in particular.

So we know that data is very clear in supporting a significant, perhaps up to 40 to 70% depending on the sport, decrease in the risk of lower extremity injuries in athletes who properly follow these knee injury prevention programs before and in season of whatever sport they're wanting to play. And this is true for both sexes, although I think the amount of difference may weigh more heavily on girls because their burden of knee injury is a little bit higher than the boys. How you get a 14 year old to buy into that is a little bit more difficult. Of course it's harder to get them to probably follow that train of thought as concretely as we might be able t o.

But making warmups and training as. Part of the training process as a part of the competitive process, as a part of the season, making it a team related activity and making it as fun as possible while keeping it safe and productive. Are some strategies that different sports can use, different coaches and different families can use to get that buy-in from our young ones to help them as much as possible.

Scott Webb: Absolutely. Let's talk about diet and hydration. I'm always telling my kids, I'll make sure you drink a lot of water. My daughter got her booster shot today. I said, Drink a lot of water. Yeah, yeah, yeah. Dad, But Doctor, from an expert so I can play this for her. Does diet and hydration make a difference?

Tremendously, and I think probably undervalued a lot in terms of the differences it can make in performance and in general health for our athletes. The way that we think about it in pediatrics and in sports medicine for pediatric patients is by and large, until about the pubertal age, we expect the nutritional and hydration requirements of our boys and girls to be approximately the same with a little bit of variability. Once puberty begins and progresses, the differences start to amplify a little bit more.

We expect because boys put on quite a bit of lean muscle mass as they're going through puberty, their bodies are going to require a higher caloric intake in order to maintain normal physiologic processes. And then you have to add a little bit more if they're also part of a relatively competitive sport and are exercising on top of their normal physiology. That same thing happens with girls as they go through puberty, but to a lesser extent. So we know that calorie-wise, nutritional wise, we really have to turn up the nutrition that we're providing to boys and girls as they're going through their early and middle and late pubal stages.

So that we're appropriately nourishing them for normal growth and we're appropriately nourishing them to recover from their activities related to training, competition, and exercise. One of the things that we've learned about with girls is that as they're going through their pubertal changes, their bodies really key in to requiring a certain level of nutrition to go through this change normally. So we know that if we don't properly nourish our girls, Especially if they're in a sport where leanness, for example, is emphasized. And those examples of that might be competitive dancing, cheer, gymnastics, those sports in particular, maybe also something like track and field and cross country.

We know that those activities in sports emphasize a certain physique, whether intentionally or unintentionally. Girls may be under pressure to meet that physique by not appropriately nourishing themselves during a very vulnerable time of growth. The unfortunate thing is that that can lead to some unintended consequences, and specifically that can lead to issues related to bone health. And some of those changes if we're too late in recognizing it and properly treating it. We may not be able to get back some of that bone health and it might be lost relatively permanently.

So there's been a push in the pediatric community to really make sure that we're educating ourselves as providers and we're educating parents and coaches to properly nourish and keep an eye on how we're doing with our girls to prevent some of these losses that can happen. Because we really don't wanna see that happen to anybody. For boys, it doesn't quite seem to present that physiologically, but I would say that if we're undernourishing our boys and not appropriately nourishing them with the appropriate calorie intake. They may develop issues where they're just not able to perform as well as possible. They're more fatigued, their muscles are weaker.

They're not able to concentrate as well, both for their sport as well as class irritability. Sleep disturbances, these are probably common for both sexes, but we know that boys generally tend to present with this a little bit more prominently when they're suffering from under nourish. When we think about hydration, there's different rules of thumbs that you can follow in order to make sure your athlete is getting enough water intake and getting enough micronutrients and those sorts of things to keep them hydrated.

In general, what I've said is about five to seven or eight ounces per 20 minutes of vigorous activity is a generally good way of preventing significant dehydration and keeping athletes nourished. Now, that doesn't mean they have to take a break every 20 minutes to get five ounces in. It's just general guidelines and an average that you can kind of figure out based on how long you're gonna be practicing or competing in those sorts of things. Once activity is progressing to 60 minutes or longer, we really do want to incorporate some sort of electrolyte containing solution in order to better provide the sort of losses of sodium and other electrolytes that are happening through sweating.

We know that the commonly, and most popularly advertised sports strengths are pretty good, but they do have a little bit more sugar content than we would like, which can lead to some unintended consequences, abdominal pain and other things like that. So we would probably recommend athletes if they're getting to an hour or longer. We would probably recommend that they rather use some sort of more concentrated electrolyte solution that's less on the sugar in order to replenish those sorts of things that they're losing through their sweat and competition.

Dr. Arvind Balaji: This has been such a great conversation. Like I said, as a host, as a dad, to have your time today is just great. I'm sure listeners agree, and I know we could keep talking, at least. I know I could keep talking as we wrap up here. Doctor, what advice do you give parents and kids about sports, whether that's before they start playing or as they begin to have some injuries. , from your expertise, what do you share with them? What do you tell them about playing sports and maybe what they can expect?

The number one thing that the pediatricians of our country really want to encourage parents and their young athlete children to do is to first have fun. The goal of sports participation in this age group is to really enjoy yourself, to understand what it's like to be a part of a team, to appreciate competition, but really we really want our youngsters to be having fun out there. We don't want them to be miserable and forced to do something they don't wanna do, and we also want them to take the appropriate time to take breaks and recover.

In general, the guidelines are that in one year of competition, pediatric patients should be taking about three months that are non-consecutive of a break from their primary sport. So that means pick three months throughout the year where we're not asking our youngsters to be competitive. They shouldn't be playing year round. They should not be playing every single day. They should not be playing every single month. They need some breaks to both help them psychologically, emotionally, and physically.

We really think all of these things are important to consider when we are encouraging our youngsters to be active in sports and in activities. And throughout the week, we should also be recommending about one to two days of rest from significant exercise. Now, when I say rest, as I mean through my weeks and my months, I don't mean that during those months or weeks, they should be absolutely sedentary. That's what I'm saying,

Scott Webb: Onthe couch watching Netflix.

Dr. Arvind Balaji: YEah, we're not trying to turn our youngsters into couch potatoes three months outta the We're trying to keep them active, but we're trying not to push them to do things that their bodies are not physiologically needing to do. And we have found appropriate rests and recovery actually improves their performance in season. It actually does the opposite of what you might think. You think they get Rusty, actually turns out they have less injuries, they're more active, they're getting more enjoyment outta their sport. So there's a lot of positive benefits of taking these appropriate breaks.

And lastly, I would say that on this topic we talked about a lot of differences and certainly they exist, but when you get down to the granular approach, Taking care of pediatric patients, boys and girls, and all of the ones that may identify in between, physiologically speaking, the body actually responds very well to equal treatment and equal approaches both ways. Certainly, we can be doing better in some aspects, as we've talked about, but as we look into the differences between boys and girls as they play sports, there's a lot more. Similar between the two of them than there is. That's different.

And I think that if we can find ways to appropriately providing the right guidance appropriately, providing the right mentorship, role, modeling, and we on the provider end appropriately identifying patients when they come in with a problem and intervening in a timely manner, we can really improve the care we're providing for both sexes, boys and girls.

Scott Webb: Yeah, boys and girls, and you're so right, Doctor. I have to remind my daughter that this is about fun, right? Yes, she wants to play basketball in college and we do everything we can to help her travel teams and so forth, but it really is about being a kid and having fun. And then I also have to remind myself. That I'm not watching a professional athlete out there, maybe someday, but right now she's my 14 year old daughter and I love her and I wanna help her and protect her and nourish her and all of those things. So, , this has been a great conversation today, Doctor. Thank you so much. You stay well.

Dr. Arvind Balaji: I appreciate it. Thanks so much for having me. This was a lot of fun. Thank you.

And for more information, go to Stanfordchildrens.Org, and we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb, stay well, and we'll talk again next time.