During volleyball game, teenage girl prepares to bump the ball to her teammate

Girls in sport: Understanding potential health issues

Disordered eating, career-ending injuries, and lingering questions about long-term health. When adolescent girls compete in sport and activity, they can run into serious health problems if the pubertal changes in their bodies aren’t taken into account. 

The last three decades have produced important research into the unique needs of girls in sport. Much of this research has been driven by the testimonies of female athletes describing the physical, mental, and emotional trauma suffered in their teens as they tried to stay top of their game.

Two common issues have emerged: a much higher rate of anterior cruciate ligament (ACL) knee injuries compared to boys their age, and an unhealthy complex of three interrelated conditions called the Female Athlete Triad, more recently known as relative energy deficiency in sport (RED-S). 

If you’re a parent with a daughter in sport and activity, it’s important to know about these potential health hazards.  

ACL injuries

Following the passing of Title IX of the Education Amendments in the United States in 1972, the number of young female athletes began to grow exponentially in response to greater opportunities to participate in high school and college sports. Suddenly girls were training and competing in numbers never seen before. One of the first issues to emerge was an equally exponential increase in ACL injuries.  

Depending on the sport and the age of the athletes, it has since been estimated that females experience between two and eight times the incidence of ACL injury as males. Since ACL injuries can end an individual’s career in sport and activity, much effort has gone into understanding why girls are more prone to these injuries and how the injury risk can be reduced.

Some research has suggested that changing levels of female hormones during adolescence (principally estrogen and progesterone) create laxity in the knee ligaments, which leads to them being incorrectly stressed during activity. Other research has suggested that teenage girls simply have wider hips than boys, leading to disproportionate stress on their knees and ankles. Some have suggested they simply have smaller ACLs. The most popular theory suggests that neuromuscular factors are the biggest problem—failure to engage the right muscles while decelerating, changing direction, and landing while running and jumping.  

Based on the neuromuscular theory, different exercise programs have been developed to activate targeted muscle groups and train correct movement patterns before training sessions or competition events. The Santa Monica PEP program [PDF] was one of the first programs developed for this purpose. The FIFA 11+ is a more recent program designed specifically for soccer players.   

The Female Athlete Triad, or RED-S

Beyond ACL injuries, the broader concern for female teen athletes is a set of health issues known as the Female Athlete Triad, or what’s been more recently called relative energy deficiency in sport (RED-S).  

RED-S is a destructive cycle created by three interdependent conditions: poor fueling and rest (low energy availability), disrupted hormonal and menstrual function, and resulting decreased bone mineral density (BMD) that can lead to fractures in the short term and osteoporosis in the long term.  

During their teen years, girls’ hormone levels start to change dramatically. Most notably, higher levels of estrogen increase fatty tissue, particularly around the hips, thighs, and breasts. This tends to decrease speed and agility, at least temporarily, as the body works to accommodate the changes. 

To avoid weight gain, girls often feel pressured to eat less while still training hard to stay competitive. Unfortunately this contributes to developing RED-S, which can mean suppression of their menstrual cycle and loss of BMD. It means they undermine their health, and ultimately their long-term competitive edge, for a short-term gain. 

What female athletes say   

Olympic distance runner Alexi Pappas has written about the difficulties faced by her and her classmates as competitive high school athletes. One classmate developed an eating disorder while trying to stay thin, and the combined effect of overtraining and underfueling led to chronic injuries throughout her collegiate career later. Canadian indoor mile record holder Kate Van Buskirk similarly describes going through long periods of disordered eating during high school in order to lose weight.  

The testimony of athletes like Pappas and Van Buskirk fits squarely in the domain of the Female Athlete Triad or RED-S. It reveals how the goal of being the best can sometimes cause substantial physical, mental, and emotional harm to the athlete.  

What parents can do

As parents, we can do a couple of important things to reduce the risk of RED-S and ACL injury in our daughters. We can start by teaching them about the energy demands of their training and the connection between nutrition, bone health, menstruation, and injury risk. Then we can make sure that they are eating three meals a day, with healthy snacks as required. Finally, we should watch for any signs of unusual weight loss, problems in menstruation, and changes in mood as they train in their sport or activity over the long term.

If you have a teenage daughter in physical activity and sports, especially if they’re spending long hours in training and competition, it’s important to understand the hazards they may be facing. Puberty and high school last only a few years, but our daughters still need to live in their bodies for decades to come.  

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