Monday, February 28, 2005. "The Evolution of the Female Athlete," Dr. Bert Mandelbaum.

 

MS. HOGAN: Hello, everyone. Grab a last cup of coffee and be seated, and we'll start with the second part of our program this morning. It sounds like the first day of school when everybody returns and they're so glad to see each other.

 

It's my pleasure to introduce Dr. Bert Mandelbaum, orthopedic surgeon extraordinaire, champion of female athletes, and, most importantly, my friend and Rachel Mandelbaum's dad.

 

Before I get to the specifics of his introduction, I have a few personal comments I'd like to make to the group. First is to thank Bodie, Reveta, and Bruce for bringing us all together here, and for finally letting me back into the organization personally. I want to show you that I have a rose. I'm going to keep this for forever, because I hope not to have to be let back in again. My first meeting with this group was in 1985. Nancy Kussrow was the executive director. I can't remember where we met at the time, but Billy Collins' poem allows me to understand that there will be many things that I will not be remembering as I go on. I was a regular attendee for 13 years, and then moved to Los Angeles to help a group of people start the Archer School for Girls, which will be ten years old next year, with 500 students.

 

That was one of the things that I said I would never do. I would never live in LA, and I would never start a school. So I would say to all of you, be careful what you say "Never" to, because there's a good possibility it's going to come and get you when you least expect it.

 

I know this conference is about mentoring, and I made an executive decision -- I make a lot of them and I just tell myself that I'm doing these things because no one else wants to listen after 20 years of heading schools -- but my decision is that this will be National Mentors Week. It will develop into a Hallmark holiday. The reason I bring this up is my mentor, Edes Gilbert, is in the room. I was thinking how few opportunities one gets to thank the people who had the most profound impact on your life. This is my twentieth year of heading schools. If it hadn't been for Edes, who was then at Mary Institute, I never would have had the crazy idea that I was capable of doing something like this, and would have missed 20 wonderful years of stellar opportunities. So to Edes and to all of the people who mentored us and got us into these crazy jobs, a big thank-you. Reach out this week and thank your mentor. (Applause.)

 

Now, about Dr. Mandelbaum: First of all, you need to know that Bert is the go-to guy in LA if you are having any problems orthopedically. You know how in all cities, if something goes wrong with you, five people will say, "You have to see Dr. So-and-so." Well, this is the have-to-see person.

 

This man has no free time. He travels around the world working on behalf of women's athletics. You can read in your programs so I won't repeat it. He has been involved with the Olympics. He's very dedicated to the evolution of the female athlete. And yet he's one of these human beings who is so gracious and so giving, he will always find time to do what he's asked to do if he thinks it's important. He always finds time for his patients. He always finds time for his daughter's school. It's an amazing role-modeling and a vivid example of how stretched a human being can be and still be so gracious and wonderful.

 

In looking through the papers that Bruce gave me -- Bruce had downloaded a few things from the Internet -- the first thing I pulled out said he treated Arnold Schwarzenegger. I don't know that that's a claim to fame, but this is the kind of person who would go to somebody like a Bert Mandelbaum.

 

His other claim to fame, which I think Bert would probably say is the most important thing in his life, is that he is the father of a spectacular ninth-grade girl at the Archer School who is a poet, an athlete, a pioneer, and just an all-around neat kid. I believe that so much of that has come from a cheering dad on the sidelines who has given her the feeling that she can do anything she wants.

 

I could go over his long list of medical accomplishments and it wouldn't serve as much purpose as to say we are going to hear from a spectacular doctor, a wonderful human being, and most importantly, a great dad, Dr. Bert Mandelbaum. (Applause.) (1)

 

DR. MANDELBAUM: Thank you for having me here today, for a number of reasons. As you heard in that outstanding talk earlier, we're interested in young people. We're interested in young people's welfare. We're interested in body, mind, and spirit, and as Ross so eloquently stated, it is really an integration of variables. Sometimes what happens in evolution is actually concepts-changing. A little light bulb goes off, and then technology kicks in, and then together that integrates what we call evolution. Steps, sequentially, over time, physically, psychologically, emotionally, as Ross so eloquently put it, from the mind standpoint, called out. He deserves a tremendous hand, because what's so compelling about Ross' talk is that, in fact, he is our children speaking to us, telling us in a very articulate and emotional way what we need to hear. So my kudos go to Ross for such an outstanding talk, and I'd like to give him a hand. (Applause.)

 

Having an opportunity to come to a conference such as this, I reflect on the clinicians and scientists with whom I spent last week at our American Academy of Orthopedic Surgery. When we deal with patients and people, we need to understand and make observations, and we need to push science and medicine in new directions, and we don't really understand exactly how and where we go from there.

 

Our children are in your responsible hands, and many times there is a drop-off and no bridge between what we all do in medicine and science and what you do every day of your lives, so it's critical that this partnership, this collaboration on multiple levels be done. I will say that perhaps one of our societal problems is the fact that there is a gap between you here and us in Washington. And I'd like to take the opportunity to build that bridge between different organizations, because when one day I sit in a meeting, discussing how important it is to implement what we're saying, you are the vehicle to help us implement that. So it's critical that we must think this way.

 

It's an interesting time that we're in. As parents, as physicians, as members of society, we have several issues to deal with. We have our young female athletes who are ninth, tenth, eleventh graders, who boast -- boast -- about taking five AP courses, who boast about going between club volleyball and club soccer, who come home and do their homework between 10:30 and 1:00 in the evening.

 

Fortunately, that's not my daughter at this point in time, because we absolutely won't let her do that. But I will tell you that if we allow that, it is going on in so many children's households, to the point that I sometimes call it child abuse. And as I speak to parents, I say, "Why would you hold her to that standard? You didn't do that."

 

I played one sport per season. I was a good athlete and I played three seasons. But it was only one at a time. And I did AP courses. I only did one. I didn't do five. So why are we holding our kids to these standards? Why? "Oh, it's very competitive now." It wasn't 20 years ago? Of course it was. Perhaps numbers are different. Maybe not.

 

But I think it's concepts and technology and evolution. We're confronted here in 2005 with these issues, and there is a compelling story here, and that compelling story is what I'm here to talk about.

 

First, the time is now for our daughters and our schools, our wives, and our mothers to understand how the paradigm has to change. The story starts in the beginning. An historic evolution. We're going to focus on exercise, sport, young and old, benefits and risks, and what we're going to look towards in our future, as we look at these young people, as we move forward, and how we misunderstand it as we change the paradigm.

 

The male athlete is well broadcast and much written about. You see that evolution. It comes out of Africa seven million years ago. The Pliocene, Pleistocene, and Miocene eras all brought to us an evolutionary sequence. Australopithecus, the quadruped. Homo erectus, the biped. Homo sapiens, Neanderthal man, hunter-gatherers, 10,000 years ago, becoming athletic, focusing on survival mechanisms only.

 

As we go further in evolution, we think about the female. The woman or girl walks only close to the cave with a baby on her front or back. And interestingly enough, she only had a baby once every four years. Why? She could only carry one at a time. One on the front or the back, as you see here. How did I get that picture? That's Zambia in 2004, just like it was hundreds of thousands of years ago. Carrying children on the front or the back, having babies once every four years, but never as stalkers and gatherers. So the female is at an unprecedented level in terms of understanding this.

 

The male athlete has some tremendous images. My son, who is 11, looks up to all of these and is so inspired by these images. But the female doesn't quite have that luxury.

 

The female story starts in the Book of Genesis. And God created the first man, as we all know. Adam, of course. But remember that Eve was an afterthought. Regardless of whose books you're reading, Eve was an afterthought. And whatever Bible you're reading, it's androcentric at all times. It never changes, regardless of religion, and there's nothing regarding sports and the female athlete.

 

These are all new principles. As we move through early civilizations, we go into the Phoenician civilization and we learn that the Phoenicians were great merchants and traders of the Mediterranean. There was absolutely nothing regarding female or athletes.

 

As we think about ancient Greece, we learn from Homer about the Trojan War and the Iliad and, of course, the Odyssey. We learn about Achilles, the Greeks' revenge, of Helen, the wife of Menelaus, king of Sparta, by Paris, the Trojan prince. And en route to Troy, Achilles kills the queen. And it was actually the Amazons at that time, allied with the Trojans -- a story not told very much -- which is the first time we really get the sense that women were involved in battle of any kind.

 

As we look toward ancient Greece, 1280, we hear the stories, we learn about the Trojan horse. Achilles was killed. We all know the story. Your students all read it in the ninth grade and are well-versed in all these details. Ulysses returns to Greece.

 

In Greece, in 776, in honor of Zeus, the Olympic Games were begun. They were offered up to the gods, to appease them and combat a devastating plague that existed in the Peloponnese at that time. King Iphitos of Elis said the Delphic Oracle proclaimed the Olympiad.

 

From that point on, the paradigm changed. Evolution, concepts and technology. The Olympics was born. Now, there was only one event at that time: Running.

 

The problem was that in this Athenian democratic society, women, slaves and convicts were barred from participating or even watching the Olympic events. They had no involvement in any way, shape, or form in the Olympic Games at that point in time. She was an outsider.

 

As we move towards 479 and 323, we begin to learn, as you well know, the concepts of body, mind, and soul, where they all originated. We learn within the Greek and Athenian society, the writers of poetry, Alcaeus, Aleman. Drama, Sophocles, Eurypides. Philosophers Plato, Socrates, Aristotle, Euclid. Aristotle was a wise man, perhaps one of the great medical philosophers of his time. We learned about Euclid, Diogenes, what we now uphold as the foundation of today's culture and society.

 

As we move forward in Greek civilization, we learn that Aristotle, 331 BC, said that Olympic victors were those men -- not women -- who did not squander their powers by early and over-training. What did he say? "Do not squander those powers by early and over-training."

 

Let's go back to that 11th grader doing volleyball and soccer, simultaneously, five AP courses. "Do not squander those powers." 331 BC. Again, concepts and technology and evolution of our time. And he had the wisdom to understand that at that early point. We need to heed those warnings.

 

In 300 BC, Kallipateira was a priestess of Demeter. There are very interesting writings about her. She was noble, monied, and loved, and wanted to participate in sports. Because she had money, she was allowed to watch her sons, who were very competitive athletes. Perhaps there was a connection between her and some of the games, the Heran games for women. Running was the only sport at that time.

 

Later there were Pan-Hellenic festivals, in Isthmia, Pythia, Nemea, Sicyonia, and the Asclepian games, all of which focused on the female athlete, all of which were only in running.

 

Unfortunately, there are no other records, and there's a blank from that point on in terms of exactly what happened through Greek civilization, other than in Sparta.

 

The Spartans trained girls to be warriors, and everything in Spartan society was focused on battle. Mothers would train their daughters because they were part of war, freed from delicacy and effeminacy. The reason was to create powerful male and female soldiers.

 

On the other hand, Athenian society was opposed to the concept, but Plato said that women should be part of every society. If you go to the Acropolis, what you find there -- and most people don't know this -- are six women at the Parthenon. The six women are standing apart from the building and it's there to symbolize that females could stand alone in society. And this is a very important part, but not spoken about in terms of Athenian society at that time, but Plato urged that it be upheld.

 

As we move forward to the Roman Empire, 100 BC, we learn the Punic Wars came to an end. It was a savage war between Carthage and the Romans. In 80 BC they built roads and aqueducts and the Coliseum for the gladiators. But never, ever a female athlete. It was never even a consideration within this group.

 

We learn from 80 BC to 400 AD of Galen, who is considered the first sports physician, who was amazing. He discussed some basic principles. He said that athletes overindulge, they live shorter lives, and get arthritis. Sound familiar? Again, we must listen to history: concepts and technology in evolution over time.

 

In 394, Theodosius ended the Olympic games, because he said that you cannot worship God, that you are pagans. And that led to what? The fall of Rome and a sequence of events, in addition to several earthquakes, which eliminated any focus of society on sports whatsoever. So with the earthquakes and Theodosius, out went the Olympic movement. And what's fascinating, from this point on, there was absolutely no talk of Olympic sports, exercise, society, concepts, and it became what we know as dark ages overall, specifically for the athlete.

 

It was an interesting time. The Dark Ages, 700 AD to 1400 AD, brought the Moors. It gave us architecture, art, and medicine. Avicenna, who wrote a lot about medicine and some basic principles. Women and sports were suppressed at all times. And it wasn't until the 1400s to 1500s, in the reconquest, where Moslems and Christians were pitted against one another, as you see in this painting, from the Prada in Madrid, Spain. And at that point the re-conquest, the Inquisition, led to Christianity taking back Europe.

 

This led to several events. In fact, it was at the behest of probably the most influential female in history, Queen Isabella, at least in relationship to the United States, that Ferdinand solicited and found Columbus. Ultimately, in 1492 and beyond, the New World, the Colonies, were discovered. This ultimately led to the golden age of the monarchies in Europe, the Bourbons, the Hapsburgs, and ultimately our recent American history, our founding fathers, who believed that men were subservient to God, and women to men.

 

We learned that in English common law, women had a nonexistence. They had no rights. They could not own land. They weren't part of the initial constitution. The Puritan ethic was that women were the weaker sex. They had names such as Weaker, Pious, and Obedience. We listened to Abigail Adams in 1780 who said to her husband, "John, please remember the ladies and be more generous to them than your ancestors." But he wasn't.

 

In 1850, we began to see the women's rights movement enmeshed in the abolitionist movement, and we began to see some movement in terms of women and slavery.

 

In 1894 -- and again, there were no Olympics from that point in 394. Pierre de Coubertin is now thought to be the founder of the modern-day Olympics. He was intrigued and excited about these old Greek concepts. He said, "Let's think about this again, and let's reactivate the Olympics," and he is credited as being the founder of the modern-day Olympic Games.

 

He said, interestingly enough, that the games were reserved for men and, what's more amazing, the female body was controlled by nerves, not muscles. What was he thinking about? And he said that if women participate in our Olympics, children run the risk of being motherless. And this is the founder of the modern-day Olympic Games.

 

He also said that there would be a loss of decorum at the events and, quite frankly, it is not natural. These are all his quotes, well-documented in history.

 

Well, look at women's participation in 1900, 1908. Olympics tennis, golf, archery, and figure skating were the only sports in these Olympic Games. By 1920, Susan B. Anthony's movement gave women voting rights, as you well know.

 

In 1932, there were some great athletes. Babe Didrikson was the ultimate female athlete, competing in the decathlon, and she certainly proved to the world that women could do it at the highest levels.

 

In recent history, we have different images. In 1972, the Equal Rights Amendment gave us voting. In 1972, Title IX gave equality in collegiate sports, which subsequently led to images such as this that we see today and we take for granted. It's important to recognize exactly where these came from. 1984, believe it or not -- we forget about this -- was the first women's Olympic marathon, and by Athens 2004, here we are winning the gold medals, which was one of our most proud moments in US history.

 

How about this situation? How does it all balance out? At the time I was in high school, in 1972, we had 3.7 million boys and only 294,000 girls. That's incredible. Look at today. 2.7 million girls, 3.9 million boys in high school sports. So just the statistic alone is your statistic. That's what you all are dealing with in this tremendous change.

 

So when you hear the father on the sidelines who says, "The way we did it in 1972, buddy," there were only 294,000 girls at this time. This is new stuff. You have got to learn concepts, and technology, evolution over time.

 

The 1999 World Cup, the largest single athletic event for women in history. And Mia Hamm helped us celebrate that.

 

By the year 2000 in Sidney, there were 29 sports and 3,700 female athletes. It was great to see that participation.

 

By 2003 the US Women's World Cup, we learned a very interesting principle: Democratic countries expressing democracy through women's sports. Germany, Sweden, Norway, China, and the US obviously, Australia, Russia, and others. But interestingly enough, Moslem countries suppress the sports. Saudi Arabia, Iraq, Afghanistan.

 

And lastly, another group of countries, the underdeveloped countries, are under duress. Express, suppress, and duress. As Arlene Hogan and I have learned, if we educate a girl in an underdeveloped country, there are three children per mother. But with no education, there are six children per mother. A simple statistic, but how impactful.

 

But sports is all where it starts. Democracy, suppression, and duress. All in sequence, all potentially on the athletic field.

 

Our recent history is: Where are we now and where do we go from here? And I think it's a great opportunity for us to think about these issues and put together some basic principles about how this all starts.

 

It all starts in the trends of the 21st century that we know now as the soccer mom. The soccer mom is an interesting beast, coming from evolution. But I can raise my hand, and many of you are suburban dads, who not only live in suburbia, but drive to suburbia. Hence the suburban dad.

 

We know that youth participation is growing. Organizations are growing. There are 18 million soccer players in the United States. AYSO. How many of you are associated or have had children in AYSO? So you know this acronym. AYSO means "All your Saturdays are over."

 

Clubs all year. Hockey, soccer, ring time. I drive my daughter home from club volleyball at 10:00 at night, because they can't get enough gym time. But what's the benefit? What's the risk? Why we doing this? What is it all about? And how do we think about it? We develop this very interesting partnership with our children, and what I'd like to say is, there are good and bad and ugly details to it.

 

We also must understand concepts and technology. In the book "See Jane Run" by Rimm, we learn the competition is the key to future success, regardless of the chosen career, whether it be in the arts, in medicine, in law, in education. Competition is the key to future success. And it's so critically known and understood over and over in our populations as we move forward.

 

But the problem is, we have media images. Girls dare to dream on all these levels, and they see tremendous potential opportunities by these great athletes: Golf, tennis, basketball, volleyball, soccer, hockey, water polo, dance, and Olympic sports, gymnastics, track, skiing. The media organizations are bringing it to us, so now girls are seeing these images and wanting to be the best they can. Citius, altius, fortius.

 

But they're limited, and limited by -- what is that? We're limited by corporate America. As you see in this particular sign, "The price of saving the WUSA," the only professional women's organization. "The price of saving my daughter's dream: Priceless."

 

It's limited because corporate America does not believe in this in the same way. It's a real conundrum. In golf, we know that individuals can do it. In tennis the Williams sisters have done it. In basketball the WNBA does it because it's married to the NBA. In volleyball, AVP is just about bankrupt.

 

But Olympic sports continue in a very successful way. They continue to evolve, and again, our young female athletes continue to follow that Olympic credo, "Citius, altius, fortius." "Faster, higher, and harder."

 

They continue to see these images and move those concepts further and further to impact their life at the highest level.

 

We must think about this in philosophy as a circle in life, in terms of where we put sports in this progression. We must understand that in life we are children to our parents, we are parents to our children, parents to our parents, and lastly, children to our children. It's that cycle that becomes very important to understand, because we must understand where along this axis, this cycle, do we think about exercise and sports? We must understand how to be parents to our children.

 

Sports and exercise remain our only fountain of youth at all ages. We must understand that obesity affects 64 million Americans. On the other side, there's a balance of faster, higher, stronger, too little, too much, and how we think about these issues as we move forward. There's national societal pressure: Homework, homework, homework. More, more, more. But what are the benefits and what are the risks and how is this incorporated in what we know as success, and the blend of how we want our kids to be successful?

 

It is all of you in partnership with all of us who will define what success is all about. One of the perhaps most important icons in my life has been getting to know John Wooden. Over the last 25 years I spent a great deal of time with him, listening to what he has to say, and I speak very little, because he's a tremendously wise man.

 

I have learned a lot about what is success. He says the peace of mind of knowing that you did your best to become the very best you are capable of becoming is perhaps one of the best ways that I think of success. And he bases this on the pyramid of success, industriousness, loyalty, creativity, teamwork, friendship, and enthusiasm. Again, putting these elements into schools, corporations, law firms, political organizations, the United Nations, embodies what success really has to be about.

 

So how do we think of ourselves, then, as mom to our children? Again it's the fountain of youth and understanding how important this balance is in our own lives. Our goal as mom is to live longer with a better quality and more quantity, obviously.

 

But we have a major problem. In the last decade there has been a 14 percent increase in obesity in America. Look at the evolution of man, because that's where we're going in many ways. We're seeing a society that on one side I'm worried about too much. On the other side, 64 million Americans are constantly transforming bone, cartilage, tendon to what? Adipose fat tissue. And it's associated with significant arthritis. Why is this important? Because once our joints become arthritic, we lose the fountain of youth. We can't be active. We can't clean our blood vessels, keep our brains free. We then end up having a significant problem.

 

How significant is this problem? Well, look at this statistic coming from the Rand Corporation. Since 1986, these are women with greater than 50 BMI. Greater than 50 BMI for a woman is 5'5", about 270 pounds. And look at this progression. For BMIs 50, 45, 40. 40 is about 230 pounds. 35 is about 210 pounds. But look at this increase in our society. So we need to think about the importance of this. This limits their lifestyle from a very different perspective. Why is this?

 

It's about super-sizing everywhere we go. There are many competitive hypotheses. People are working more. There's less exercise. There's transportation, TV, fast food. There's no comparative data, because we've never had this in the history of man -- or woman. We must understand this, get a better handle on these societal trends.

 

Here's one of those trends. In 1987 you see sporting goods and bicycle shops -- pretty flat. Not a whole lot of increase. But look at radio and TV stores in this interval of time. Tremendous and significant exponential increase.

 

How about cable TV? Let's look at cable TV, professional sports clubs, promoters. Here's TV. Look at the significant difference over time. This is a trend that is really causing significant havoc in our society.

 

So when we talk about the trends in societal issues, we must talk about the benefits of exercise, in terms of physiology, greater fitness strength, less body fat. For those who ask the question, pregnant women and their babies do much better with exercise overall. We also understand the physical. You're healthier, have a younger appearance, greater muscle tone, you don't lose your muscle or bone in the same way. And also psychologically, the improved spirit has been shown, study after study. Improved self-esteem, school and work productive, the use of teamwork, are all parameters that have been shown to have a statistically significant effect by involvement of young female athletes in club and other sports. So these are the three Ps, the major benefits of sports and exercise as we know it.

 

Also sociologically, the family and team dynamics. Lastly, the category of therapeutic intervention that could help obese young people, those with cystic fibrosis, ADD, diabetes, Down's syndrome, and also those individuals who have had cardiopulmonary transplantation. So the benefits of sports and exercise are significant.

 

But the risks should also be considered in this major equation. We talk about burnout, and as Ross pointed out, eating disorders. Physiologic issues, dehydration and heat issues. We hear about deaths in August all over the country of individuals participating in a variety of sports. And then physical, the injuries that I'll speak to in a second.

 

One of the issues that we must talk about is the burnout issue. The greatest risks are the most intense sports, such as gymnastics, swimming, soccer, and dancing. Those of you who work in schools hear young athletes say it's no longer fun. It becomes a challenging thing overall. They many times may even feign injury or pain to get themselves out of it. Ninth, tenth, eleventh, twelfth graders, who take five AP courses and do two sports -- you can't tell me that's fun. There's nothing fun about that. That's too much. So it's got to be fun for the parents and it's got to be fun for the kids.

 

Otherwise, we're going to see more situations like this which result in death. So it becomes a challenge for us. And one of those issues is eating disorders, which are even more complex. We learn about anorexia, bulimia, we learn about eating disorders not otherwise specified. On the other side, we learn about obesity.

 

We are learning more about the balance of the female athlete triad, between anorexia, low bone density, stress injuries, loss of menstrual periods. It's becoming a much more significant issue.

 

This has to be factored into the issues, the basic classical issues. This is a picture of Vince Lombardi, the famous coach who said, "No pain, no gain." He wasn't talking to young female athletes at the time. He probably knew nothing about female athletes in 1965. He was talking about these offensive linemen on Monday morning. "Guys, we got another game next week. No pain, no gain." He wasn't talking about young female athletes. We must understand that.

 

I frequently hear girls using these words, but it has nothing to do with that. We must separate those concepts out. We must also understand the relationship between the age of initiation and that progression. When should we start a young female? When should we start her doing what parts of activities? When should we lift weights? We also must understand that more is not better. More is less. Five to seven games in a weekend is a problem.

 

I spend a lot of time in our national organizations trying to convince people that it's not just about how much money you can make in a tournament. It's about these kids playing soccer in 17 degrees in Lancaster during the weekend who walk around looking like zombies at the end of it. You must have rest phases, and it must be balanced overall. We need to increase quality, not quantity.

 

One problem that we have in female sports is ACL and cruciate ligament injuries. It's common in sports, but even a bigger problem in female sports, a two-to-eight-times-greater incidence amongst our young female athletes. The peak injury is right in your schools, between the ages of 14 and 16. This is something, as the leader of your school that you must have an understanding of. I just want to tell you some basic issues. Athletes in basketball, soccer and volleyball are most susceptible to these kinds of injury.

 

We have looked at all these risk factors: Anatomy, hormones, environment, shoes, equipment, surfaces. We came up with what we call biomechanical or muscular details. The fact that the woman runs and jumps in a much more extended position at hip and knee, running flat on her feet, rather than up on her toes, is probably most responsible for that.

 

There are some other very important neuromuscular issues I want to point out. I know most of you are not physicians or scientists, but you'll understand this when I explain it to you. When we do this in the laboratory, and look at women running in comparison to men, they run and cut very differently. This is the female. She's in much less extension, significantly different than the male. When she makes that cut, she's upright. When that young boy makes that cut, he's bent, like that hunter-gatherer we saw in the evolution of man. Females are upright, carrying babies on their backs. The male is down like this. We see it over and over. We don't say anything. We just say, "Make this cut," and that's what happens.

 

We also look at position. The young girl has her leg out over here, in what we call a valgus position. The boy tends to be more in a varus position. Valgus and varus. So she puts herself in a very different position.

 

In addition, if you look at the quadriceps activity, female to male, she's much more quadriceps-dominant in relationship to her male counterpart.

 

The hamstring is much weaker. What do we learn from these? We learn that she runs upward, her knees aren't bent, there's valgus position, that her hamstrings are weaker than her quads, and interestingly enough, that is the worst type of situation, because that puts her knee most at risk.

 

There was a very interesting study done recently which looks at jumping and stopping activities. The female is in red and the boy is in blue. You see a statistical difference between the shear on their ligament just by stop-jump activities, because of the variables I just talked about. (56, 57)

 

It even gets worse, because as they fatigue, this is the effect now, the same study done with a fatigue effect. As you see, as they get out over here, the girls are significantly worse when they fatigue. So not only are there greater forces, but with fatigue, they are even worse. This is statistically significant.

 

So we're beginning to learn exactly the situation of how these things occur. And again, as I told you, it's concepts and technology in evolution over time.

 

So we got together and we developed a program called PEP program, simple acronym. Prevent injury and enhance performance. Simple things. Teaching them how to avoid; flexibility strengthening, plyometrics and agility. We taught them that in the first 15 minutes of any program, there are flexibility exercises, hamstring stretches. There are things anybody can do at any time. Strengthening exercises, walking lunches. Plyometrics become really critical. We developed the program to be simple, something anybody can do. The program is now being translated into Norwegian, German, soon to be translated into Italian and Spanish. Agilities. Simple things that anybody can do at any time.

 

We had an opportunity to study this. Anytime you introduce a program, like any intervention, one must look at efficacy. In the year 2001, we looked at 1900 in our control group, and our enrolled group of the therapeutic program. There were only two. These numbers were statistically significant, p equals .05 value. We felt we were doing pretty good with that in year One. There was an 88 percent reduction in ACL injuries.

 

So we did it for a second year, and we found for the control group in year 2 there were 35 ACL injuries, and in the intervention group, there were only four. Once again, a 74 percent reduction in ACL tears. We're pretty excited about the time.

 

Not only we were excited about it, but we just had the opportunity to then do a randomized control trial. The CDC came to us, when they saw our first two years, and said, "Let's study this in the Division I NCAA group."

 

So in year 2002, in concert with the CDC, we evaluated 61 teams during the program. These girls are a little older now. Division I NCAA teams. We had 1,394 athletes. We found that there was a statistical difference in terms of the program and those who weren't participating in the program.

 

In addition, because this was such a large study, we learned some very important details that we then carried to other sports.

 

What do we learn about the female in evolution? History has not been kind to the female athlete. Female in sports is only, at very most, 100 years old, and in most sports, it's only 30 years. So we're constantly being challenged by these very interesting and intricate challenges that have multiple levels.

 

We're learning that participation and competition are essential to become successful women, as we have seen on a number of studies. Sports, fitness, and exercise are essential for all children and all adults at all times for optimal physical, physiological, and psychological benefits.

 

The development of elite athletes requires a systematic process of selection and progression, safety, of getting focus in competition. We can do that well, as we've seen in 2004 Olympics. We've also learned that the athletic field is still an ideal classroom. As Joe Paterno said, "Use it wisely."

 

There are two sides to this. Our children are important. But understand, although they have the same jersey, the female athlete is not just a small male. There are significant gender, physical, physiological, and psychological differences that all of us must understand. They must be identified, respected, and managed current to other aspects in their lives, such as eating disorders, delayed menarche, estrogen issues, adolescent ACL tear, and the potential for obesity.

 

We must also understand our objectives, our key, that we must optimize benefits, minimize risks, and be successful at all times.

 

I have some parting words. To our daughters, you have only just begun. Compete, enjoy, develop a new paradigm. You can be every bit the athlete that you want. You can be a professional, a wife, and a mom.

 

To our doctors, we must continue to educate you, to learn more about the female athlete. The learning curve is steep, because these are all new principles.

 

To all of you, the schools, be open to this new model. Continue to define and foster what success is and will be.

 

To our wives, be part of the new paradigm and facilitate our daughters, but don't overreact. Timing is anything, in this case, everything.

 

To our moms, it is never too late to discover that exercise is our only true fountain of youth.

 

To us dads, be there for all of it.

 

And lastly, it doesn't get any better.

 

As I said, in the beginning, there was Adam. And Eve? She was just a late bloomer. (Laughter.) Thank you. (Applause.)

 

Any questions, answers, comments?

 

SPEAKER FROM THE FLOOR: You had on one of your slides something about the optimal time to start sports and the benefits of strength training. Can you talk a little bit about that, with the girl athlete?

 

DR. MANDELBAUM: That's a very interesting question, and a very comprehensive answer has to go with that question. We know now from our PEP program, which is focused on the 14-to-18-year-old athlete, there are different issues. We must deal with them as young soccer players. We need to deal with young volleyball and basketball players. We need to develop programs that are more specific for the ten-to-14-year-old, the 14-to-18 and the 18-to-23-year-old.

 

What I'm trying to say here is that we have learned this issue of evolution, our concepts and technology, and what we've learned in the last four years is that we need to be more specific with that. It's probably a very good thing to teach those five principles to our eight-, nine-, ten-year olds. Again, those principles that 'less is more,' addressing quality over quantity.

 

Although you want a specific answer, the more specific answer depends on who is that athlete? Is that an eight-year-old who's just beginning to play AYSO soccer? Or is it a 14-year-old Olympic development program athlete from southern California who must be dealt with in a very specific way?

 

So I think we're learning in each of those populations a menu of potential things, but the principles are what I really talked about, and we're getting to this. We have a web site that is called ACLprevent.org, which discusses a lot of these issues.

 

I sat two days ago in a lecture hall with 1200 orthopedic surgeons from around the world. This is now the roller coaster. Click, click. Concepts, technology in evolution over time. We're learning more, we are getting better. We were the recipients of an NIH grant this past year to study the 10-to-14-year-old athlete. We don't have the answers yet. In two or three years we'll be very specific about that. But that's what we're learning.

 

SPEAKER FROM THE FLOOR: The boys' sport world has been hit hard with the advent of magazines that tell teens how to self-diagnose for the use of steroids, to minimize damage effects in order to get gross muscle gains that they feel they have to have to be more competitive.

 

Has the world of steroids moved into girls' athletics on the same scale?

 

DR. MANDELBAUM: Unfortunately, the answer is yes. We haven't yet had it in soccer or football, globally speaking, but certainly if we go back to pre-Soviet Union and East Germany, the old Soviet Union, they really taught us everything about steroids early on, and the effects on women.

 

Unfortunately, there have been a lot of female athletes who did take steroids in recent times. We certainly saw them in the Falco investigation, and we've seen the death of Florence Joyner. Unfortunately, our population still falls under the radar in this regard. They continue to take steroids, and I think that part of those behaviors are very similar to what Ross was talking about: Athletes dealing with their own mental disorders, who just happen to be elite athletes, they just don't have the capability of balancing out all these issues. Whether your name is Jose Canseco or Florence Joyner or Tom Smith or Sally Jones, the issue is: They do have these mental disorders, and they do take these steroids, for reasons that I can't explain.

 

SPEAKER FROM THE FLOOR: I'm a clinical psychologist. Some people just might find this connection interesting, as I do. I was a teacher of history, philosophy and religion for many years. I did a study that was published in "Sex Roles," once I became a psychologist, on women's dreams. My sample was largely independent schools' young female teachers, school heads who were female, and parents who were female.

 

I questioned in my study the accepted canon about the difference between men's and women's dreams. It was always accepted and stated that men dream of more outdoor spaces, more locomotor activity, more familiar things, more adventures. There's lots of evidence about that.

 

I felt, from speaking to women today, that women's dreams were changing. What I found were significant results which were published on the changing story of women through their dreams, where they're dreaming of climbing mountains, more locomotor activity, more outdoor spaces. Instead of domestic pets, they're dreaming about lions and tigers.

 

I also used a lot of measures for anxiety and depression and well-being, and found a shift in the dreams, that women had much greater levels of well-being with the changing dreams. So I just thought you might find that interesting.

 

DR. MANDELBAUM: I think that's fascinating. In the last five to seven years, these 14-to-18-year-old athletes are so tough, the female athletes. They're much tougher physically, and they probably have more frequent dreams of playing soccer and basketball and volleyball than their male counterparts. Where the male counterpart is listening to the iPod, the female is much more intense about her sports right now.

 

I created a metaphor. It reminds me of the male elephant now. You know, the female is out hunting, doing all the work, and the male is sitting there sleeping. I think we're in that generation now, so I think it depends on the generation.

 

SPEAKER FROM THE FLOOR: You spoke in your talk about the positive psychological benefits for mood, spirit, and esteem. I wondered if you could talk a little bit about what kind of exercise and how much exercise is associated with positive mental health. You have described the extremes of no exercise and extreme athletes who are running into serious risk of injury. What's the right balance for our kids?

 

DR. MANDELBAUM: Again, think of exercise like any intervention. There's a route of administration, a dose, and a response. I'm really biased towards exercise, so what I'm going to tell you is probably a little more than a lot of my colleagues in medicine would say. But I think that every child should be doing close to an hour of exercise a day. Basic. Basic foundation. An hour a day of exercise. It really doesn't matter what it is. It can be Pilates or yoga. It could be club soccer team or volleyball, swimming, whatever.

 

To accrue the benefits that we're talking about physically, physiologically, psychologically, it must be an investment of time, and intensive. We're just learning of those benefits.

 

Cooper, who gave us the word "aerobics," grew up in the '60s and talked about three times a week doing low level. Now they have modified all that up to see the benefits. So we're learning we've got to spend more time doing that. So I'll make it easy. I say an hour a day. Practically, could people hit that nowadays with five AP courses and everything else? No. But I think it becomes a paradigm we hold and try to shoot for.

 

SPEAKER FROM THE FLOOR: Doctor, I'm from the state of Delaware. We have sort of a state epidemic with club soccer intruding upon the interscholastic world. Last year in our state soccer tournament, our team had a quarter final position. During the course of that weekend, the rep league coach told the players on our team that they needed to play for his team before they could play for ours. So that when it came time for the evening game on Saturday, we had 90 minutes of soccer already played for two of our girls.

 

We met with the state association this year, and it is the number-one problem that the state association is dealing with. I'm wondering whether you have any suggestions as to how to create some kind of a balance between what the rep league coaches are requiring and obviously the school sports.

 

DR. MANDELBAUM: Well, the problem is more complicated. I'm very familiar with the problem in Delaware, as a matter of fact. Our national team trainers are both from Wilmington, Rudy Rudowski and Jim Hashimoto. So I've heard about the problems, but those problems are no different than they were in California.

 

We solved that problem in California by creating a blackout time for schools. So during the period of November, December, January, the clubs can't participate. I think that wisdom should be the prevailing concept wherever we are, whatever state we're in. There are issues on the East Coast which are different than the West Coast. You have the seasons, and there are only so many months you can play soccer.

 

People have to remember that we're doing this for these athletes. We're doing this for the benefits. We're doing it because we're trying to minimize the risks, trying to develop the most ideal situation. It's like politics. The politicians focus on differences rather than similarities. If you take the club/school paradigm, put it together, you can understand it, and they both have issues, but it's the same. They have to focus on the similarities, rather than the differences.

 

SPEAKER FROM THE FLOOR: Going back to the middle school -- and I don't know if you can answer it, but there may be some other school heads here -- I find competition for seventh to eighth graders to play up, because the parents want them to, they're a great soccer player, or field hockey player, or swimmer, and you can play them six years and still have them qualify at college level.

 

I'm wondering if there are any views on that, or any policies. We even see it trickling down, not on that level, but similar to third, fourth, fifth grade, where parents want them to come out with stick work and field hockey. I wish we could get some best practices about the middle school sports, because we I think a lot of us worry about that.

 

DR. MANDELBAUM: Playing up, to me, doesn't really concern me, because when you look at a group of girls who are 13 years old, you see some of them who look like they're 19 and some look like they're 11. The problem is that there's not a uniformity on chronological versus pubescent age, how to determine who's who. The one who looks 19 should not be playing with the kids that are 4'4".

 

So playing up, in and of itself, is not a problem. It's really indoctrinating the programs, indoctrinating the principles that I have just talked about. I think that's the key thing. If that girl who happens to be an outstanding athlete in the eighth grade is All World and they get her for four different clubs simultaneously, that's when it's a problem. The concept of playing up doesn't concern me. It's what goes with it that concerns me.

 

As a school head, you must look at this and take a wise approach. Once we understand the concepts, how it is evolved, that's okay. That's one of those categories where it's okay. But it has to be done with a proviso. And it shouldn't be a knee-jerk kind of response.

 

SPEAKER FROM THE FLOOR: The girls on the screen look very happy. Please tell me that those girls and the World Cup girls did not start at age 8 and play soccer three hours a day, every day, for 365 days a year. Did they play other sports, is the question.

 

DR. MANDELBAUM: You know, it's interesting. Linda Hanley was a professional volleyball player, a very close friend of ours.

 

She's a mom. She was a professional volleyball player for many years, one of the best. She was an Olympiad.

 

She said it best. When she was going through high school, she played any and all sports she wanted to play, and she really enjoyed that, because it helped with her athleticism.

 

One of the problems that we get into now is this tremendous focus where they're in one sport and in California they're doing it 11 to 12 months a year, all the time. They keep on adding games and tournaments.

 

I'm going to tell you, I have a solution to some of this. This one I don't have a solution for. Because it's the observation that these girls, as well as the boys, are overdone. They spend too much time doing what they're doing, and it's got their focus. But then again, this is the vanguard? This is the first group. So people like all of us are now observing that group and saying, "Okay. All that is good, but how can we make it better?"

 

In our World Cup men's team, of 24 men, we had one college graduate. One college graduate. Now, is that good? For my son, who may be a very competitive soccer player, do I want to see him do that? No. But we're going to learn from that. We're going to learn that just because Freddie Adu is 14, we don't pull him out until he graduates from high school. We mandate he must finish high school, which he did. So I think we're learning. There's a learning curve here, and as I said in the beginning, its concepts are in evolution with technology.

 

SPEAKER FROM THE FLOOR: Just a follow-up on that last question. Are there any studies that actually compare the fitness and the proneness to injury for the three-sport athlete or the two-sport athletes, as opposed to the one-sport athlete?

 

DR. MANDELBAUM: No. There are lots of studies showing that unfit have a higher probability of injury. We know that UEFA, which is the governing body for international soccer in Europe, has looked at issues of over-participation in relationship to competition and success, and it finds a direct relationship. But there's never been a study like the one you just asked about.

 

One of the issues we have -- I talk about this -- our society is very interesting, in that our kids and our health are usually the most important things that we hold near and dear. But on the other side, when it comes to what we vote on as a society -- and Ross talked about this, in monies for insurance companies and details -- we don't spend as much time and effort on our kids and our health. And if the president says it's a problem that 14 percent of our gross national product is spent on health care, I say, maybe it should be 20 percent. How about 25? We have to get real.

 

I'm biased here. Groups like this should interact with groups like us. You're our vehicle. We sit around in meetings about how we can implement educational programs. Well, I'm preaching to the choir, so to speak. You guys are it. This is it. But there should be some summits. There should be some coordinated effort from a societal perspective. We're out there doings these meetings and conferences and consensus. We all agree, a bunch of doctors sitting around in a corner. But you don't hear it.

 

So I think that these kinds of issues, conclusions, directions, need to be organized better, that we don't have the mechanisms in our society.

 

I think our time is late, and it's time to go to a winery. (Applause.)

 

MS. HOGAN: Bert, on behalf of all of us, thank you so much. We appreciate your driving down to be with us.

 

We're off to lunch.

 

MR. GALBRAITH: We do have a couple of announcements. In keeping with what Dr. Mandelbaum has just said, Coach Harmon has asked that anyone interested in playing an hour of doubles tennis this morning huddle with him back in the corner. Mixed doubles. Thank you very much.

 

Secondly, tomorrow, for the artist presenter, it would be very helpful if you had a writing surface, a notebook or a pad, or something like that. If you could bring that along, you'll see why, as that evolves.

 

The boat trip tonight, as Bodie mentioned earlier, is included in the conference fee, so it's for everybody. The east entrance is just down this walkway, and then to the right. There is not a lot of parking, so a bus will come at ten to 6:00 and load and depart, and then another bus will come. So there's a window in there of 20 minutes, probably, starting around 6:00.

 

The boat trip is on the Spirit of San Diego. We have the whole ship. The second deck is enclosed. The top deck is open, but it probably will be a little chilly, so make your plans accordingly as far as clothing. It's certainly informal, but layers, as my mom used to tell me.

 

There are more copies of Ross Szabo's handout.

 

The winery tour leaves promptly at 12:30 today. Folks who signed up late for that, we were able to get lunches for you, so you don't have to take all the cookies or whatever you were planning to do. Again, east entrance for that, and that will depart promptly at 12:30.

 

Anything else for the good of the order?

 

Dr. Mandelbaum, thank you very much. (Applause.)