Optimizing Podiatric Care for Female Athletes
Targeted, personalized care can often create opportunities for enhanced patient-doctor relationships and potentially, improved outcomes. For several years, the American Association for Women Podiatrists (AAWP) has shone light on unique aspects of caring for female podiatric patients through local and national lectures. In this panel, these thought leaders share specific pearls and insights on treating female athletes, along with foundational concepts that could have a positive impact on broader patient populations.
Q: In your experience, why should clinicians focus on specific best practices for treating female patients in general?
A: Karen A. Langone, DPM, DABPM, FACPM, FAAPSM, points out that research has mostly focused on males, with either exclusion or limited inclusion of female subjects.
“Ultimately, this leads to continued high rates of injury in women’s health as well as (disparities in) treatment protocols,” she says.
Alicia Canzanese, DPM, ATC, FAAPSM, DABPM, DABFAS, agrees, noting that she has reviewed studies that show inherent gender bias in medicine towards female patients.1–3
“Bias in our education structure, gender bias in how we are presented with female patients, in the design and make of medical devices, in medical research, in literature, and in the practice of medicine itself,” she explains. “Doctors of all genders are exposed to this biased system. An important first step in overcoming bias is first acknowledging that the bias exists.”
It wasn’t until 1993 that the National Institutes of Health (NIH) mandated the inclusion of women and minorities in government funded biomedical research and clinical trials, notes Dr. Canzanese, but still, she says the number of female subjects is often inadequate.4,5
“Even if women are in the studies, sex- and gender-based analyses are not routinely performed, though there is a current push for the importance of sex-disaggregated data,” she says. “Female lab animals and cells from female organisms are rarely used (~80% are male).6 It is important for those doing research to understand that, and try to include more female patients, and to stratify the data for gender and sex. It is important for those doing research to understand that, and try to include more female patients, and to stratify the data for gender and sex.”
Women are more likely than men to have their symptoms dismissed. Dr. Canzanese brings up a study in the Journal of Clinical Oncology that cited ignorance of complaints as the major reason for diagnostic delay (52.2%) in cancers.7 Of that group that had their complaints ignored, 63% were women, notably those with mostly subjective complaints.
“In my own personal experience, I have seen many patients for second options who express that I was the first doctor who seemed to really listen, perform a hands-on physical exam, and ask appropriate questions,” she shares. “If I think back, I believe the majority of these patients were women. One example was a patient with shin pain. Other doctors told her she was just overexercising and anxious, but it turned our she was cycling with improper form and equipment. It was an easy and quick fix, but she wasn’t taken seriously by her other doctors who didn’t take the time to ask the right questions and made assumptions.”
Alyssa Carroll, DPM, notes that it is easy to get into a routine or have an algorithm for common podiatry conditions. However, clinicians must remain mindful of those unique factors that contribute to female patient pathology. She, too, encourages practitioners to review the available research and apply this knowledge to targeted patient workups.
Elizabeth Piselli, DPM, DABPM, also brings up a statistic that sheds light on the importance of better serving female patients. According to the Centers for Disease Control and Prevention (CDC), women are 33% more likely to go to the doctor when they have a problem and are 100% more likely to go to preventative care appointments.8
Aabha Suchak, DPM, FACFAS, DABPM, CWS, and Priya Parthasarathy, DPM, DABPM, FASPS, both say regardless of gender, it is very important for physicians to treat each individual patient and their specific problems with evidence-based medicine and at minimum, standard of care. They add that female patients go through different physiologic changes, and therefore have different resultant risks for certain conditions and health issues compared to males.
Q: In what unique ways do you feel DPMs should approach female patients from a biomechanical perspective?
A: In general, says Dr. Piselli, female patients have more ligamentous laxity than males and therefore the structural needs are different.9,10
“Women are not just little men—foot structure differs, they land and load differently, and that needs to be taken into consideration,” she comments.
For all patients, she advocates performing a gait exam on anyone that has any pain. “Treat the foot that is in front of you,” she says.
Dr. Parthasarathy cites certain conditions more prevalent in female patients, such as hallux valgus, Morton’s neuroma, and metatarsalgia that all rely on biomechanics and shoe gear to fully address.
“It is important to consider the unique biomechanics of the female patient in these situations,” she adds. “What is her current shoe gear? What is her occupation? What are acceptable alternatives to fit her lifestyle and profession (in light of the biomechanics)?”
Dr. Langone additionally stresses that women have a higher rate of knee pathologies, including anterior cruciate ligament tears. A component that contributes to this is the narrower intercondylar notch of the knee in women. This and a wider pelvic structure lead to an increased Q angle seen in women.11,12
Dr. Langone goes on to explain that clinicians must consider that women have numerous and significant morphological and biomechanical differences that impact gait, deformity, stability, alignment, and pathology. This includes, but is not limited to, greater internal hip rotation, greater weight-bearing knee valgum, increased hip excursion, greater hip adduction and velocity, less transverse plane control, slower recruitment of the vastus medialis, tighter hamstrings, less resistance to valgus knee stress, increased functional foot deformation in the longitudinal arch, and a thinner plantar fascia both at origin and insertion.13–22
Dr. Canzanese echoes these thoughts, adding that foot shape is not the same among genders and that applying these biomechanical differences to our understanding of the kinetic chain is vital. She advocates for clinically evaluating the Q angle, hip tilt and excursion during gait, cross-over, Trendelenburg sign, hip strength and other factors.
“Also, look at the entire limb and ask pertinent questions when there may be multiple joints involved,” she adds. “Are there any other associated symptoms? Could there be systemic or autoimmune issue? Look at the biomechanics but also be aware of specific red flags for other systemic conditions. As a podiatrist you may play a critical role in recognizing these conditions. With autoimmune diseases, on average, it takes five years and five doctors to receive a proper diagnosis.23 Half of these patients were labeled “chronic complainers” in the early stages of their illness and >75% of the patients are women.”
While most clinicians know to ask about pregnancy, says Dr. Carroll, she reminds that some may overlook postpartum and/or lactating patients, specifically, relaxin hormone and its role in decreasing collagen synthesis.
“Hormone regulation can take months after pregnancy or cessation of lactation,” she says. “The pathomechanics can be vastly different for these patients, especially in flexible deformities, and this should be taken into consideration in the evaluation.” Thus, Dr. Carroll recommends a thorough history include details on pregnancy, lactation, or hormonal therapy.
Dr. Suchak adds that clinicians must also remember osteoporosis when thinking about biomechanics, as it could impact shoe gear, inserts/orthotics, and activity levels.
“I frequently order X-rays and vitamin D levels on patients,” she explains. “Osteopenia and vitamin D deficiency can be diagnosed by a podiatrist and we can work with primary care to help improve bone health in our female patients, prevent stress fractures and fragility fractures.”
Q: In what unique ways do you feel DPMs should approach female patients from a sports medicine perspective?
A: Expanding the focus of one’s exam more proximally is key, says Dr. Langone. A thorough sports evaluation should include complete and total lower extremity joint range of motion and strength.
“The presenting issue (for female athletes) is the result of all the functional issues of the entire lower extremity,” she shares. “We must look above the foot and ankle to completely and successfully treat the female patient.”
Dr. Canzanese agrees, adding that clinicians must take their female athletes seriously, asking questions to understand their fitness level and goals.
“Don’t assume the main fitness goal is always aesthetic,” she says. “Don’t assume their athletic and functional demands aren’t as high or as important as those of their male counterparts.”
The literature supports that gender disparities and even “gender blindness” are a concern in musculoskeletal medicine, meaning not only are there challenges that female patients face in treatment, but ignoring the key anatomic and physiologic differences can also prove problematic. For example, females with chronic knee pain, she cites, have been found to receive referrals for total knee replacement less frequently and further along in the disease process than males.24 Research has also suggested that doctors prescribe diagnostic tests sooner and more often for men versus women with similar orthopedic conditions.25 Dr. Canzanese also points out that even in certain musculoskeletal conditions that occur more frequently in female athletic patients, females are not often the subjects in research studies.26
Dr. Carroll feels that incorporating more nutrition counseling into care plans for female athletes is one potentially effective approach.
“From bone density to caloric needs, these active patients need to ensure they fuel their bodies adequately,” she adds. “Depending on the sport and the patient’s age, these needs vary, so taking time to educate these women will set them up for success.”
One key perspective on treating female athletes that Dr. Piselli advocates for is that clinicians should know about the impact that different phases of the menstrual cycle can have on injury profile and muscle torque, specifically in the follicular phase.27
Dr. Suchak raises a unique condition as a vital component of an approach to this patient population.
“As sports become more competitive at an earlier age, it is important to keep relative energy deficiency in sport (RED-S) and the female athlete triad syndrome in mind,” she says. “RED-S is a syndrome named by the International Olympic Committee in 2014 to screen athletes.28 It discusses lack of fuel, which can contribute to poor overall health and poor athletic performance. The female athlete triad includes osteoporosis, amenorrhea, and eating disorders, which is helpful in diagnosis during one’s teenage years.”29
Orthotic therapy is an important factor, says Dr. Parthasarathy, with its own challenges related to types of female shoe gear.
“It is important to review shoe gear and orthotic accommodation with the patient,” she says. “I provide a shoe guide of all types of shoes that can accommodate orthotics.”
Echoing the panel’s previous points on the female athlete triad and nutrition, she also cautions clinicians to have a higher index of suspicion for stress fractures in these athletes, and to obtain thorough histories related to bone health and eating habits to make any of appropriate diagnoses and referrals.
“Any signs of osteopenia on plain X-ray, coupled with a history of amenorrhea and evasiveness about eating habits, should prompt further investigation,” she explains. “Making the appropriate diagnosis can prevent future injuries.”
Q: What additional key pearls would you like to share to help improve outcomes for female athletes?
A: The panelists mention several items in addition to those previously discussed: dive deeper into menstrual cycle trends if needed, discuss protein intake, assess bone health, supplement vitamin D when needed, advocate for more evidence-based treatment recommendations in the literature, and work with a multidisciplinary team, including dieticians and athletic trainers.
“I believe that nutritional profiles need to be performed or registered dietician referrals need to be made for any athletic patient that is not getting better despite adequate rest and rehabilitation,” says Dr. Piselli. “This can be especially true for patients who have recently started an exercise regimen without properly researching how to fuel their bodies.”
Q: In what unique ways do you feel DPMs should approach female patients, including athletic patients, from a surgical perspective?
A: Dr. Canzanese encourages appropriate and targeted assessment of pain. Studies show women are less likely than men to receive postsurgical narcotic pain medications.30 She notes that stereotypes may exist that women have a high pain tolerance due to events like childbirth and menstruation. These stereotypes can begin in childhood, as evidenced in the literature as well.31 Additionally, chronic pain in women is more likely to be ascribed to a psychological cause, while men are more likely to receive a referral to pain management.30
Deep vein thrombosis (DVT) prophylaxis is also a point for focus in female surgical patients, she notes. Women are less likely to receive DVT prophylaxis and more likely to die of a postoperative DVT than men.32 Men were 21% more likely than women to receive prophylaxis.
Dr. Carroll agrees with the importance of focusing on DVT prophylaxis, but adds that preoperative anxiety is a lesser recognized important concern.
“Using a tool like Caprini Scoring System33 is great for DVT risk stratification because it is straightforward and helps determine appropriate protocol,” she explains. “A study by Freidrich and team found preoperative anxiety to be highest in female patients.34 While better management protocols are needed, it’s great practice to take extra time to really prep the patient and walk through the entire (perioperative) process. Understanding the ‘road map’ and decreasing the unknown can go a long way.”
Dr. Piselli thinks all podiatric surgeons should have frank conversations about shoe gear expectations postoperatively and check to ensure they have the help and support they need at home. Specifically, to check that there aren’t people dependent on them that would prevent adherence to the recommended weight-bearing status.
Also, patients assigned female at birth are 3 times more likely to experience complex regional pain syndrome (CRPS), especially if they smoke, have diabetes, or other chronic disorders, she points out.35
“I would recommend prophylaxing with vitamin C and educating the patient to be honest about their pain, so you can be aggressive about treatment should CRPS occur,” says Dr. Piselli.
Dr. Suchak acknowledges the complexities of best serving female surgical patients, including female athletes. She reinforces the importance of bone health evaluation and having realistic conversations about the postoperative course. She additionally recommends checking vitamin D levels prior to proceeding with bone surgery and not operating on patients who communicate unrealistic expectations.
Q: In what unique ways do you feel DPMs should approach female patients from a wound care perspective?
A: Although athletes are not the first population one thinks of in wound care, they certainly can sustain traumatic wounds, and patients of all generations pursuing an active lifestyle may also cross into this population category. Nutritional status is one important factor to consider in wound care that many of the panelists mentioned.
They noted chronic anemia, along with pre-albumin, albumin, vitamin D, and hemoglobin A1c as being impactful metrics to consider. Patient education is also something Dr. Piselli incorporates intentionally into her practice across all populations, including for wound care.
“I give handouts to my patients for any home care that they need to do, not just for wound care,” she notes. “I find this really has helped my patient outcomes. Often a patient is nodding (agreement) in the chair but the stress of having a wound can mean they forget everything you said the moment they leave the office.”
Q: Please feel free to share any final thoughts that you especially hope readers will apply to their practices upon reading this roundtable.
A: The panelists all agreed that good, sound, targeted practices to improve outcomes for female patients and female athletes can also reap rewards across broader patient populations, as well. Themes of personalized, focused care, taking the time to dive deeper, and considering the unique aspects that each patient brings to the process emerged repeatedly. However, they are passionate about working to overcome challenges faced by female athletes and other female patients in medicine.
“Successful treatment of the female patient must involve keeping abreast of the latest research and comprehensive and thorough evaluation of the patient both on and off weight-bearing,” says Dr. Langone. “These practices will deliver the best results for the patient.”
Dr. Suchak agrees that keeping on top of the research is vital. Taking the additional time and steps to address what makes our female patient population unique is also essential, says Dr. Carroll.
“Getting familiar with how dynamic the female patient is will surely make you a better provider,” Dr. Carroll notes. “We also need more research for women not assigned female at birth and individuals assigned female gender at birth but who identify differently or have undergone hormone therapy.”
Providers may be tempted to treat in too “cookie cutter” a fashion. But Dr. Piselli says there are ways to balance evidence, protocols, and personalized medicine.
“I am very protocol-driven, but I think it’s important to remember to treat each patient as an individual with unique needs and hurdles to jump in order to heal,” she explains.
Dr. Canzanese encourages readers to examine the concept of bias in medicine as a whole, including explicit and implicit bias, and understand it is not perpetrated by one particular demographic.
“(These conversations) are a commentary on healthcare as a whole, and what we can do to make it more equitable,” she says. “Gender bias in medicine is a cooked-in systemic issue. It’s presented to us all in our education and in our research. Remember, the first step to improving outcomes for our female patients is acknowledging the issue, acknowledging potential biases, and then taking steps to improve.”
Published in partnership with the American Association for Women Podiatrists.
Dr. Carroll is a Co–Vice President of the American Association for Women Podiatrists and practices in Raleigh, NC.
Dr. Canzanese is a Fellow and current President of the American Academy of Podiatric Sports Medicine and a member of the American Association for Women Podiatrists. She is an adjunct faculty member at Temple University School of Podiatric Medicine and practices in Glenside, PA.
Dr. Langone is a Past President and Fellow of the American Academy of Podiatric Sports Medicine and the Immediate Past President of the American Association for Women Podiatrists. She is a member of the American Board of Podiatric Medicine’s CAQ on Sports Medicine Committee and the American Podiatric Medical Association’s Diversity, Equity, and Inclusion, Podiatric Population Health, and Education and Legislative committees. She practices in Hampton Bays, NY.
Dr. Parthasarathy is Chair of the APMA Communications committee. She is also President-Elect of the Maryland Podiatric Medical Association and a member of the American Association for Women Podiatrists. She is the former Podiatry Section Chief at Medstar Montgomery Medical Center and practices in Silver Spring, MD.
Dr. Piselli is the current President of the American Association for Women Podiatrists and practices in Rockville Center, NY.
Dr. Suchak is a Co–Vice President of the American Association for Women Podiatrists. She is an Assistant Professor in the Section of Podiatry, Department of Orthopaedics, at West Virginia University School of Medicine, practicing in Waynesburg, PA.
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