Sports Injuries: Are Women More At Risk?

By understanding their unique risks when exercising, women can take measures to avoid injury.

Engaging in sports has many benefits. Sports increase agility, strength, and stamina; burn calories; and improve mood and confidence. They also increase analytic skills. Team sports create a social opportunity and teach cooperative skills. Before 1972, women were less likely than men to participate in competitive sports in school. That changed radically with the passage of Title IX.

This law allows federal funding only for schools and colleges that include both sexes in sports programs or activities. One measure of its success is girls’ participation in high school sports: since 1971, the number of high school girls who play sports increased from 300,000 to nearly 3 million today.¹ But with gender equity has come the greater likelihood of sports-related injury for girls and women. In fact, injury rates are similar in men’s and women’s sports. Injury patterns, however, differ.²

Five factors influence sports injuries: form, alignment, body composition, physiology, and physical performance. These differ between the sexes, especially once puberty starts and hormones influence development.³ Table 1^3-5 describes prominent differences, most of which are due to estrogen’s influence in women and androgen’s influence in males. Girls also mature earlier than boys both skeletally and physiologically.

Head and Shoulders

Females appear to sustain concussions at higher rates than men, with women playing basketball, lacrosse, and soccer at highest risk. They often have more severe signs and symptoms, and recover less quickly than men.^2,6,7 Online Table 2^8-11 describes interventions for concussions and other injuries common in women that health professionals can pursue.

Women also experience shoulder injuries more often than men. Compared with men, they have less upper body strength, weaker rotator cuff and periscapular muscles, and looser supporting tissues. This creates shoulder instability. Sports that use the shoulder muscles extensively (eg, swimming, softball, volleyball) increase the risk of rotator cuff injury, tightness, and pain. Shoulder injuries are more likely to recur than other injuries.²

Table 2: Addressing Common Sports Injuries in Women

Sports-Related Injury

Intervention

Concussion

• Complete rest until the concussion resolves
• Close monitoring for behavioral change or vomiting
• Analgesics as recommended by the attending physician

Shoulder injuries

• Joint rest and immobilization
• Strengthening programs
• Short-term treatment with NSAIDs and/or topical analgesics and liniments

Patellofemoral syndrome or miserable malalignment syndrome

• Short-term treatment with NSAIDs and/or topical analgesics and liniments
• Short-term use of medically directed compression and physical therapy
• Patellar braces and foot orthotics

Anterior cruciate ligament injuries

• Teaching women to land in more stable positions
• Strengthening of injuries that reduce joint laxity
• Analgesics appropriate to the patient’s pain level; these injuries can cause severe pain
• May require surgical correction

Bone stress fracture

• Restricting weight-bearing activity for 6 weeks to 6 months
• Ensuring that the diet provides sufficient calories, calcium, vitamin D, vitamin K, vitamin C, magnesium, and iron

Gastrointestinal upset

• Avoiding dehydration
• Avoiding large meals for 3 to 4 hours before heavy endurance exercise
• Restricting exercise until symptoms resolve
• Avoiding NSAIDs and caffeine
• Trying ginger-based teas or drinks to reduce bloating and discomfort

MMS = miserable malalignment syndrome; NSAIDs = nonsteroidal anti-inflammatory drugs. Adapted from references 8-11.

Knees and Feet

Females have a greater propensity to develop knee and foot problems. One explanation is patellofemoral or miserable malalignment syndrome (MMS), which involves 3 anatomic findings:

• Excessive femoral anteversion (inward rotation of the knee relative to the hips
• Increased knee Q angle (connecting tendon alignment that pulls kneecaps outward)
• External tibial torsion (outward leg rotation)^12,13

Females are at greater risk of MMS because their feet tend to be flat and they pronate (ie, roll inward). An internal femur rotation and inner quadriceps/pelvic muscle weakness can increase the force on kneecaps. This creates an inward-facing patella. MMS causes anterior knee pain.¹² Patients report pain or discomfort that seems to originate at the point where the back of the kneecap contacts the femur. The rubbing and pain can limit form and function or lead to patella dislocation or subluxation (kneecap displacement).^11,13

Women are also at 3 to 6 times more risk for anterior cruciate ligament (ACL) injuries, especially if they play soccer, volleyball, or basketball. The ACL is one of the 4 major ligaments of the knee. These noncontact injuries follow sudden deceleration or jumping. Women’s knee biomechanics make them land in positions that are more upright than men do, increasing risk.^10,14-16

Female Athlete Triad

Researchers propose a “female athlete triad”—insufficient energy availability (fewer calories consumed than expended, with or without an eating disorder), bone loss, and menstrual disturbances—that affects performance and increases risk for sports injuries. Females who develop this triad are at higher risk for injury, especially if they exercise for more than 12 hours weekly.⁸

Bone Mass

Bone mass accumulates in women until 25 to 30 years of age. Athletes who restrict calories or don’t eat diets replete with bone-building nutrients are at risk for osteoporosis. In addition, menstrual abnormalities brought on by poor diet and lean body weight reduce circulating estrogen and increase risk.¹⁷

Weight-bearing exercise can stress, strain, or deform bone, and if the strain is large enough, microcracks can develop.¹⁸ In healthy athletes who allow adequate recovery time and eat well, the insult to bone will resolve. If the bone doesn’t heal because of repeated insults or poor diet, damage may expand into larger cracks (macrocracks) or a bone stress injury.

Abrupt increases in training, versus gradual increases in training that encourages muscle strength or endurance development over time, can predispose female athletes to stress fractures. Bone stress injuries occur most often in the lower tibia and metatarsals, but can develop in other bones. Female endurance runners, track and field athletes, and dancers are at greatest risk, and approximately 11% of females with female athlete triad develop stress injuries.⁸

Gastrointestinal Upset

Female endurance athletes with or without eating disorders often report gastrointestinal (GI) problems, including bloating, cramps, and constipation.^9,17 Among female endurance athletes (and especially runners), GI problems are more likely in those who have the lowest caloric intake. Researchers propose that persistent energy deficiency causes intestinal mucosal atrophy, and dehydration can cause or contribute to stomach upset. In addition, the high force of impact and intestinal jostling can cause symptoms.⁹

Conclusion

Engaging in physical activity has proven benefits throughout life, and all women are encouraged to stay active regardless of age. Some studies report that although females do tend to sustain more injuries, much of the increased incidence can be attributed to the amount of training they schedule.^4,5 Clinicians should remind women to avoid insufficient warm-up, high training intensities, muscle fatigue, and hamstring tightness.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy.

References

• Landmark moments for women’s sports. Sports Illustrated website. http://sportsillustrated.cnn.com/multimedia/photo_gallery/0702/gallery.genderequity/content.5.html. Accessed March 6, 2014.
• Peck KY, Johnston DA, Owens BD, Cameron KL. The incidence of injury among male and female intercollegiate rugby players. Sports Health. 2013;5:327-333.
• Casey E, Hameed F, Dhaher YY. The muscle stretch reflex throughout the menstrual cycle. Med Sci Sports Exerc. 2014;46:600-619.
• Ristolainen L, Heinonen A, Waller B, Kujala UM, Kettunen JA. Gender differences in sport injury risk and types of injuries: a retrospective twelve-month study on cross-country skiers, swimmers, long-distance runners and soccer players. J Sports Sci Med. 2009;8:443-451.
• Stracciolini A, Casciano R, Levey Friedman H, et al. Pediatric sports injuries: a comparison of males versus females [published online February 2014]. Am J Sports Med.
• Covassin T, Swanik CB, Sachs ML. Sex differences and the incidence of concussions among collegiate athletes. J Athl Train. 2003;38:238-244.
• Dick RW. Is there a gender difference in concussion incidence and outcomes? Br J Sports Med. 2009;43(suppl 1):i46-i50.
• Barrack MT, Gibbs JC, De Souza MJ, et al. Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: a prospective multisite study of exercising girls and women [published online February 2014]. Am J Sports Med.
• Fallon K. Athletes with gastrointestinal disorders. In: Burke L, Deakin V, eds Clinical Sports Nutrition. 3rd ed. New York, NY: McGraw Hill; 2006:721-738.
• Shelbourne KD, Liotta FJ, Goodloe SL. Preemptive pain management program for anterior cruciate ligament reconstruction. Am J Knee Surg. 1998;11:116-119.
• Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome [published online November 2013]. Knee Surg Sports Traumatol Arthrosc.
• Heyworth BE. Miserable malalignment syndrome. Encyclopedia of Sports Medline website. http://knowledge.sagepub.com/view/sportsmedicine/n324.xml. Accessed March 4, 2014.
• Knee pain, anterior/patellofemoral malalignment syndrome. MedicineCentral website. http://im.unboundmedicine.com/medicine/ub/view/Select-5-Minute-Pediatric-Consult/14193/all/Knee_Pain__Anteriorpatellofemoral_Malalignment_Syndrome. Accessed March 4, 2014.
• Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33:492-501.
• Hewett TE, Zazulak BT, Myer GD. Effects of the menstrual cycle on anterior cruciate ligament injury risk: a systematic review. Am J Sports Med. 2007;35:659-668.
• Tilp M, Rindler M. Landing techniques in beach volleyball. J Sports Sci Med. 2013;12:447-453.
• Melin A, Tornberg AB, Skouby S, et al. The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad [published online February 2014]. Br J Sports Med.
• Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. 1999;28:91-122.