Women and Sports Injuries: Why It's a Different Game

It's a fact: women athletes are more prone to suffering certain sports injuries than their male counterparts, particularly when it comes to knee and ACL problems.

The difference lies in the interplay between form, alignment, body composition, physiology, and physical performance.

"Men and women are obviously built differently," says Dr. Bridget Quinn, a primary care sports medicine physician specializing in female athletes in the Division of Sports Medicine and Shoulder Surgery at Beth Israel Deaconess Medical Center. "By around age 10 to 12, when these physical differences become more prominent, we start to see girls perform differently than boys."

This is when girls begin puberty and hormonal differences exhibit themselves. Girls reach skeletal and physiological maturity earlier than boys. Beyond that, women have more body fat and less lean body mass due to increased estrogen while men have more androgens.

Women's bodies are more lax or flexible than men's, Quinn says. Women have wider pelvises than men and less developed musculature. These factors affect the alignment, strength and movement of women's extremities.

This can lead to a condition known as miserable malalignment, where women's feet roll inward or pronate, are flat, and the force on their kneecaps is exacerbated by an internal rotation of their thigh bones and weakness in their inner quadriceps and pelvic muscles.

Knee Injuries

Kneecap

All these things place increased force on the knees, often resulting in kneecap injuries such as patellofemoral syndrome. The kneecap is pulled towards the outside of the knee and does not track properly, resulting in rubbing and pain that can limit form and function. It can also lead to other injuries including patella dislocation or subluxation, where the kneecap comes out of its groove.

Anterior Cruciate Ligament (ACL)

Injuries to the ACL — the anterior cruciate ligament, one of the four major ligaments of the knee — are also more common in women due to the same factors, Quinn says.

"The rate of ACL injuries is three to six times higher in women than men, especially in soccer and basketball," she says. "There's a lot of research going on about this. These are usually non-contact injuries, resulting from sudden deceleration movements or jumping. When women land, they land more upright."

Programs are in place in many locations to help teach women how to land in less vulnerable positions and to have more neuromuscular control. They also focus on strengthening due to the laxity of women's joints, especially hamstring strengthening that is vital for controlling deceleration.

"Studies have shown these decrease ACL injury rates," Quinn says.

There is also some thought that ACL injury rates may be tied to hormones and the menstrual cycle, but this has not yet been fully explained, she adds.

Shoulder Injuries

Women are also prone to shoulder injuries, Quinn notes.

"Men are stronger up top than women," she says. "The combination of not having strong shoulder muscles, including the rotator cuff and periscapular muscles, and having loose supporting tissues can lead to instability in the shoulder ."

As a result, women taking part in sports such as swimming, softball or volleyball typically are at risk for rotator cuff weakness, tightness, and pain, she says. 

Strengthening programs exist to help cut down on such injuries.

Female Athlete Triad

Another factor separating women athletes from male athletes is the so-called " female athlete triad." This involves a combination of decreased energy availability due to disordered eating (such as not obtaining the right amount of calories compared to what is expended), bone loss, and menstrual disturbances that can interfere with health and performance.

Disordered eating ranges from poor energy intake to anorexia and bulimia, Quinn says. Bone mass accumulates until 25 or 30 years of age, so women who are not accumulating during adolescence and their 20s enter their 30s at a deficit. This requires appropriate levels of estrogen that is present during normal menstruation.

The female athlete triad places female athletes at risk for stress fractures and chronic injury, Quinn says.

"This is more prevalent in women's athletics than was previously recognized, especially in athletes who place a high demand on aesthetics, like runners and ballet dancers," she says.

Anemia or iron deficiency is also a risk.

Quinn recommends female athletes be aware of the potential dangers and work closely with their doctor, nutritionist, coach, family and psychologist.

"Parents, coaches and primary care physicians need to be watching out for these things," she says.

June 2016

Sports Medicine & Shoulder Surgery