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Am Fam Physician. 2022;106(1):52-60

Patient information: See related handout on RED-S in the active female, written by the authors.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Physical activity has many health-related benefits, including prevention and management of chronic disease, weight management, and improved mental health. Active girls and women of all ages and abilities are at risk of relative energy deficiency in sport, a syndrome encompassing low energy availability, menstrual irregularities, and disordered bone metabolism. Presence of amenorrhea or oligomenorrhea may suggest reduced energy availability. Active females are at risk of overuse injuries, including patellofemoral pain syndrome, iliotibial band syndrome, and stress fractures; treatment usually includes activity modification, a period of rest, and physical therapy. Active females are also at risk of acute injuries, including concussion and anterior cruciate ligament injuries. Pregnant patients without contraindications who were physically active before pregnancy can continue these activities, and those who were not previously active may gradually increase their activity level to a goal of 150 minutes per week. Moderate exercise during pregnancy reduces the risk of gestational diabetes mellitus, preeclampsia, and cesarean delivery. Postpartum exercise focused on core and pelvic floor strengthening can improve pelvic floor dysfunction. Supervised exercise programs focused on strength and balance have been consistently shown to reduce the risk of falls and injurious falls in older women.

Since the passing of Title IX in 1972, female participation in sports at all levels has steadily increased1; however, overall, females continue to be less active than males, starting in childhood.2 Active play in childhood has a major impact on weight management, socialization, and self-confidence. Girls can be encouraged to be physically active during early childhood to cultivate a lifetime enjoyment of sport. Education on participation in multiple sports as opposed to early specialization can help promote this enjoyment because children who participate in multiple sports are less likely to experience overuse injury and burnout.3,4 The benefits from athletics in childhood continue throughout adulthood. In adult women, exercise is associated with myriad benefits, including reduced risk of depression, chronic diseases (e.g., cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, obesity), breast and ovarian cancers, and falls and fractures. Although there are significant benefits of exercise across all populations and ages, active females are also at risk of overuse and traumatic injuries. This article discusses special considerations for the active, female-gender-assigned-at-birth patient. Information about caring for transgender athletes can be found in a previous issue of American Family Physician (AFP).5,6

Clinical recommendation Evidence rating Comments
Physical therapy focused on hip and quadriceps strengthening improves short- and long-term outcomes in patellofemoral pain syndrome.9,12,13 C Expert opinion and clinical guideline
Preventive strategies for anterior cruciate ligament injury during athletics include lower extremity strengthening exercises and neuromuscular training focused on landing mechanics.1619 A Expert opinion and meta-analysis of randomized controlled trials demonstrating clinically significant reductions in rates of anterior cruciate ligament rupture
The presence of amenorrhea or oligomenorrhea should trigger additional screening for other components of reduced energy availability.3134 C Expert opinion, consensus guidelines, and limited-quality patient-oriented evidence
Patients should continue regular moderate exercise during pregnancy to reduce the risk of gestational diabetes mellitus, preeclampsia, cesarean deliveries, and operative vaginal deliveries, and improve postpartum recovery time.3941 C Expert opinion, consensus guidelines, and limited quality patient-oriented evidence
Pelvic floor therapy helps prevent urinary incontinence in late pregnancy and the postpartum period.4244,46,47 B Consistent results from case-control studies demonstrating reduced onset of incontinence in previously continent women and small, randomized controlled trials
Exercise focused on strength and balance reduces the risk of falls and injurious falls in older women.5358 B Consistent results from randomized controlled trials and case-control studies demonstrating reduced risk of falls in older adults with a structured exercise program

Common Concerns in the Active Female


Overuse injuries are more common in active females than acute musculoskeletal injuries.7,8 Several anatomic considerations predispose females to specific overuse injuries, including iliotibial band syndrome, patellofemoral pain syndrome, and stress fractures; Table 1 describes these considerations, which include pelvic and knee alignment, increased joint laxity, and decreased average muscle mass compared with males.819

InjuryPelvic abnormalitiesKnee abnormalitiesFoot abnormalitiesMuscular imbalance
ACL tearFemoral anteversion
Hip varus
Decreased femoral notch width
Knee valgus
Smaller ACL
NAIncreased quadriceps to-hamstrings muscle activation
Iliotibial band syndromeFemoral anteversionNANAHip abductor weakness
Quadriceps and hamstring weakness
Patellofemoral pain syndromeWider pelvisDynamic knee valgus
Patellar instability
Rearfoot eversion
Hip abductor weakness
Quadriceps weakness
Stress fracturesNANARearfoot eversionReduced bone density and muscle mass

Patellofemoral pain syndrome, one of the most common knee problems affecting females, causes knee pain as the patella glides along the femoral condyles. Patients present with insidious onset, poorly localized anterior knee pain exacerbated by using stairs and prolonged sitting, kneeling, and squatting. Patellofemoral pain syndrome is more common in females compared with males, and 70% of cases present between 16 and 25 years of age.8,9 Risk factors include repetitive knee flexion and extension activities, including running and squatting, knee and foot position, increased activity, and quadriceps weakness913 (Table 1819). Physical therapy focused on posterior hip and quadriceps exercises results in more short- and long-term benefits than quadriceps exercises alone.9,12,13 Patellar taping and bracing and foot orthoses for those with overpronation offer short-term improvement when combined with therapy but do not show prolonged benefit. Ice and anti-inflammatories may also provide short-term relief.12,13

Iliotibial band syndrome is a common cause of lateral knee pain in female athletes due to repetitive knee flexion and extension activities. Risk factors include high weekly running mileage and weak hip abductors.13 Patients describe insidious onset, lateral knee pain following activities that is worse with downhill running or a longer stride. A short period of active rest, stretching, anti-inflammatories, and exercises to strengthen hip abductor muscles offer short-term benefit. Most patients return to activity in two to six weeks.

Stress fractures occur in males and females due to overtraining or increased repetitive forces; however, females have a higher incidence of stress fractures.13,14 Lower-extremity bones are usually affected; the tibia is the most common location for all patients, but femoral neck, tarsal navicular, metatarsal, and pelvic stress fractures present more frequently in females than males. Patients describe pain aggravated with activity and often recall an antecedent increase in activity level. On examination, patients present with localized tenderness and pain with range-of-motion exercises. Stress fractures can be reliably diagnosed by magnetic resonance imaging and bone scan, but radiography is often normal. Treatment involves a period of relative rest and protected weight bearing until the patient is symptom free, usually three to four weeks, then progression to full weight bearing and physical therapy with gradual return to activities over four to six weeks. High-risk stress fractures at risk of progression to frank fractures due to poor blood supply or persistent tension forces (i.e., the tension side of the femoral neck, patella, anterior cortex of the tibia, medial malleolus, talus, tarsal navicular, fifth metatarsal, and great toe sesamoids) require orthopedic evaluation.

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