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Train Like a Girl
by Eileen Nicol

Have you ever seen historical footage or photos of women playing basketball? It’s a riot to see their funky bloomers and to consider that they weren’t allowed to cross the center line onto the opponent’s side because it might tire them out. Half-court boundaries faded away long ago, and since Title IX’s passage in 1972, girls and women have engaged wholeheartedly in athletic activity with huge emotional, social and physical benefits.

Yet neither Title IX nor spandex have changed one important factor in sports: women’s bodies differ from men’s in fundamental ways, and our gender differences warrant special consideration and specific training. In terms of inherent upper body strength, we really are the weaker sex. We have a pelvic structure that makes us tend to land flat-footed, thereby increasing the risk of knee injury. Female athletes are more prone to disordered eating than the general population. Hormones related to menstruation, conception and pregnancy affect athletic conditioning too, and must be reckoned with. What’s a female jock to do?

Dr. Stanley A. Herring, a nationally recognized expert on athletic conditioning and team physician for the Seattle Seahawks, stresses that “female athletes will obtain strength gains and aerobic gains in the same proportion as male athletes, if you train them appropriately.”

Perhaps sharing a house that looks like “a cross between REI and Big-5 Sporting Goods” with an athletic daughter and wife has turned Herring into an advocate for gender-specific training. In any case, he has always encouraged both his daughter and his son to be stong, and there is real glee in his voice when he recounts that the last time his daughter was home from college, she flexed her arms and “showed me some biceps!” Dr. Herring, who is also the medical director of the Spine Center at Harborview Medical Center and a clinical professor at the University of Washington, advocates a total body conditioning program for women that emphasizes the upper body, as well as specific resistance and strength training to reduce the risk of unique sport-related injuries.

One major issue female athletes face is their increased risk of anterior cruciate ligament (ACL) injury. “Females should spend more time with upper body strengthening and they should certainly spend more time with lower body conditioning for core and lower extremity strength, balance and motor control because it does have a direct effect on the ACL,” says Dr. Herring.

The ACL is one of a pair of ligaments in the center of the knee joint that stabilizes the knee from front to back during normal and athletic activities. Increased estrogen production during puberty causes the pelvis to widen, which can cause the knees to turn inward. These hormonal and anatomical facts lead to female athletes sustaining noncontact ACL injuries between two and 10 times more often than male athletes. High risk sports include basketball, soccer, skiing, and lacrosse — any sport that features jumping, running and cutting. An ACL tear usually requires surgery, especially if an athlete desires to return to her sport, and rehabilitation takes up to six months of rest and physical therapy. So it makes sense to try and lower the risk. But how?

Lower Extremity and Core Work

Jocelyn Melton, an exercise physiologist at Athletic Engineering, explains that resistive exercises strengthen the secondary muscles that support the hips, knees and ankles. She hands me a yellow band and instructs me to put it around both ankles, and then take wide steps forward across the mat, feet forward and knees bent. This exercise particularly strengthens the gluteus medius and maximus — important in reducing the knee extension and off-balance body positioning that contributes to ACL injuries.

Melton promotes what she calls functional training: placing real life or real sport demands on the body — hence the absence of traditional weight machines at Athletic Engineering. Rather, Melton helps her clients use bands, balls and balance aids like the BOSU® ball to train the core and secondary muscles. At Athletic Engineering, “core” means everything from the mid-thigh to the neck. We’re talking three major deep muscles here: the pelvic floor; the transversus abdominis, the deepest of the abdominal muscles; and the multifidus, a group of small muscles that attach vertebra to vertebra on the back of the spine. Training these small stabilizer muscles involves some exercises that look suspiciously like taking a nap. Concentration and visualization are key. But just because they’re subtle doesn’t mean they’re easy. If you’re a mother, think Kegel. Find out more about these exercises and see diagrams of the muscles involved on the FAQ page at www.athleticengineering.com.

Upper Body

In general, women are more flexible than men, and combined with our inherent strength deficit this can put more strain on joints like the shoulder. “Regardless of the sport you’re going to train for, you have to understand women need work on the upper body strength more,” says Dr. Herring. Sports such as gymnastics, swimming, tennis, volleyball and any throwing sport require extra conditioning to increase upper body strength, which will decrease the possibility of shoulder trauma as well as improve athletic performance.

Melton finds that her female clients also often need training to overcome a tendency to hunch forward, whether due to work habits or compensating for a large bust. To demonstrate one upper body strengthening resistive exercise, she instructs me to put the band around my wrists this time. Stepping across the mat again, I push my arms apart as I lift them up over my head and around to the other side to meet my knee as I step forward. Then up and over again for the next step. Head up, feet forward, knees over the feet; there’s a lot to think about and the outside of my arms are burning by the time I cross the room.

Female Athlete Triad

Unfortunately, three related symptoms (disordered eating, menstrual dysfunction and bone mineral density loss) are common enough among female athletes to have acquired a name: Female Athlete Triad (unsurprisingly rarely referred to by its acronym FAT.) An athlete may have only one symptom or all three. Dr. Mimi Johnson, who practices pediatric sports medicine in Kirkland, says it’s difficult to say how prevalent it is because of different definitions used for dysfunctional or disordered. “Some studies show up to 62 percent of female athletes aren’t meeting energy needs,” says Johnson.

It all starts with food, or lack of it. “The important thing for women to hear is that as they increase their training they need to increase their caloric intake,” Johnson stresses. Insufficient energy availability leads to hormonal changes like a decrease in estrogen production. This leads to menstrual dysfunction, such as amenorrhea (not having a period for three consecutive months) or oligomenorrhea (periods further apart than 35 days.) Most of Johnson’s female patients come to her because of menstrual dysfunction caused by nutritional deficits. “So women have a great marker, actually, of health,” says Dr. Johnson. “Once your periods stop, bingo, you’re not eating enough.” (Since they are artificially regulating their hormones, girls and women taking birth control pills don’t have that marker.)

A girl might not exactly miss her visits from Aunt Flo, but the hormonal imbalance that causes menstrual dysfunction also contributes to loss of bone mineral density, which in turn leads to increased risk of stress fracture. This is particularly alarming for teenagers, who are acquiring the bone mass that will sustain them for life. “Some of that bone loss is irreversible,” says Johnson. “Once you restart your menstrual periods, you regain bone, but the studies show that you don’t ever gain back to where you should be.”

Treatment depends on the etiology of the energy availability problem. Dr. Johnson’s first question is usually, “How much did you weigh when you last had a period?” and the goal is for the patient to reach that weight again. Some women and girls don’t realize they need to eat more, she says, and they’re puzzled when menstrual dysfunction occurs. For these patients, nutritional counseling and monitoring their progress helps them reach the goal of normal menstrual functioning. The larger group — those who are intentionally trying to lose weight or body fat — need more help. “That group of women is tougher to treat because they oftentimes have some issues around body image,” says Johnson. “Often they need psychological counseling to help them figure out why did I go here in the first place? Why do I feel like my hips should be smaller? Why am I not happy with myself?”

Fifteen years ago, Dr. Johnson co-authored the first position paper on Female Athlete Triad for the American College of Sports Medicine. Since then, a concerted effort has been made to educate coaches, athletes and sports organizations. “The NCAA has done a really good job at trying to educate the collegiate level, and the high school association has also done a good job.” Has she seen a difference? “Even though we’re getting fewer cases where I think coaches are the instigators, I don’t see it backing off,” she says. “Unfortunately, our society is permeated with messages about women being thin. Our athletes can’t get away from that any more than anyone else can.” We need fats and carbohydrates as fuel especially when we are spending lots of energy in training. “It’s okay to eat healthy, but eating healthy doesn’t mean eating no fat,” says Johnson. “They can be healthy fats — nuts and cheese and yogurt and oils. But they’ve got to get that fat in there.”

Give it a Rest

Perhaps the hardest advice for hard-core athletes to hear is that they need to lay off periodically. “Young athletes over-train in terms of volume and intensity,” says Dr. Herring. “It’s amazing to me that they train many more days a year than the professional athletes I take care of. If you don’t periodize your training and have some recovery days, you’re setting yourself up for injury. There’s an off-season for a reason.” A complete conditioning program always includes rest and varying levels of training. Herring worries particularly about school-age athletes who go from one sport to another with no break in between. “You can be in great shape for skiing but not for tennis,” he says. “You have to customize the program to the demand.”

Ideally, female athletes should be involved in a total athletic program that includes acquisition of athletic skills and improvement in speed, flexibility, strength and physical conditioning while maintaining good nutrition. Coaches and parents should be alert to any signs that athletes are using unhealthy shortcuts to lose weight. Athletic girls and women should keep track of their periods even if they don’t feel they have any food issues. And if you don’t have a good coach (or even if you do!) you can enlist professional help to create an appropriate fitness plan for your sport and your gender.

We’ve come a long way since the bad old days when we were taught that breaking a sweat was unfeminine. But too many girls and women today are risking long-term health problems to meet unrealistic demands. We need to listen to our bodies and help our daughters do the same. “Just like any other athlete, you have to work on conditioning both in terms of strength and cardiovascular and you have to work on motor control and you have to set goals for sport,” says Herring. Recognizing gender-specific issues can help us train effectively without ever going back to half-court.

Eileen Nicol is a frequent contributor to Seattle Woman.

©2007 Caliope Publishing Company