Sports Injuries can Warn of Bigger Problems in Female Athletes

When is exercise not a good thing? For most women, increased physical activity means they've followed all the best medical advice toward fitness and better health. However, the pressure to excel can lead to three serious medical problems: disordered eating, amenorrhea (loss of menstrual periods) and osteoporosis (brittle bones).

Disordered Eating

"The incidence of eating disorders is incredibly high in female athletes," said Paul Shonnard, MD, local orthopedic specialist. These athletes — especially those involved in track and gymnastics — place a tremendous emphasis on body weight and composition. Often, a woman feels that the leaner she is, the quicker she'll be. In the quest for lighter bodies, some women deprive themselves of nutrients vital to their performance.

By doing so, many develop eating disorders ranging from an occasional use of diet pills or laxatives to bulimia (self-induced vomiting) and anorexia (withholding food excessively).

People who study eating disorders say parents and those who work with young children need to start educating young girls in healthy nutrition by age five or six, because, unlike boys, girls begin to reduce milk and calcium intake by age eight or nine in misguided attempts to be thin. "It's much easier to prevent than try to deal with behavior that's already established," said Dr. Shonnard. "By adolescence, eating patterns are well ingrained," he added.

Amenorrhea and Oligomenorrhea

Some women think they're finally getting into shape when they exercise so much that they stop having periods, said the American College of Sports Medicine's Ad Hoc Task Force on Women's Issues in Sports Medicine. But this absence of menses, known as exercise-associated amenorrhea, indicates a system edging toward collapse.

"Amenorrhea or oligomenorrhea, infrequent menstruation, is not normal after puberty," said Dr. Shonnard. It's a warning from the body that too much energy is being expended without enough energy replenished through adequate nutrition and rest. Studies have shown that female runners with amenorrhea have low bone density which could pave the way for osteoporosis.


"It's important and normal for women to have higher body fat than men," said Dr. Shonnard. "A woman's body fat directly impacts estrogen metabolism." Estrogen is the hormone that helps in the absorption of bone-strengthening calcium. When women push themselves to very low body fat levels, normal estrogen levels decline which creates low calcium absorption, directly impacting the strength of bones and tendons.

When women athletes skip periods, their estrogen levels dip to a level common among women over 50. With the decline in estrogen, young bones become thin, fragile and prone to fracture — especially stress fracture.

Female gymnasts particularly have very high rates of injury to the lower back, one of the common stress fracture types. Tendinitis — sprain of tendons, usually in legs — also may be related to nutrition and possibly estrogen imbalances, but research is not yet conclusive on these issues, said Dr. Shonnard.

"It is clear that this type of injury in female gymnasts tends not to be treated well enough, and injuries tend not to heal as they should," said Dr. Shonnard. "Carrie Strug is a perfect example of this syndrome," he added.

These gymnasts have a high continuing injury rate, averaging about 25 percent prolonging even after they have ceased being athletically active. This is due to pushing beyond the injury, causing the injury eventually to become chronic.

Women in high-level athletics have twice the rate of rupture of the knee ligament, probably due to two reasons, said Dr. Shonnard: some scientific evidence suggests that women's anatomy is different from men's in this area, and the strength of ligaments in women may be lessened when nutrition-related estrogen imbalances exist.

As a result, women athletes who miss periods need to increase calcium intake to 1,500 milligrams daily (vs. 1,000 milligrams daily for women with normal periods). Women athletes need to get medical care within three months of missing a period, according to the American College of Sports Medicine.

You Never Outgrow Your Need for Calcium

Women need to be particularly careful about getting enough calcium throughout their lives, and parents of girls need to educate them at an early age — before age six — that drinking milk and eating calcium-rich foods will assure they become strong, healthy women — the best kind of beautiful.

Women gain maximum body calcium by age 30; after that, it's depleted. Bone thickening can continue beyond adolescence to 30. In light of several recent studies that found bone density actually doubles before girls reach puberty, the U.S. recommended daily allowance for calcium is expected to be doubled from its current level of 800 milligrams. Thus, when women hit menopause and experience a reduction of bone density by half, they'll be "ahead of the game."

In those cases in which enough bone thickness wasn't laid down during the formative years, the skeleton eventually can get very weak and easily be subject to fractures — the condition of osteoporosis.

What can be done? Not surprisingly, diet and exercise throughout life are important ways to head off osteoporosis:

  • Eat sufficient calcium-rich foods at all ages, but especially between early adolescence and age 30 to lay down the largest peak bone mass possible.
  • Eat moderate amounts of protein (up to 15 percent of total calories) and fiber-rich foods equal to 25 to 35 grams of fiber daily. Excessive amounts of protein and fiber can interfere with calcium absorption and storage.
  • Participate in regular weight-bearing exercise such as jogging, walking, weight training or skiing — but avoid overtraining. This type of moderate activity may minimize bone-mass loss.
  • Consult with your physician about estrogen-replacement therapy if you are entering or experiencing menopause. It is particularly important if you have a family history of osteoporosis.
  • If you are unable to eat calcium-rich foods, consult with a registered dietician or physician to find out if a calcium supplement is appropriate. Lactose-intolerant people can try over-the-counter lactose-digesting enzyme to their milk to increase their daily tolerance.

Fortunately, it is easy to find calcium-rich foods that are low in fat and affordable. Many dietitians recommend calcium-rich foods such as nonfat milk, yogurt, low-fat cottage cheese and other reduced-fat cheeses. Fortified juices and cereals also are available with calcium.