Shoulder Instability

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Shoulder laxity has been traditionally associated with the female athlete. Hormonal factors such as progesterone, estrogen, and relaxin11 as well as decreased upper extremity muscle mass12 have all been implicated. Yet there has been much debate as to whether these gender-specific differences contribute to injury patterns. The shoulder is a complex, highly mobile structure. In order to accommodate for extremes in motion, there is a delicate dynamic between normal and pathologic. The glenohumeral joint is inherently unstable. Relative to the glenoid, the humeral head is very large, providing only a small contact surface area for bony support. Thus, the joint relies heavily on balanced contraction of rotator cuff musculature, coordinated scapulotho-racic motion, and the integrity of the soft tissues. It has been proposed that the female athlete is predisposed to atraumatic or multidirectional shoulder instability due to laxity of capsu-loligamentous constraints. McFarland et al13 and Borsa et al14 investigated these issues and found shoulders to be appreciably more lax in females than males. However, it must be noted that the terms laxity and instability should not be interchanged.

While laxity describes the physiologic motions of the gleno-humeral joint, it is not itself pathologic.15 The term instability should be reserved for painful motion resulting in subluxation or dislocation.11 In 1980, Neer and Foster12 recognized multidirectional instability as a specific entity. While the essential lesion was initially thought to be capsular redundancy, operative findings of capsular tears and labral avulsions (Bankart lesions) have shown that the etiology is multifactorial.11,16-18 It is thought that direct trauma or repetitive microtrauma, such as that found in overhead-throwing athletes, superimposed on a lax shoulder might result in instability.18

The physical examination is important in differentiating these two entities. The patient may present with vague complaints of pain, apprehension, and shoulder fatigue with or without voluntary subluxation. The shoulder should be assessed for range-of-motion deficits, rotator cuff weakness, and asymmetry of scapular motion. Excessive anterior and posterior motion of the humeral head and inferior translation with downward traction on the humerus (sulcus sign) can help identify laxity (Fig. 8-2). Many provocative tests such as the load and shift test, the apprehension relocation test, and the release test, described in the shoulder section of this book, can be used to elicit instability. In general, pain or apprehension while placing the shoulder in the abduction external rotation position is suggestive of instability.

Initial treatment for multidirectional instability should be conservative. With the assistance of a physical therapist, a program of mobilization, flexibility, and strengthening should be initiated. Graduated resistance training using elastic bands or weights through internal and external rotation motions are

Breast Tumor Jpg
Figure 8-2 Sulcus sign. Note displacement of the humeral head inferiorly when traction is applied to the extremity.

useful for strengthening the rotator cuff, thereby improving dynamic stability of the joint (Fig. 8-3). Scapular stabilizing muscles (trapezius, serratus anterior, rhomboids, and levator scapulae) must also be strengthened. Scapulothoracic motion is vital to overhead activity; in order to abduct the arm, the scapula must tilt and elevate. Failure of this motion can result in impingement on the underlying structures. To address this, activities such as pull backs, shoulder shrugs, and knee and wall push-ups, which emphasize protraction of the scapula as well as the correction of poor posture, are typically prescribed (Fig. 84). In addition, athletes should be enrolled in sport-specific training to enhance muscular control and proprioception.

Surgical treatment should be offered if the patient has not responded within 6 to 9 months of rehabilitation. The original surgical procedure was the open inferior capsular shift, aimed to reduce capsular redundancy.12 Many authors report improvements in stability and return to preinjury activity level with this procedure or variations of open stabilization techniques.17,19,20 Arthroscopic stabilization has been introduced as an alternative to established open procedures. The advantages include better identification of underlying intra-articular pathology,16 less morbidity, and improved cosmesis. With the development of improved arthroscopic techniques, several clinical trials have reported excellent results for the treatment of multidirectional instability. Arthroscopic repair has also been shown to withstand the stress of sports activities.21,22 Mazzocca et al22 examined the results of arthroscopic anterior shoulder stabilization in collision and contact athletes. They reported 100% return to organized sports and believe that participation in collision and contact athletics was not a contraindication for arthroscopic repair. No gender-specific trials on the fate of patients treated operatively or nonoperatively are available.

Arthroscopic thermal capsulorrhaphy, which uses heat to shrink capsular volume, has been introduced in recent years. However, several authors have reported high failure rates and increased incidences of postoperative complications,23,24 making this a less favored procedure.

Anterior Knee Pain

Difficulties with patellofemoral tracking can result in acute injuries (patellar subluxation or dislocation) or overuse problems (patellofemoral stress syndrome or anterior knee pain). Patellar subluxation and dislocation are discussed in detail in Chapter 57 and are not covered in this section.

Patellofemoral stress syndrome is a name given to the syndrome of anterior knee pain or patellofemoral pain associated with diffuse anterior knee pain that increases with such activities as squatting, kneeling, running, walking down steps, or walking downhill and is common in women athletes, especially young women. The diagnosis of patellofemoral stress is based on history and clinical examination (Table 8-1). Squats and lunges (i.e., those activities that increase patellofemoral forces) frequently enhance symptoms. Swelling is rarely present. Other symptoms of this syndrome include popping, catching, and snapping. Athletes may experience acute episodes of the knee giving out or giving way. Occasionally, crepitus may be present, although in general, this symptom more typically occurs in those with true softening and fraying of the retropatellar surfaces (chondromalacia) rather than the overuse problem of patellofemoral irritability, anterior knee pain, or patellofemoral stress syndrome.

Athletes will frequently report that they have a change in their exercise activity prior to the onset of symptoms with either

Patellofemoral Instability ExercisesPatellofemoral Instability ExercisesInternal Snapping Hip Syndrome Exercises Patellofemoral Instability ExercisesInternal Snapping Hip Syndrome Exercises

Figure 8-3 Exercises to strengthen the rotator cuff. A, External rotation: Stand with elbow at side and gently rotate arm out as illustrated. B, Internal rotation: Rotate arm across front of body as illustrated.

Table 8-1 Diagnosis of Patellofemoral Stress Syndrome

Frequent Symptoms

Locking Catching Giving out

Increased pain with flexion-extension movements (e.g., kicking, running)

Pain while squatting, kneeling, prolonged sitting, sitting cross-legged style, and climbing stairs

Physical Examination Features

Increased hip varus Increased knee valgus Vastus laterals > vastus medials Foot pronation Increased lumbar lordosis Weak core strength

Increased tightness (apparent or real) of the hamstrings, iliotibial band and/or quadriceps an increase in running-type activities or an increase in squats and lunges or knee extension exercises. They may report completing the same number of knee extensions but with a higher weight than what they would normally lift. Occasionally, and particularly in recreational athletes, the inciting factor may be related to job or home activities, for example, using a clutch car, moving to an upstairs apartment, or sitting more at work, even though the pain is elicited with sport.

The onset of pain in women is often during the mid-to-late teenage years at the time of transition from the narrower pelvis of adolescence into the wider pelvis of womanhood. College may bring a dramatic change in lifestyle to young women resulting in more seated study time and less active sport play or exercise, resulting in persistent patellofemoral forces from the bent knee position of studying and less vastus medialis obliquus strength.

The patella is guided in the trochlear groove by the bony anatomy of both the patella and the trochlear groove, by the surrounding quadriceps muscle and by the complex ligamentous structures that surround the patella, including the lateral patellofemoral ligament. If, during adolescence, the four heads of the quadriceps do not all develop symmetrically, the asymmetrical pull of the quadriceps can create abnormal patellofemoral forces or at least uneven patellofemoral forces.25-27

On physical examination, alignment and flexibility of the extremity should be carefully assessed. Hip varus, knee valgus, and foot pronation are frequently, but not always, present. The athlete may stand with her knees "locked" in hyperextension, a posture that is thought to be associated with increased patellofemoral forces. Tightness of the hamstring and quadriceps muscle groups can add to the abnormal mechanics about the knee and the increase or unequally distributed patellofemoral forces.28 The normal progression of patellofemoral contact areas during knee flexion is illustrated in Figure 8-5.29 As the knee

Transverse Pullbacks

Figure 8-4 Exercises to strengthen the scapular stabilizers. A, Pull backs; B, shoulder shrugs; C, wall push-ups; D, knee push-ups.

Figure 8-4 Exercises to strengthen the scapular stabilizers. A, Pull backs; B, shoulder shrugs; C, wall push-ups; D, knee push-ups.

flexes, the contact area on the patella moves proximally as the contact area on the femur moves inferiorly. At no time is the entire surface of the patella in contact with the trochlear groove of the femur.

Symptomatic athletes will generally have pain to palpation around and behind the patella. Infrequently they have apprehension with lateral deviation of the patella (i.e., a positive apprehension test). They do, however, have pain with slight downward pressure of the patella in the femoral groove. This sign can be enhanced by asking the patient to actively contract the quadriceps muscle while the examiner places an inferiorly directed force on the patella (Fig. 8-6). Typically, no effusion is present. The range of motion of the knee is full.

One theory of the cause of patellofemoral pain is based on the premise that abnormal patellofemoral mechanics can cause increased retropatellar forces that overwhelm the articular surface's ability to absorb the increased stress, resulting in increased pressure on the bone beneath. Dye,30 who has done a great deal of research in this area, stresses the need to stay within one's "envelope of function." The envelope is determined not only by one's own personal anatomy but also can be influenced by exercise, braces, and orthotics, that is, by altering patellofemoral forces favorably, one can increase the envelope of function.

Radiographs can also be helpful as they may demonstrate an asymmetrical position of the patella in the trochlear groove (Fig. 8-7). Many different radiographic views have been used to describe the relationship of the patella to the trochlear groove. However, the degree of quadriceps contraction at the time the radiograph is taken can markedly change the patella's position in the trochlear groove.31 Therefore, care must be taken in interpreting these views.

Skyline views of the patella are helpful, however, to provide indirect evidence of the thickness of the patellofemoral articular cartilage. With chondromalacia of the patella, this space may be diminished, but in the overuse syndrome of anterior knee pain or patellofemoral stress, the thickness of the patellofemoral articular cartilage should be normal, indicating a reversible situation (Fig. 8-8). The progression of patellofemoral stress syndrome to chondromalacia is not well known. Most young people

Figure 8-5 Normal progression of patellofemoral contact forces. A, Method of applying force to patellofemoral joint; B, 20 degrees of flexion; C, 60 degrees of flexion; D, 90 degrees of flexion; E, 120 degrees of flexion; F, 135 degrees of flexion. (Adapted from Ficat and Hungerford.29)
Figure 8-6 Patients with patellofemoral stress syndrome generally will have pain with downward pressure of the patella in the femoral groove.
Figure 8-7 Note asymmetrical position of the patella in the trochlear groove.

with the overuse problem of anterior knee pain do not develop pathologic softening of the retropatellar surface (chondromala-cia). More studies on the natural history of anterior knee pain are needed.

The treatment of athletes with patellofemoral pain centers on altering patellofemoral forces by altering the patella's position in the femoral groove (Table 8-2). Quadriceps strengthening, typically focused on the vastus medialis muscle, is combined with exercises to strengthen muscles of the hip and trunk. Exercise routines can employ machines, rubber tubing, or free weights.

Athletes should incorporate flexibility exercises for all muscles of the lower extremity and trunk into their program. A hyperextended lumbar spine (i.e., increased lumbar lordosis) can result in apparent shortening of hip external rotators including the iliotibial band and hamstrings and hence influence patellofemoral mechanics. A strong core (i.e., trunk muscles) to absorb impact force on landing may minimize increased stresses to the knee and foot. A good example to use for athletes is to explain that they need to land as "light as a feather" like the ballerina does when she lands en pointe.

Braces or tape are used to shift the patella's position to a more favorable one in the femoral groove.32,33 Some patients prefer braces with a lateral pad; other patients prefer braces that have a pad about the entire patella. Others prefer an open patellar brace; some like merely an infrapatellar strap that lifts the patella superiorly in the groove or at least attempts to decrease pressure on the patellofemoral surface by elevating the patella (Fig. 8-9). A trial-and-error method in selecting a brace is often used as it may be difficult to predict which type of brace will be most helpful to the athlete. Orthotics to decrease foot pronation may be used to better align the patella as foot pronation can result in an increase in apparent knee valgus and hence lateral displacement of the patella in the groove.34

Oral nonsteroidal anti-inflammatory drugs can be used at a time of marked increased symptoms, but athletes must understand that these drugs do not alter the course of the overuse syndrome, but merely temporarily decrease symptoms caused by the inflammatory reaction. Therefore, it is essential to participate in an exercise program and incorporate other conservative measures into their routine. Activity modification, even if

Patella Skyline View Denegerative Joint

Figure 8-8 Skyline view of the patellofemoral joint. A, Note the width of the cartilage space (arrow) in a young knee with patellofemoral stress syndrome and no loss of articular cartilage space. B, Note the reduced width of the cartilage space (arrrow) in the knee of a patient with significant chondromalacia.

Figure 8-8 Skyline view of the patellofemoral joint. A, Note the width of the cartilage space (arrow) in a young knee with patellofemoral stress syndrome and no loss of articular cartilage space. B, Note the reduced width of the cartilage space (arrrow) in the knee of a patient with significant chondromalacia.

only temporary, may be needed to decrease irritability until patellofemoral forces can be altered advantageously.

Anterior Cruciate Ligament Injuries

The rate of noncontact ACL injuries in high-risk sports such as soccer and basketball is greater in female than in male ath-letes.35-37 The young appear to be most at risk, with the vast majority of ACL injuries occurring in those 15 to 45 years of age.38 In one study, the average age of those who sustained an ACL injury was 26 years.39 Neither risk factors nor the mechanism of injury is well defined for ACL noncontact injuries. Proposed risk factors include shoe-surface interactions and other environmental concerns; anatomic factors such as hip varus, knee valgus, foot pronation, femoral notch size, and size of the ACL; hormonal factors (levels of estrogen, progesterone, relaxin, and others); and neuromuscular factors such as upright posture, landing a jump and cutting on a straight knee, leg dominance, and poor hamstring strength relative to quadriceps strength (quadriceps dominance).40,41

Landing a jump, cutting, pivoting, or changing directions accounts for 80% to 85% of all noncontact ACL injuries. Often

Table 8-2 Overview of Treatment for Patellofemoral Stress Syndrome


Quadriceps, particularly vastus medialis obliques and core

Increase flexibility

Trunk and lower extremities


To support, lift, or move the patella medially

Shoe orthotics

To decrease foot pronation

Activity modification

Decreased flexion/extension activities until acute symptoms subside

Nonsteroidal If no stomach irritability and no history of anti-inflammatory drugs allergies to these medications

the athlete recalls that just prior to making a planned move, someone cut in front of her, bumped her, or in some similar way made her accommodate quickly to the change in direction of movement or landing.42

Men have less hip varus and knee valgus than women, and they appear to land a jump with their hips and knees more flexed than women.43 Unlike women, men's strength is relatively equal in both lower extremities, and they fire their hamstrings more rapidly and prior to their quadriceps with an anteriorly directed tibial force, both appropriate responses to protect the ACL.40,44 The diagnosis and management of ACL injuries in women are similar to those in men, as discussed in Chapter 51. Although at one time it was theorized that women would fare less well than men following ACL reconstruction, studies have not found this to be true. ACL reconstruction using autologous bone-patellar tendon-bone is as functionally stable in females as in males, and Tegner and Lysholm's scores after reconstruction are similar.45,46 Although Barrett et al47 reported increased laxity scores in women following ACL reconstruction with autologous quadruple hamstring tendon, others have reported equivalent results in males and females.48-50

During rehabilitation following ACL reconstruction, the therapist should emphasize avoidance of abnormal mechanics leading to ACL injury, substituting instead proper landing and cutting skills and agility skills minimizing dominant leg characteristics if such exist. Moreover, these same principles should be highlighted as a part of preseason conditioning programs. Drills to enhance balance and agility, incorporating plyometrics with an emphasis on proper landing techniques (i.e., landing light as a feather by contracting core muscles and with more hip and knee flexion and with the body balanced over the lower extremity) should be practiced.

In fact, a six-part preseason and in-season prevention program has been proposed by some and includes recognition of injury mechanics, flexibility and strengthening exercises, aerobic conditioning, plyometrics, and agility drills (Table 8-3).51 These exercises should be incorporated into normal sport conditioning programs. Programs using these strategies or even those merely

Figure 8-9 Braces/taping are frequently used as part of the treatment for patellofemoral stress. A, Brace with lateral pad; B, brace with a doughnut pad around patella; C, infrapatellar strap; D, patellar taping. The tape "pulls" the patella medially.

Figure 8-9 Braces/taping are frequently used as part of the treatment for patellofemoral stress. A, Brace with lateral pad; B, brace with a doughnut pad around patella; C, infrapatellar strap; D, patellar taping. The tape "pulls" the patella medially.

Table 8-3 Six-Part Alternative Warm-up Program for Anterior Cruciate Ligament Injury Prevention

Enhance recognition of injury mechanics

Increase flexibility of core and lower extremity muscles

Increase strength of core and lower extremity muscles

Aerobic conditioning

Incorporate plyometrics

Perform agility drills incorporating simple balance drills into preseason and in-season condition routines have been reported to decrease the incidence of ACL noncontact injuries (Table 8-4).41,52

Some investigators have also proposed that those girls found to have poor landing skills and significant deficits in hamstring strength may benefit from participating in an intense therapy program prior to the beginning of the season or even during the season, in addition to performing an alternative in the field conditioning program.53 More data from randomized, controlled trials with numbers sufficient to have adequate power from which to draw reliable conclusions are needed. However, early reports from trials of existing programs are very encouraging.

Forefoot Pain

It has been reported that 8% of all females wear shoes smaller than their feet and that this trend starts with adolescence. Girls also engage in more "foot abusive" sports than men. Although women spend more than men on athletic shoewear ($5.4 billion versus $5.3 billion), many shoe manufacturers do not make a last sized to a female's foot but merely scale down their male last. This results in a shoe with an inappropriate forefoot width-to-length ratio, predisposing female athletes to develop corns, calluses, bunions, bunionettes, and hammertoes.

Treatment of these forefoot abnormalities is generally symptomatic conservative care with pads, creams, moleskin, exercises, and shoe modification. Surgery should be approached with great caution as secondary biomechanical problems can result. Figure 8-10 is a radiograph of a young cross-country runner who had bunion surgery and then developed stress fractures in the second and thirds metatarsals from altered mechanical forces resulting from a shorter first metatarsal.

Stress fractures of the metatarsals are also frequent in dancers as well as runners and gymnasts. Bone is a dynamic tissue constantly repairing damage to its structure caused by activity. Stress fractures or microfractures of the bone occur when the rate of bone repair falls behind the rate of bone formation. This can occur if the athlete does too much too fast without proper conditioning or the repair processes are slowed secondary to one of several factors including inadequate sleep, a poor diet, or lack of adequate estrogen (as discussed in the section on the female athlete triad).

Clinically, the athlete with a forefoot stress fracture will complain of pain and swelling in the midfoot just behind the metatarsal heads. The swelling and pain increase with activity and improve with rest. They are better in the morning after a night's sleep. Initial radiographs may not demonstrate the early stress reaction, but if the athlete continues to participate in her sport despite pain, the increased insult to the bone results in a fracture line, which can be seen radiographically. If rest is instituted early when pain first begins, radiographs may never show a fracture line but instead may reveal an area of increased bone density indicative of healing. Because foot mobility is needed for performance by many female athletes (e.g., the gymnast, runner, and dancer), these athletes cannot perform in a hard-soled shoe, as might a football lineman, and will lose from 4 to 10 weeks from sport until their fracture heals. Preventing stress fractures by proper conditioning, adequate sleep, and appropriate diet and footwear is essential.

Figure 8-10 Runner who sustained a stress fracture of the second metatarsal after bunionectomy. Note shortening of the first metatarsal increasing stress to the second.

Figure 8-11 Schematic diagram of the compression of the interdigital nerve by adjacent metatarsal heads.

Interdigital neuroma or Morton's neuroma is a painful condition of the forefoot resulting from entrapment and perineural fibrosis of the interdigital nerve as it traverses the web space between the metatarsal heads (Fig. 8-11). This condition, which is eight times more prevalent in women than men, occurs most commonly between the second and third metatarsal heads but can also occur between the third and fourth metatarsal heads. The term neuroma, which is often used to describe this condition, is incorrect. The condition arises from entrapment and perineural fibrosis rather than a proliferation of neuronal tissue.

Patients will report paresthesias in the adjacent two toes as well as a vague pain relieved by removing the shoe and massaging the foot. On physical examination, swelling may be present between the metatarsal heads at the involved interspace, and pain can be reproduced by transverse pressure on the metatarsal heads while simultaneously placing upward pressure on the plantar surface of the foot at the site of discomfort (Fig. 8-12). Radiographs are normal but may show close proximity of the metatarsal heads at the involved site.

Conservative treatment includes the use of a wide toe box shoe, metatarsal pads, foot and toe exercises, and consideration of a steroid injection. If these measures fail to relieve symptoms, the most common surgical procedure is resection of the nerve in the intermetatarsal area, which can achieve satisfactory results.54,55 Once again, caution should be exerted before surgery is undertaken as scar secondary to surgical intervention may alter performance in a female athlete who depends on mobility of the foot for her sport.


The Female Athlete Triad

The term the female athlete triad was selected by a 1992 consensus conference called by the Task Force on Women's Issues

Avascular Necrosis Feet

Figure 8-10 Runner who sustained a stress fracture of the second metatarsal after bunionectomy. Note shortening of the first metatarsal increasing stress to the second.

Table 8-4 Prevention Programs

No. Author




Sex Random






1 Griffis et al



B yr

F No

Jump box,




No, landing






2 teams

Ettinger Alpine T: 4000 1 yr with M/F No Video clips of No et al skiing C: ? 2 yr of skiers sustaining

(1995) historic ACL injuries and controls those who avoided injury in very similar falls

Caraffa et al

Soccer T: 300 3 seasons C: 300

No, Balance boards prospective

PNF Yes facilitation exercises

Hewett et al

Basketball, volleyball, soccer


1 yr

M/F Yes

Jump box, balance

Heidt et al


intervention (7-wk period)

Sports cord, box Yes jump

Yes Balance board in No addition to regular training

Myklebust et al

Team 900


3 yr

Wobble board, balance foam mats

Planting NM


No, landing technique

B Wedderkopp Team 236

et al handball

10 mo

Yes, Balance board No cluster (proprioceptive) RCT in 4 levels

Gilchrist et al


1 yr

Cones, soccer ball

Yes, Yes glut med. abd, ext, hamstring, core

Deceleration, No, landing sport technique, specific multiplanar

Pfeiffer et al



9 wk

Cut, NM control

No, landing technique

11 Mandelbaum Soccer T: 1041 et al C: 844

2 yr

No, Cones, soccer voluntary ball enrollment

Hamstring, Yes core

Soccer No, landing specific technique, with multiplanar dec tech

Team handball


1 yr

M/F Yes, cluster RCT

Wobble board, balance foam mats

Cut, NM control

No, landing technique

A, Anterior cruciate ligament (ACL) injuries not specifically assessed; M, male; F, female; RCT, randomized controlled trial; S, sample size relatively small (power inadequate?). From Griffin LY, Albohm MJ, Arendt EA, et al.41



Program/Study Strengths

Program/Study Weaknesses


Yes, deceleration pattern (3-step shuffle)

Changing deceleration and landing technique (encouraged knee and hip flexion)

Not randomized, unpublished

89% decrease in noncontact ACL injury

Nonrandomized, controlled interventional study. Large number of injuries

Not randomized. Not all potential participants trained. Historic controls. Exact diagnosis of knee sprain not always available. Exact exposure to risk not precisely determined

Severe knee sprains were reduced by 62% among trained skiers (patrollers and instructors) compared to unperturbed group who had no improvement during the study period

Nonrandomized, controlled interventional study. Large number of injuries

Not randomized. Not all potential participants trained. Historic controls. Exact diagnosis of knee sprain not always available. Exact exposure to risk not precisely determined

Severe knee sprains were reduced by 62% among trained skiers (patrollers and instructors) compared to unperturbed group who had no improvement during the study period

Yes, balance board activities, multilevel

Mechanoreceptor/ proprioception training

Additional equipment; not cost-effective on large-scale basis

87% decrease in noncontact ACL injury, 1.15 rate reduced to 0.15/1000 AE

Decrease peak landing forces 1-on-1 program in sports facility, not and valgus/varus perturbations, feasible to implement across large increase vertical leap, increase cohort hamstring strength and decrease time to contraction

Female injury rates 0.43-0.12 (male = 0.9) over 6-wk program. Untrained group 3.6-4.8 higher rates of ACL injury

Increased strength, lower overall injury rates

Not statistically significant, 7wk 61.2% injuries in knee/ankle, 2.4% injury rate insufficient for NM education to occur in intervention vs 3.1 in control at mechanoreceptor level

Yes, balance


Small number, low overall injury incidence. 37% dropout rate, not all subjects received same amount of training. Unknown whether additional training was controlled

Intervention did not reduce risk of primary traumatic injuries to lower extremities; 4 of 5 ACL injuries in total sample occurred in intervention group

Balance activities on mats and boards

Compliance to program monitored; instructional video

Not randomized

In elite team division, risk of injury was reduced among those who completed program (odds ratio: 0.06 [0.01-0.54]) compared with control, overall reduction of ACL injury

Balance training with ankle disks

Injury types not specified. Description of ankle disk training not provided. Intervention group also did warm-up exercises but not specified. Compliance not assessed

Ankle injuries were significantly greater in control group (2.4 vs 0.2). Unspecified knee injuries were not significantly less in trained group (0.9 vs 0.6). Five knee sprains and 1 knee subluxation in control group vs 1 knee sprain in trained group

Strength on field perturbation on grass

Instructional video, Web site, compliance monitored (random site visits)

1 yr intervention, began at day 1 of season

Overall 72% reduction in ACL injury, 100% reduction in practice contact and noncontact ACL injury, 100% reduction in contact and noncontact ACL injury in last 6wk of season

Compliance monitored; significant reduction in F & RFD in intervention

No decrease in injury, intervention 6 noncontact ACL injuries: 3 in treatment and performed at end of training, possible 3 in control = no direct effact fatigue phenomenon

Strength on field perturbation on grass

Instructional video, Web site, compliance monitored

Not randomized, inherent selection bias

Injury rates: yr 1: 88% reduction in noncontact ACL injury; yr 2: 74% reduction in noncontact ACL injury

Balance activity on mats and boards

Randomized, compliance monitored, reduction of injury

Efficacious component(s) of intervention not known

129 acute knee & ankle injuries overall, 81 in control (0.9 overall, 0.3 train, 5.3 match) vs 48 injuries in intervention (0.5 overall, 0.2 train, 2.5 match)

Figure 8-12 The pain from a Morton's neuroma can be elicited with upward pressure on the plantar aspect of the foot between the metatarsal heads simultaneously with transverse compression across the metatarsal heads.

of the American College of Sports Medicine to refer to the association of disordered eating, amenorrhea (lack of normal periods for three consecutive months), and osteoporosis (low bone mineral density), three conditions seen with increasing prevalence over the past several decades in female athletes, which individually, and certainly together, can result in impaired health and athletic performance.

Disordered eating can result in inadequate nutrition or energy, which can lead to abnormal menstrual function; abnormal menstrual function can result in low estrogen amenorrhea, which can result in osteopenia (minimally decrease bone mineral density) or even osteoporosis (more severe loss of bone mineral density). Stress fractures may be the consequence of the latter. Bone mass is influenced by estrogen, calcium, and exercise. Peak bone mineral density is achieved by age 25 after which pre-menopausal women lose 0.3% of their skeleton per year and postmenopausal women or those without periods (e.g., amen-orrheic athletes) lose 2% of their bone mass per year. Therefore, concern has been raised that either inadequate calcium intake and/or inadequate estrogen from amenorrhea during the years of maximal bone mineral storage (young teens through 25) may lead to significant osteoporosis during the postmenopausal years. More recently, amenorrhea has been linked to cardiovascular disease and disordered eating to poor function of the immune system.

Athletes most at risk of developing the triad are young women involved in sports in which the lean look is thought to be advantageous (e.g., gymnastics, figure skating, dance, diving, and cheerleading), sports in which weight categories exists (e.g., rowing), and endurance sports (e.g., swimming and crosscountry running).56

Disordered eating refers to a continuum of abnormal eating behaviors of which three categories have been recognized: anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (Tables 8-5 through 8-8). The athlete with disordered eating has abnormal eating behaviors that may involve the quantity of food ingested; abnormal eating patterns (e.g., eating excessively and vomiting following eating); or inappropriate use of laxatives, diuretics, or other medical substances.

The prevalence of disordered eating is higher for athletes than nonathletes; female athletes are more affected than male athletes. Studies have reported a 62% occurrence rate in female collegiate gymnasts, a 47% occurrence in long-distance female runners, and a 15.4% occurrence rate in elite female swim-mers.57,58 Overall, 32% to 64% of all female athletes have been reported to display some type of disordered eating.59

Recognition of the athlete with disordered eating is frequently difficult. Coaches may report a decrease in performance. Abnormal behavior during meals or a preoccupation with food may provide clues to the diagnosis. Once the diagnosis is made, treatment is provided through a team approach with a sports medicine physician, sports nutritionist, and mental health provider, preferably an eating disorder specialist.

Amenorrhea is defined as 3 or more months of missed menstrual cycles and has been associated with heavy physical training. Primary amenorrhea has been redefined by the American Society of Reproductive Medicine as the absence of menstrual cycles in a girl who has not menstruated by age 15. Secondary amenorrhea is cessation of menses after the first menstrual cycle.60 Prevalence of amenorrhea has been documented as high as 65% in long-distance runners and 44% in dancers compared to 2% to 5% in nonathletic collegiate women.60 Amenorrhea was

Table 8-6 Diagnostic Criteria for Anorexia Nervosa

Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

Intense fear of gaining weight or becoming fat, even though underweight.

Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Binge eating/purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

American Psychiatric Association.70

Table 8-7 Diagnostic Criteria for Bulimia Nervosa

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxative, diuretics, enemas, or other medications; fasting; or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of anorexia nervosa.

Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Nonpurging type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

American Psychiatric Association.70

initially thought to result from low body weight and low body fat. More recently, its onset is thought to be more related to energy deficit. The energy deficit may be caused by inadequate energy intake (disordered eating).

Once thought to be a benign, reversible condition that many athletes considered a benefit for athletic participation, pro-

Table 8-8 Eating Disorder Not Otherwise Specified

This category is for those eating disorders that do not meet the criteria for any specific eating disorder. Examples include the following:

For females, all the criteria for anorexia nervosa are met except that the individual has regular menses.

All the criteria for anorexia nervosa are met except that, despite significant weight loss, the individual's current weight is in the normal range.

All the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months.

The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies).

Repeatedly chewing and spitting out, but not swallowing, a large amount of food.

Binge eating disorder: Recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa.

American Psychiatric Association.70

longed amenorrhea is now thought to be a serious medical problem linked to diminished estrogen and a resultant loss of normal bone mineral density as well as to cardiovascular disease as occurs in postmenopausal women. Therefore, recognition and treatment are essential. Treatment consists of correcting the disordered eating and energy deficit, a major challenge in most of the athletes with this disorder.

Osteoporosis, the third component of the female athlete triad, is defined as decreased bone mass with disruption of the normal microarchitecture of bone. Bone is a living tissue and is continually undergoing remodeling and repair. Discrepancies that occur when the rate of bone resorption exceeds the rate of formation lead to the onset of diminished bone mineral density. The degree of loss of bone mass has been defined by the World Health Organization based on the amount of bone mineral density detected by bone densitometry. Bone densitometry measurements are most commonly done by dual-energy x-ray absorptiometry. In this technique, an aerial section of the spine or hip is analyzed for mineralized tissue. The results are compared with peers and against a young healthy adult population known to have peak bone mass, resulting in a value termed a T score (Fig. 8-13). Individuals found to be between 1 and 2.4 standard deviations below peak bone mass are considered to have osteopenia or low bone mineral density, and those with values greater than 2.5 standard deviations below peak bone mass are thought to have osteoporosis or severe loss of bone mineral density (Table 8-9). Recently, Khan et al61 have suggested replacing the term osteoporosis in the triad with osteope-nia, a far more common entity than osteoporosis among athletes and one that lends itself to early recognition and lifestyle changes to avoid further bone loss.

The International Society for Clinical Densitometry has recommended that the bone density of young women (adolescents and premenopausal women) be compared to that of women of their own age group. This is known as the Z score.60 Values are interpreted according to the same scale as the T scores. A loss of 1 standard deviation of bone mineral density results in a 1.9 increased risk of spine fracture or a 2.4 increased risk of hip fracture in the elderly.62 Such data are not available for young athletes, but inferences can be drawn.

As in the discussions on disordered eating and amenorrhea, detection of athletes with the female athlete triad is difficult. Screening athletes for menstrual, diet, and exercise history may be helpful (Table 8-10); however, frequently athletes with this disorder do not wish to be detected and will supply inaccurate answers. The sports medicine specialist must be alert to indirect signs of this disorder such as alteration in performance and secretive eating behaviors. A stress fracture in a lean female athlete should prompt further investigation into menstrual and dietary habits. Consideration of bone mineral density studies should be given to those following an initial stress fracture and indeed for those who have recurrent stress fractures.

Treatment intervention in the athlete diagnosed with the triad is frequently difficult and requires a multidisciplinary approach typically involving the physician, athletic trainer, physical therapist, coach, nutritionist, and sport psychologist. Improving the energy deficit through increasing caloric intake will help to establish regular periods and hence increase estrogen to improve bone health. A reasonable goal should be smaller amounts of food throughout the day to avoid the sensation of "overeating" or "being too full." Women athletes are not unique compared to men in needing to maintain a good nutritional state, but they are unique in regard to many medical conditions linked

Dual femur bone density

Dual femur bone density

BMD1 Young adult2,7 Age-matched

Reference: neck

Reference: neck

Trend: neck mean


Age (years)

BMD1 Young adult2,7 Age-matched



(%) T-score






















































neck mean










(% per yr)






Figure 8-13 An example of a dual energy x-ray absorptiometry scan of a female athlete.

to poor nutritional or energy states. Athletes are frequently resistant to increasing calories for health reasons but frequently understand the need to improve energy for improved performance. (The analogy of a car being unable to go far without adequate fuel is often used.) Along with an increase in calories, athletes must also look at the quality of food ingested. A balance of protein, fats, and carbohydrates is needed, and adequate calcium is required, 1200 to 1500mg daily (Tables 8-11 and 812), along with 400 to 800 IU of vitamin D.

Controversy surrounds the use of oral contraceptives in the treatment of athletes with the triad. One study reported an increase in the lumbar spine and total bone mineral density following their use,60 while other studies have not shown an

Table 8-9 Definition of Normal Bone Mineral Density, Osteopenia, and Osteoporosis


BMD <1 SD below the mean peak bone mass in normal women


BMD >1 but <2.5 SD below the mean peak bone mass


BMD >2.5 SD below the mean peak bone mass

BMD, bone mineral density; SD, standard deviation.

BMD, bone mineral density; SD, standard deviation.

Table 8-10 Screening History for the Female Triad

Menstrual History

Age at menarche

Frequency and duration of menstrual cycles Longest period of time without menstruation Last menstrual period

Physical signs of ovulation, such as cervical mucus change or menstrual cramps Hormone replacement therapy taken previously or currently

Diet History

What was eaten in the past 24 hours? List of forbidden foods Highest/lowest weight since menarche Satisfaction with current weight Ideal weight according to the patient Disordered eating practices (binging and purging) Use of laxatives, diuretics, or pills

Exercise History

Exercise patterns and training intensity for the sport (hours per day and days per week) Additional exercise outside if required training History of fractures History of overuse injuries

Adapted from Hobart and Smucker.71

Table 8-11 Calcium-Rich Foods (Milligrams of Calcium per Serving)





Cottage cheese


American cheese


Swiss cheese


Ice cream


Sardines (with bones)


Salmon (canned with bones)




Oysters (raw)


Shrimp (canned)


Beans (dried, cooked)


Dark green leafy vegetables



150mg/large stalk



Macaroni and cheese





50mg/medium-sized orange

increase in bone mass.63 Regardless of the controversy, many physicians use oral contraceptives as a part of their treatment programs for this disorder. Two treatments available to treat diminished bone mineral density in postmenopausal women, bis-phosphonates and selective estrogen receptor modulators, are contraindicated for premenopausal female athletes. The female athlete triad remains a challenging diagnostic and therapeutic problem of female athletes.

Table 8-12 Guidelines for Calcium Requirements


Daily Elemental Calcium Requirements (mg)*



Growth spurt to young adult (10-25yr of age)


Adult male (25-65 yr of age) Adult female (25-65 yr of age)










Healing long bone fracture (women and men)


*One daily equivalent of calcium is equal to 250mg of elemental calcium;

one equivalent is equal to an 8-oz glass of milk. Adapted from Brostrom et al.72

*One daily equivalent of calcium is equal to 250mg of elemental calcium;

one equivalent is equal to an 8-oz glass of milk. Adapted from Brostrom et al.72


Anemia can negatively affect the female athlete's performance. Controversy surrounds whom to screen and when to screen. Four types of anemia that often affect female athletes are athletic pseudoanemia, sports anemia, iron deficiency anemia, and anemia from blood loss (Table 8-13).

Athletic pseudoanemia is a result of heavy aerobic training causing an increase in red blood cell mass and plasma volume. This dilutional effect is a physiologic adaptation to training and is not true anemia. No treatment is necessary, and the abnormalities should correct with elimination of the aerobic training.

Sports anemia is a condition of low ferritin and normal hemoglobin. Ferritin is a protein that binds iron and is a marker of stored iron. There has not been a consensus on the appropriate level of ferritin for the female athlete. It is generally believed that ferritin levels above 20 will improve performance. It is also not clear whether an increase in hemoglobin, in addition to an increase in ferritin, is needed to improve performance. It has been reported that an increase in ferritin concentration without an increase in hemoglobin concentration has not been shown to improve endurance performance.64 At present, treatment is oral iron supplement to increase the ferritin.

Women especially are at risk of iron deficiency anemia. In most cases, this is an easily treatable condition. Iron deficiency anemia is the most common cause of true anemia in the female athlete, usually resulting from menstrual blood loss. If the female athlete has long-standing heavy menses, the anemia can be significant. The athlete does not have enough iron in the diet to keep up with the loss. Laboratory studies would show low hemoglobin, hematocrit, ferritin, and red blood cell levels. Treatment involves increasing dietary intake of iron and oral iron replacement (Table 8-14). It may take 6 to 12 months to normalize, depending on the severity of the deficit.

Anemia can also result from blood loss seen in other diseases. Gastrointestinal blood loss can come from peptic ulcer disease, diverticulitis, and inflammatory bowel disease, to name a few, or more acutely from diarrhea after prolonged endurance events such as marathons. Foot strike hemolysis is seen primarily in runners, but can be seen as a result of other sports without repetitive foot strike. The leading theory as to its cause is intravascular destruction of red blood cells. Other theories that have been proposed include intravascular turbulence, acidosis, and elevated temperature in muscle tissue.65 Treatment consists of correcting or treating the underlying gastrointestinal condition if this is the cause. No treatment other than rest is necessary for foot strike hemolysis.

Table 8-13 Characteristics of Anemia Types


Red Blood Cell






Slightly decreased



Iron deficiency




Sport anemia




Blood loss








MCV increased

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