Sex-Based Differences in Sports Injuries

Overview

Although playing sports offers a number of benefits to athletes, there does always exist a risk of injury. While both male and female athletes are susceptible to similar sports injuries, research has shown that not all injuries affect male and female athletes at the same rate or in the same way.

Particularly in recent years, as their participation in sport has increased, it has become apparent that female athletes may need to train differently than or take additional precautions compared to male athletes to protect against certain common injuries.

Common Sports Injuries with Sex-Based Differences

Sex-based differences in sports injuries are caused by a number of factors including the influence of hormones, balance and biomechanics, and anatomy, all of which differ between males and females. Three of the most common sports injuries that have been shown to have sex differences in risk factors, presentation, and / or treatment are bone stress injuries, anterior cruciate ligament (ACL) injuries, and concussions.

Bone Stress Injuries

Bone stress injuries (BSIs) are injuries to bone caused by overuse, such as stress fractures. BSIs are quite common: 20% of college-aged runners of both sexes are diagnosed with BSIs each year.

However, BSIs are more common in female athletes, for both physiological and nutritional reasons. Females are more likely to experience BSIs for anatomical reasons because they typically have smaller calves and the angle at which the upper leg meets the pelvis is different than in men, both of which cause increased stress on the leg bones.

Additionally, BSIs are strongly tied to relative energy deficiency in sport (REDS) and other nutritional deficits that cause decreased bone strength, which are more common in females.

In females, the larger angle between the upper leg and the pelvis causes increased stress in the leg bones.

BSI risk can be reduced by ensuring appropriate calcium and vitamin D intake, watching out for symptoms of REDS, and training (such as gluteal strengthening and gait retraining) to reduce bone stress and improve landing mechanics.

ACL Injuries

The ACL is the key stabilizer in the knee and is especially at risk of injury during cutting motions - when movement switches rapidly from one direction to another. Annually, about 200,000 ACL injuries occur, with more than half of those occurring in high school- and college-aged athletes. ACL injuries are more common in females during high school and college overall, but in certain sports, such as basketball and soccer are 2-8 times more likely in females at all levels.

Females are at higher risk of ACL injury primarily due to different anatomy of the leg, including smaller ACL size and suboptimal landing mechanics. Additionally, the ACL is particularly sensitive to hormonal fluctuations, so females are more likely to experience an ACL injury during the follicular or preovulatory phases of the menstrual cycle. The hormones most active during those phases of the cycle cause reduced stiffness and increased ligament flexibility in the knee (and throughout the body) making overextension of the ACL more likely.

Treatment for ACL injuries include rehabilitation, bracing, and surgery. Despite these options being available to males and females, female athletes are less likely to return to their prior level of athletics after an ACL injury than males.

Methods to prevent or decrease the risk of ACL injuries typically include specific training techniques to optimize motor patterns during landing and cutting motions. FIFA, the international soccer association, has developed a training plan which has been shown to at least somewhat decrease incidences of ACL injury. The training plan includes 15 exercises in three subgroups: running and stretching, core and lower limb strengthening, and fast-paced functional movements like cutting.

Concussions

Concussions are a type of traumatic brain injury which have gained increased public attention in recent years.

Concussions appear to be more common in females, however, females also tend to report concussions more reliably than males. Furthermore, females tend to score higher on concussion assessments even at baseline (when there is no reason to suspect a concussion), so they may also be more likely to be misdiagnosed. Females are at higher risk, however, due to a smaller neck size and strength compared to head size.

Symptoms and recovery time also differ between males and females with a slower recovery time and prolonged symptoms reported in females. In some cases, concussions may also cause menstrual cycle irregularities.

Once again, the best method of prevention is specific training and strengthening. In the case of concussions, balance training and neck strengthening have been shown to be effective.

Summary

Understanding the sex-specific risk factors, symptoms, and prevention methods for sports injuries helps coaches and athletes know what to look out for and train in such a way as to prevent these injuries. Training for male and female athletes should differ, since anatomical and physiological differences between males and females affect the ways their bodies perform during activity. This awareness and conscientiousness can help to reduce sports injuries, thus allowing athletes to perform their best for many years.

Update

Since this post was originally written, FIFA has announced that it is funding a study to investigate the link between ACL tears and the menstrual cycle. The driving force of the study is the rising rate of serious ACL injuries occurring among female soccer players. To assess the correlation, a team of researchers and sports scientists will analyze blood samples to track hormone concentrations (specifically estrogen and progesterone) over the course of their cycles in professional and amateur soccer players.

Since estrogen and progesterone have been linked to changes in ligament laxity and neuromuscular reaction times, researchers are interested in seeing how physical performance and injury risk is affected as the levels of these hormones rise and fall over the course of the cycle.

If the study does show increased proneness to injury during certain phases of the menstrual cycle, coaches may choose to adjust training regimens accordingly, thus reducing injury risk.

Sources

• Lin CY, et al. Sex Differences in Common Sports Injuries. PM R. 2018 Oct;10(10):1073-1082.