Women’s Sports Medicine: What Is It,and Why Should We Care?

As I join the team at the American Journal of Sports Medicine as the inaugural Associate Editor of Women’s Sports Medicine, I am honored and grateful not only to fill this role, but also that such a role even exists in this elite journal. It is important to highlight that this concept is not to promote female physicians caring for female patients. Rather, this is a call to action for all of us, as orthopaedic sports medicine surgeons and team physicians, to advance the level of care that we provide for our female patients, who constitute 50% of our practices. Female athletes are becoming increasingly regarded in the world of sports, yet our ability to provide them with elite levels of care is still limited by the lack of expert medical knowledge that exists for this population.

The clinical gaps that exist for women are not necessarily intentional or based on bias against female athletes. Medical advancements simply have not been able to keep up with the pace of the rapid evolution of women’s sports. Results from a study based on data from the National Federation of State High School Associations ²⁵ showed that the fastest-growing sports for girls are traditionally male sports such as ice hockey and wrestling, which raises the question, what defines a women’s sport? In addition to the rapid increase in the number of female athletes, the types of sports that they play are evolving, necessitating constant updates to the epidemiology of injuries and injury mechanisms in women’s sports.

One of the most commonly studied areas related to female athletes is the topic of anterior cruciate ligament (ACL) injuries. It is well known that ACL injuries are 4 to 8 times more likely in female athletes, with the rate of noncontact injuries being much greater in females than in males.^1,2,27 We know that differences in neuromuscular control contribute substantially to this increased risk, and that addressing them through preventive training programs can result in a 67% reduction of noncontact ACL injuries in females.^15,16,21,26 What we still do not understand is the role of hormonal differences that may contribute to these injuries. Estrogen and relaxin and their relationships to ACL injuries have been studied in the past, with so far little application to clinical practice.^8,9 Some authors have studied the role of oral contraceptives (OCPs) in preventing ACL injury, although the evidence for this is currently low. ¹⁴ A more recent animal study, however, compared the different formulations of OCP based on ratios of progestin and estrogen and found that OCPs with a greater progestin to estrogen ratio may have a protective effect on the ACL. ¹⁸ As our understanding of this topic becomes increasingly sophisticated, we will be able to apply this knowledge to other ligaments, indicating multiple areas for advancements in our treatments for women. ¹²

While the topic of hormones has been somewhat of a black box in the orthopaedic world, we must acknowledge that the hormonal system is closely tied to many aspects of our athletes’ overall health. Whether it relates to bone health, nutrition and energy availability, psychological health, and even concussions, all of these areas have been directly associated with musculoskeletal injuries, highlighting the importance of hormones as a growing area of study within the orthopaedic field.^{3,6,7,11,13,19} One example that emphasizes this was the case of a woman who was indicated for surgical treatment of scapholunate instability, which was found to resolve completely without surgery once her obstetrician pointed out that her instability would stop after cessation of breast feeding. ²⁰ Scenarios like this demonstrate what we as orthopaedic surgeons have yet to learn regarding hormonal fluctuations and their roles in our operative and perioperative decision-making. Although our studies must remain relevant to our work in the musculoskeletal and surgical disciplines, these reports should challenge us to learn from our colleagues in other areas and encourage multidisciplinary collaborations to ensure our treatments are truly optimizing our athletes as a whole.

Another commonly studied injury that impacts women athletes is patellofemoral instability. In this evolving area, our indications for surgery have become increasingly specific, utilizing precise radiographic measurements and algorithms for surgical decision-making. However, the ways in which we have defined the thresholds for normal versus abnormal values have not historically been sex-specific. Morphological measurements, such as tibial tuberosity–trochlear groove distance, are measured in millimeters, but have been found to be more predictive when individualized as a ratio based on the patient’s size. ⁴ Long-standing thresholds defining normal versus abnormal trochlear morphology have been found to change when analyzed by sex, indicating that females and males may have different thresholds of abnormality. ²⁴ Despite the vast improvements we have made in understanding this challenging condition, we are now finding more questions than answers as we evaluate our treatment algorithms through a new lens that incorporates sex-specific analyses.

As such, the field of women’s sports medicine is not simply about comparing females to males. While all studies should involve identifying and reporting on differences in outcomes between males and females, these findings represent just the tip of the iceberg when it comes to truly furthering our understanding of this topic. Investigators ought to ensure that the populations are appropriately matched, and that they are being consistent with how they compare sports and levels of competition between males and females (all while considering differences in sporting equipment and rules that may exist by gender). When reporting on sex differences, we should incorporate critical factors such as size-matched comparisons, sport-specific considerations, and the elusive aspect of hormonal factors in the way they may influence the patient’s biopsychosocial health. Lastly, we must commit to identifying ways to better support female athletes in the unique phases of their lives that impact their musculoskeletal health, including pregnancy and menopause, for which we as a field currently have very few solutions.^{5,10,17,22,23}

Women’s sports medicine is not simply for female clinicians; it is the responsibility of all of us to support these female athletes in their quest to excel. In a time of change when women continue to challenge and redefine what it means to be a female athlete, it is our job as surgeons and team physicians to reassess our own knowledge and ensure that our care is not the limiting factor in their efforts to grow. By seeking greater understanding of sex-specific considerations as they relate to surgical indications and optimization of outcomes, together we can improve the level of care we provide for our patients, while contributing to the advancement and future of women’s sports during these exciting and rapidly changing times.