Children's Hospital Boston primary care sports medicine physician Ellen Geminiani, MD, specializes in family, sports and dance medicine. Here, she discusses young female athletes' susceptibility to injury.

What kinds of injuries are most common?

Most are overuse injuries from repeating the same activity, move or skill. Typically, it's because the athlete hasn't formed the correct flexibility for the activity, and without it, she alters her techniques, creating stressors on structures not designed to withstand stress. We still see our share of acute injuries, but overuse injuries of the knees, ankles and lower extremities are the most common. In sports such as softball, lacrosse or even field hockey, we tend to see injuries to the upper extremities.

What makes young women prone to injury?

The alignment of girls' lower extremities plays a significant role. We often see cases of patella femoral syndrome, or mal-tracking of the patella, which create a lot of chronic knee pain. Women tend to have a broader shaped pelvis, which can create rotation at the hips and alter the angle of the femur. This may generate increased stress at the knee. Other factors may include the shape of the arch of the foot and proper arch support. Injuries to the upper body are often related to posture and proper positioning of the scapula.

At what age should pediatricians start screening for these injuries?

It's important to screen and emphasize flexibility and core strength as preparation for any sports activity at every age. This is particularly important during growth spurts, when deficiencies in flexibility are most dramatic.

Should girls choose one sport or play a variety?

Children start playing sports at early ages and become active exclusively in one sport, but they should play a variety of sports. Young children especially should focus on developing good basic athletic skills such as core strength, agility and hand-eye coordination. Early specialization in one sport can lead to asymmetry of muscle strength, development and flexibility (from anterior to posterior or one side to the other). We believe that the higher incidence of ACL injuries in women is related to a lack of balanced strength training.

Should physicians recommend certain exercises?

Young female athletes should stretch regularly, preferably daily, to improve and maintain flexibility. The common trouble spots are the quadriceps, hip flexors, hamstrings and Achilles groups. The shoulder joint is stabilized mainly by the surrounding muscular structures, and proper strengthening of the rotator cuff group is important if the athlete is throwing and performing repeated overhead movements. Also, the development of strength in the scapular stabilizers is important in shoulder stability and avoiding overuse problems.

Are there long-term affects of overuse injury?

We're concerned about stress fractures in the back among skaters, dancers and gymnasts, who perform repeated extension moves. If not properly treated, a long-term problem with pain may develop. The biggest concern is the issue of the female athlete triad: irregular menstrual cycles, eating disorders and osteoporosis. It's thought that abnormalities in hormone levels triggered by the physical stress of the activity, combined with inadequate caloric intake from eating disorders, put the body into survival mode, shutting down functions like reproduction, leading to amenorrhea. It's not normal for a woman to lose or experience change in the pattern of her menstrual cycle from exercise. Prolonged amenorrhea leads to estrogen deficiency and possibly osteoporosis.

What precautions can female athletes take?

We need to give young athletes time to develop basic athletic and physical skills before we put them into a sport-specific activity. An athlete should get aerobic training so her stamina is where it needs to be, ensure flexibility and strength in the right muscle groups, and most importantly, take rest periods. She should take at least four weeks off in between each season. When she isn't doing that sport, she can do something like biking, running or swimming to stay active. Many young athletes jump from one sport to the next. That intersection is where people get injured because they're doing twice the amount of activity without a break.

How many hours should they play sports each week?

The rule of thumb is not more than 20 hours for an athlete who is skeletally immature. It's also important that time spent training and practicing gets counted, and that the types of training are varied.

When should pediatricians refer?

When they see any pain that's persistent and doesn't improve in a day or two after an injury. Or a pain that's progressive, especially if it's connected to the activity, or associated with swelling. Also, if there are concerning symptoms or unclear exam findings, it may be helpful to get a consultation to assist in injury management. And definitely refer if a young woman does not have her period or it changes during, or as a result of, a high level of activity.

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