Hi everyone, thanks for having me in this session. I have no financial disclosures. So our female adolescent athletes are a really challenging patient population and I would argue probably the most high risk group that we take care of. Adolescence is a significant time of growth and development, the body is changing a lot in a short period of time. Teenage years is also when people sort of establish their identity and sometimes that athletic identity is part of a core portion of who that person thinks that they are. We all know there's a lot of social and societal pressures for athletes to excel in sports and there's still the myth, especially among teenage girls, that healthy means being skinny. These patients also have incredibly high activity levels which puts them at risk for injury in the first place and also presents challenges post-operatively. We all know that females are at increased risk for ACL injuries and there's anatomic, biomechanic, and physiologic factors that contribute to that. And when we start to look at our ACL surgical outcomes, we see that the young female athletes have a tremendously high rate of risk for secondary ACL injury and this study showed that females were more likely than males to sustain contralateral injury after ACL reconstruction. We know our return to sport rates in the literature are far from perfect, sort of questioning what other factors can contribute to this. The best demographic in terms of return to sport tends to be in young male patients. Multiple studies have shown that psychological status can predict outcomes in return to sport rates in young patients and fear has been studied as one of the most common reasons for participation reduction. It's been associated with at-risk jump landing mechanics in female ACL reconstruction patients and it's also been associated with higher secondary ACL re-injury rates. This was a study that showed very high levels of post-traumatic stress disorder symptoms in young patients upon hearing the diagnosis of having an ACL tear. In this study, they found greater emotional disturbances in older adolescents as well as female patients. Psychological readiness to return to sport has been shown as a predictor of ultimate return to sport after ACL reconstruction. This study looked at predictors of psychological readiness and found that male sex and young age, among those other factors you see there, predicted psychological readiness and that's that same demographic that's tending to return to sport at higher rates. This subsequent study showed that females reported lower psychological readiness at all time points in the study compared to their male counterparts. This is unpublished data, but in our prospective study at Boston Children's, our ROAR study, we are finding similar findings. Our females are reporting lower psychological readiness and higher levels of psychological stress at six months compared to male patients, and this is in spite of the fact that there's no differences between males and females in their functional muscle recovery. This is a qualitative study of adolescent patients and how they approach return to sport from a psychological perspective. You can see that there's some good overlap there in the middle, but there are differences between male and female patients, and we should be considering these when we are treating these young athletes. So as an orthopedic surgeon, my job is to fix the knee. I'm contributing to the physical health of the patient, but I think it would behoove all of us to think about all of the things that can play into what affects our surgical outcomes, and particularly in this group, treat the whole patient. There are distinct issues facing female athletes, including gender inequity, discrimination, abuse, body image issues, disordered eating and energy deficiency, which I'll touch on briefly, fatigue, poor sleep, mental distress, and having minoritized identities. The definition of energy deficiency in sport, or REDS, is the expanded definition of that traditional female athlete triad, and really the basic definition is there's an imbalance between energy intake and energy expenditure. Many things can contribute to that, as you can see in this diagram, including many of the components of the female athlete triad. Female athletes are at high risk for developing eating disorders compared to the general population, and elite female adolescents are most at risk for this. Thank you. Studies in high school athletes have shown significant eating disorder eating behaviors, and dancers are a particularly at-risk population with high levels of eating disorders, which has implications for recovery from injury and number of injuries sustained over time. With all the pressures our young female athletes face to be perfect and to look perfect, it's really important to educate this population that being healthy can look all sorts of different ways. You can be fit, and you don't have to be skinny in order to be healthy. The last thing I want to leave you with is, remember, these injuries are devastating for people at this age. They can be career-inspiring, they can be life-changing, and this was a quote from one of my patients, who was the most upbeat, happy patient that you can imagine. She said receiving the diagnosis from her surgeon was one of the worst moments of her life. She thought she had done everything right, and it wouldn't happen to her. I think a lot of our patients can relate to that statement. It's important to understand the psychological factors that can both help recovery, but also inhibit recovery, and when you see a patient at risk, guide them towards the appropriate resources. And probably the best thing we can all do for our patients is simply to ask them how they're doing when they come back to the office. So in young female patients, you always want to ask about their eating habits, their menstrual history. We want to encourage both physical and emotional recovery, engage multidisciplinary teams when possible, and then also try to keep the athletes engaged and involved with their teams so that they don't lose that sense of identity in being an athlete. So in conclusion, gender differences in surgical outcomes, psychological responses, and return to sport rates do exist. Our adolescent females are a tremendously high-risk population. A better understanding of the issues they face and taking a multidisciplinary approach really can give us the best chance to improve our patient-reported outcomes and return to sport rates. Thank you. I'm happy to answer any questions.

female adolescent athletes

injuries

body image issues

ACL injuries

psychological factors