Within the framework of the Sports Tomorrow Congress, Dr. Eva Ferrer, physician of the first female team of the FC Barcelona, and Dr. Gil Rodas, physician in charge of Barça Innovation Hub, they have presented a unique event dedicated to the advancement of the knowledge of female sports.

The science in women’s sports is more like a fruit salad

In a very illustrative first presentation, Dr. Celeste Geertsema (Aspetar, Qatar) has analysed the problem that concerns research in sports sciences: most studies are conducted only in men. “How is it possible to address the preparation of athletes individually if there are hardly any scientific studies conducted on the female population?” She has explained how research published in the best journals in the world in sports sciences has barely included women in her studies. Sports Medicine, for example, published 0% of studies that included women between 2018 and 2019. This places us in a paradox if we address the genetic differences between men and women (around 1-4%): medical professionals and technicians are so close to knowing the physiology of the woman than that of a chimpanzee, knowing that the genetic difference between species also varies in these parameters. “When we talk about science in women’s sports, we must leave aside the perspective of “the fruit salad” and start to do science that takes into account the individuality of women.”

The importance of education in women’s sports

Dr. Eva Ferrar has highlighted the importance of education to improve the preparation processes of the players. “One of the first things I noticed when I arrived at the team was that the players did not have gynaecological visits on a regular basis. How can we educate on the importance of the menstrual cycle with this reality?” In this way, the club is being committed to monitoring the menstrual cycle as an essential part to begin to understand its importance in the performance and prevention of injuries.

The physiology of women and its implications in sports

Dr. Anthony C. Hackney, professor of physiology and nutrition at the University of North Carolina, has talked about the physiological perspective of women. One of the main differences between sexes lies in sex hormones and their impact on bone, muscle and immune health. This contrasts with the reality that for decades has prevailed in the world of research and performance, where women have been treated like “small men”.

The menstrual cycle, a vital sign

Dr. Georgia Brunvels at St Mary’s University has tried to answer the question of how the menstrual cycle affects sports performance. First, he has insisted on using the menstrual cycle as a vital sign of health. If the cycle is regular, it indicates that the athlete has a good physiological condition. On the contrary, if the cycle is erratic, it denotes an alarm that needs to be taken into account. Thus, for example, it has been indicated that 87% of women present symptoms during each cycle. One very relevant fact is that 85% of athletes feel that they receive little information about the menstrual cycle. Finally, he has highlighted the change of narrative that has occurred around the menstrual cycle. If it used to be seen as a limiting factor for women, it now becomes an important tool for improving their health and performance.

In this regard, Dr. Blanca Romero, the physical trainer of the Spanish football team, has explained the importance of controlling the menstrual cycle (e.g., days of bleeding, length, premenstrual symptoms, use of oral contraceptives and polycystic ovary syndrome) to modulate the individual load. As a practical tool, she has explained a work proposal based on the different phases of the cycle, although she has made it clear that performance is conditioned by many other factors.

Dr. Meghan Keating (Boston Children’s Hospital) has talked about gender differences in sports. For example, it was not until 1972 that women in the USA were able to apply for sports grants, which meant an increase in the participation of sports disciplines. On the other hand, she has analyzed different studies showing the impact of the triad of female athletes, a syndrome characterized by low energy availability, alteration of menstrual function and low bone mineral density. In young athletes, around 78% have at least 1 of the triad’s symptoms.

One relevant aspect in relation to the difference between men and women is the impact that sex hormones have on the ligament structure at all ages and their relevance in the risk of injury. Dr. Keating has pointed out that, for example, in teenagers, players who play sports involving jumps or turns have 2-8 times more risk of breaking the anterior cruciate ligament (ACL).

How do oral contraceptives influence performance?

This issue is relevant because a large part of women who practice sports use contraceptives (about 50%), with the oral pill being the most used hormonal contraceptive. Does its use influence performance? This question has been addressed by Dr. Kirsty Sale, of Nottingham Trent University. Several recent meta-analyses show a trivial reduction in performance in those women taking the pill. “Although it can be a trivial decrease, it can be significant for the athlete. However, the results should be analyzed with caution, since the quality and number of studies are not desirable.” The problem is still the same. There is no evidence of sufficient quality to affirm a possible protective or deleterious effect. “If we want to improve the performance of athletes, we must do high-quality research and then apply it individually.”

Hormone profile in athletes, how does high performance affect?

A problem in high performance is the impact that low energy availability has on the hormonal network in female athletes. Dr. Nicky Keay has explained that it is a priority objective to detect this status early in athletes, which as has been analyzed, has a high prevalence in athletes. Another status that also alters the menstrual cycle is polycystic ovary syndrome. Although some of its conditions are common to those presented by athletes with low energy availability, their consequences are opposite, so it has been stressed that it is important to know how to discern these two situations to act accordingly.

Injuries in women’s football: epidemiology and complexity

Dr. Markus Walden, Swedish FRG researcher at the University of Linköping, has discussed the impact of injuries on women’s football. He has presented data from a pioneering female football study where the “pandemic” of ACL injuries has been shown during 2020. The number has increased alarmingly.

If we talk about the total number of injuries, during matches the injuries are much more frequent than in training (19.5 injuries/1000 hours of play vs. 5.3 injuries/1000 hours of play). A very striking piece of information has been given by Dr. Liesel Geertsema (Aspetar, Qatar), who has explained that players have a 5-10% risk of breaking the ACL over the course of a season, which contrasts with the limited medical support they have.

The differences between men and women

Dr. Celeste Geertsema has made a new presentation in which she has detailed the anatomical, hormonal, neuromotor and genetic differences that exist between men and women and that could explain the greater risk of injury that they present (2-3 times more). Despite the fact that this is being investigated, the prevalence continues to be higher in women, which according to the investigator suggests that we are not taking into account all the factors. There are educational issues that we are not looking at: the rate of injuries may be partly influenced by gender social issues.

In relation to these data, the physician of the FC Barcelona Javier Yanguas has presented the data of an internal study of the club where he has analyzed the incidence of ACL injuries over 11 seasons in all club categories. During this time, women were almost 4 times at a higher risk of being injured by ACL. In this sense, a piece of data provided by Dr. Francesco Della Villa is that almost 70% of ACL injuries occur in defensive situations, where deception or distraction actions lead to producing sensory or motor errors that determine the production of this injury. Something to consider also in relation to the incidence of the ACL injury is that there is a greater risk of them occurring in the first part, something that could be related to the intensity of the game.

It is common that in high performance after an ACL injury, surgical reconstruction is chosen. Dr. Hege Grindem has analyzed the impact of conservative treatment on the rehabilitation of this injury, presenting cases in which athletes successfully return to high performance without having undergone a reconstruction surgery.

Rehabilitation after an ACL injury is crucial. The physiotherapist Silvia Ortega Cebrián has detailed aspects of the programs she performs and in which it includes isometric exercises, blood flow restriction or neuromuscular work. All this to minimize pain, attenuate muscle atrophy and restore the previous range of motion.

The injuries have a complex origin

“For many years, we have tried to finish a puzzle (that of injury prevention) that is missing parts. There are many factors that can influence an injury and its management and that we still do not know,” Dr. Caroline Bolling. Since its aetiology is so complex, communication between athletes and those responsible for the different areas is particularly relevant. He has emphasized that athletes have to be able to speak and technicians to listen.

Football boots are often overlooked in terms of performance and injury prevention. Despite being an extrinsic factor present at all times, it is not given the necessary importance, especially in women. To alleviate this knowledge gap, Dr. Katrine Kryger (St Mary’s University), who did her thesis on this subject, has analyzed the importance of footwear in women’s football. She has explained how in most cases, players choose boots designed for men, even when the shape of their feet is very different. Reducing the size of a boot and thinking that it will already be optimal for the player is not the solution.

Preparation of a professional hockey team every day

Professional sports require a high load of games, training and travel. This makes the management of the load and the rest an essential part of the preparation of the athletes. This reality has been shown by Dr. Esther Morencos, physical trainer of the Spanish hockey grass team. The methods of recovery and prevention of injuries play a relevant role. The results over the years show how only 10-20% of the national team players have suffered an injury, including the Olympic year.

The player’s vision

A very interesting part of the day was listening to the player of the first team Caroline Graham, who talked about how she copes with her physical preparation. For her, information is critical to understanding why she does things. It has also highlighted the lack of knowledge about the menstrual cycle and its influence on performance. “There are times when I see that my body doesn’t respond and I don’t really understand why.” Like many of the researchers throughout the day, she has stated that she lacks knowledge and has encouraged us to continue researching with real athletes.

A symptom of the progress that is taking place in women’s football and of the questions asked by athletes is that some of them, when they finish their sports career, continue to be part of the coaching staff. This has been the topic of debate of a round table made up of Andrea Esteban (Valencia CF), Sara Mérida (RCD Espanyol), Laura Rafols (FC Barcelona) and Laura Díaz (UDG Tenerife), who from her experience have explained how they work and face the physical preparation and rehabilitation processes after an injury.