#5 - 5 Considerations to Promote Performance in the Female Athlete, with Dr. Melissa MacDonald - Part 1

Today's episode is brought to you by Rehab to Fitness. FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents, serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. In today's episode, we will be unpacking a brand new 2-part training on the 5 considerations to promote performance in the female athlete with Dr. Melissa McDonald. Dr. McDonald is a graduate of Northwestern Health Sciences University, where she earned her Doctorate of Chiropractic degree. She then spent 2 years of specialty training in the Human Performance Center, where she focused her research and clinical skills on specific testing and treatment protocols. Dr. Mack, as she's known locally, has served as team clinician for a professional women's football team and Minnesota Roller Derby and has achieved both international and national certification as a chiropractic sports provider. She is also a speaker on sports chiropractic issues in the United States as well as abroad. In part 1 of this 2-episode training, our focus is on the special considerations that healthcare practitioners, coaches, and trainers should be aware of when training and treating female athletes. For instance, did you know that female athletes are more susceptible to injury at different phases of their monthly cycle, or that female athletes are 3.5 times more likely to have an ACL tear than their male counterparts? Dr. Mack will cover these topics and more in today's episode. As always, if you have questions as you're listening in to today's training, you can submit your questions in the Q&A link in the show notes. We'll be sure to cover those in a future Q&A episode where we'll bring Dr. Mack back and ask her all of your burning questions. Also, if you love what you hear and are more of a visual learner, you can complete the full webinar and even receive CE credit through our new Patreon program. So for more details, simply visit the Patreon link in the show notes. With all of that being said, let's get started with today's training.

So let's really dive into this now that you can actually hear me. So we're going over the 5 considerations of being a female athlete. Let's actually get on to what we're talking about. Now, disclaimer, all of these are my personal opinions and based off the research that I have found, but they are not necessarily the views of my employer or my colleagues. Now, the first thing you have to consider when working with female and male athletes, the predominant point of this conversation is going to be with cisgendered females. So we're not going to be talking about any transgender males or transgender females. We're talking about cisgendered. And when it comes to maturation, so their growth, their height, their skeletal maturity, everything occurs faster than their male counterparts. Their metabolic activity is lower, and they typically are smaller framed individuals with higher body fat percentages. This all makes for a different type of athlete that you need to contemplate when training. Majority of the training programs you do, 90% of it is going to be identical whether it's a male or a female athlete. But there are 5 things you need to take into account. One is ACL injury risk. The strength deficit differences. The increased joint laxity. And then from the reduced energy deficiency spectrum, there are high risk of iron deficiency and the body image issues. So let's dive into ACL. Why is this an issue? Well, research has shown that female athletes have a 3.5 times more likelihood of rupture, meaning it doesn't matter what they do, they're going to tear their ACL 3 times, almost 4 times more often than their male counterparts. Now, there are many different things that can contribute to this, but there's not one specific thing that has been proven in the literature. So of course we have our QL angle, and QL angle alone has not been proven to be a significant contributor to ACL injury. There's also increased posterior tibial slope, The notch with which the ACL actually inserts is smaller. The ACL, the literal size of the ligament is smaller. And then there are significant effects with hormones and how the actual hormone cycling of a female menstrual cycle has major effects. Research is showing that mid-cycle for a female is their highest risk area. So Menstrual cycle basics. You have your follicular phase to your luteal phase, 0 to 14. So the start of menstruation to ovulation, and this is based off an average 28-day cycle, which if you ever actually talk to a female and actually track their cycles, very rarely unless they are hormonally managed for birth control are their cycles actually a consistent 28 days. But this is the average we're going to work with. So that first phase we have all estrogen, the second phase we have all progesterone, and then we have the middle phase of ovulation. And ovulation, there is a 3rd hormone that comes into play, and that's relaxin. Now, relaxin is commonly only thought of during pregnancy, but during ovulation, it actually is released and increases that ligament laxity, which has been shown to cause an increase in ACL rupture risk. So the types of menstrual cycles. So someone who is regularly cycling around 28 days has amenorrhea. Which is just normal menstruation. If someone is oligomenorrheic, so any cycle lasting longer than 35 days, which means they may have as few cycles as 3 per year, research has shown that they can have up to 6 to 8 times the ACL rupture risk. Now, why that is isn't well understood, and it could be because they're staying longer in the estrogen phase and not going to the progesterone phase as quickly. For whatever reason. Now, amenorrheic individuals who have fewer than 3 cycles hasn't been shown to have a different ACL rupture risk comparatively. When looking at athletes, they have a higher risk for having oligomenorrheic and amenorrheic risk, especially in high-caloric sports and sports that emphasize someone being lean. So weight-restricted sports, runners, dancers, all of these have that higher risk for having an abnormal Normal cycling pattern, putting them at a higher injury risk. And really, when looking at luteal phase defects— so those luteal phases is that progesterone phase, and we're going to go through why progesterone might be protective in just a second— but when they have those luteal defects, this is where you have more common in sports, you have that higher injury risk, you also have the bone loss risk, you have infertility. And really These individuals aren't diagnosed until they attempt to get pregnant. People with luteal phase defects aren't found until they have infertility issues because it's not something you really recognize. You can still have a normal, in quotes, normal menstrual cycle that is regular and still have this shortened progesterone phase. Other disorders that are highly found in athletes, so you have polycystic ovarian syndrome and hyperandrogen syndrome. So Polycystic ovarian syndrome—they have cysts on their ovaries. They can have abnormal menstrual cycles. They are more likely to have fewer menstrual cycles per year, and then hypoandrogen syndrome is where they actually produce excess testosterone, and this can cause some traditionally male characteristics with hirsutism and increased muscle development. In the photo, we have Castor Semena. She is the top female athlete in the eight and four hundred. Meter distance. And now to compete, she has to take medication to lower her inherent testosterone level because it has been deemed unfair, which I can't even express how upset this makes me that she's being punished for a normal genetic condition versus we praise other athletes that have similar syndromes such as Michael Phelps, who has a higher lactate threshold, so he doesn't have the effects of lactic acid the way other athletes do. And then there have been male distance athletes that produce excess erythropoietin, which enhances performance. And again, they're praised versus she excels, has inherent excess testosterone, and is punished and forced to take medication that basically almost makes her unable to compete. Now, when we're looking at strength deficits, For the upper body, the female athlete is typically 50% on average weaker, and in the lower body, 30%. So you can do a lot more heavy, similar lifting patterns in the lower body, and the upper body is going to take some more modification. For how estrogen affects things, there isn't a clear relation to muscle mass in females. If a male goes through an acute exercise phase, they can actually produce some excess estrogen. And again, progesterone is where females can have that increase in muscle growth phase. So when looking at when you're going to do hypertrophy training and strength training in a female, it may benefit to put those intense hypertrophy phases during their progesterone stage of their cycle so you get the most bang for your buck when looking at hormones. And again, testosterone is the typical muscle mass protein synthesis hormone. Now, for joint laxity issues, estrogen. Again, estrogen is where the ACL has the most ligament laxity. So when you have an athlete that has a shortened luteal phase, so that shortened phase that negates the effects of estrogen, they can have increased ligament laxity, putting them at a higher risk for an ACL rupture. And then again, relaxin. So you have estrogen and relaxin combining at that ovulation point. And that can lead to your ACL ruptures at ovulation. Granted, with my Minnesota Vixen, it's a contact sport, which in and of itself causes some challenges. The athletes that had ACL ruptures during the season typically were within 3 to 5 days of the start of their cycle. I'm not sure why for that sport they weren't directly at ovulation, but it was that 3 days prior to the start of their cycle that majority— I'm going to say out of the 12 ACLs I saw, 11 of them occurred during that 3-day period prior to start of menses. Now we're going to get into some of the more nutritional aspects. Iron deficiency. So the research article I'm citing here basically took rugby 7 players, both males and females, checked their iron levels preseason, and found that one, Males have 3 times the amount of iron inherently in their circulatory system, which makes sense. They're not shedding blood every single month the way a female is. Now, at the mid-season of a Rugby 7, all athletes, male or female, had a 20% decline in their iron ferritin levels of their blood. A male athlete, not a big deal. They have a large cushion. But what this meant for the females is majority of them slipped to a potential iron deficiency. And another research article from Miller found that a third of postpubescent female athletes are iron deficient. Now, whether this is due to their diet or from menstruation or the two combined, that was a big issue for body image. This is where athletes are more likely to restrict their calories. And female athletes, only 10% of collegiate female swimmers, when asked, actually consumed their daily calorie amount. 10%. That meant 90% of them were eating in a caloric deficit, meaning they're gonna have a higher risk for injury. They're gonna have higher risk for bone loss and bone insufficiency. And I think the thing that clued me into how significant body image can affect an athlete is when I was working a sideline as an EMT. And I was working a volleyball game, and I was like, awesome. It was my third time on the sideline by myself, and I was like, cool, volleyball. Nothing can go wrong. I'll be fine. At the end of the game, I had an athlete just suddenly drop, and I looked at the coach, and I'm like, what is going on? Get over there. Athlete is in full cardiac arrest. I found out later on that this athlete had stopped taking the medication that they needed for their autonomic disorder and their Postural orthostatic tachycardia syndrome because their medication made them bloated, and it was homecoming the next day. They decided it was worth the risk to stop taking the medication that kept their heart regulated, and they almost died because of it. They ended up missing homecoming and spending the weekend in the ER recovering. So body image is a huge piece, which means we as providers need to be very cognizant of the language we use. Because it can lead to reduced energy deficiency.

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Reduced energy deficiency is what the female athlete triad used to be called. It is no longer the term that is readily used. It needs to be RED-S simply because they're recognizing that not only female athletes can have this, any athlete that works in a caloric deficit. So your physique athletes, your wrestlers that have to make certain weights, could be in this category. And this could be as severe as an eating disorder with bulimia or anorexia or purging, a significant purging. Or it could be a combination of overtrainings to where they're calculating their calories and they're figuring out how much exercise they have to do to go even further beyond what is their eating. And again, the most common sports is your weight sensitive and your appearance required. And I really sat down and tried to think of a few female sport that isn't appearance-related per se. And I would say probably the heavy, heavy weightlifting might be, but other than that, most female sports have some form of body image involved in it. So here are the effects of Red S, whether it be from a health or a performance standpoint. So again, the female athlete triad really only accounted for Reduced energy, menstrual dysfunction, and bone health. And as we expanded our bubble, we got to understand that this really has an effect on every aspect of the athlete's health and on their performance. So if you have someone that has been excelling, has been doing incredibly well, and then they start to slip with not being able to keep up, just having some decreased coordination, and you're also noticing some visual changes to their appearance, it may be important to have a discussion about what they're taking. And big things are with these is early detection. The best thing to do is figure out who's at risk or who is currently having it and track and keep on top of it to make sure that they don't slip into having red S and having the increase in injury. So those are the 5 things. But what do you need to do as a provider to best benefit them? And the first thing is make sure you get a solid baseline of where you're starting with your athletes. So from a strength perspective, I want to know what my quad to hamstring ratio is. I've also started adding a glute ratio for strength just to make sure, because you need the glutes to have good lower extremity control. So for quads to hamstring ratio, I want a 1 to 1 ratio. And for hamstrings to glutes, I want a 1 to 0.7. So hamstring to glute is 1 to 0.7. That has kind of been shown to have the highest efficacy of understanding to reduce hamstring injuries and ACL injuries. And then I want to look at a t-test to see what their overall movement capabilities are when they're having to quickly decelerate and quickly change direction, since most activities athletes are going to be participating in. This is what I need. I'm specifically focusing in on the knees and then the hop performance test. So single leg hop, we're looking at distance and making sure right to left is equal. We're looking at the knee to make sure there isn't excessive valgus. We're looking at a triple hop to see what the control is, and then a triple hop crossover, again putting some additional stress. Now the hop performance test Is a great one, both for preseason assessment and then return from ACL injury to the field. Now for the prevention program, as soon as you can, you want to start it. Best is when it's 6 weeks prior to the start of season. It should only take about 15 to 20 minutes, and it should continue into the season if possible. Find a way to create the prevention program so that it can be the team warmup. You'll get the highest level of compliance for your athletes. And it'll be the most beneficial. One of the challenges we faced for the Vixen is that their preseason training took place in a gymnasium on hardwood. Then once we moved them outside, because we're in Minnesota and there's a bunch of snow— so preseason was in the gym and that stayed until March. The beginning of their season, they went out and practiced on a grass field, but then all their games took place on turf. So we never actually got to train them on the type of surface that they were going to have to be on. And I think that may have contributed to some of the injuries that we saw during the season. For the prevention program, you want to include your strengthening. You want to check recruitment patterns. Females have a high risk of being quad dominant, and we want to make sure that we're getting some balance between the quads, the hamstrings, and the glutes. You want to look at landing patterns. Especially in any sport that involves jumping, but volleyball comes to mind for having a high risk for that valgus pattern when they're landing after hitting. Deceleration patterns, what is their joint proprioception, and then plyometrics. To emphasize strength training, female athletes need heavy, heavy weights. Ligaments love to be loaded, and that is what Builds their strength and builds their endurance for their ability to compensate. I had 2 seasons with the Vixen where preseason we had a heavy, heavy strength training, heavy squat, heavy lunges, like just loaded these athletes up. And that season we only had 2 ACL injuries. One was a reinjury due to a bad graft, and the other one was just an athlete that I swear was made of glass. The next season, the team was not able to secure a location that had access to weightlifting. So I did everything I could from recruitment patterns and proprioception and plyometrics and decels. I did everything the exact same minus the muscle strengthening. And we had 8 ACLs that season. And I don't know if it was just a freak accident. We had 3 in one practice. That went down. And I don't know if it was a combination of frozen turf or snow, but it was an absolute nightmare. And I honestly think back to if I had had access to the gym to do the muscle strengthening, I wouldn't have had the same number of injuries. So you've got to load these females up heavy, heavy, heavy to really get the strength into those ligaments. So again, preseason, you want those heavy squats, you want weighted lunges, You want broad jumps to put stress on the ligaments. Prevention programs start off with some walking lunges. So we scale those beginning seasons. So we start with just walking lunges and some lateral lunges, some hip ins and outs, scorpions, inchworms, mountain climbers, whatever is easiest to incorporate. You want to design each preseason, each warmup to be specific to the team, specific to what the athletes need. For soccer, there's a great pre-made program by FIFA. I think it's FIFA 11 that is designed just for soccer. And you can take that program and modify it to the sport you need. Then as we progress, we start adding some walking lunges with upper body rotations, some single leg squats. The athletes are given this to do at home preseason on top of all the loading we're doing. Just to start, again, core stability, glute bridging, and we're just trying to build this. Other things, again, for running, we have our decels, we have plant and cuts, we have bounding. If an athlete has to make quick movements on the field, we want to make sure that they can break down into an appropriate start position and then push off versus over-pursuing and then trying to cut back in, which can put the outer leg as they push in to drive back into the inside of the field at a higher risk for having a non-contact ACL injury.

All right guys, that's it for today's episode. Be sure to tune in for part 2 of this training in episode 6, where we will dive deeper into topics such as nutrition, weight training, and injury patterns Along with monthly hormonal shifts that affect athletic performance, injury susceptibility, and endurance. You won't wanna miss it. Episode 6 drops in 2 weeks, or 1 week for our Patreon subscribers. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a 5-star rating to help us grow the show. Every little bit helps. And be sure to look out for our Patreon link in the show notes to access additional bonus content. Early release episodes, an opportunity to earn CE credit for the trainings, and an ad-free listening experience. We are constantly looking for ways to add more benefits for our patrons, so be sure to get in early for maximum value. The Factor Podcast is edited and produced by the incredibly talented Marissa McCool. A special thanks goes out to her for making all of this possible. And of course, last but certainly not least, please remember to visit the show notes for a link to download the PDF of today's full presentation. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.