Now accepting Telehealth appointments. Schedule a virtual visit.
Skip to main content

The Female Athlete


The Female Athlete

Women’s sports has definitely come of age. Professional leagues currently exist in women’s basketball, volleyball, tennis and golf and other sports are sure to follow. By law, most high schools and colleges now offer women’s athletic programs equivalent to the men’s programs. The myth that women were not meant to participate in sports has clearly been debunked.

With greater participation of women in sports, has come an increased understanding of injuries and problems associated specifically with the female athlete. It is important for the coach, trainer, parent and athlete to be aware of these risks.

Pre Season Sports Physical for Females

Female athletes need to be evaluated for certain specific ailments specific to women.


Curvature of the spine is much more common in females, and tends to occur in adolescence. Pre season screening should evaluate for curvature of the spine and if identified referral should be made for x-rays and medical evaluation. Altered posture, particularly a difference in shoulder height or hip height should raise concern and prompt coaches or parents to suggest evaluation as well.

Mitral valve prolapse

A common and usually benign abnormality of one of the heart valves and occurs primarily in females. This entity is identified usually by a very specific type of murmur found on pre season cardiac evaluation with a simple stethoscope. The great majority of cases are asymptomatic and will not affect sports participation. Athletes with a history of syncope (fainting) arrhythmias, chest pain, or family history of heart disease should be referred for evaluation by a cardiologist.


The medical history should include a menstrual history. Amenorrhea should be identified as a flag for possible eating disorders and the female triad.

Ligament laxity

Females with excessive laxity of their ligaments should be advised that they may be at increased risk of knee, shoulder and ankle injuries and should be particularly encouraged to participate in pre season strengthening exercises to protect the joints. Additionally, certain findings might be useful in advising young females regarding choice of sport. For example, at an early age, females with hyperlax shoulders might be dissuaded from pursuing such sports as swimming or volleyball, and those with unstable patellas might be discouraged from running and twisting type sports.

Are female athletes different?

Certain physiological and sociological factors differentiate the female athlete. The sociological differences are based on generations of attitudes in society that create conflicting images for the young female. Although sports have become more accepted for girls, the media continues to bombard young women with the perception that they also need to maintain a super model figure and a certain feminine image. These conflicting signals create significant stress for some females, causing eating disorders and along with certain physiological female traits can combine to create a serious disorder called the female triad.

Physiologically, the female athlete has to deal with menstruation and hormonal balance. Stress, diet ,overtraining and other factors can alter the normal menstrual cycle and hormonal balance, which can then affect the musculoskeletal system.


The Female Triad:

Eating Disorders/Amenorrhea/Osteoporosis

Eating disorders

Eating disorders are most common in appearance sports, such as gymnastics, ice skating and diving. Severity ranges from occasional binge eating and fasting, to extreme self starvation (anorexia nervosa), and prolonged binge eating and purging or vomiting (bulimia). The prevalence of eating disorders is between 15-62% depending on the survey. Coaches, parents and trainers should be alert to behaviors like eating alone, trips to the bathroom during or after meals, and the use of laxatives. Other signs and symptoms of the female athlete triad may include fatigue, anemia, depression, cold intolerance, and eroded tooth enamel from frequent vomiting.

Anorexia Nervosa

One should suspect anorexia in the athlete who demonstrates an unreasonable fear of being fat, has a distorted sense of body image, fails to maintain body weight within 15% of the mean for her age and height. Associated problems with extreme and prolonged weight loss include disturbances of the cardiovascular, endocrine, and gastrointestinal systems, disruption of temperature regulation, psychological sequelae, and irreversible bone loss. The mortality rate in severe cases is particularly high at 10-15%, with death occurring primarily due to cardiovascular failure, endocrine disturbances or suicide.


The bulimic athlete engages in binge eating and forces purging either with vomiting or with laxatives. These athletes may engage in excessive exercise or fasting due to a morbid fear of gaining weight. Athletic performance tends to fluctuate dramatically. Suicide attempts are common with this disorder.


The onset of menstruation is between 12-15 for non athletic females, and 13-15.5 in the athlete. Menstruation can be delayed or disrupted as part of the female triad. Amenorrhea is defined by a decrease in periods to less than 6-9/year. Poor nutrition from eating disorders, and excessive exercise contribute to this problem. Amenorrhea tends to occur when body fat falls below 17-18%.


Decreased estrogen associated with amenorrhea, along with decreased calcium intake from eating disorders leads to decreased mineralization of bone. This can increase the risk of stress fractures in these athletes. Multiple stress fractures or fractures associated with limited activity should raise a red flag for the female triad.



Danger Signs

Anorexia Nervosa: Weight loss obsession with exercise withdrawal, “loner” excessive concern with weight, diet, and appearance, overlying sense of unhappiness, stress fractures, shin splints, etc., avoids social eating situations (likes to eat alone), complaining of always being cold.


Irregular weight loss, variable athletic performance, drug abuse, binges, disappears after binges, multiple complaints, weakness, aches and pains, use of laxatives.

Treatment of Eating Disorders

If an athlete is suspected of having the female triad, a multidisciplinary approach is often necessary for treatment. Parents, coaches, friends and professional assistance are required. Treatment includes nutritional guidance, emotional support and psychiatric guidance. Hormonal replacement therapy may be required.

If you are struggling with the extremes of disordered eating-anorexia or bulimia-or if you are a concerned parent, coach, or friend, you can turn to the following organizations for help:

American Anorexia/Bulimia Association, Inc
418 E 76th St
New York, NY 10021
(212) 734-1114

American Dietetic Association
National Center for Nutrition and Dietetics
216 W Jackson Blvd, Suite 800
Chicago, IL 60606-6995
(800) 366-1655

Anorexia Nervosa and Related Eating Disorders (ANRED)
Box 5102
Eugene, OR 97405
(503) 344-1144

National Anorexia Aid Society
1925 East Dublin Granville Rd
Columbus, OH 43229
(614) 436-1112

Overeaters Anonymous Headquarters
World Service Office
383 Van Ness Blvd, Suite 1601
Torrance, CA 90501
(310) 618-8835

National Collegiate Athletic Association
c/o Karol Media
350 N Pennsylvania Ave
Wilkes-Barre, PA 18773
(800) 526-4773
(provides videotapes on eating disorders)


Anatomical Differences

Women can be just as competitive as men, and can enjoy sports as much as men, but there are physiological and anatomical differences which affect these athletes.


Female athletes as a group are not as strong as their male counterparts. Studies have shown that with weight training, females will increase their strength percentage wise in equal increments to males, but that their overall strength will begin and end at lower levels.


Leg length in women is a smaller percentage of overall body length, and may be one reason that females tend to be slower runners than men.


Women seem to be approaching men in endurance performance much more rapidly than in strength or speed events. It is speculated that women may in fact be more suited physiologically to endurance activity than men due to an enhance ability to conserve muscle glycogen and ability to utilize fat for energy. (more efficient utilizers of oxygen)


Anatomical Factors:

OK. So we all know that girls are different than boys. Here are some differences you may not have been aware of.


Females tend to have more lax ligaments than males, which is thought to put their joints at increased risk for injury. A recent study has shown that the risk of injury in females may correlate to hormonal changes associated with the menstrual cycle. In particular, female athletes may be more prone to knee ligament injuries, shoulder instability and ankle sprains.

Body shape

The patella


Women have wider hips than men, which creates a wider angle at the knee, where the knee cap (patella) articulates with the femur. This increased angle (often called the Q angle) affects the tracking of the patella and predisposes the female athlete to tracking problems. Abnormal tracking of the patella may lead to instability, or dislocation of the patella, or simply cause pain due to unbalanced loading of the joint. Think of this as a tire out of alignment, where unbalanced loads lead to the treads wearing out of one side of the tire. A similar phenomenon occurs under the knee cap. The female athlete should emphasize strengthening exercises that help to stabilize the patella, to help improve tracking and prevent injury. These exercises should focus on the inner quadriceps muscles (Vastus Medialis Obliqous or VMO).



The female athlete seems to be disproportionately at risk for injury to the anterior cruciate ligament (ACL). There are several theories for this. For one, females tend to have a narrower space in the knee available for this ligament, so that less stress is required to tear the ligament than in the male athlete. A recent study has also shown that female athletes tend to rely on their quadriceps more than their hamstrings compared to their male counterparts. Since the hamstring muscles are one of the main protectors of the ACL, relative weakness in this structure may lead to ACL injuries. Additional risk of injury is related to estrogen levels. Female athletes tend to sustain injury to their ACL during the ovulatory period of their menstrual cycle (day 10-14). This is the period when estrogen levels are the highest. Researchers have shown that the ACL contains estrogen receptors, and that the ACL responds to estrogen by decreasing cell activity and synthesis of the basic ligament fibers (collagen).

Pre season conditioning to build and maintain knee muscle strength, particularly the hamstrings, may help reduce the risk of injury.

Ankle and foot

Female athletes have been shown to have a higher incidence of ankle sprains than males. This is most likely due to several factors including increased ligamentous laxity, and decreased muscle strength and coordination. Women also have a narrower heel in relation to their forefoot than men. Strengthening and coordination exercises for the ankle are recommended to limit the risk of this injury. Use of a balance board and elastic bands for inversion and eversion exercises are particularly helpful.

Women tend to get bunions and hammer toes from narrow shoewear. These can be painful and affect athletic performance. Wider athletic shoes and bunion pads may be helpful. Improved shoewear off the field may help prevent this problem.


Increased ligament laxity may place the female athlete at higher risk for shoulder instability. Particularly in overhead sports such as volleyball, tennis, swimming and baseball. Women tend to have decreased upper body strength as well, adding to the risk. Rotator cuff strengthening exercises may help to prevent this injury. Internal and external rotation exercises using elastic tubing with the arm at the side is particularly helpful.

Shin Splints

Exertional compartment syndrome is one of the causes of leg pain commonly known as shin splints. This form of shin splints occurs only during exercise, and quickly resolves after activity ceases. In female athletes, menstrual cycle and use of birth control pills can affect fluid shifts in the muscle compartments. In the female athlete suspected of having exertional compartment syndrome, modification of birth control medication may be curative.


Scoliosis is a curvature of the spine that occurs in growing adolescents, and is much more common in females than males. In the early stages of scoliosis there are usually no symptoms. Suspicion should arise in the tall female athlete who appears to have an imbalance in shoulder or pelvic height. Small curves are not a contraindication to sports participation, but should be referred to a physician for evaluation and should monitored for progression.


The young female gymnast or ballerina is particularly at risk for developing a spinal injury called spondylolysis, which is basically a stress fracture of the posterior elements of the spine. This is thought to result from the repetitive hyperextension required of these activities. Many of these athletes are also amenorrheic making them more prone to develop stress fractures. The female gymnast or dancer with localized back pain that does not resolve quickly should be referred for medical and x-ray evaluation.


3000 California Street, 3rd Floor
San Francisco, CA 94115
Phone: 415-923-0944
Fax: 415-923-5896

Office Hours

Get in touch