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    Gap in treating female athletes

    New centers, including at Boston Children’s, seek to understand sports injuries that more commonly plague female athletes

    Chloe O’Connell at Children’s Hospital. The 20-year-old from Wellfleet is going through the hospital’s new Female Athlete Program after suffering stress fractures in both heels.
    Chloe O’Connell at Children’s Hospital. The 20-year-old from Wellfleet is going through the hospital’s new Female Athlete Program after suffering stress fractures in both heels.

    Chloe O’Connell, 20, of Wellfleet, has gotten pretty adept at using crutches over the last nine months, as she’s waited for the stress fractures in both of her heels to repair themselves.

    Athletics have always been a crucial part of the runner, biker, swimmer, and avid yogi’s life. Even now, O’Connell manages to swim an hour a day, despite the walking casts she must wear on both feet and the crutches she uses to get around.

    That determination and focus may be part of what got her injured in the first place.


    “I definitely think I overdid it and wasn’t taking care of my body as I should have been,” said O’Connell, a business and economics major at Northeastern University.

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    Her doctor at the new Female Athlete Program at Boston Children’s Hospital, Dr. Kathryn E. Ackerman, said she sees injuries like O’Connell’s as “teachable moments” to educate women and girls on how to be both great athletes and healthy ones.

    The Female Athlete Program was started last fall to build on the expertise and interest of Ackerman and her colleagues.

    “There are some issues that are more common in women and we wanted to help prevent them, and we wanted to expand our research and knowledge about them,” said Ackerman, the center’s co-director and a former national team rower.

    Though both genders need to learn how to play their sports safely, athletic training for girls continues to lag, because coaches, parents and doctors are less familiar with girls’ distinct needs, said Bridget Quinn, a primary care sports physician at Children’s and Beth Israel Deaconess Medical Center.


    “Girls are not necessarily given the attention boys are at the middle school level,” Quinn said.

    Girls differ from boys in anatomical, hormonal, and psychological ways that need to be taken into account, said Dr. Jo A. Hannafin, an orthopedic surgeon and director of the Women’s Sports Medicine Center at the Hospital for Special Surgery in New York City.

    Jessica Rinaldi for The Globe
    Dr. Kathryn E. Ackerman, co-director of the Female Athlete Program, with Chloe O’Connell.

    And the risks are increasing as younger children — both girls and boys — focus on one sport, fail to cross-train, and play under tremendous stress.

    “I think we’re in a crisis,” said Amy Baltzell, director of the sports psychology track at Boston University’s school of education and a psychologist in private practice. “The injury rate is going up, the pressure is going up, the anxiety is going up. . . . And the parents are more invested.”

    For O’Connell, the pressure was mostly self-imposed; she wanted to excel.


    But she and the people around her missed some warning signs: She hated milk, and didn’t get enough calcium; she’d had a previous stress fracture — in her spine in 8th grade; and her period stopped.

    Adolescence is a crucial time for bone development but O’Connell’s exercise and eating habits were weakening her bones at precisely this pivotal time. Ackerman, an endocrinologist, is convinced that this triad of nutritional deficits, poor bone health, and hormonal changes led to O’Connell’s heel fractures.

    This so-called Female Athlete Triad Syndrome is common among female athletes — up to 78 percent of high school varsity players have at least one of its symptoms. But the syndrome is often missed by doctors who focus on specific injuries, rather than the big picture, said Ackerman. Unaddressed, the Female Athlete Triad syndrome can lead to serious bone problems, as well as potential fertility issues, more frequent injuries, depression, and declining performance.

    At Ackerman’s urging, O’Connell is now eating spinach and kale and drinking fortified almond milk to get calcium. She’s eating enough calories to compensate for her workouts, and she’s getting regular bone density tests to make sure her bones are recovering.

    O’Connell is hoping the pain in her heels will recede enough to allow her to lifeguard this summer. “Now, I’m nagging my friends” to take better care of themselves, she said. “It’s all about prevention.”

    In addition to being more vulnerable to stress fractures, female athletes are more likely to suffer knee injuries, such as tearing ligaments or patellofemoral syndrome, also known as runner’s knee. They are also more likely to injure their shoulders, which are typically not as strong as a male’s.

    Here are some problems that are more common among female athletes:

    Eating disorders

    The same work ethic and perfectionistic instincts that can make a girl a great athlete can also put her at high risk for eating disorders, said Sherrie Delinsky, a clinical psychologist in private practice in Wellesley.

    Delinsky said she tries to help her patients find the right balance between training hard and putting their body at risk. “Obviously they have a passion and a talent,” she said. “At the point I encounter them, that is being threatened because of the toll it’s taking on their health and their well-being.”

    Certain sports are more prone to eating disorders, such as rowing, which has weight classes, and ballet, figure skating, and gymnastics, which emphasize a certain kind of body type, Ackerman said.

    ACL tears

    In addition to facing an increased risk for stress fractures like O’Connell’s, female athletes are more prone to injuring certain bones and ligaments, including the anterior cruciate ligament, or ACL, in their knee.

    Boys tend to tear an ACL when someone crashes into them on the field; girls tend to tear it when they pivot or land incorrectly from a jump, Ackerman said.

    To prevent ACL tears and other orthopedic injuries, girls need to be taught from an early age how to land safely. They also should cross train, and not play only one sport all year long, said Hannafin, who founded and directs the Hospital for Special Surgery’s Women’s Sports Medicine Center, the first program in the country specifically for female athletes.

    Hannafin said she’s seeing problems crop up in younger and younger girls, because of the intensity of today’s middle school sports, and because of the trend to focus on a single sport.

    “Once you’ve had injury and had surgery, your knee is never perfect again,” said Hannafin. “The optimal goal is focused prevention.”


    Girls also differ from boys in their response to concussions, but research explaining those differences is still in its infancy, said Tracey Covassin, an associate professor of sports medicine at Michigan State University.

    Female neck muscles are generally weaker and girls tend to rotate their heads faster than boys, which may predispose them to concussions, Covassin said.

    There’s also some indication that girls may take longer to recover from concussions than boys, she said, but more research is needed.

    Psychological stress

    The old model of a coach screaming at players and telling them all the things they did wrong has to change, said BU’s Baltzell.

    Baltzell, a former Olympic rower, said her office is filled with girls and young women “crushed by coaches who don’t consider the emotional state of the female athlete.”

    Boys and men also need more supportive coaching, she said, adding that she’s been approached by three professional ball clubs in the last year because their players were losing confidence after harsh coaching.

    “If you yell at them, you scream at them and motivate by never telling them they’re good enough, ultimately your team will not be as good,” she said.

    Parents contribute to the stress, too, by pushing their children to succeed in sports – sometimes for their own reasons. Baltzell said she can understand the urge to help your daughter win a college scholarship, but most athletic scholarships at private schools are just a few thousand dollars toward a $50,000 annual tuition — not worth the risk of a lifelong injury.

    Constant stress, Baltzell added, is bad for athletes. “If you are chronically anxious you will get injured more quickly than the person who is in a better state of mind.”

    What shouldn’t be lost in all the concern for female athletes, Covassin said, is the benefit of sports — for all children and young adults.

    “I believe sports are there to build positive youth development, and keep children and adolescents healthy and out of trouble,” she said. “I see the positives outweighing the negative.”

    Karen Weintraub can be reached at