Risk Factors for Patellar Chondral Surface Injury in Professional Female Footballers
Screen this athlete immediately for Relative Energy Deficiency in Sport (RED-S) using the Female Athlete Triad Coalition cumulative risk assessment tool, as low energy availability is the single most critical modifiable risk factor that increases bone and cartilage injury rates 4.5-fold in female athletes. 1
Critical Intrinsic Risk Factors
Energy Availability and Hormonal Status
- Low energy availability affects 26-33% of female collegiate football players during the season, creating a mismatch between energy intake and expenditure that directly impairs cartilage and bone health 1
- Menstrual dysfunction occurs in 9-19% of female footballers and indicates chronic energy conservation that compromises tissue repair capacity 1
- Female athletes classified as moderate or high risk on the Triad assessment tool have 2.6- to 3.8-fold increased risk for stress injuries compared to low-risk athletes 1
- The LEAF-Q (Low Energy Availability in Females Questionnaire) should be administered to classify energy availability status 1
Biomechanical and Anatomical Factors
- Previous injury is the strongest predictor of subsequent injury in female footballers, with prior bone stress injury increasing recurrence risk sixfold 1
- Increased joint laxity is associated with higher injury risk in elite female players 2
- Low hamstring-to-quadriceps (H/Q) strength ratio increases injury susceptibility 2
- Deficits in balance and coordination correlate with increased injury rates 2
- Body mass index variations affect injury risk, though optimal ranges vary by position and playing style 2
Skeletal Maturity Considerations
- While this athlete is professional (presumably skeletally mature), skeletal immaturity increases risk of isolated patellar-based injuries when they occur 3
Extrinsic Risk Factors
Training Load and Exposure
- Higher soccer exposure directly correlates with increased injury rates, with game incidence (24/1000 hours) being 3.4 times higher than training incidence (7/1000 hours) 4
- Sudden increases in training volume or intensity without adequate adaptation time represent the primary modifiable mechanical risk factor 5
- Physical contact with opponents accounts for nearly 80% of traumatic injuries in female elite players 4
- Playing position influences risk, with defenders and attackers at higher risk due to opponent contact 6
Seasonal and Temporal Patterns
- Overuse injuries occur predominantly during preseason training and at the beginning and end of competitive seasons 4
- Traumatic injuries peak at the beginning of the competitive season during games 4
- Fixture congestion periods increase overall injury susceptibility 1
Psychological and Systemic Factors
Mental Health and Stress
- Psychological stress and depression are associated with increased illness and injury risk 1
- Disordered eating affects 8-24% of female footballers and contributes to energy deficiency 1
- Unrealistic body composition expectations can drive severe energy restriction 1
Nutritional Deficiencies
- Inadequate protein-energy intake impairs tissue repair and immune function 1
- Calcium deficiency (RDA 700-1000 mg/day) compromises bone and potentially cartilage health, particularly with high sweat losses 1
- Magnesium deficiency affects energy production, muscle function, and has been linked to tendon pain in athletes 1
- Iron deficiency impairs high-intensity performance and tissue healing capacity 1
Clinical Implications for This Case
The presence of patellar chondromalacia with surface delamination and underlying edema in a professional female footballer with no definite trauma history strongly suggests an overuse mechanism potentially compounded by energy deficiency. 1
Immediate Assessment Priorities
- Administer Female Athlete Triad Coalition cumulative risk assessment tool to stratify RED-S risk 1
- Evaluate menstrual history and function as a marker of energy availability 1
- Assess recent changes in training load, body composition goals, or dietary restrictions 1
- Screen for disordered eating behaviors using validated tools 1
- Evaluate nutritional intake, particularly calcium (target 700-1000 mg/day), protein, and overall energy balance 1
Common Pitfalls to Avoid
- Do not attribute the injury solely to mechanical factors without screening for RED-S, as this misses the underlying systemic contributor 1
- Do not delay nutritional assessment while focusing only on local cartilage pathology 1
- Do not implement body composition changes or caloric restriction during injury recovery, as this will impair healing 1