Female+ Athlete Program Addresses Unique Sport-Related Needs

Most athletes face a sports-related injury at some point in their careers. But for female athletes, certain problems—including anterior cruciate ligament (ACL) injury, concussion, and stress fracture—happen more often than they do in male athletes.

To better address the unique needs of female athletes, Yale Medicine and Yale New Haven Children’s Hospital created the Female+ Athlete Program, which focuses on girls and young women (up to their early 20s).

The program, located in the Pediatric Specialty Center in Trumbull, Conn., includes athletic trainers and nurses, a pediatric orthopaedic surgeon, a primary care sports medicine specialist, an adolescent medicine specialist, and a psychologist.

The team aims to treat patients with a wide array of issues related to sports participation, whether they compete with a team or train on their own. For example, the program might see a ballerina with chronic foot pain who could also benefit from one-on-one psychotherapy if she’s struggling with internal pressure to excel in dance and school. Or the team might see a high school cross-country runner who has had multiple stress fractures and would benefit from a thorough workup to see if there is something wrong with her strength or with her nutrition.

“We are all experts in understanding the biological needs of female athletes,” says Corinna Franklin, MD, a pediatric orthopaedic surgeon and director of the program. “We treat every injury related to sports, from concussions to ankle fractures, stress fractures, and shoulder instability. We also look at a patient’s overall health and address concerns related to nutrition, menstruation, overtraining, and mental health, especially in how to safely balance training with schoolwork or how to handle being sidelined with an injury.”

Below, we talk more with Dr. Franklin about the program.

One potential reason females are more susceptible to certain injuries is their anatomy. After puberty, a female’s hips widen, which can affect the leg's mechanical axis and change the stress put on the knee.

This stress can result in either chronic overuse or acute injuries, such as ACL tears. The ACL, a strong band of tissue that connects the thigh bone to the shin bone at the knee, can tear under excessive stress, especially in sports that involve pivoting and jumping, such as soccer and basketball.

“Women and girls are two to eight times more likely to have an ACL injury than men playing the same sport,” Dr. Franklin says. “But that difference doesn't appear until after puberty. One possible reason involves estrogen and the menstrual cycle. Hormonal fluctuations occurring naturally during the cycle can lead to increased susceptibility to ACL injury at certain times.”

Female athletes also tend to be more “quad dominant,” meaning that the quadricep muscles (in the front of the thigh) are stronger than the hamstring muscles (along the back of the thigh), Dr. Franklin says. “If the hamstrings can't activate as strongly, the knee will be less protected, especially when it is twisting or otherwise absorbing a lot of force, and that can lead to an ACL injury,” she says.

Furthermore, females tend to land from jumps in a way that can cause injury. “It’s called a ‘stiff landing,’ meaning that you're bending the knees and hips less and putting more force through the ACL and knee, rather than if you are landing a jump softly with a lot of hip and knee bending, which absorbs more of the impact through your muscles and distributes it more evenly,” she says.

Females are also more susceptible to stress fractures and concussions than male peers when comparing the same sport.

“For soccer and basketball, girls are more likely to get concussions than boys—for instance—but the overall number of concussed patients is higher in boys because boys play football,” Dr. Franklin explains. “We don’t yet fully understand why. Research is underway.”

As a former teenage athlete herself, Dr. Franklin says she is sensitive to the needs of young female athletes, “particularly when they are competing for space in what is often a male-dominated area.”

Furthermore, Dr. Franklin says there are specific risks and components to female athletes’ health that she thinks are easier to address in a specific way with specialized health professionals, which was top-of-mind when designing the program.

“I have expertise in surgery, recovery from surgery, and the injuries that lead to surgery. But I don’t have a degree or training in nutrition, adolescent health or gynecology, nonoperative sports medicine or concussion, or psychology,” she says. “For female athletes, all of these aspects intersect, which makes delivering comprehensive care very important for these patients.”

That’s not to say the program wouldn't be helpful, in theory, for male athletes, too, but there are some important reasons why female athletes require specialized care. Key is the fact that although there are now many studies that look at girls and women, many existing practice standards for athletes have been designed for males based on older research performed on males and not females, Dr. Franklin notes.

“For example, you can’t apply a study that has been done on male football players to female volleyball players. Female athletes have different sets of risks, and they may have different sets of needs. So, in this program, we both apply evidence from studies looking at female athletes and also look at each patient individually; it's important to understand our patients’ biology and needs from a sex and gender-based perspective.”

While much of the Female+ Athlete Program is about addressing existing injuries, it’s also about prevention.

“ACL tears are preventable to a certain extent. Obviously, you can't stop an individual from crashing into the side of your knee in a game, but you can work on your strength, stability, and landing mechanics,” Dr. Franklin says. “And those are things we can teach our patients. Also, if we see an early stage of a bone stress injury, we can stop it before it progresses to a fracture.”

While any injury that stops a young athlete from playing their sport is unwelcome, something serious, like an ACL tear or a broken bone, can be devastating, Dr. Franklin says.

“Safe return to play after ACL surgery takes at least nine months. For someone in high school or college, that’s three seasons of sports they’re missing, which is a huge loss in terms of opportunity. And that is in addition to the work and expense of rehabilitation, plus the stress of an athlete who is also still going to school through that whole period,” she says.

The psychological toll of balancing rehab, academics, and life is significant, she adds. “Not only does the young person have to endure the pain of the injury and possibly surgery, but there is the loss of their athletic identity from not being able to play, as well as missing the camaraderie of their teammates for months,” Dr. Franklin says.

These psychological factors, Dr. Franklin says, are examples of what the program’s psychologist can address with the athlete in one-on-one therapy sessions. Additionally, a psychologist can help athletes with issues like performance anxiety, self-image, and eating disorders, she adds.

Often, young athletes begin to specialize in one sport at a young age. This “overspecialization” leads to overtraining and is problematic, Dr. Franklin says, because it can result in overuse injuries, including stress fractures—not to mention burnout.

“This is not just a problem with females, but males, too, and we spend a lot of time educating our patients about this. We encourage them to try different sports and activities during their off-season, rather than playing only one sport year-round,” Dr. Franklin says. “If you’re doing the same movements over and over, your muscles and joints don’t get a break. Plus, adolescents are still growing, and they need time to sleep and heal.”

Dr. Franklin says she isn’t advising athletes to be sedentary but to experiment with varied activities. “Maybe you swim or run or work on your core if you are usually doing a different sport,” she says.

Mentally, changing things up can also be beneficial, she says. “I tell athletes that they should take one season and do something they’re bad at, because it reduces the emotional and mental pressure to perform. I, for example, am a terrible bowler. So, I really enjoy bowling, because I don't feel competitive, and it’s a mental break,” she says. “For athletes, it can be exhausting to have to perform. I tell patients to do something where they’re not the team captain, the fastest kid on the field, or the starting striker.”

When a patient calls to make an appointment—which can be done by the person or her parents or through a physician referral—we ask for a medical history to help us route them to the right physician.

“Our athletic trainer decides which doctor they should see,” Dr. Franklin says. “If it’s a patient who we know needs surgery, they meet with me. But usually, our patients first see our specialists who focus on nonoperative sports medicine and adolescent health. We also assess if they need to see our psychologist. If so, we would make a brief introduction in the clinic. If patients need ongoing therapy, we schedule that separately.”

Regardless of how patients come to the program, Dr. Franklin says she wants to spread the word that they’re here to provide individualized, comprehensive care to every type of female athlete.