Although continued exercise is generally safe for a pregnant athlete and her fetus, caution is required when there is increased risk for premature delivery, or other special conditions exist. Multiple gestation, placenta previa, history of early labor or premature births, and incompetent cervix all contraindicate aerobic exercise during pregnancy.18 With these exceptions in mind, physicians can safely counsel pregnant women to do moderate exercise 30 minutes every day.17,18 Other recommendations are listed at the American College of Obstetricians and Gynecologists website.23
4. Anterior cruciate ligament injuries
ACL injuries affect a staggering number of athletes. In the United States, approximately 100,000 people sustain these injuries annually.24 As they occur up to 8 times more often in women than in men, ACL injuries are a top concern for physicians treating female athletes.
This disproportionate injury rate is influenced by differences between male and female anatomy. The width and shape of the femoral intercondylar notch have been studied as potential variables influencing the risk for ACL injury. Analysis of notch-view radiographs revealed a significant inverse relationship between notch width and ACL injury.25 A-shaped notches, notches with a significantly larger base and a narrowed roof, were more prevalent in women but did not correlate with increased risk for ACL injury. Studies have shown that female athletes with a noncontact ACL injury have a higher lateral tibial plateau posterior slope; this slope is associated with increased peak anteromedial ACL strain, which may contribute to injury.26 An analysis of magnetic resonance imaging scans in patients with and without ACL injury revealed that, for female patients, decreased femoral intercondylar notch width at the anterior outlet combined with increased lateral compartment posterior slope correlated best with risk for ACL injury.27
Although static anatomical factors contribute to ACL injuries in female athletes, dynamic neuromuscular influences are potential opportunities for intervention. Female athletes with high relative quadriceps strength and weak hamstring strength may be at increased risk for ACL injury.28 This “quadriceps dominance” becomes important in sports involving high-risk activities, such as running, cutting, pivoting, and jumping. In addition, compared with male athletes, female athletes demonstrate increased lateral trunk motion and knee valgus torque while landing during noncontact ACL tears, making core stability a factor in ACL injury.29
The collaborative efforts of physicians, physical therapists, athletic trainers, and coaches have yielded multifactorial neuromuscular training programs for the prevention of noncontact ACL injuries. Ideal ACL prevention protocols involve sessions that last for at least 10 minutes and take place 3 times a week. At these sessions, exercises are focused on strengthening, balance, and proprioceptive training.30 The programs last about 8 weeks, but sustained benefits require maintenance after the program has been completed and during the off-season. Program adherence must be encouraged and can be facilitated by varying workouts and raising risk awareness. The most effective programs have reduced the relative risk of noncontact ACL injuries by 75% to 100%.31 These promising results have led to increased focus on program implementation in an effort to prevent ACL injury.
5. Continued sex discrimination and social injustice
In 1972, Title IX was passed as part of the Education Amendments Act. Title IX states, “No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any educational program or activity receiving Federal financial assistance.” Passage of this law, which has implications outside of athletic participation, marked an important turning point in women’s ability to participate equally in college sports.32,33 The Civil Rights Restoration Act, passed in 1988, strengthened Title IX and made it applicable to all institutions receiving federal funding.34 Before the 1970s, women typically were restricted to club sports, and funding and participation opportunities were weighted heavily toward men. Over the past 40 years, women’s participation in high school, college, and professional sports has taken a huge leap forward.32 For example, the number of women participating in high school sports increased from 294,000 (7.4% of all athletes) in 1972 to 3.4 million (>41% of all athletes) in 2014.
Despite advances in women’s civil rights, examples of inequality in US schools remain, particularly in the distribution of funding, which still strongly favors men’s football.32 Men’s sports receive 90% of media coverage.33 In 2002, women represented 55% of college students but only 42% of varsity athletes.34 The schools that have complied the least with Title IX are schools in the Midwest and the South and those with football teams.34 Women are underrepresented as coaches, and funding continues to be disproportionately spent on men’s sports.