Female Triad in Runners with Katie

SAM: For this post, we are fortunate to have Katie Noble, DPT, writing with us. When I talked with her, what’s one of her passions when treating, she said the female triad in runners. She has done tons of research on the topic, and was a competitive runner in a division 1 university. Our goal is for this to be a resource for female runners and SPTs/PTs treating female runners, to elevate their understanding about their health and training; to help women prevent injuries and promote a healthy, balanced, knowledgeable approach to running. We believe women are strong, durable, and capable athletes. Katie, can you explain to me what the culture of competitive running looks like?

KATIE: The culture of competitive running is complex and multi-factorial. Specifically, I have the most knowledge about competitive distance running, as I was a varsity member of MSU’s Cross Country and Track teams from 2003-2008. Distance runners are some of the most determined people you will ever meet. They accept a high level of responsibility for their training and racing and are often relentless in the pursuit of their goals. Being around runners can be incredibly inspiring and intense. Runners tend to be high-achievers, analytical, responsible, self-critical, and perfectionists. It’s common to hear runners talk about detailed running logs, extensive training plans, and the latest news in elite performances. In short, runners love running and find it very easy to dedicate their lives to it. In college, I was like this, almost completely consumed with my own running and training.

I don’t want to paint a dim picture of collegiate running because it was an incredible experience for me. I learned so many things about myself during those 5 years that I may have never otherwise discovered. I had incredible teammates and friends, who I value over any PR or performance. I would never take back the experience of running for a D1 university. However, it can be a highly charged, intense atmosphere to live and breath in everyday. As you can imagine, runners feel a lot of pressure especially intrinsically. One bad race or workout used to make me feel like I was no longer a talented runner. A good workout or race would leave me wondering how much faster I could or should have been. I was never satisfied. For me, there was a lot of high-achievement mixed with the downfalls of perfectionism and self-doubt. (More on that later!)

There were times when I placed immense pressure on myself to perform my best on every single base run, workout and race. I became obsessive about my performance and weight, which lead to chronic underfueling and overtraining. (Which makes no sense anyway, because underfueling leads to reduced strength, power, and performance. Face palm.) I eventually became chronically injured by my fifth year. I had no idea what to do to change my behavior and get better outcomes. I associated my failures with myself, my will, and my toughness. I made simply being me the failure, not my actions or lack of help with my issues. Distance running is a sport that emphasizes leanness for the sake of performance and efficiency. I’m not the first runner to develop issues surrounding weight and performance, but I know from the benefit of hindsight that it is unnecessary. If I had allowed myself to be healthy and train consistently, I would have gotten much faster in college. If young women allow this for themselves right from the start of their college careers, we will see faster times and fewer injuries.

SAM: Yeah, that makes sense. I really appreciate the honesty in your answers. Being at that high level of competition, I feel like you need that drive. Do you see the same type of drive in the patients you treat? And when you didn’t have a great run, what reminded you that you are a great person? For me, I think I was fortunate enough for my experience with competition to have coaches to remind me to look at bigger patterns, and remind me that all athletes have an off day.

Katie: That is an important point to consider: all athletes have an off day. I could not accept this at the time. For me at the time, I linked running goals to my value as a person. If I wasn’t at my best as a runner, I struggled with self-doubt until I could perform and prove to myself I was “good” or had value. This is pretty heavy stuff, but it was definitely real for me. This is not the same as having drive. Drive can propel athletes to achieve great feats and to persevere through hard times. Drive needs to be accompanied by perspective. Drive needs to be paired with maturity to see the big picture. Drive is a good thing, just not at the expense of physical and emotional health.

SAM: What was your favorite aspect about being a competitive runner, then? Now?/What do you think the big benefits are of running?

I love competitive running. It provides an outlet for me to feel like a total badass once in a while. That is strange to say, but I think all runners can agree that they’ve had a moment where it all came together and they feel incredible. Those are the moments runners live for. Aside from those few and far between badass moments, running helps me feel happy and balanced. I truly enjoy running and I don’t think of it as exercise. It feels like a privilege and a part of who I am. When I first started running in high school, it gave me an identity in a time when I needed to belong to a group. It kept me on the right track during a difficult time in my life (puberty!). I got a much-needed self-esteem boost when I received recognition for my running achievements. Now that I’m an adult and have a deeper understanding of who I am as a person, the benefits of running are different. I don’t need it to anchor my self-esteem, but it’s a source of joy. I was set up with my husband through a mutual running friend. It’s safe to say running has influenced my life greatly.

SAM: Besides physical stress, what other pressures do female athletes face that affect their health?

Runners in general deal with a lot of pressure. Running-specific pressure includes the pressure to race well, train well, eat well, and recover well. On top of that, runners have to study, go to work, spend time with family and friends, and do other activities that make up a full life. But female runners often face a steeper hill in terms of pressure and social expectation. Female runners often feel pressure to not only run well, but to look good while doing it. (Any Instagram user knows the feeling of looking at a “perfect” runner, who has good form, good hair, perfect makeup, and a perfect smile to boot. Don’t believe me? Check #fitspo.) Female runners face more criticism about their bodies than male runners do. Professional runner Kara Goucher recently shared on the “Running for Real” podcast by Tina Muir that every coach she has ever had suggested she lose weight. (Note: Goucher is a multiple NCAA champion, finished 3rd in the 2009 Boston Marathon, and has a marathon PR of 2:24. She’s amazing.) In fact, research shows that girls begin to drop out of sport around the onset of puberty, a trend not seen in adolescent boys. A recent study in the Journal of Adolescent Health found that three-quarters of the 2,089 girls ages 11-18 surveyed said they have at least one breast-related concern regarding sports and exercise.1 Simply put, as cup size increases, physical activity decreases. Body image is something girls begin dealing with at a young age and those insecurities and pressures can travel with them to adulthood.

Q: What expectations do you feel like could be changed to help improve running?/As a female athlete, why is it hard to talk about or admit to aspects of health in which many women struggle? Things like eating issues, over-training, self-doubt, loss of menstrual cycles, etc?

Quite simply: we don’t want to be judged. We don’t want to be judged by other runners, by coaches, by physical therapists, or by anybody we respect. We want to be seen as “top-notch” people who have it all together; who can balance EVERYTHING life throws at us. We don’t want anybody thinking about us as if we’re weak, broken, or sick.

As far as loss of menstrual cycles and overtraining, I don’t think most women know enough about these issues. It is estimated that 65% of collegiate distance runners experience secondary amenorrhoea (losing their periods for >3 months).2 If that number doesn’t shock you, I don’t know what will. When I was a teenager, I repeatedly told my doctor that I had lost my period from training. The research at the time (maybe lack of research at the time) supported that this was OK with no health consequences to worry about. Now research tells us that losing your menstrual cycle due training is never normal. Your menstrual cycle is a measure of your health; a vital sign. It gives women crucial information about energy balance, bone health, and more. Our bodies go through monthly hormonal fluctuations of estrogen and progesterone, two hormones that which help regulate how quickly bone cells are broken down. When you lose your period, those hormone fluctuations are interrupted and bone-protecting estrogen and progesterone are decreased. Long term, this leaves bones more susceptible for fracture. Anne Loucks, who has done a lot of research on this subject put it well: Osteoporosis in a 20 year old is a disaster. Osteopenia in a 20 year old is a disaster waiting to happen. This does not need to happen to young female runners and prevention is the key.

Energy balance is another aspect of health female runners need to know. Runners expend a lot of energy training and need to recoup that energy through a healthy and robust diet. That means eating nutrient-rich and calorically dense food. If a runner is refueling properly, they can achieve a balance between energy burned vs energy consumed. When runners don’t eat enough to support training, an energy deficit is created, which can lead to decreased performance, strength, and endurance; decreased concentration and judgement; increased irritability, depression, and risk of injury. That’s all bad stuff. Still, many runners struggle with eating disorders, disordered eating, and body dysmorphia. Female runners often face scrutiny over their looks, despite performance. I struggled with these issues in college. I truly believed that I was “bigger than the typical runner” and that I needed to fit into other people’s expectations. It took a long time, self-reflection, and a doctorate education to help me truly understand who I am and who I want to be as a runner. It’s a lesson I wish I could have figured out 15 years earlier. But I got there. Other young women do not need to fall into these pitfalls and I believe providing high-quality education about their health will help move the culture of women’s distance running in the right direction. I truly believe that if we can move that needle in the right direction, we will see women’s distance running as a whole get stronger and faster.

SAM: Are there any differences between women and men for running? Training?

Physiologically, women generally are smaller, lighter, and have a high proportion of body fat than men. Women also tend to have smaller hearts and lungs. Essentially, our engines are smaller, which affects how much oxygen we can use to fuel exercise. Women also have menstrual cycles, which causes monthly hormone fluctuations which has an effect on ligament laxity and bone health.

But to tell the truth, I think women have suffered as a result of being left behind by science. To use the words of exercise physiologist Stacy Sims, “Women are not small men.” Much of research about running has tested mostly male subjects, with the results generalized to women. A 2014 study looked into articles published in three major Sports and Exercise Medicine journals over a three-year period. Female made up only 39% of study subjects out of more than 6 million participants. Female were significantly under-represented across all the journals.3 The more we know about women (about ourselves!), the more opportunity we have for better performance. What I would like to see is more research about female athletes that compares women to other women, not women to men.

SAM: What expectations do you feel like could be changed to help improve running?/Why do female athletes strive for perfection? Is this holding them back or a necessary part of running your best?

No doubt, perfectionism is a problem for runners. It’s easy to focus on every aspect of your running that isn’t perfect and to obsess over little things. Professional runner Alan Webb has referred to “never-satisfied syndrome.” This terms pains me because it is so real. It’s also dangerous and can lead runners to overtrain in pursuit of unreasonable expectations. There is even evidence that perfectionistic concerns predict injuries in juniors athletes over time.4 Researchers found that the more athletes had concerns over mistakes and negative reactions to imperfections, the more likely they were to sustain an injury. It’s loud and clear: being overly concerned about mistakes and imperfections will hold you back from your goals long-term and can be very toxic.

Q: What have been injuries you’ve seen among female runners? What does the research say?

From research I’ve read, there are aspects of female physiology that may increase the chance for certain injuries, like ACL injuries, patellofemoral pain, and bone stress injuries. But I would never set someone up to experience a nocebo effect, where you’re taught to expect a bad outcome that hasn’t happened yet and may never happen. Keeping that in mind, I will say that injuries happen to almost every runner. A recent systematic review found evidence that about 80% of runners will incur a lower extremity injury at some point.5 Running injuries happen, and I believe you have a better chance at preventing them if you know the risk factors, signs and symptoms. Basically, education is power and not a cause for anxiety. So take this information for what it is: education that can help you recognize an injury, not grounds for panic and fear. It’s important to note that while women are at a higher risk for some injuries compared to men, that does not mean women are weak. Bodies are strong, resilient, and durable. Getting injured doesn’t change that. Rather, injuries are likely the result of something going awry in our training or how we’re taking care of our bodies, which are modifiable risk factors. I don’t want to minimize this in any way: how we train, eat, recover, and think about our bodies is extremely personal and complex. These important aspects of a runner’s life may not be easy to modify, but they will be worth it in the long-term.

Q: Why should female athletes care about health issues if they’re running well? What is the link between health and performance?

Women should care about health issues, even if they are running well, because there is nothing more important. Just because someone is running well does not mean they are healthy. Just because someone is running poorly does not mean they are unhealthy. You have one body for your entire life and you will continue to ask it to do amazing things. Longevity should be a goal for runners. We can easily get caught up in the next race or goal, but we need to be thinking about the next year or five or ten. Underfueling and overtraining is not sustainable and you cannot build a running career or a healthy skeleton this way. Putting together multiple training cycles with appropriate intensity, consistent effort, and good nutrition is going to make a runner the best they can be. Plug away, prioritize your health, and don’t get in your own way.

Q: What are the Female Athlete Triad and Relative Energy Deficiency in Sport models? What can physical therapists do about it?

Women are strong and capable athletes. When there is a drop in performance, there are different factors of female physiology to look to at. The female athlete triad is three factors that often affect athletic women: low energy availability, low bone mineral density, and amenorrhoea (lack of menstrual cycle). This can set women up for bone stress injuries in the short-term and poor bone health in the long-term. This is seen in distance running and in sports where leanness is a factor for performance or appearance. The International Olympic Committee recently provided a more comprehensive model of health concerns in athletes (that includes the Female Athlete Triad) called Relative Energy Deficiency in Sports (RED-S).6 RED-S includes more factors that affect health and athletic performance caused by low energy availability. This model also includes men. To quote the paper, “The underlying problem of RED-S is an inadequacy of energy to support the range of body functions involved in optimal health and performance.” I appreciate the updated term of “RED-S” for its comprehensive and inclusive nature. I appreciate Barbara Drinkwater’s history-changing research and coining of the Female Athlete Triad, which served as a springboard for these updated concepts.

(As a champion for women, Barbara Drinkwater is a total badass, BTW. She became the first woman president of the American College of Sports Medicine in 1988.)

Figure 1 shows that health consequences associated with RED-S. Figure 2 shows the performance effects of RED-S. Both health and performance decrease when an athlete develops a mismatch between energy consumed/restored and energy burned. (Images: Mountjoy M, Sundgot-Borgen J, Burke L, et al. Br J Sports Med 2014;48:491-497)

As PTs, we need to be able to recognize when a female runner displays signs of an energy imbalance. Early detection is crucial to improve performance and minimize long-term health risks. Recent weight loss, increased mileage or training loads, drop in performance, increased fatigue, history of chronic colds or respiratory infections, and mood changes are all things I listen for in a subjective history. This can be a sensitive issue and an athlete should never be made to feel ashamed for struggling with their health as it relates to their sport. Listen carefully, ask thoughtful questions, and develop a rapport with the athlete as a foundation to deliver high-level education about their health. Most of all, let someone tell their story. Providing individualized treatment comes from understanding who a runner is as a person, and who a person is as a runner. The best way to prevent a runner from going down the path of RED-S is education. Runners need to know what it is and how to either prevent it or how to get back on track if they (or you) recognize aspects of it in them.

Q: What is the “right” way to train in order to stay healthy and decrease risk of injury?

There are a few aspects of training I would say are mainstays, such as moderate and progressive loading and appropriate strength training. There is no “right” way to train, only the best way for each individual. I have a friend who runs professionally tell me that she got caught in a mental trap of playing by everyone else’s rules for running. When she stopped, she got faster and happier. It’s easy for runners to think that they are not doing the right things by listening to what works for other people. There is no perfect plan. Stay true to yourself and your process.

Q: As a physical therapist, what do you think are key aspects for treating female runners?

If the exact same thing is happening to more than half of your patients, would you think it’s important to talk about it? Of course you would! Physical therapists need to ask women (who make up 51% of the US population!7) about their menstrual cycles. I take a hard line about this. No excuses. It can be awkward if you do not have experience talking or thinking about this subject, so practice. Figure out a way that works for you. Do whatever you need to do, but this needs to be a part of the conversation. PTs need to be able to read their patient for comfort level for such a discussion and approach the topic with professionalism and appropriateness, which is what we should be doing with all subjects anyway. Let’s take the embarrassment barrier down and see the menstrual cycle for what it is: vital information. Even if a patient doesn’t want to talk about this, PT’s can provide information about why having a regular period is important. I’ve addressed this subject a lot lately with the reaction has always been the similar to, “Wow. I didn’t know any of this about my period. I’m glad I know now.” Jackpot. Patient education level 1000.

Another key to treating runners (male and female, alike) is to actually watch them run. Many runners will not have pain until they’ve been running for a while. It’s important to see the mechanics and movement strategies they use. Discussing a runner’s training progression of mileage/intensity and strength training is also important. Once those things are clear, I try to ask questions that give me a clear picture of a runner’s life: How much are you sleeping? How do you recover? How much stress do you have outside of running? It’s all important and it can help you put together a clear picture of who your patient is as a runner and person.

  1. Scurr, J., Brown, N., Smith, J., Brasher, A., Risius, D. and Marczyk, A. (2016). The Influence of the Breast on Sport and Exercise Participation in School Girls in the United Kingdom. Journal of Adolescent Health, 58(2), pp.167-173.
  2. Dusek T. Influence of high intensity training on menstrual cycle disorders in athletes. Croat Med J 2001: 42:79-82.
  3. Costello J, Bieuzen F, Bleakley C. Where are all the female participants in Sports and Exercise Medicine research?. Eur J Sport Sci. 2014;14(8):847-851. doi:10.1080/17461391.2014.911354.
  4. Madigan, D., Stoeber, J., Forsdyke, D., Dayson, M. and Passfield, L. (2017). Perfectionism predicts injury in junior athletes: Preliminary evidence from a prospective study. Journal of Sports Sciences, 36(5), pp.545-550.
  5. van Gent R, Siem D, van Middelkoop M et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine. 2007;41(8):469-480. doi:10.1136/bjsm.2006.033548.
  6. Mountjoy M, Sundgot-Borgen J, Burke L, et al. Br J Sports Med 2014;48:491-497
  7. Census Bureau QuickFacts. (2018). U.S. Census Bureau QuickFacts: UNITED STATES. [online] Available at: https://www.census.gov/quickfacts/fact/table/US/PST045216 [Accessed 23 May 2018].

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