Considerations for the Female Athlete



Considerations for the Female Athlete
Mini Symposium: Considerations
for the Female Athlete
Cap City Sports Symposium
April 14, 2017
Ann Kurtenbach, PT
Laura Wegener, MS, PT
Lisa Krumlauf, PT, MBA, DPT
Post Partum Considerations with
Return to Sport
Ann Kurtenbach, PT
1. Identify most common problems seen post partum with
return to sport.
2. Identify screening tools to be best utilized when
evaluating and/or treating the post partum patient.
3. Identify special considerations when treating post
partum patient.
How quickly can a post partum
athlete return to sport?
• ACOG guidelines:
– If you had a healthy pregnancy and a normal vaginal
delivery, you should be able to start exercising again
soon after the baby is born. Usually, it is safe to begin
exercising a few days after giving birth—or as soon
as you feel ready.
How quickly can a post partum
athlete return to sport
• Other factors
Do they have medical clearance from OB/GYN?
How active were there during pregnancy?
Did they have pain or any problems during pregnancy?
Type of delivery?
Any complications during delivery?
Any injuries sustained during delivery?
Common Post Partum Problems
Generalized Weakness and Fatigue
Diastasis Recti
Hip pain
Pubic/Pelvic Pain
General weakness/fatigue
Some increased fatigue post partum is expected due to sleep cycle
changes and hormonal changes that are part of pregnancy and post partum
changes after delivery.
Other things to consider and screen for:
– Dietary imbalances
• will need extra nutrition and fluids if patient is still breast feeding.
• Vitamin deficiencies
– Post partum depression
– Thyroid dysfunction
– If these things haven’t already been checked, educate the patient and consider
referral to Ob/gyn, PCP, and/or Dietician for additional testing and resources.
General Weakness/Musculoskeletal
Diastasis Recti
• Finger Width Assessment
• Real Time Ultrasound
Finger Width Assessment for Diastasis Recti
Position: Supine hook lying
Ask for head and shoulder lift
Evaluate at umbilicus and 4cm above and below umbilicus
Assess width and depth of diastasis
H. Herman
Diastasis Recti Risk Factors
Irion & Irion, 2010
• Age >33 years
• Multiparous (having given birth two or more times or to more
than one offspring at a time)
• Multiple gestation (the presence of two or more embryos
present in the uterus
• Large baby
• Greater weight gain
• Cesarean section birth
Diastasis Recti Treatment
Abdominal Bracing
with Approximation
Education in body mechanics
and defecation mechanics to
minimize increase of intra-abdominal
Education in proper
abdominal progression
Kinesiotape for proprioceptive
Diastasis Recti Treatment
Diastasis Recti Treatment
Abdominal Progression
Diastasis Recti Treatment
• Physical Therapy has been demonstrated to be an
effective management approach for patients with
diastasis recti
– Collie & Harris, 2004
• Prenatal exercise directed at abdominal strengthening
has decreased the incidence of diastasis recti
– Chiarello et al., 2005
Prevalence of LBP
Hegle Franke et al, 2014
12 months
5 months
3 months
• The cause of pain appears to be nonspecific and
may be related to changes in body posture with
the development of joint, ligament, and
myofascial dysfunctions
Helge Franke et al, 2014
• Do typical lumbar assessment
– mechanical
• Derangement
• Dysfunction
• Postural
– SI dysfunction
• Treatment
– Direction of treatment should be indicated via assessment
– Posture/Body mechanics will be very important in this patient population.
Hip Pain
• Differential Diagnosis
• Musculoskeletal changes
• Nerve injury
• Labral Tear
Nerve injuries
• Less than 1% of vaginal deliveries will result in
nerve injury
– Wong et al 2003
• Compressive due to lithotomy position
• Most resolve in 6-8 weeks
Lateral Femoral Cutaneous
Femoral and Obturator Nerve
Labral or intraarticular hip disorder
• Aggravated by weight bearing,
twisting motions, stairs,
prolonged sitting, prolonged
standing and walking
– Can be constant or intermittent
– May c/o locking and/or catching
• Treatment –
– Focus on pain control, may
need to limit activity initially,
activity restriction (flexion/IR
specifically), strength hip
Pubic/Pelvic Pain
• Pubic Symphysis Dysfunction
– Too much laxity
• Belt, stabilization exercises
• Osteitis Pubis
– Inflammatory
• r/o infection
– Overuse
• Runners
Prevalence of urinary incontinence
post partum is 33% in the first 3
– Thom et el
Many have urinary incontinence,
think it is normal, and do nothing
to try to improve it.
Ask if they are experiencing any
leakage as it may also be
suggestive of pelvic floor
weakness and/or dysfunction.
– Early education on kegels if not
already doing them
– Refer to pelvic PT as additional
Postural Changes
– LBP, hip pain, pelvic pain
– Postural re-education will be very important
Diastasis Recti
– Correction exercises and core stabilization
– Check with all post partum patients prior to return to sport
Birthing position
– Higher risk for nerve injury and labral tears
Don’t forget to include pelvic floor as part of the treatment plan for core
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Pelvic Floor Considerations for
the Female Athlete
Laura Wegener MS PT
1. To understand the incidence of pelvic floor dysfunction
in female athletes
2. The importance of the pelvic floor as a core muscle
3. How to address pelvic floor dysfunction in athletes
The Pelvic Floor
Pelvic Floor Dysfunction
• Most common: stress incontinence - involuntary loss of
urine with an increase in intraabdominal pressure
• Incidence:
– Goes up with age, parity, obesity, smoking, chronic coughing
– Women at risk during and after pregnancy
– Urinary incontinence early in life – predictor of UI later in life
Pelvic Floor Dysfunction
• Athletes: 28 – 80 % urninary incontinence (null parous)
Trampoline: 72% - 80%
Swimmers (one study 50%)
Tri-athletes: 37% stress; 28% fecal
Increases with years of training and training > 7 hrs /wk
Leaking higher at end of training session
• Risk factors: High impact sports and eating disorders
• Fecal incontinence: high impact 3x> than low impact
Normal Core Function
Transverse abdominus (TA)
Pelvic floor
• Local vs Global – local contract in anticipation of load
• Hodges et al: synergistic relationship: pelvic floor, TA, diaphragm
• Cresswell et al: TA recruited before intra-abdominal pressure is
Strong = Functional Pelvic Floor?
• Asymptomatic former high impact athletes – (nulliparous) –
thinner PVM, increased LH width and area (J Sports Med Phys Fitness 2015)
• EMG – increased pelvic floor function during running than
standing (Arch Gynecol Obstet 2016)
– Must be able to contract AND relax pelvic floor
Fatigue of Pelvic Floor
• 90 minute workout
• Decrease in maximum voluntary contraction and resting
– Acto Obstetricia et Gynecologica 2007
• Recommendation: high impact athletes need to add pelvic
floor training to their fitness routine
Training Pelvic Floor
• Well documented support for pelvic floor training to
successfully treat stress and urge incontinence
• However: most athletes do not specifically train pelvic floor
• Pilot study: training increased pelvic floor strength and
decreased frequency and amount of incontinence episodes
– Int Urogynecol J 2012
• Multiple studies: recommend pelvic floor training for female
Training the Pelvic Floor
• Education – leaking is never normal
• Coaches, ATC, pediatrician, PCP, orthopedist, fitness
instructors, personal trainers, athletes
• Incidence high – assume many athletes are leaking
• Incorporate pelvic floor with core exercises
• How?
Isolation of Pelvic Floor
• Verbal instruction </= 50% will do correctly
• Relationship between TA and pelvic floor
• So, imagine you are on an elevator……
Add Pelvic Floor to Core Exercises
• Pelvic floor and TA pulled in first
• Breathe!
• Slow  Fast
• Simple  Complex
Male Athletes
• Cycling – 13-24% erectile dysfunction (> 4 hours per week)
--50-91% nerve entrapment syndrome
• Modify training schedule
• Modify saddle design
• Bike fit
• Sommer et al, Schwarzer et al. Spears et al.
Assume problem is widespread
Consider asking questions
Incorporate pelvic floor in to ALL core exercises
Know when to refer to physician, pelvic floor therapist
Bike fit
Running clinic
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Skeletal Maximization in the
Female Athlete
A Bone Health Perspective
Lisa L. Krumlauf, PT, MBA, DPT
1. Gain an appreciation for maximizing hormone health
and Energy Availability (EA)
2. Recognize basic levels of EA for bone health and
3. Appreciation for and incorporation of multiple jump
types and novel movements for your training room and
clinic to encourage peak bone mass maximization
My Definition of “Athlete”
Any person who undertakes to challenge their physical
capabilities by performing activities outside of their typical
daily movement patterning and in a way that competitively
stretches the limits of their strength, power, mobility, mental
toughness (resolve), cardiovascular capacity and/or speed.
This is independent of the athlete’s age, gender, body type,
overt physical giftedness, and any other outwardly imposed
or applied limitation or stereotype.
-L. Krumlauf
Adapted from http://courses.lumenlearning
New Model of the Female Athlete Triad
(De Souza et al., 2014)
Hormone Health for the Female
• Menarche by age 12
• Maintenance of Eumenorrhea
• Enough EA for the above to occur
Initiation of Menarche
(McArdle, 2017, Occhipinti PhD, 2014)
Maintaining Menstruation
(Singhal et al., 2014, Ihle and Loucks, 2004)
Signs of low EA
• BMI < 17.5kg/m2
• <85% expected
bodyweight (in
(, 2017)
Hormone Health
Energy Availability
Skeletal Loading Definitions
(WITZKE and SNOW, 2000, Gunter et al., 2007))
• High impact loading (GRF >4x BW): vertical jump,
jumping rope, running(> 9kmh or about a 10 min mile),
• Odd-impact loading: cutting drills, games
requiring multi-directions, hurdle/long jumps
• Low-impact loading(GRF , </=2 x BW): jogging (< 9kmh)
Definitions continued
• Moderate Intensity 2-4 x bodyweight
• Combined loading protocols: impact activity + high magnitude joint
reaction force via resistance training
Olympic Lifting
• U/e: Plyometric med ball throws, burpees
Skeletal Loading Benefits
Pre- and Peri-Pubertal
• High Impact (3.5 x BD) ↑ Whole body, spine and hip BMC
(Gunter et al., 2007)
• High impact + Odd impact + resistance training have the
greatest effect on FN and LS BMD (Martyn-St James and Carroll, 2009)
• High impact alone impacts FN only(Martyn-St James and Carroll, 2009)
Skeletal Loading Benefits continued
Athletes from early age (pre-adolescents) have up to 30% higher BMD than
Excessive exercise may impair reaching Peak BM: Think EA and hormones
“Narrow critical window” of 3 years surrounding puberty (MacKelvie, 2002)
Approximately 40% of BMD of the adult female spine is accumulated in the
3-4 years surrounding puberty (Tenforde, 2016)
Skeletal Loading Benefits continued
• Bone tissue responds to dynamic vs static loading
(Lanyon and Rubin, 1984)
• Athletes in high impact and odd impact sports have
greater bone density than low impact (think basketball,
gymnastics, Olympic lifters)
• Increase in BMD of 3-5% can reduce fracture risk by 2030%
(WITZKE and SNOW 1051-1057)
Why Incorporate Osteogenic Movements Into
Our Treatments and Training Sessions?
“Bone exhibits cellular
desensitization to a
continuous mechanical
load, exhibiting a
threshold above which
additional strain
exposures do not benefit
bone.” from Burr et al via A. Tenforde, MD
Posture benefits of various activities
Gray Cook on jumping rope:
“Although jumping rope may not seem sport specific,
it is extremely posture specific. It improves the ability
to maintain a long spine” (Cook, 2003)
Look Familiar?
[online] Available at: [Accessed 4 Apr.
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Cook, G. (2003). Athletic body in balance. Optimal movement skills & conditioning for performance. 1st ed. Champaign: Human Kinetics.
De Souza, M., Nattiv, A., Joy, E., Misra, M., Williams, N., Mallinson, R., Gibbs, J., Olmsted, M., Goolsby, M. and Matheson, G. (2014).
2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. Clinical
Journal of Sport Medicine, p.1.
Gunter, K., Baxter-Jones, A., Mirwald, R., Almstedt, H., Fuchs, R., Durski, S. and Snow, C. (2007). Impact Exercise Increases BMC
During Growth: An 8-Year Longitudinal Study. Journal of Bone and Mineral Research, 23(7), pp.986-993.
Ihle, R. and Loucks, A. (2004). Dose-Response Relationships Between Energy Availability and Bone Turnover in Young Exercising
Women. Journal of Bone and Mineral Research, 19(8), pp.1231-1240.
Kohrt, W. (2017). Physical Activity and Bone Health. ACSM Position Statement. pp.1985-1996.
Kohrt, W., Bloomfield, S., Little, K., Nelson, M. and Yingling, V. (2004). Physical Activity and Bone Health. Medicine & Science in Sports &
Exercise, 36(11), pp.1985-1996.
Lanyon and Rubin, (1984)tic review * Commentary. British Journal of Sports Medicine, 36(4), pp.250-257.
MacKelvie, K. (2002). Is there a critical period for bone response to weight-bearing exercise in children and adolescents? a systema
Martyn-St James, M. and Carroll, S. (2009). Effects of different impact exercise modalities on bone mineral density in premenopausal
women: a meta-analysis. Journal of Bone and Mineral Metabolism, 28(3), pp.251-267.
McArdle, w. ed., (2017). body composition, obesity and weight control. In: 1st ed. Mundy, G. (2017). Bone remodeling. In: 1st ed.
Mundy, G. (2017). Bone remodeling. In: 1st ed.
National Osteoporosis Foundation. (2017). Home - National Osteoporosis Foundation. [online] Available at: [Accessed 22
Mar. 2017].
Newton, C. and Nunamaker, D. (1985). Textbook of small animal orthopaedics. 1st ed. Ithaca, N.Y.: International Veterinary Information
Occhipinti PhD, m. (2014). Athletic Amenorrhea: Women at Risk. [Blog].
Osayande, S. (2014). Body Mass Index Influences the Age at Menarche and Duration of Menstrual Cycle. American Journal of Health
Research, 2(5), p.310.
Singhal, V., de Lourdes Eguiguren, M., Eisenbach, L., Clarke, H., Slattery, M., Eddy, K., Ackerman, K. and Misra, M. (2014). Body
Composition, Hemodynamic, and Biochemical Parameters of Young Female Normal-Weight Oligo-Amenorrheic and Eumenorrheic
Athletes and Nonathletes. Annals of Nutrition and Metabolism, 65(4), pp.264-271.
Smith, g. (2017). Biomechanics pertinent to fracture etiology, reduction, and fixation. In: newton, ed., 1st ed.
Nunamaker, ed., the Textbook of Small animal Orthopaedics, 1st ed. J.B. Lippincott Company, p.Chapter 12.
Tenforde, (2017). Bone. In: Casey, ed., 1st ed.
Witzke, K. and Snow, C. (2000). Effects of plyometric jump training on bone mass in adolescent girls. Medicine & Science in Sports &
Exercise, 32(6), pp.1051-1057.

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