Sports Injuries in Female Athletes

by Meghan Richardson, MD

Sports Injuries in Female Athletes

Common injuries in female athletes.

Not too long ago, this subject matter would not have been a topic for in-depth discussion on a public platform. Here’s a quick history lesson. Title IX, an act written to address the gender inequalities in education and access to sports in federally supported entities, was not passed until 1972. Prior to the legal passing of Title IX, there were roughly 300,000 female athletes in 1971. Today, there are over 3,000,000 women playing sports at highly competitive levels.

The anatomy of the female and male bodies are obviously different, and this variation in muscle structure and bone alignment causes each sex to more prone to certain types of injuries. Women are more likely to suffer from overuse injuries, whereas their male counterparts typically have higher energy contact injuries.

When talking about female sports injuries, the common injuries that come to mind are stress fractures, patellofemoral disorders, shoulder instability, femoral acetabular impingement, and ACL tears, which will be our main focus of discussion.

ACL Tears in Female Athletes

The ACL is in charge of stabilizing the knee joint and connects your thighbone or femur to your shinbone or tibia. Now, you may be asking yourself, “Is there really a difference between female and male athletes’ ACL tear rates?”

Yes.

Women are three times more likely to sustain an ACL tear at some point in their lifetime. In the NCAA soccer player population, females have about 5% rate of ACL injuries in one season compared to males at 1.7% In the NCAA basketball population, women are almost three-fold more likely to have an ACL Injury.

Where we often see the largest amount of ACL injuries in both females and males are in active sports that require instantaneous changes of direction or quick cutting motions. Sports such as basketball, soccer, lacrosse, and gymnastics have higher risk rates for ACL tears. Additionally, most ACL tears are non-contact injuries. They occur more from awkward movements or landings rather than a big collision.

What are the risk factors for an ACL injury?

Extrinsic factors or things that we can potentially control regarding ACL injuries are actually the playing surface of your sports. Anything that increases friction increases your risk for ACL tears. So, sports that involve cleats as opposed to sports played on wood surfaces will heighten the chance of ACL injuries for both females and males.

Some intrinsic factors that are modifiable and that we should be aware of include the Q angle. The Q angle is really just the angle of your knee and is where your femur meets your tibia. Generally, it is found that women are more “knock kneed” than men are and that places women’s ACLs at greater risk for being injured.

The other intrinsic factor that affects women more than men is the tibial slope. Women naturally have a larger tibial slope compared to men. Imagine your tibia is flat and then hold it vertically. Stack your femur on vertically on top of your tibia and then slope your tibia downwards. This increase in slope slides your tibia forward, putting more stress on your ACL.

What can be modified?

Some things that we can potentially change and modify are some of the biomechanics and neuromuscular factors.

Females have a higher quad to hamstring mass and a ratio of recruitment. What all that mumble jumble means is basically females’ quads are stronger than their hamstrings. The hamstrings act as a secondary restraint, and if your ACL is feeling stretched, your hamstrings are supposed to activate and pull things back in. However, if you have a ratio where your quad is much stronger, you’re at higher risk for a tear.

Another thing we can address is an athlete’s landing mechanics. Women tend to land more straight up and down, and their pelvis is more vertical to the ground with less bend. Women also frequently land with more knee abduction or in that knock knee position and with their tibia rotated outward. All of these are just natural landing mechanics in females.

Interestingly, a study involving prepubescent girls and boys found that the ACL tear rate in girls and boys was pretty similar before puberty. After puberty and maturation however, the landing mechanics of the female shifts.

What can we do to prevent ACL tears in females?

Obviously, the best thing to do is to prevent an ACL injury in the first place. There is a lot of date supporting the implementation of neuromuscular and proprioceptive training.

For women, this type of training in season can help prevent around 50% of ACL tears. For men, it can help reduce ACL tears by up to 85%, so, it is an excellent training regimen for both women and men.

Training should also heavily focus on addressing athletes’ landing mechanics and work on having athletes land softly. We don’t want to hear a loud slam or thud when coming down from a header in soccer or layup in basketball, and we want to really practice landing in the knee over toe position. The other thing female athletes should particularly focus on is strengthening their hamstrings with lunges and heel calf raises.

Studies also looked at the effect of balance and agility training on ACL injury rates, and unfortunately, there were no significant findings. That being said, balance and agility training can help with reducing athletes’ risk for ankle sprains.

Neuromuscular and proprioceptive training should start in the preseason or about eight weeks before the start of the season. There is evidence that shows if you stop this program for two to eight weeks, you will lose the neuromuscular feedback you gained. The younger the athlete you are, the better this program is for you long term. There are plenty of resources online that you can look up as far as your training program goes, and there are some scoring systems you can find that are really, really helpful for developing a training plan.

Frequently asked questions  

At what age should a child start the neuromuscular and proprioceptive training?

I think that is something you can start as soon as you possibly can. Youth leagues with children ages eight, nine, and ten should definitely beginning preparing these young athletes. The data shows that the earlier you start with addressing proper landing mechanics, the better these athletes will be throughout their sporting careers.

What’s the best way to prevent re-tearing your ACL?

One thing that doesn’t necessarily make anyone feel better when they hear it is that you’re actually at a slightly higher risk of tearing your other ACL after your initial ACL injury, especially for women. Things you can do to protect yourself are rehab, getting your quad strength back, and working on your hamstrings.

There have been a lot of question over the years about whether or not you should be wearing a functional ACL brace while you’re playing your sport. There is some benefit to wearing one particularly in the early post-operative period of your recovery while your quadriceps are still not fully functioning. As you reach that one-year mark and beyond, I think bracing is honestly more of a mental placebo than a physical benefit. If wearing the brace makes you feel confident to play, I fully support it, but I don’t think it will necessarily prevent a future ACL tear.

Is there anything senior citizens should do to protect their ACL?

As we get older, our bodies definitely do not function quite as well. But, that doesn’t mean we should neglect focusing on our quadricep and hamstring strength and our conditioning in general.

Another thing for seniors in particular to keep in mind is footwear. It’s very helpful to have a sturdy shoe when you’re doing a physically demanding activity such as a long hike. You want to make sure you’re on something supportive to try to protect yourself while walking.

When doing lunges and squats, is it important to incorporate weights?

Usually, I would promote starting with body weight type activating before adding in any weights. If you don’t have the strength initially to support your own body weight and then you add weights, you’re going to pushing your body past its limit and potentially injure yourself.

I would recommend starting with a wall squat where you’re not going all the way down to 90 degrees. Maybe begin with 45 or 60 degrees and then as you build strength you can add to it. Another workout you can try is heel slides. Most people don’t have access to these at home, but you can get in touch with a physical therapist, and they can work with you by doing some heel slides. This exercise is also a really low impact way to work on your hamstring as well.