Understanding the Female Athlete Triad and How to Beat It

Generally, exercise is known to be a beneficial component to a healthy body. Most people begin an exercise program for the sake of losing weight, which is then coupled with lowering calories and restricting certain types of food. Over time, the weight comes off, you feel more energized, and the benefits of these changes are recognized. Hopefully for the most part these lifestyle habits continue in order to maintain the healthy bodyweight. In the world of sports many athletes, especially women, exercise and diet intensively in hopes to enhance their performance. When it does, the notion is to continue the intense regimen. Little do these athletes know that the long-term effects of these habits become risky, particularly in the female population.

The Female Athlete Triad is a syndrome consisting of three symptoms: energy deficiency, menstrual irregularity, and bone loss. It is significantly common in the running population but can be found in many other sports. Most of these symptoms are ignored initially due to the fact that one is able to perform just fine. The majority will pay attention once an injury occurs. The syndrome usually begins with the intent to lose weight in order to improve performance. For runners, it is the same concept as wearing lighter running shoes—a lower bodyweight versus being overweight generally helps you run faster since your joints have less to carry. Once an athlete realizes the weight loss assists their faster paces, they want to continue getting lighter.

This pattern of dieting and intensively exercising is the beginning of the Female Athlete Triad. This eventually leads to developing eating disorders, menstrual problems and low bone mineral density, yielding a high risk of fractures. For women who were already at a low weight to begin with, the resulting outcomes are expedited. Of course, the end result of a devastating fracture is not something an athlete is seeking by adopting these habits, but in many cases it is inevitable. Although difficult to diagnose early on, this condition is most definitely preventable. The key is to be educated on and aware of the symptoms and what a true healthy body means.

Energy Deficiency

The first and most common symptom of the Female Athlete Triad is energy deficiency. Originally the term used was disordered eating, but over the years, energy deficiency seemed more appropriate because extreme weight loss and poor diet compared to the extreme exercise can exist without an eating disorder in the picture. Younger females already have the pressure these days to be thin, and when sports come into play, the emphasis is much greater. As mentioned earlier, being thinner, rather than overweight, may yield faster finish times for runners. Coaches, teammates, and parents sometimes play a role in the encouragement of “being thin to win”. This along with society’s reinforcement of the beauty of thinness is what eventually leads to eating disorders in young girls.

Anorexia and bulimia are the most common eating disorders among women and are fast and true ways to lose weight. By no means, are these weight loss options anywhere near healthy, though. Restricting calories by extreme dieting and excessive exercise are symptoms that fall into the categories of anorexia and bulimia. The extreme diet will only lead to lack of nutrients, as well as fluid and electrolyte imbalances, that will eventually leave the athlete with very low energy, poor strength and endurance, impaired reaction times, and risk of injury. Initially these outcomes go unnoticed and the athlete is attracted to the improved performance in her sport. The negative outcomes will then arise once there is a significant amount of weight lost.

Menstrual Disorders

Following the poor diet and exercise habits mentioned arises the next component of the Female Athlete Triad. Excessive exercise and calorie restriction leads to extremely low levels of estrogen. Research shows that women in good health who train for marathons can lower their estrogen levels by over 50%. Given this data, it is clear that athletes who are at an unhealthy bodyweight with significantly poor eating habits and incorporate a high level of training, most definitely lower estrogen levels by a much greater amount.

Estrogen is responsible for the growth of reproductive organs, regulation of the menstrual cycle, and the protection of bones. Normally the body will compensate for a large calorie restriction by lowering metabolism in order to maintain body weight. The loss of the menstrual cycle, or amenorrhea, is a sign that the body is in an energy deficient state. Although amenorrhea as part of the Female Athlete Triad is brought about by energy deficiency, it is also linked to low body fat percentage, nutrient imbalances, and physical and mental stress.

Bone Loss

Poor diet and the loss of estrogen are the leading cause of low levels of bone mineral density. Exercise, mostly weight-bearing, is known to be beneficial to bone health. Therefore running should be a healthy sport for the bones. Several studies on the bone health of female athletes have been conducted and the majority conclude that the bone loss occurs in the cases where there are menstrual irregularity, particularly women with amenorrhea. One study even showed that these intense athletes have bone mineral densities comparable to women in their 80s! This low bone density puts females at an extremely high risk of fractures. Stress fractures are in fact more common in athletes who present with menstrual irregularities, due to low estrogen levels.

The cases who eventually gain weight to a healthier point, resume regular menstrual cycles, and get back to a healthy diet for their training improve their bone density levels. Research has indicated that if the negative symptoms of the Female Athlete Triad are not addressed early on there is a chance that some of the resulting bone loss is irreversible. It is crucial to be aware of this condition and the early signs including extreme dieting and excessive training for the means of dropping weight for performance. Although initially an athlete may perform better, the excessive training is not realistic for the long term and will only lead to burnout and injury among other medical problems.

Steps to getting back the much needed energy, a regular menses, and strong bones start with lowering mileage and intensity, adding more calories to your diet, and regularly following up with your doctor, preferably one specialized in sports. It may seem scary to lower your running load and eat more, but taking these steps gradually can assure you get to and maintain a healthy weight and not alter your performance gains.

Awkward Tightness in the Legs? It May Be Compartment Syndrome

The most common area of the body in which runners complain of pain is the lower leg. Of course when you think about the mechanics of running, the lower leg receives the majority of the impact since it carries the most weight throughout the running cycle. This is why conditions such as knee pain, and more commonly plantar fasciitis are frequent. One of the more misdiagnosed conditions seen in recreational runners and elite athletes is chronic exertional compartment syndrome (CECS). During exercise blood flow increases and muscles expand. The pain from CECS is felt when the lower leg areas become swollen during exercise, if the fascia, which is basically a sheath that wraps around the muscles, does not expand with the muscles.

Symptoms

The type of pain usually felt with CECS is aching or burning in a specific area of the lower leg that begins at a certain time after beginning activity. Most commonly, the pain occurs in both legs and either in the posterior compartment (calves) or anterior compartment (shins). Along with pain, numbness or tingling, as well as tightness can be felt that worsens as you continue the exercise. These symptoms usually subside within 10 to 20 minutes after stopping the activity.

Differential Diagnosis

The reason this condition is misdiagnosed is because it resembles other more common conditions such as shin splints and tibial stress fractures. Shin splints are caused by overuse of the muscles connected to the shin bone, causing small tears which result in the muscle being “pulled” off the bone. The pain from shin splints is felt along most of the shin bone, whereas a tibial stress fracture is felt at a localized point in the bone. Both of these conditions, along with CECS, result in pain in similar areas and are usually caused by either improper biomechanics or overuse from adding mileage or intensity too soon during training.

If you are experiencing pain during exertion, especially if it begins within the first 10 to 20 minutes of a run and relieves within 10 to 20 minutes after stopping, get evaluated by a professional. If along with the pain is a sensation of significant tightness in the lower legs, CECS is most likely expected. An MRI will help rule out specific muscular issues. There are newer, more advanced MRI exams that can assess how much fluid accumulation there is in the compartments of the lower leg during activity, which has been found to be accurate in diagnosing CECS. It may limit the need to use the more invasive approach of diagnosing which is compartment pressure testing where needles are inserted into the muscles to evaluate the amount of pressure present.

Treatment

The goal of treating CECS is to relieve the pressure in the affected compartment during exertion. Unfortunately, the first step in treatment is avoiding aggravating activities, such as running. Doctors may prescribe NSAIDs and an icing regimen to help decrease the inflammation. During this rest time from activity, it is effective to include techniques to keep the muscles and fascia flexible such as massage and stretching. Once the symptoms are more controlled, it is important to ease back into running VERY gradually to be able to monitor returning symptoms. As you do this, strengthening all lower leg muscles, including the feet, should be incorporated.

Calf stretching should include performing with the knee straight, to stretch the outer muscles, and bent to stretch the deep soleus muscle.

The simplest way to keep the anterior dorsiflexors (along the shin) loose, is to use the foam roller or other deep tissue massager.

The first exercise most athletes include for the lower leg are basic heel raises. As mentioned above, the calves also include a deeper muscle called the Soleus, that often lacks sufficient strength. You can target these muscles by performing the heel raise exercise with a bent knee, or sitting adding weight to your lap.

Weakness in the ankle and foot may also contribute to lower leg issues. To target these ankle and foot stabilizers, using a resistance band is effective. Other exercises include single leg standing on a stable and unstable surface such as a foam mat or balance disc.

Unfortunately, in the majority of the more severe cases, a surgical procedure, called a fasciotomy, is required. Basically the fascia itself is cut open to relieve the tension in order to allow normal blood flow and muscle expansion to cause less pressure during activity. The recovery time after this procedure is quite short and allows athletes to return to their sport within 6 to 12 weeks. Post-surgical rehabilitation requires the same treatment as the conservative approach mentioned above.

Prevention & Maintenance

Biomechanics, or running form, is commonly blamed for lower leg dysfunction, such as CECS. Research has been done on evaluating foot strike patterns in runners and how these patterns may cause mechanical issues in joints from the lower leg to the hip and spine. When one uses the heel strike for landing during running, the anterior compartment muscles, the dorsiflexors, must act eccentrically to control the foot from slapping onto the ground with every step. This causes overuse and inflammation in the area. Many studies have evaluated the outcome of changing this foot strike pattern to a mid-foot or forefoot landing, and have concluded that this may help control and even resolve CECS. This is a change that should be done gradually, such as beginning with 5 minutes of forefoot strike in a single run and adding 5 minutes every few runs.

Another prevention option is running with shoes and/or orthotics that limit pronation of the foot. Overpronating requires even more work for the dorsiflexor muscles and causes increased tightness to the entire lower leg compartment muscles.

The exercises mentioned above should be incorporated to help prevent CECS and other lower leg dysfunction, as many times weakness and inflexibility are the cause. If you have been diagnosed with CECS or are experiencing symptoms, make sure to back off of the aggravating activities and always ease back into it during recovery. Seek medical advice if symptoms do not resolve or become severe. Remember, the quicker you take care of your pain, the quicker you will be back to doing what you love.

Sources

Tucker, Alicia K, Chronic Exertional Compartment Syndrome of the Leg, Current Reviews in Musculoskeletal Medicine, April 2, 2020.

Gallo, Robert A., Michael Plakke, and Matthew L. Silvis, Common Leg Injuries of Long-Distance Runners: Anatomical and Biomechanical Approach, Sports Health, April 2, 2020.

Gibson, Alexander, Chronic Exertional Compartment Syndrome and Forefoot Striking: A Case Study, International Journal of Athletic Therapy & Training, April 2, 2020.

Got Shin Splints? Learn How to Treat & Prevent This Annoying Injury

One of the most annoying, but significantly common, running injuries is shin splints. Well, this is the usual diagnosis from a doctor or other medical professional when you tell them you have pain in the front part of your lower leg, even without examining you first. Besides learning how to treat and prevent this issue, it is important for athletes to understand the symptoms and different diagnoses that are associated with shin splints in the first place, since there are other similar injuries that can be career (and life!) threatening.

“Shin Pain” Causes

The number one cause of pain in the shins is overuse. You will hear from many doctors and physical therapists that biomechanical factors—think: flat feet, heel striking and overpronating, are the main cause, but it actually has more to do with overloading in general. Yes, these factors contribute to pain and other problems, but without the “overuse” part, most injuries wouldn’t occur. When it comes to runners, those who skip strength training and run excessively are more prone to any overuse injuries. It can be difficult to keep up with other exercises when your mileage builds up and you have a life outside of running, but this is when it is most important.

Differential Diagnosis

A specific condition that often times gets overlooked when diagnosing shin splints is compartment syndrome. Although distance runners will have the less dangerous type—chronic compartment syndrome, it is important to note the symptoms of the acute version, which can be life threatening. This condition consists of increased pressure in the lower limbs from “trapped” fluid. It mimics shin splints in the sense that there is achiness in the shin bone and surrounding areas during activity. With compartment syndrome, this pain rapidly worsens during activity and almost feels like “congestion” in the lower limbs. If you are experiencing similar symptoms, DO NOT continue running and seek medical care as soon as possible!

Stress fractures are often times caused by prolonged shin splints due to the increased use of already inflamed muscles and weakening of the tibia (shin bone). This weakening is the result of degeneration of the bone from overuse. Proper treatment of shin splints can lead to a fast recovery, but it is not the case with a stress fracture. Training through shin pain to the point that it leads to a stress fracture will only delay your progress and cause you to sit out of running for months.

Treating Shin Splints

The first step to recovery is rest (as it is with almost every injury). Start by taking a few days off and icing the area of pain three times per day if you can. Initially it is best to figure out what caused your shin splits to begin with, which is usually a combination of tight calf muscles, weak lower leg and ankle muscles, and inefficient strength of muscles higher up in the body such as the knees, hips, and core. Once the pain is under control and any swelling has relieved, then a gradual progression of strengthening and flexibility exercises should be incorporated. Below are simple ankle exercises used to strengthen the muscles that run down the entire lower leg, as well as stretching techniques for both groups of calf muscles.

When easing back into running, it is a good idea to rotate between different types of shoes throughout the week. Alternating surfaces is also helpful. Try switching between the road, grass, treadmill, and track to relieve pressure in different areas of the feet and legs. For runners who overpronate, choose shoes that help correct your foot strike, or wean into a pair of orthotics that help align your feet. Of course, if any pain starts to trickle back into the picture, take a few days off, ice, and keep working on the exercises. You should always continue strengthening and stretching a few times per week, even if your treatment is successful, in order to prevent shin splints and many other problems in the future.