Common Musculoskeletal Disorders in Women
2005; Elsevier BV; Volume: 80; Issue: 6 Linguagem: Inglês
10.1016/s0025-6196(11)61534-6
ISSN1942-5546
AutoresShannon K. McClure, Julie E. Adams, Diane L. Dahm,
Tópico(s)Sports injuries and prevention
ResumoWomen are prone to certain orthopedic conditions and may present to their primary care physician for treatment. An appreciation of the physiological and anatomical differences between women and men and the musculoskeletal conditions that commonly affect active women can aid the physician in diagnosis and treatment. We discuss common musculoskeletal conditions of active women including those affecting the low back, knee, shoulder, and foot. We also discuss common stress fractures seen in women. Various treatment and prevention strategies are reviewed and include physical therapy, bracing, medications, and surgery. Women are prone to certain orthopedic conditions and may present to their primary care physician for treatment. An appreciation of the physiological and anatomical differences between women and men and the musculoskeletal conditions that commonly affect active women can aid the physician in diagnosis and treatment. We discuss common musculoskeletal conditions of active women including those affecting the low back, knee, shoulder, and foot. We also discuss common stress fractures seen in women. Various treatment and prevention strategies are reviewed and include physical therapy, bracing, medications, and surgery. In 1996, 37.1 million people, 55% of whom were women, presented to outpatient clinics with new orthopedic conditions.1Clin Orthop Relat Res. March 2000; 372: 3-322Crossref PubMed Scopus (8) Google Scholar Differences in the documented injury rates of men and women may be at least partially due to differences between the sexes in symptom reporting.2Almeida SA Trone DW Leone DM Shaffer RA Patheal SL Long K Gender differences in musculoskeletal injury rates: a function of symptom reporting?.Med Sci Sports Exerc. 1999; 31: 1807-1812Crossref PubMed Scopus (111) Google Scholar However, there are other contributing factors. Women not only make up a larger proportion of the US population but also are participating in athletics in ever-growing numbers. Differences in physiology between men and women, including hormonal effects on the connective tissues and decreased total muscle cross-sectional area, may play a role.3Knapik JJ Sharp MA Canham-Chervak M Hauret K Patton JF Jones BH Risk factors for training-related injuries among men and women in basic combat training.Med Sci Sports Exerc. 2001; 33: 946-954Crossref PubMed Scopus (389) Google Scholar, 4Bell NS Mangione TW Hemenway D Amoroso PJ Jones BH High injury rates among female army trainees: a function of gender?.Am J Prev Med. 2000; 18: 141-146Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar Also, anatomical differences in women, such as the wider pelvis as well as their increased valgus angulation at the knee and increased foot pronation, may increase their risk of injury of the lower extremity.3Knapik JJ Sharp MA Canham-Chervak M Hauret K Patton JF Jones BH Risk factors for training-related injuries among men and women in basic combat training.Med Sci Sports Exerc. 2001; 33: 946-954Crossref PubMed Scopus (389) Google Scholar, 4Bell NS Mangione TW Hemenway D Amoroso PJ Jones BH High injury rates among female army trainees: a function of gender?.Am J Prev Med. 2000; 18: 141-146Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar, 5Kowal DM Nature and causes of injuries in women resulting from an endurance training program.Am J Sports Med. 1980; 8: 265-269Crossref PubMed Scopus (108) Google Scholar In general, men and women with similar orthopedic injuries should be treated similarly. However, many musculoskeletal injuries are seen more frequently in women or are in some way unique to women. This article discusses musculoskeletal disorders seen commonly in active women. Women make up a large proportion of the aging population in the United States because their life span averages 7 years longer than that of men. Furthermore, women are affected more commonly by certain widespread orthopedic conditions such as osteoarthritis and osteoporosis. Also, women have been increasingly active in athletic endeavors. Since enactment of Title IX of the Education Amendments of 1972, which mandated that all educational institutions receiving federal funds provide equal athletic opportunities to men and women, female participation in high school athletics has increased by more than 700%,1Clin Orthop Relat Res. March 2000; 372: 3-322Crossref PubMed Scopus (8) Google Scholar with 1 in 3 high school girls participating in varsity sports in 1998.6Clin Sports Med. April 2000; 19: 163-380Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Similar trends have been observed in collegiate and elitelevel sports. Numerous benefits have been attributed to athletic participation. Studies have shown lower rates of teenage pregnancy, depression, and cigarette smoking, along with increased self-esteem and higher rates of high school and college graduation in young female athletes compared with nonathletes.6Clin Sports Med. April 2000; 19: 163-380Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 7Asci FH Kosar SN Isler AK The relationship of self-concept and perceived athletic competence to physical activity level and gender among Turkish early adolescents.Adolescence. Fall 2001; 36: 499-507PubMed Google Scholar Women who participate in sports also have decreased risk of obesity, coronary artery disease, hypertension, diabetes, colon cancer, and osteoporosis.1Clin Orthop Relat Res. 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Although most musculoskeletal injuries sustained during sporting activities are sports-specific rather than sex-specific, women appear to be more prone to spondylolisthesis, anterior cruciate ligament (ACL) injuries, patellofemoral pain, and stress fractures of the pelvis and hip.1Clin Orthop Relat Res. March 2000; 372: 3-322Crossref PubMed Scopus (8) Google Scholar, 15Sallis RE Jones K Sunshine S Smith G Simon L Comparing sports injuries in men and women.Int J Sports Med. 2001; 22: 420-423Crossref PubMed Scopus (141) Google Scholar, 16Ireland ML Ott SM Special concerns of the female athlete.Clin Sports Med. 2004; 23: 281-298Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Women who participate in athletics are more likely to experience repetitive overuse injuries and microtrauma6Clin Sports Med. April 2000; 19: 163-380Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar and are at high risk of having an abnormal eating behavior that may lead to amenorrhea and osteoporosis, a constellation of conditions known as the female athlete triad.16Ireland ML Ott SM Special concerns of the female athlete.Clin Sports Med. 2004; 23: 281-298Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 17Wiggins DL Wiggins ME The female athlete.Clin Sports Med. 1997; 16: 593-612Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 18Gibson JH Mitchell A Harries MG Reeve J Nutritional and exercise-related determinants of bone density in elite female runners.Osteoporos Int. 2004; 15: 611-618Crossref PubMed Scopus (39) Google Scholar, 19Timmerman MG Medical problems of adolescent female athletes.Wis Med J. 1996; 95: 351-354PubMed Google Scholar, 20Beals KA Manore MM Disorders of the female athlete triad among collegiate athletes.Int J Sport Nutr Exerc Metab. 2002; 12: 281-293PubMed Google Scholar, 21Lantz CD Rhea DJ Mesnier K Eating attitudes, exercise identity, and body alienation in competitive ultramarathoners.Int J Sport Nutr Exerc Metab. 2004; 14: 406-418PubMed Google Scholar, 22Hinton PS Sanford TC Davidson MM Yakushko OF Beck NC Nutrient intakes and dietary behaviors of male and female collegiate athletes.Int J Sport Nutr Exerc Metab. 2004; 14: 389-405Crossref PubMed Scopus (77) Google Scholar As defined by the World Health Organization, osteoporosis represents a bone mineral density of 2.5 SD or more below the young adult mean. This condition occurs 4 times more frequently in women than in men. Approximately 30% of postmenopausal Caucasian women in the United States have osteoporosis at any given time, and half of postmenopausal Caucasian women will experience an osteoporotic fracture during their lives.1Clin Orthop Relat Res. March 2000; 372: 3-322Crossref PubMed Scopus (8) Google Scholar, 23Lenchik L Sartoris DJ Current concepts in osteoporosis.AJR Am J Roentgenol. 1997; 168: 905-911Crossref PubMed Scopus (40) Google Scholar The most common sites of fracture are the vertebrae, hip, wrist, and proximal humerus.23Lenchik L Sartoris DJ Current concepts in osteoporosis.AJR Am J Roentgenol. 1997; 168: 905-911Crossref PubMed Scopus (40) Google Scholar, 24Riggs BL Melton III, LJ The worldwide problem of osteoporosis: insights afforded by epidemiology.Bone. 1995; 17: 505S-511SAbstract Full Text PDF PubMed Scopus (1131) Google Scholar The economic burden of osteoporosis in the United States exceeds $10 billion per year,23Lenchik L Sartoris DJ Current concepts in osteoporosis.AJR Am J Roentgenol. 1997; 168: 905-911Crossref PubMed Scopus (40) Google Scholar and with the aging population, this cost is likely to increase. Hospitalization for hip fracture among women aged 65 years and older increased 23% from 1988 to 1996.25Stevens JA Olson S Reducing falls and resulting hip fractures among older women.MMWR Recomm Rep. 2000; 49: 3-12PubMed Google Scholar In women older than 75 years, the most commonly performed surgical procedure is for osteoporotic hip fracture.1Clin Orthop Relat Res. March 2000; 372: 3-322Crossref PubMed Scopus (8) Google Scholar Up to 20% of these patients die within 1 year of their injury, and up to 70% do not return to their preinjury functional capacity.1Clin Orthop Relat Res. 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Peak bone mass usually is reached between ages 18 and 25 years, with 92% of total body mineral content typically achieved before age 18 years.17Wiggins DL Wiggins ME The female athlete.Clin Sports Med. 1997; 16: 593-612Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 26Weaver CM Teegarden D Lyle RM et al.Impact of exercise on bone health and contraindication of oral contraceptive use in young women.Med Sci Sports Exerc. 2001; 33: 873-880Crossref PubMed Scopus (59) Google Scholar Preventive treatment of osteoporosis includes maintaining adequate calcium intake from a young age and participating in regular weight-bearing exercise.8Ford MA Bass MA Turner LW Mauromoustakos A Graves BS Past and recent physical activity and bone mineral density in college-aged women.J Strength Cond Res. 2004; 18: 405-409PubMed Google Scholar, 11Marti B Health effects of recreational running in women: some epidemiological and preventive aspects.Sports Med. 1991; 11: 20-51Crossref PubMed Scopus (55) Google Scholar, 14Meyer NL Shaw JM Manore MM et al.Bone mineral density of olympic-level female winter sport athletes.Med Sci Sports Exerc. 2004; 36: 1594-1601Crossref PubMed Scopus (24) Google Scholar, 27Yamazaki S Ichimura S Iwamoto J Takeda T Toyama Y Effect of walking exercise on bone metabolism in postmenopausal women with osteopenia/osteoporosis.J Bone Miner Metab. 2004; 22: 500-508Crossref PubMed Scopus (118) Google Scholar, 28Winters-Stone KM Snow CM One year of oral calcium supplementation maintains cortical bone density in young adult female distance runners.Int J Sport Nutr Exerc Metab. 2004; 14: 7-17PubMed Google Scholar All patients should be encouraged to limit use of tobacco and alcohol. The older population should be instructed in fall prevention including avoidance of uneven surfaces, removal of area rugs from living quarters, and use of gait aids as necessary.25Stevens JA Olson S Reducing falls and resulting hip fractures among older women.MMWR Recomm Rep. 2000; 49: 3-12PubMed Google Scholar Medical treatment of osteoporosis may include estrogen, bis-phosphonates, and calcitonin.17Wiggins DL Wiggins ME The female athlete.Clin Sports Med. 1997; 16: 593-612Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 23Lenchik L Sartoris DJ Current concepts in osteoporosis.AJR Am J Roentgenol. 1997; 168: 905-911Crossref PubMed Scopus (40) Google Scholar, 24Riggs BL Melton III, LJ The worldwide problem of osteoporosis: insights afforded by epidemiology.Bone. 1995; 17: 505S-511SAbstract Full Text PDF PubMed Scopus (1131) Google Scholar, 29American Academy of Pediatrics Committee on Sports Medicine and Fitness Medical concerns in the female athlete.Pediatrics. 2000; 106: 610-613Crossref PubMed Scopus (16) Google Scholar Estrogen replacement therapy reportedly increases bone mineral density in the spine and hip; however, its use is controversial because of the potential association with breast cancer and heart disease.23Lenchik L Sartoris DJ Current concepts in osteoporosis.AJR Am J Roentgenol. 1997; 168: 905-911Crossref PubMed Scopus (40) Google Scholar Bisphosphonates suppress osteoclastic activity leading to decreased bone resorption and have been shown to increase bone mineral density in the spine and hip.23Lenchik L Sartoris DJ Current concepts in osteoporosis.AJR Am J Roentgenol. 1997; 168: 905-911Crossref PubMed Scopus (40) Google Scholar, 24Riggs BL Melton III, LJ The worldwide problem of osteoporosis: insights afforded by epidemiology.Bone. 1995; 17: 505S-511SAbstract Full Text PDF PubMed Scopus (1131) Google Scholar Calcitonin also inhibits osteoclast activity and has been shown to modestly increase bone mineral density in the spine.23Lenchik L Sartoris DJ Current concepts in osteoporosis.AJR Am J Roentgenol. 1997; 168: 905-911Crossref PubMed Scopus (40) Google Scholar Osteoporosis in young women may be part of the female athlete triad.11Marti B Health effects of recreational running in women: some epidemiological and preventive aspects.Sports Med. 1991; 11: 20-51Crossref PubMed Scopus (55) Google Scholar, 17Wiggins DL Wiggins ME The female athlete.Clin Sports Med. 1997; 16: 593-612Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 20Beals KA Manore MM Disorders of the female athlete triad among collegiate athletes.Int J Sport Nutr Exerc Metab. 2002; 12: 281-293PubMed Google Scholar, 22Hinton PS Sanford TC Davidson MM Yakushko OF Beck NC Nutrient intakes and dietary behaviors of male and female collegiate athletes.Int J Sport Nutr Exerc Metab. 2004; 14: 389-405Crossref PubMed Scopus (77) Google Scholar Loss of bone density in these young women may be irreversible and may lead to increased risk of osteoporotic fractures in the future. Of note, amenorrhea is not considered a normal consequence of exercise, and a thorough medical evaluation should ensue for any premenopausal patient with this condition. Those with functional hypothalamic amenorrhea should receive estrogen replacement therapy as well as calcium and vitamin D supplementation.17Wiggins DL Wiggins ME The female athlete.Clin Sports Med. 1997; 16: 593-612Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 18Gibson JH Mitchell A Harries MG Reeve J Nutritional and exercise-related determinants of bone density in elite female runners.Osteoporos Int. 2004; 15: 611-618Crossref PubMed Scopus (39) Google Scholar A multidisciplinary approach that includes specialists in nutrition, psychology, and endocrinology should be used in treating eating disorders.11Marti B Health effects of recreational running in women: some epidemiological and preventive aspects.Sports Med. 1991; 11: 20-51Crossref PubMed Scopus (55) Google Scholar, 20Beals KA Manore MM Disorders of the female athlete triad among collegiate athletes.Int J Sport Nutr Exerc Metab. 2002; 12: 281-293PubMed Google Scholar, 22Hinton PS Sanford TC Davidson MM Yakushko OF Beck NC Nutrient intakes and dietary behaviors of male and female collegiate athletes.Int J Sport Nutr Exerc Metab. 2004; 14: 389-405Crossref PubMed Scopus (77) Google Scholar Low back pain in active female athletes is commonly due to muscular strain. However, other potential causes of pain must be considered. A defect in the pars interarticularis (spondylolysis) may account for 47% of back pain in adolescence.30Micheli LJ Wood R Back pain in young athletes: significant differences from adults in causes and patterns.Arch Pediatr Adolesc Med. 1995; 149: 15-18Crossref PubMed Scopus (384) Google Scholar Female athletes who repetitively load the spine in hyperextension, such as gymnasts, divers, figure skaters, and dancers, are at higher risk than the general population.1Clin Orthop Relat Res. March 2000; 372: 3-322Crossref PubMed Scopus (8) Google Scholar, 31Omey ML Micheli LJ Gerbino II, PG Idiopathic scoliosis and spondylolysis in the female athlete: tips for treatment.Clin Orthop Relat Res. 2000; 372: 74-84Crossref PubMed Scopus (56) Google Scholar Patients with spondylolytic low back pain define their pain as a dull aching that frequently is made worse with hyperextension. The pain is localized usually to the L4 or L5 region and may radiate to the buttocks but rarely has an associated radicular component. Physical examination should include range of motion of the spine, and a thorough neurologic examination should be performed. Pain with hyperextension and hamstring tightness may be elicited. Radiological evaluation should begin with anteroposterior, lateral, and, most importantly, oblique views of the lumbosacral spine. Flexion and extension views may help rule out spondylolisthesis, a condition of slippage of the involved vertebral body anteriorly with respect to the caudal adjacent vertebra. A bone scan or computed tomogram may be necessary to rule out a subtle pars interarticularis defect.1Clin Orthop Relat Res. March 2000; 372: 3-322Crossref PubMed Scopus (8) Google Scholar Conservative treatment generally consists of rest from the offensive activity with bracing in the acute setting and a lumbar stabilization program in the more chronic setting. Treatment typically involves exercises to strengthen the trunk or “core” musculature. Patients are able to return to their usual activities when asymptomatic. Surgery is rarely necessary and generally is reserved for patients with notable spondylolisthesis, progressive neurologic deficits, or intractable symptoms despite conservative measures.31Omey ML Micheli LJ Gerbino II, PG Idiopathic scoliosis and spondylolysis in the female athlete: tips for treatment.Clin Orthop Relat Res. 2000; 372: 74-84Crossref PubMed Scopus (56) Google Scholar, 32Lonstein JI Spondylolysis and spondylolisthesis.in: Morrissy RT Weinstein SL Lovell & Winter's Pediatric Orthopaedics. 4th ed. 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Growing children with curves greater than 40° and skeletally mature patients with curves greater than 50° to 60° are considered for surgery.15Sallis RE Jones K Sunshine S Smith G Simon L Comparing sports injuries in men and women.Int J Sports Med. 2001; 22: 420-423Crossref PubMed Scopus (141) Google Scholar, 31Omey ML Micheli LJ Gerbino II, PG Idiopathic scoliosis and spondylolysis in the female athlete: tips for treatment.Clin Orthop Relat Res. 2000; 372: 74-84Crossref PubMed Scopus (56) Google Scholar, 34Tolo VT Surgical treatment of adolescent idiopathic scoliosis.Instr Course Lect. 1989; 38: 143-156PubMed Google Scholar In an elderly woman who presents with acute onset of back pain, an osteoporotic compression fracture is likely; plain radiographs show loss of vertebral body height. The fractures generally are treated conservatively with activity modification, external bracing for comfort, and analgesia. Vertebroplasty (injection of polymethylmethacrylate into the vertebral body) may relieve pain but does not necessarily restore vertebral body height.35Alvarez L Perez-Higueras A Granizo JJ de Miguel I Quinones D Rossi RE Predictors of outcomes of percutaneous vertebroplasty for osteoporotic vertebral fractures.Spine. 2005; 30: 87-92PubMed Google Scholar, 36Liliang PC Su TM Liang CL Chen HJ Tsai YD Lu K Percutaneous vertebroplasty improves pain and physical functioning in elderly osteoporotic vertebral compression fracture patients.Gerontology. 2005; 51: 34-39Crossref PubMed Scopus (24) Google Scholar, 37McKiernan F Faciszewski T Jensen R Quality of life following vertebroplasty.J Bone Joint Surg Am. 2004; 86-A: 2600-2606PubMed Google Scholar, 38Ohlin A Johnell O Vertebroplasty and kyphoplasty in the fractured osteoporotic spine.Clin Calcium. 2004; 14: 65-69PubMed Google Scholar If the etiology of low back pain is determined to be muscular strain, treatment involves use of ice in the acute phase, followed by heat and massage to decrease secondary muscle spasm. Tight hamstrings, weak abdominal and paraspinal musculature, and lack of flexibility of the lumbosacral spine should be addressed with appropriate stretching and strengthening exercises.33d'Hemecourt PA Gerbino II, PG Micheli LJ Back injuries in the young athlete.Clin Sports Med. 2000; 19: 663-679Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar Compared with men, active women more commonly experience patellofemoral pain and disruptions of the ACL. This increased incidence may be due to anatomical and physiological differences between men and women. An understanding of these differences may help guide treatment and prevention.15Sallis RE Jones K Sunshine S Smith G Simon L Comparing sports injuries in men and women.Int J Sports Med. 2001; 22: 420-423Crossref PubMed Scopus (141) Google Scholar, 16Ireland ML Ott SM Special concerns of the female athlete.Clin Sports Med. 2004; 23: 281-298Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 39Ford KR Myer GD Toms HE Hewett TE Gender differences in the kinematics of unanticipated cutting in young athletes.Med Sci Sports Exerc. 2005; 37: 124-129Crossref PubMed Scopus (284) Google Scholar, 40Hass CJ Schick EA Tillman MD Chow JW Brunt D Cauraugh JH Knee biomechanics during landings: comparison of pre- and postpubescent females.Med Sci Sports Exerc. 2005; 37: 100-107Crossref PubMed Scopus (71) Google Scholar, 41Bergstrom KA Brandseth K Fretheim S Tvilde K Ekeland A Activity-related knee injuries and pain in athletic adolescents.Knee Surg Sports Traumatol Arthrosc. 2001; 9: 146-150Crossref PubMed Scopus (20) Google Scholar The patellofemoral joint bears up to 7 times body weight with squatting and jogging and 50% of body weight with walking. Abnormal alignment of the knee extensor mechanism can increase stress at the patellofemoral articulation and contribute to softening of the articular cartilage and associated pain and inflammation. The Q angle is the angle formed by the intersection of the axis of the quadriceps extensor mechanism and the axis of the patellar tendon. An increased Q angle may lead to increased lateral subluxation forces and increased pressure on the lateral facet of the patella. Factors that contribute to an increased Q angle in women include a wider pelvis, increased femoral anteversion, increased knee valgus, external tibial torsion, increased ligamentous laxity, and hyperpronation of the foot.41Bergstrom KA Brandseth K Fretheim S Tvilde K Ekeland A Activity-related knee injuries and pain in athletic adolescents.Knee Surg Sports Traumatol Arthrosc. 2001; 9: 146-150Crossref PubMed Scopus (20) Google Scholar, 42Livingston LA The quadriceps angle: a review of the literature.J Orthop Sports Phys Ther. 1998; 28: 105-109Crossref PubMed Scopus (99) Google Scholar In addition, patella alta, a tight lateral patellar retinaculum, and a hypoplastic or weak vastus medialis obliquus can contribute to patellofemoral maltracking. The combination of increased femoral anteversion, external tibial torsion, and hyperpronation of the foot is often termed the miserable malalignment syndrome and is seen more commonly in women. Treatment of patellofemoral pain is aimed at relieving discomfort and addressing patellar maltracking. First-line treatment includes rest, use of ice, and judicial use of nonsteroidal anti-inflammatory medications. Patients also should begin a rehabilitation program aimed at strengthening the quadriceps and, in particular, the vastus medialis obliquus. Medially directed patellar mobilization may be indicated in patients exhibiting a tight lateral retinaculum. Stretching of the iliotibial band, hamstrings, and gastrocnemius/soleus complex may decrease forces across the patellofemoral joint. Finally, hip abductor strengthening may decrease lateral tilt of the pelvis during single-leg stance and thus decrease valgus force at the knee.6Clin Sports Med. April 2000; 19: 163-380Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Orthotics and braces often are used. Orthotics with medial longitudinal arch support frequently limit hyperpronation and thus decrease valgus forces at the knee.43Johnston LB Gross MT Effects of foot orthoses on quality of life for individuals with patellofemoral pain syndrome.J Orthop Sports Phys Ther. 2004; 34: 440-448Crossref PubMed Scopus (68) Google Scholar Knee sleeves with a patellar cutout may decrease pain and may improve stabilization of the patella within the femoral groove. Taping to improve patellar tracking and decrease patellar tilt can help the patient temporarily to participate in athletic events in conjunction with a formal rehabilitation program. Surgery is rarely necessary for patellofemoral pain. Realignment procedures are used occasionally for severe patellar maltracking problems refractory to nonoperative management. Athletic women participating in noncontact sports have an increased incidence of ACL disruption compared with men participating in the same activities.39Ford KR Myer GD Toms HE Hewett TE Gender differences in the kinematics of unanticipated cutting in young athletes.Med Sci Sports Exerc. 2005; 37: 124-129Crossref PubMed Scopus (284) Google Scholar, 44Baker MM Anterior cruciate ligament injuries in the female athlete.J Womens Health. 1998; 7: 343-349Crossref PubMed Scopus (18) Google Scholar, 45Ferrari JD Bach Jr, BR Bush-Joseph CA Wang T Bojchuk J Anterior cruciate ligament reconstruction in men and women: an outcome analysis comparing gender.Arthroscopy. 2001; 17: 588-596Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 46Gwinn DE Wilckens JH McDevitt ER Ross G Kao TC The relative incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy.Am J Sports Med. 2000; 28: 98-102PubMed Google Scholar For example, female soccer players are more than twice as likely to experience ACL injuries than are male soccer players.46Gwinn DE Wilckens JH McDevitt ER Ross G Kao TC The relative incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy.Am J Sports Med. 2000; 28: 98-102PubMed Google Scholar, 47Arendt E Dick R Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature.Am J Sports Med. 1995; 23: 694-701Crossref PubMed Scopus (1244) Google Scholar In basketball, the injury rate is more than 3 times higher in women.46Gwinn DE Wilckens JH McDevitt ER Ross G Kao TC The relative incidence of
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