SPORTS INJURIES
ACL Injury and Hormones
Though males
and females have the same musculoskeletal
structures, there are some unique differences
that actually make female athletes more prone to
injury. In regard to skeletal differences, males
usually have wide shoulders and narrow hips,
whereas a female generally has a wide pelvis in
relation to the width of her shoulders. This
wider pelvis is necessary for childbirth. This
wider pelvis is stabilized by the sacroiliac
ligaments in the back and the pubic symphysis
and pubic ligaments in the front. It is these
ligament structures that are stressed and
account for the significant back pain that
occurs in 50 percent of women who are pregnant.
This wider pelvis in females leads to an
increased inward slant of the thigh and,
therefore, an increased Q-angle of the knee. The
Q-angle, a measurement of the angle created by
the line from the anterior superior iliac spine
and the patella, and the line from the patella
to the tibial tubercle, is normally less than 12
degrees. An increased Q-angle produces excessive
lateral forces on the quadricep's mechanism and
abnormal tracking of the patella. This is one of
the reasons why chondromalacia patella or
patellofemoral syndrome is more common in women.
(Hutchinson, M. Knee injuries in female
athletes. Sports Medicine. 1995; 19:288-302.)
As stated above, a female's thighs tend to slant
inward towards the knees more than a male's.
This puts additional strain on a woman's hips
and their ligamentous support. This is one of
the reasons that the majority of the 120,000 hip
replacements done each year are in women.
Females also have a wider carrying angle of the
elbows. This is similar to the Q-angle of the
knee. This wider angle places additional stress
on the medial elbow stabilizers, namely the
ulnar collateral ligaments, which are usually
the culprits when a female athlete has medial
elbow pain.
Body composition is also different between males
and females. The average body fat content of the
female is approximately 26 per-cent, compared
with that of the male at 14 percent. The female
has a lower lean body mass indicating less
muscle mass. The greater muscle mass in males is
due to the predominant effect of the androgen
hormones, whereas estrogen, predominant in
females, results in increased body fat. As it
turns out, this difference in hormones is key to
understanding why female athletes are more
easily injured and repair more slowly than their
male counterparts. Testosterone stimulates
fibroblastic proliferation, whereas estrogen,
especially estradiol, inhibits it.(Liu, S.
Estrogen affects the cellular metabolism of the
anterior cruciate ligament. A potential
explanation for female athletic injury. American
Journal of Sports Medicine. 1997; 25:704-709.)
It is for this primary reason that female
athletes can benefit from Prolotherapy for their
sports injuries. Estrogen makes a woman a woman,
but they have a definite negative effect when it
comes to healing sports injuries.
Females also have a smaller proportion of muscle
in relation to body size because of the hormonal
differences. Having less muscle tissue means
there is less muscle to stabilize the joints if
the ligaments are injured. This causes more
stress to be placed on injured ligaments in
women than in men, because women do not have as
much muscle back-up. This is another reason for
female athletes to become familiar with the
local Prolotherapist.
Females, compared to males, have a lower
metabolic rate, the rate of conversion of food
to energy under conditions of total rest. This
appears to be related to the greater lean body
mass of the male and the greater proportion of
adipose tissue in the female. This could be one
explanation why females heal sports injuries
slower than men and why more of them develop
chronic pain, and need operations such as hip
replacements.
The Hormone Factors
Walk into any chronic pain clinic and who do you
see? You see women. Caring Medical and
Rehabilitation Services in Oak Park is no
different. About three out of every four
patients coming for Prolotherapy are woman. Why
are the women getting most of the arthritis and
needing the majority of the artificial joint
replacements? It is easy to explain when you
take into account the hormone factor.
The dominant hormone in males is testosterone.
Testosterone is very anabolic, which means that
it stimulates the growth or repair of tissues.
Men have about 10 times the amount of
testosterone as women. This is why they have a
sex drive that is about 10 times as strong as
women do. It is also the reason why, on average,
men are 33 percent stronger than women. Males
are stronger because of their increased muscle
mass due to testosterone. When males perform
strength training, they develop increased
strength and increased muscle size due to
hypertrophy of the muscles. This hypertrophy is
due to the effect of testosterone. Females
performing strength training gain increased
strength with relatively less muscle
hypertrophy. This is because females have
significantly less testosterone. If a woman
shows up at the Olympics looking like a man, the
other athletes will accuse her of using anabolic
hormones like testosterone. The complaint is
justified. When a woman does weight strength
training, she will get stronger, but she cannot
turn herself into a body shaped like a man
because the hormones are just not there.
Recent epidemiological studies have recognized a
significantly higher anterior cruciate ligament
(ACL) injury rate in female athletes as compared
with male athletes in sports such as basketball,
hand-ball, gymnastics, and soccer. (Gray, J. A
survey of injuries to the anterior cruciate
ligament of the knee in female basketball
players. International Journal of Sports
Medicine. 1985; 6:314-316.; Nilsson, S. Soccer
injuries in adolescents. American Journal of
Sports Medicine. 1978; 6:358-361.; Slauterbeck,
J. The incidence of anterior cruciate ligament
tears in men and women collegiate soccer players
Orthop. Trans. 1996; 20:259.; Whiteside, P.
MenĘs and women's injuries in comparable sports.
Physician and Sports Medicine. 1980; 8:130-136.)
Although various causes of this phenomenon have
been postulated, including differences in
ligament or muscle strength, conditioning,
endurance, anatomy, and training techniques, the
most plausible appears to be the hormone factor.
Unique to the female athlete is her exposure to
a constantly changing hormonal milieu throughout
her reproductive years. For most of her life,
the female athlete is exposed to rhythmic
variation in either endogenous hormones during a
regular menstrual cycle or exogenous hormones
via oral contraceptives.
It has been only recently that it was discovered
that there are estrogen receptors on the
fibro-blasts of the human ACL, suggesting that
female sex hormones may have an effect on the
structure and composition of this ligament. Dr.
Stephen Liu and associates, at the UCLA School
of Medicine, made this discovery and went the
next step to find out exactly how estrogen
affects ligament growth. They investigated the
effects of 17B-estradiol on the cellular
proliferation and collagen synthesis of
fibroblasts derived from the rabbit anterior
cruciate ligament. Measuring 3H-thymidine and
14C-hydroxyproline incorporation assessed
fibroblast proliferation and collagen synthesis,
respectively. They found that collagen synthesis
was significantly reduced with increasing local
estradiol concentration. Declining collagen
synthesis was first noted at a 17B-estradiol
concentration of 0.025 ng/ml. Within physiologic
levels of estrogen (0.025 to 0.25 ng/ml),
collagen synthesis was reduced by more than 40
percent of control, and at pharmacological
levels of 2.5 and 25 ng/ml, as typically occurs
in female atheletes taking birth control pills
or estrogen replacement therapy, by more than 50
percent of control. A significant reduction of
fibroblast proliferation was also observed with
increasing estradiol concentrations.
These results are startling. Estrogen, the
female hormone, dramatically inhibits
fibroblasts. These fibroblasts are what make the
collagen that makes up the ligaments and
tendons, which are injured during sports.
Estrogen was shown in the above study to inhibit
the fibroblastic growth and thus collagen
formation in a dose-dependent manner.
The more estrogen a woman has, the more
inhibition will occur. This has direct effects
for all women taking birth control pills. Birth
control pills have pharmacological levels of
estrogen, which are far in excess of a woman's
normal production. The simplest way for a female
athlete, who is on artificial estrogen, to
overcome sports injuries, is to stop taking
them. Inevitably, women are placed on birth
control pills because of menstrual
irregularities, which are easily treated with
natural medicine techniques including diet
manipulation and nutritional supplements. At
Caring Medical and Rehabilitation Services in
Oak Park, we perform Diet Typing and hormonal
testing on our patients. The female athletes
inevitably come up essential fatty acids
deficient. This means they need to injest more
good fats in their diets in the form of omega-3
fatty acids as is found in fish oils. They are
encouraged to drink cod liver oil and eat more
fish. Better kinds of fats are also found in
nuts and seeds, flaxseed oil, and olive oil.
Just this mild change in diet is typically all
that is needed to get rid of menstrual cramps
and other menstrual irregularities. Sometimes,
however, more sophisticated dietary
manipulation, herbal supplementation, or other
natural medicine techniques may be needed.
Article from CaringMedical.com
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