Sex and Orthopedic Injuries

No, this is not about horizontal tango injuries.

It is about the observed and occasionally measured phenomenon of sports medicine injury rate differences between males and females.

But, in the evolving language of science, these are not gender studies per se, these are sex studies. As we learned at AAOS (American Academy of Orthopaedic Surgeons) this year, sex refers to the biological distinction between males and females while gender concerns the social differences between males and females. More simply stated, humans have the ability to choose their gender but not (without surgical intervention, that is) their sex.

We bring all this up because the Women’s Health Issues Advisory Board of the AAOS conducted a survey of orthopedists on the very topic of sex and orthopedic injuries. Furthermore, AAOS hosted a two hour symposium on Sex and Sports: Caring for the Female Athlete at the March 2016 annual meeting.

The three leading researchers on this subject, Cordelia Carter, M.D., Yale University, Mary Ireland, M.D., University of Kentucky and Elizabeth Matzkin, M.D., Harvard Medical School, discussed the latest research with OTW.

Sex Based Differences

Sex based differences affect both the incidence rates of some musculoskeletal disorders and their treatment. Adolescent idiopathic scoliosis, ACL (anterior cruciate ligament) injuries and fragility fractures, for example, occur more often in females than in males. Clubfoot, Sheuermann’s kyphosis and osteosarcoma occur more often in males.

Furthermore, depending on which study one reviews, there is as much as a 2-to 9-fold increase in the relative risk of ACL rupture in female athletes.

Other researchers have documented that mean global and focal acetabular anteversion is greater in women.

And there is some evidence, although the research remains inconclusive, that concussion injuries may be both quantitatively and qualitatively different depending on whether the athlete is male or female.

Eating Disorders, Amenorrhea and Osteoporosis: The Female Athlete Triad

But a new area of urgent concern has emerged.

As described by Drs. Carter, Ireland and Matzkin, female athletes are presenting with eating disorders, amenorrhea and osteoporosis as either a single condition or as an unholy triad at greater rates than would be expected in the general female population.

This phenomenon is referred to as either the female athlete triad (TRIAD) or as the relative energy deficiency in sport (RED-S). Either way, scientists are referring to, generally, an imbalance of energy input (food) and output (physical activity).

These symptoms in female athletes present a very real and urgent danger. Athletes and their physicians who do not attend to them are courting serious and lifelong health consequences.

The female athlete triad (Triad) was first defined in as a disorder involving three distinct but interrelated conditions —eating disorder, amenorrhea, and osteoporosis.

Initially researchers thought that the TRIAD most commonly affected women participating in aesthetic and weight-dependent sports, including gymnastics, ice skating, and endurance running. Furthermore, as Drs. Carter, Ireland and Matzkin made clear, many (even most) athletes are undiagnosed and do not receive treatment because they did not meet the classic TRIAD criteria.

To address these issues, the concept of the TRIAD was updated by the American College of Sports Medicine in 2007 in order to capture more athletes who may be at risk for the TRIAD health sequelae. The female athlete TRIAD is now considered to be a three-disorder spectrum which is defined in terms of energy availability (EA), menstrual function, and bone health (low bone mineral density).

The point is that athletes can fit under the TRIAD “umbrella” without having all three poor clinical components of TRIAD simultaneously.

The Orthopedic Community Is Largely Clueless

At this year’s Academy the Women’s Health Issues Advisory Board, in conjunction with the AAOS survey research office distributed an anonymous web-based survey amongst a randomly selected sample of 6, 000 AAOS members.

The 20 question survey used a five point Likert scale to quantify the extent to which orthopedic surgeons evaluate and treat patients with common musculoskeletal complaints. The final question was the big one—it asked surgeons to self-report their ability to recognize and treat patients with musculoskeletal disorders characterized by sexual dimorphism.

Three hundred and forty-five AAOS members completed the online survey, 83% were male.

The survey found that orthopedic surgeons do not routinely consider the sex of a patient as a factor when evaluating and formulating treatment plans for patients with musculoskeletal disorders. Interestingly, female and less-experienced surgeons were even less likely to do so. So, apparently, older male surgeons are more likely to regard sex based differences in musculoskeletal disorders.

Score one for the old guys.

But, to the main point, the TRIAD is no trivial matter and, soon, MUST be part of every sport doc’s diagnostic and treatment algorithms.