Uncharted Waters

January 29, 2015
The needs of girls and women in sport have always required a specific kind of care. The new Female Athlete Program at Boston Children's Hospital makes sure they get it.
By Nicole Bottino

Nicole Bottino, PA-C, ATC, is Lead Physician Assistant in Boston Children's Hospital's Division of Sports Medicine. She can be reached at: [email protected].


Before Title IX was passed 42 years ago, there were fewer than 295,000 girls active in high school athletics nationwide. Today, that figure stands at more than three million. The number of women competing in collegiate sports is also higher than ever before, with more than 200,000 in the NCAA alone. As anyone in sports medicine knows, female athletes require a specific kind of care. Yet even with record levels of participation, they are often treated with protocols established for their male counterparts.

To help change this pattern, Boston Children's Hospital's Division of Sports Medicine unveiled its Female Athlete Program in 2012. The aim of the center is to address the complex needs of female athletes, specifically, and help other health care professionals understand the best practices for this population. Our providers accomplish this through a combination of hands-on treatment and cutting-edge research into issues that hit close to home for girls and women in sports.

WHO WE ARE
With clinical options for female-specific care lacking at many locales, we strive to provide a home for every type of female athlete in our program. Our diverse staff includes sports medicine physicians, orthopedic surgeons, physician assistants, athletic trainers, nurses, nutritionists, podiatrists, and sports psychologists. They specialize in issues that impact girls and women in sports, such as the female athlete triad, ACL tears and other knee injuries, stress fractures, bone health, and nutrition.

This model ensures female athletes no longer have to go to one location for treatment of a knee injury and another for a bone health evaluation after sustaining a stress fracture. With the Female Athlete Program, we can provide a comprehensive approach to care under one roof.

Leading the program are co-directors Martha Murray, MD, orthopedic surgeon, and Kate Ackerman, MD, MPH, sports medicine specialist and endocrinologist. Dr. Murray specializes in the care of knee injuries and serves on the Executive Committee of the ACL Study Group. Dr. Ackerman, meanwhile, is an expert on the female athlete triad, and, as a former competitive rower, serves as a physician for the U.S. National Rowing Team. With girls being five times more likely than boys to suffer an ACL tear and 78 percent of female high school athletes having experienced at least one component of the triad, our program's leaders are well-versed in the issues faced by our patients.

In addition to their clinical work, Dr. Murray and Dr. Ackerman actively perform research in their fields. In order to provide optimum care, it's important for our clinicians to stay on the cusp of new approaches to female athlete treatment, so their findings in the lab are just as much a part of the Female Athlete Program as their work with patients.

STARTS WITH PREVENTION
Like many sports medicine facilities, one of the main philosophies behind the Female Athlete Program is to find a way to keep injuries from occurring. Anytime a patient comes into our clinic, regardless of her injury, it is viewed as a teachable moment to educate her on the best ways to remain healthy in all facets of her life.

Working in conjunction with the Micheli Center for Sports Injury Prevention in nearby Waltham, Mass., many of our patients receive assessments on their strength, endurance, flexibility, body angles, body proportions, training habits and methods, nutrition, and other potential risk factors for sport-related injuries. Our sports medicine physicians then use this data to determine an athlete's injury risk profile and develop a prescription for reducing that risk.

Once an injury prevention prescription has been formulated, a staff athletic trainer works with the patient to help her better understand her strengths and weaknesses. Much of the focus at this point is on addressing deficiencies in order to improve overall performance.

MEETING KNEE NEEDS
ACL tears and other knee injuries have long been a major concern for female athletes. In keeping with our emphasis on injury prevention, our approach to ACL injuries devotes as much time to keeping them at bay as it does to healing them after they occur.

Female athletes are welcome to come to our clinic for an ACL injury risk assessment anytime. In conjunction with the Micheli Center, this involves our injury team watching the patient walk, evaluating her strength and flexibility, and conducting a videotaped running analysis. During clinic visits, Dr. Murray and the staff address the risk factors they find by providing patient education and specific physical therapy and strength training recommendations.

The process doesn't end there, however. Tracking the athlete's progress after she leaves the clinic is another key to preventing ACL injuries. We have her return for reassessment after six to eight weeks of working on her flexibility, strength, coordination, and gait.

In addition to helping current athletes prevent and recover from ACL injuries, Dr. Murray is also working on research that could change the way such injuries are treated in the future. Through several investigations, Dr. Murray and her colleagues have discovered that a torn ACL tries to heal itself--cells migrate to the wound, growth factors are secreted, and blood vessels appear to nourish the new tissue. The only problem is that the ligament ends never reattach.

To address this, Dr. Murray has created a scaffolding to bridge the gap. So far, she has had success by implanting the gel into torn animal ACLs. Cells have migrated to it, regenerated the ligament tissue, and made permanent bridges to mend the tear. Preliminary results from Dr. Murray's animal studies have shown good healing, appropriate biomechanical function, and a return to 40 percent strength six weeks after the initial injury. With a few more years of testing and refining the method, Dr. Murray hopes to one day bring the model to human ACL repair.

TRIAD TREATMENT
In conjunction with musculoskeletal treatment and injury prevention, the Female Athlete Program also specializes in the recognition and care of endocrine and hormonal disorders, particularly the triad, a condition of three related entities: low energy availability, menstrual irregularity, and poor bone health. Studies have shown that the disorder hasn't always been identified or treated correctly in the past.

For instance, amenorrheic athletes were often prescribed oral contraceptive pills instead of being evaluated for under fueling, overtraining, and/or low bone density. Simply prescribing "the pill" masks the greater problem. The athlete may feel like she is healthy as long as she has a withdrawal bleed on the pill once a month. However, her lack of knowledge about proper nutritional habits may extend well beyond her athletic career and lead to greater health consequences later in life, including eating disorders, infertility, and/or osteoporosis.

The Female Athlete Program's approach to the triad is based on an assessment of the whole athlete by Dr. Ackerman and several other members of our team. If a patient comes to our clinic with a stress fracture, for example, her evaluation begins with a thorough investigation into her menstrual history, training regimen, eating habits, and growth history.

We believe that the cornerstone of triad treatment is education about nutrition, training, and overcoming emotional barriers. Furthermore, we may also include bone imaging, metabolic laboratory assessments, dietary evaluations and consultations by our sports nutritionist, guidance from our physician assistants and nurses, physical therapy protocols from our athletic trainers, and podiatry or sport psychology intervention as needed. Once the athlete's stress fracture heals, we may include a gait analysis and other biomechanical assessments to improve her sport-specific techniques and to minimize future injury risk.

Dr. Ackerman's continuous research into the triad allows the Female Athlete Program to stay on top of new treatment methods. Her latest work explores the best ways to recognize and treat it, including hormonal interventions.

Currently, she is a co-investigator in a study examining the effects of transdermal estrogen and oral progesterone on bone density in triad patients. Under existing triad treatment protocols, it can take patients months or years to gain weight and regain their menses, and bone mass can suffer in the interim. Estrogen taken transdermally rather than orally is metabolized differently and is thought to be more promising for bone health. Improved bone mineral density has already been seen while using this method with adolescents suffering from anorexia nervosa.

FUTURE DIRECTIONS
Many of the issues facing female athletes can be prevented with better education, but there are few resources dedicated to spreading awareness about their specific needs. Sports medicine professionals, athletes, parents, and coaches will not be properly informed without the proper tools. To spread relevant injury prevention and treatment information, the Female Athlete Program hosted the first-ever Female Athlete Conference in June 2013.

We invited local, regional, and national experts to speak about ACL injuries, triad treatment updates, concussive symptoms in girls, eating disorders and body image, effective communication with coaches, and mental toughness for sports performance. Representatives from the International Olympic Committee, NCAA, Academy for Eating Disorders, Female Athlete Triad Coalition, and ACL Study Group all took part in the conference.

Dr. Ackerman presented on the relationship between hormone cycles and performance while Dr. Murray discussed ACL treatment and injury prevention. They also directed attendees to our program website, which contains a collection of educational materials on topics relevant to the needs of female athletes.

The audience at the conference included doctors, physician assistants, nurses, athletic trainers, sports nutritionists, athletes, and coaches. The event proved to be such a great learning, networking, and collaborative experience that we've decided to make it a biennial event.

In the two years since its founding, we believe the Female Athlete Program has lived its mission. By taking a comprehensive approach to female athlete care, we have been able to address multiple issues that impact girls and women in sport and help others understand the best practices for this group. In the future, we will continue to use state-of-the-art treatments and research to ensure female athletes get the care they need.


SIDEBAR: BACK ON THE FIELD
A high school soccer player who is no stranger to knee injuries recently came to the Female Athlete Program at Boston Children's Hospital with her upcoming senior season in jeopardy. In her early adolescence, she suffered a torn ACL and lateral meniscus. Following a long rehab, she had returned to the field, only to tear her medial meniscus and re-tear her lateral meniscus years later during her junior campaign.

After taking aggressive approaches with her previous rehabs and getting reinjured both times, the athlete wanted to ensure the long-term health of her knee with this third rehab. So the Female Athlete Program responded accordingly.

Once Martha Murray, MD, orthopedic surgeon and co-director of the program, surgically repaired the torn menisci, she worked closely with the athlete, her parents, and a physical therapist to come up with a successful rehabilitation plan that would also reduce the risk of future injuries. An overall physical and biomechanical assessment helped cater the plan to the patient's specific needs, and a multidisciplinary team approach to the rehab made sure nothing fell through the cracks.

A year later, after following her recovery protocol to the letter and allowing her knee's pain level to guide her, the athlete was ready to return to the field. The deliberate and thorough rehab plan paid off, as the athlete reported that her knees had never felt so strong and she could play with complete confidence.

And play she did. Not only did the athlete's high school team go undefeated and win the state championship in her senior year, but she scored the title-clinching goal to cap a triumphant return from injury.
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