Upper extremity injuries are common in many sports, yet the evidence guiding how to prevent them in female, woman, and girl (female/woman/girl hereafter) athletes is surprisingly scarce. We recently conducted a systematic review to identify which prevention strategies work, and which modifiable risk factors might contribute to these injuries in female/woman/girl athletes (1). Our findings helped to inform the International Olympic Committee’s Female, Woman, and Girl Athlete Injury pRevention (FAIR) Consensus (2), and they highlight encouraging insights and important gaps that need urgent attention. 

Why is this study important?

Female/woman/girl athletes experience a substantial burden of upper extremity injuries, with upper extremity injuries comprising roughly one-fifth to one-quarter of all sport injuries across levels of play (1). These injuries can limit sport participation, affect performance, and contribute to pain, disability, and long-term consequences. Much of the existing evidence, however, is based on studies involving male/man/boy athletes or from studies that combine sexes/genders without reporting separate estimates.

Without sex- and gender-disaggregated data, clinicians are left extrapolating findings that may not reflect the specific context of female/woman/girl athletes. This can lead to incorrect assumptions, missed opportunities for prevention, and a lack of targeted strategies that address how female/woman/girl athletes train, develop, and participate in sport. 

Understanding the gaps and where to focus prevention efforts is essential for improving female/woman/girl athlete health and performance.

How did the study go about this?

We identified 55 studies that met our inclusion criteria and examined prevention strategies or modifiable risk factors for upper extremity injuries in female/woman/girl athletes. Remarkably, only 26% of participants in these studies were female/woman/girl athletes and only 17/55 of studies reported sex- or gender-specific results. This limited the strength of many conclusions but still offered valuable insights.

What did the study find?

The only evidence-informed upper extremity prevention strategy identified (based on three studies) was shoulder-focused exercise programmes that reduced shoulder injury rates by 51% across handball and volleyball athletes. These programmes typically included shoulder external rotational strength, trunk stability/strength, and sport-specific exercises.

For modifiable risk factors (listed below), the evidence was mixed and generally very low certainty:

• Range of motion: Associations between shoulder range of motion (external rotation [ER], internal rotation [IR], total rotation) and injury were inconsistent.
• Shoulder strength: Lower strength, and in some cases lower ER:IR strength ratios, were associated with increased shoulder injury risk in some studies, but not all.
• Training load: Evidence on training load came from a single study, which found that greater yearly participation in softball was associated with higher odds of shoulder and elbow injuries.
• Scapular dyskinesis (alteration in the normal position or movement of the scapula), equipment, specialisation, and sport-specific conditioning: No studies showed consistent or high-certainty associations.

Across all areas, the most striking finding was the lack of high-quality, female/woman/girl-specific research, including very limited evidence focused specifically on girl athletes (3). Additionally, there was limited evidence evaluating upper extremity prevention strategies or modifiable risk factors for Para athletes (4).

What are the key messages?

• Shoulder exercise programmes are promising.

Simple structured programmes focusing on shoulder external rotational strength, trunk stability/strength, and sport-specific exercises can meaningfully reduce shoulder injuries among female/woman/girl athletes.

• Evidence for other risk factors is limited.

Strength deficits may matter, and training load deserves attention, but current evidence is too inconsistent to guide precise clinical decision-making.

• Clinicians should adapt prevention with individual and sport context in mind.

Given the gaps in evidence, plans should be tailored by sport demands, athlete development stage, and individual risk profiles.

• We need better representation and reporting.

Female/woman/girl athletes must be included and reported on in future injury prevention studies. Without this, prevention efforts risk being ineffective or inequitable.

• Para athletes require urgent dedicated research.

With unique biomechanical demands and almost no evidence available, this is a critical next step.

Authors:

Emily E. Heming [1]

Mark Agius [1]

Merete Møller [2,3]

Carolyn A. Emery [1]

Affiliations:

1. Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.
2. Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway.
3. Department of Sports Science and Clinical Biomechanics, Faculty of Health Sciences, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark

Twitter/X:

@Emily_Heming99

@Merete_Moller

@CarolynAEmery

References

1. Heming EE, Gibson ES, Friesen KB, et al. Prevention strategies and modifiable risk factors for upper extremity injury: a systematic review and meta-analysis for the Female, woman and/or girl Athlete Injury pRevention (FAIR) consensus. Br J Sports Med. 2025;59(22):1587-1598. doi:10.1136/bjsports-2025-109907
2. Crossley KM, Whittaker JL, Patterson B, et al. Female, woman and/or girl Athlete Injury pRevention (FAIR) practical recommendations: International Olympic Committee (IOC) consensus meeting held in Lausanne, Switzerland, 2025. Br J Sports Med. 2025;59(22):1546-1559. doi:10.1136/bjsports-2025-110889
3. Heming EE, West SW, Patterson B, et al. Raising girls in sport: unique considerations for injury prevention. Br J Sports Med. 2025;59(22):1531-1533. doi:10.1136/bjsports-2025-111034
4. Grimes AC, Harrington (Quinn) N, Blauwet C, et al. Towards an evidence-informed future in injury prevention: a call to action for female, women and girls in para sport. Br J Sports Med. 2025;59(22):1534-1535. doi:10.1136/bjsports-2025-111037