Anne Z. Hoch

A Proximal Strengthening Program Improves Pain, Function, and Biomechanics in Women With Patellofemoral Pain Syndrome

Background: It is hypothesized that patients with patellofemoral pain syndrome (PFPS) have hip and core muscle weakness leading to dynamic malalignment of the lower extremity. Thus, hip strengthening is a common PFPS treatment approach. Purpose: To determine changes in hip strength, core endurance, lower extremity biomechanics, and patient outcomes after proximally focused rehabilitation for PFPS patients. Study Design: Case series; Level of evidence, 4. Methods: Nineteen women (age, 22.68 ± 7.19 years; height, 1.64 ± 0.07 m; mass, 60.2 ± 7.35 kg) with PFPS participated in an 8-week program to strengthen the hip and core muscles and improve dynamic malalignment. Paired t tests were used to compare the dependent variables between prerehabilitation and postrehabilitation. The dependent variables were pain; functional ability; isometric hip abduction and external rotation strength; anterior, lateral, and posterior core endurance; joint range of motion (ROM; rearfoot eversion, knee abduction and internal rotation, and hip adduction and internal rotation); and peak internal joint moments (rearfoot inversion, knee abduction, and hip abduction and external rotation) during the stance phase of running. Results: Significant improvements in pain, functional ability, lateral core endurance, hip abduction, and hip external rotation strength were observed. There was also a significant reduction in the knee abduction moment during running, although there were no significant changes in joint ROM. Conclusion: An 8-week rehabilitation program focusing on strengthening and improving neuromuscular control of the hip and core musculature produces positive patient outcomes, improves hip and core muscle strength, and reduces the knee abduction moment, which is associated with developing PFPS.

Prevalence of the Female Athlete Triad in High School Athletes and Sedentary Students

Objective:To determine the prevalence of the female athlete triad (low energy availability, menstrual dysfunction, and low bone mineral density) in high school varsity athletes in a variety of sports compared with sedentary students/control subjects. Design:Prospective study. Setting:Academic medical center in the Midwest. Participants:Eighty varsity athletes and 80 sedentary students/control subjects volunteered for this study. Intervention:Subjects completed questionnaires, had their blood drawn, and underwent bone mineral density testing. Main Outcome Measures:Each participant completed screening questionnaires assessing eating behavior, menstrual status, and physical activity. Each subject completed a 3-day food diary. Serum hormonal, thyroid-stimulating hormone, and prolactin levels were determined. Bone mineral density and body composition were measured by dual-energy x-ray absorptiometry. Results:Low energy availability was present in similar numbers of athletes (36%) and sedentary/control subjects (39%; P = 0.74). Athletes had more menstrual abnormalities (54%) compared with sedentary students/control subjects (21%) (P < 0.001). Dual-energy x-ray absorptiometry revealed that 16% of the athletes and 30% of the sedentary/control subjects had low bone mineral density (P = 0.03). Risk factors for reduced bone mineral density include sedentary control student, low body mass index, and increased caffeine consumption. Conclusions:A substantial number of high school athletes (78%) and a surprising number of sedentary students (65%) have 1 or more components of the triad. Given the high prevalence of triad characteristics in both groups, education in the formative elementary school years has the potential to prevent several of the components in both groups, therefore improving health and averting long-term complications.

Is There an Association between Athletic Amenorrhea and Endothelial Cell Dysfunction

PURPOSE To test the hypothesis that young females with athletic amenorrhea and oligomenorrhea show signs of early cardiovascular disease manifested by decreased endothelium-dependent dilation of the brachial artery. METHODS Ten women with athletic amenorrhea (mean +/- SE, age 21.9 +/- 1.2 yr), 11 with oligomenorrhea (age 20.8 +/- 1.1 yr), and 11 age-matched controls (age 20.2 +/- 1.1 yr) were studied. Study subjects were amenorrheic an average of 2.3 (range 0.6-5) yr and oligomenorrheic an average of 6.2 yr. All ran a minimum of 25 miles.wk. They were nonpregnant and free of metabolic disease. Brachial artery flow-mediated dilation (endothelium-dependent) was measured with a noninvasive ultrasound technique in each group. RESULTS Endothelium-dependent brachial artery dilation was reduced in the amenorrheic group (1.08 +/- 0.91%) compared with oligomenorrheic (6.44 +/- 1.3%; P< 0.05) and eumenorrheic (6.38 +/- 1.4%; P< 0.05) groups. CONCLUSION Athletic amenorrhea is associated with reduced endothelium-dependent dilation of the brachial artery. This may predispose to accelerated development of cardiovascular disease.

Association between the female athlete triad and endothelial dysfunction in dancers.

Objective:To determine the prevalence of the 3 components of the female athlete triad [disordered eating, menstrual dysfunction, low bone mineral density (BMD)] and their relationships with brachial artery flow-mediated dilation in professional dancers. Design:Prospective study. Setting:Academic institution in the Midwest. Participants:Twenty-two professional ballet dancers volunteered for this study. Interventions:The prevalence of the female athlete triad and its relationship to endothelial dysfunction. Main Outcome Measures:Subjects completed questionnaires to assess disordered eating and menstrual status/history. They also completed a 3-day food record and wore an accelerometer for 3 days to determine energy availability. Serum baseline thyrotropin, prolactin, and hormonal concentrations were obtained. Bone mineral density and body composition were measured with a GE Lunar Prodigy dual-energy X-ray absorptiometry. Endothelial function was determined as flow-mediated vasodilation measured by high-frequency ultrasound in the brachial artery. An increase in brachial diameter <5% to hyperemic flow stimulus was defined a priori as endothelial dysfunction. Results:Seventeen dancers (77%) had evidence of low/negative energy availability. Thirty-two percent had disordered eating (EDE-Q score). Thirty-six percent had menstrual dysfunction and 14% were currently using hormone contraception. Twenty-three percent had evidence of low bone density (Z-score < −1.0). Sixty-four percent had abnormal brachial artery flow-mediated dilation (<5%). Flow-mediated dilation values were significantly correlated with serum estrogen and whole-body and lumbar BMD. All the 3 components of the triad plus endothelial dysfunction were present in 14% of the subjects. Conclusions:Endothelial dysfunction was correlated with reduced BMD, menstrual dysfunction, and low serum estrogen. These findings may have profound implications for cardiovascular and bone health in professional women dancers.

Assessment of Wheelchair drag resistance using a coasting deceleration technique

Hoffman MD, Millet GY, Hoch AZ, Candau RB: Assessment of wheelchair drag resistance using a coasting deceleration technique. Am J Phys Med Rehabil 2003;82:880–889. Objective To apply a recently developed coasting deceleration method to measure rolling and aerodynamic resistances opposing wheelchair propulsion on a variety of different wheelchairs and wheel combinations and on two different ground surfaces. Design For each condition, 20–25 trials were performed across a speed range of approximately 70–300 m/min. The least-squares method was then used to arrive at values for the coefficient of rolling resistance (CR) and effective frontal area of the wheelchair and occupant. Results Wheelchair rolling resistance was found to be velocity dependent under some circumstances. CR values on linoleum differed among folding lightweight wheelchairs and when compared with a rigid ultralight and racing wheelchair. Changing rear wheels and tires on one wheelchair resulted in a 14% difference in CR. Carpet increased CR values by an average of 0.0118 over the values determined on linoleum. As expected, effective frontal area of the wheelchair and occupant values were lower for the racer than for the folding lightweight wheelchair. Conclusions Wheelchair rolling resistance is not always independent of velocity, and CR on linoleum can vary among wheelchairs by as much as seven-fold, and carpet can more than double CR.

Female athlete triad screening in National Collegiate Athletic Association Division I athletes: is the preparticipation evaluation form effective?

Objective To evaluate the screening practices and preparticipation evaluation (PPE) forms used to identify college athletes at risk for the female athlete triad (triad). Design Phone and/or e-mail survey. Setting National Collegiate Athletic Association (NCAA) Division I universities. Participants All 347 NCAA Division I universities were invited to participate in a survey, with 257 participating in the survey (74%) and 287 forms collected (83%). Main Outcome Measures Information about the nature of the PPE was requested from team physicians and certified athletic trainers during a phone or e-mail survey. In addition, a copy of their PPE form was requested to evaluate for inclusion of the 12 items recommended by the Female Athlete Triad Coalition for primary screening for the triad. Results All 257 universities (100%) required a PPE for incoming athletes; however, only 83 universities (32%) required an annual PPE for returning athletes. Screening was performed on campus at 218 universities (85%). Eleven universities (4%) were using the recently updated fourth edition PPE. Only 25 universities (9%) had 9 or more of the 12 recommended items included in their forms, whereas 127 universities (44%) included 4 or less items. Relevant items that were omitted from more than 40% of forms included losing weight to meet the image requirements of a sport; using vomiting, diuretics, and/or laxatives to lose weight; and the number of menses experienced in the past 12 months. Conclusions The current PPE forms used by NCAA Division I universities may not effectively screen for the triad.

The Female Runner: Gender Specifics

There has been a tremendous increase in the number of female runners of all ages and abilities in the past 35 years. Women who participate in running and sports are generally healthier and have higher self-esteem. However, unique medical and orthopedic issues exist for the female runner. This article reviews the history of women in sports, physiologic and biomechanic differences between genders, the pregnant runner, knee osteoarthritis, an update on the female athlete triad and the relationship between amenorrhea and endothelial dysfunction associated with athletics.

Folic acid supplementation improves vascular function in amenorrheic runners.

Objective:The purpose of this study was to determine if folic acid supplementation improves endothelial vascular function (brachial artery flow-mediated dilation; FMD) in amenorrheic runners. Design:Prospective cross-sectional study. Setting:Academic medical center in the Midwest. Participants:Ten amenorrheic and 10 eumenorrheic women runners from the community volunteered for this study. Interventions:Each participant was treated with folic acid (10 mg/d) for 4 weeks. Main Outcome Measures:Brachial artery FMD was measured before and after folic acid supplementation with standard techniques. Results:The brachial artery FMD response to reactive hyperemia improved after folic acid supplementation in amenorrheic women (3.0% ± 2.3% vs. 7.7% ± 4.5%; P = 0.02). In the eumenorrheic control group, there was no change in brachial artery FMD (6.7% ± 2.0% vs. 5.9% ± 2.6%; P = 0.52). Conclusions:This study demonstrates that brachial artery FMD, an indicator of vascular endothelial function, improves in amenorrheic female runners after short-term supplementation with folic acid.

Advances in Management of the Female Athlete Triad and Eating Disorders

Although there are numerous benefits to women from athletic participation, a complex combination of endocrine and metabolic factors exaggerates risk for a serious health concern: the female athlete triad. The purpose of this article is to provide updates on new issues related to the triad, specifically the relationship between athletic-associated amenorrhea and endothelial dysfunction-a potential fourth component to the triad that is a concern for future cardiovascular risk, public health issues, and athletic performance. Folic acid should be considered a potential safe and inexpensive therapeutic treatment to restore endothelial-dependent vasodilation.

Recognition and rehabilitation of the female athlete triad/tetrad: a multidisciplinary approach.

While the benefits of physical activity are numerous, the female athlete triad poses a significant health risk to young athletes. Emerging research links the triad to endothelial dysfunction — a sentinel event in cardiovascular disease — suggesting that this complex interplay of metabolic and endocrine factors may be described more accurately as a tetrad. Effective treatment of the triad/tetrad requires a multidisciplinary approach. Emphasis must be placed on prevention, recognition, and treatment of triad for the promotion of healthy nutritional and activity profiles in female athletes across their lifespans.