Friday, May 20, 2016
The Female Athlete Triad -- Be on the Lookout
By Dev K. Mishra, M.D.
I was recently with a friend watching his daughter in a NorCal Premier State Cup soccer game on a beautiful spring afternoon. The girls were skilled players and the game was played at a high level. The players were fit and athletic, and yet I was reminded that female athletes in many sports have unique pressures that can predispose them to injuries only girls can get.
The female athlete triad is a combination of three conditions: eating disorder, irregular menstrual periods or no menstrual periods, and osteoporosis. A female athlete can have one, two, or all three parts of the triad. An emerging concept is that these conditions start off with low energy availability and from there a cascading series of changes take place that can end in serious problems.
“Body image” sports where a thin appearance is valued can also put a girl at risk for female athlete triad. Sports such as gymnastics, figure skating, distance running, diving, and dance are examples of sports that value a thin, lean body shape. Coaches or judges may even tell some athletes that losing weight would improve their scores.
Even in sports where body size and shape aren’t as important, such as team sports like soccer, girls may be pressured by teammates, parents, and coaches who mistakenly believe that weight loss will improve performance.
Let’s briefly look at the components of the female athlete triad.
Eating Disorder. Most girls with female athlete triad try to lose weight as a way to improve their athletic performance or due to body image pressures. The disordered eating that accompanies female athlete triad can range from not eating enough calories to keep up with energy demands to avoiding certain types of food the athlete thinks are “bad” (such as foods containing fat) to serious eating disorders like anorexia nervosa or bulimia nervosa.
Irregular Menstrual Periods. Exercising intensely and not eating enough calories can lead to decreases in the hormones that help regulate the menstrual cycle. As a result, a girl’s periods may become irregular or stop altogether.
Some girls who participate intensively in sports may never even get their first period because they’ve been training so hard. Others may have had periods, but once they increase their training and change their eating habits, their periods may stop.
Osteoporosis. Estrogen is lower in girls with female athlete triad. Low estrogen levels and poor nutrition, especially low calcium intake, can lead to osteoporosis, which means there is poor bone density. Poor bone density means the athlete is susceptible to stress fractures and other injuries.
I will start thinking about the female athlete triad if a girl sustains a stress fracture
As an orthopedic surgeon, I won’t be the one treating the different components of the female athlete triad but an orthopedic surgeon is often the doctor who treats the stress fracture. I make it a habit to ask some questions of the girl with a stress fracture to screen for possible problems with the female athlete triad. I’ll ask about their general diet and weight loss habits, energy level, and menstrual periods. If there’s even a hint that something may be amiss I’ll refer her to a primary care sports medicine specialist for proper evaluation and treatment.
This condition can be difficult to fully treat and often requires what we’d call a “multidisciplinary approach,” meaning that doctors, nutritionists, psychologists, physical therapist, and athletic trainers may all need to be involved. It’s important to acknowledge the problem and take the right steps to seek help and treatment.
• The “female athlete triad” is a medical condition composed of eating disorder, irregular menstrual periods, and low bone density.
• Girls in sports in which there is pressure to conform to a certain body image are particularly at risk, such as gymnastics, figure skating, dance, and distance running.
• Treatment often involves many different types of healthcare providers.
• I will look for the female athlete triad for any girl who comes to the office with a stress fracture.
Thursday, May 12, 2016
Parental influence done right -- supportive but not overbearing
By Dev K. Mishra, M.D.
This is purely my opinion, with some observations on parental influence in
Toward the end of the school year, we gather with the athletic trainers and
coaching staff to see what worked and what didn¹t in terms of the health and
performance of our high school athletes. We do the same at the collegiate
and professional levels with one major difference: we generally don¹t have
much direct influence from parents at the collegiate and professional
But we most certainly do in high school. For better or worse (almost always
for the better) there will be parental influence in coaching and medical
recommendations. It¹s their right, and an involved parent is a very good
Influence Done Right: Focus on Development and Enjoyment
Over the years I¹ve noticed that some of the absolute best young athletes
who go on to have sports success through college or beyond have quiet and
somewhat laid-back parents.
I remember in particular one set of parents accompanying their daughter for
a discussion of issues with both of her shoulders. It was a complicated
issue, requiring her to have surgery on both shoulders followed by a
yearlong rehabilitation and no swimming.
Through it all the parents took it in stride, insisting that they would take
the long view. A few weeks in to her rehab the young lady showed me some
photos of her with winning times at various meets. Not age group meets, but
world-class international meets with adult Olympic athletes. And she had
three world records. I was astounded. I knew she was good -- but really,
really good? From her and her parents I never would have guessed.
Some of the most accomplished athletes I have seen have the least
overbearing parents. I get the feeling that these folks have seen a good
amount of success themselves and have a strong understanding of the long
view to succeed. Early focus on skill development, encouraging sport
experimentation, and handling ups and downs with equanimity. Parents who are
former professional athletes are almost always this way.
Messing With Success
And on the other end of the spectrum we seem to be seeing more parents who
are far too pushy of the coaching staff, the administration, and of their
own children. Maybe there are not actually more of these parents but they
sure are memorable.
There¹s probably a psychological term for this but basically I see them
living through their kids. Some admit to me that they have no personal
experience with sports in their own childhood, or even basic adult fitness.
In the exam room the parent often use phrases such as ³we hurt the knee last
weekend Š² or ³we worked incredibly hard last summer on training, how could
this happen to us?²
To be sure many of these kids achieve a high level of success when they¹re
very young. I¹ll always believe the parents have the best interests of their
child at heart, but an overbearing parental attitude seems like a surefire
way to mess with success.
In my 23 years in orthopedic practice I¹ve had a chance to see quite a few
of these kids over their entire childhood and teenage development years.
I¹ve often had the feeling that the kids are participating in certain sports
because their parents said they had to. Pleasing their parents is a powerful
motivator for the youngest kids but it becomes quite a drag in the teenage
years. Too many of these kids end up quitting their sport, after years of
development, because it¹s an easy way to rebel against a parent.
³Supportive but not overbearing² is a very tough path to choose especially
when there are so many pressures around to conform to community norms.
But who knows, maybe you too will end up with a daughter who becomes one of
the most celebrated athletes in Olympic history, as the parents of my young