Lower extremity injury prevention in female, woman, and girl athletes

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Lower extremity injury rates in sport are high and have significant consequences; however, the current evidence to inform the prevention of lower extremity injuries female/woman/girl athletes is sparse. Our team recently conducted a systematic review and meta-analysis to assess the effectiveness of female/woman/girl athletes’ lower-extremity injury prevention strategies [e.g., training strategies, personal protective equipment (PPE), policy/rules, and injury management] and their unintended consequences.

Why is this important?

Lower-extremity injuries account for over 60% of all female/woman/girl sport injurie (1, 2). In any given season, up to 50% of female/woman/girl athletes playing a variety of sports will experience a lower-extremity injury (2, 3). These injuries have a high financial cost (4-6) and short and long-term consequences (7-11). However, the majority of the current evidence is derived from male/man/boy athletes, or data combining genders/sexes with few studies considering female/women/girl-specific data.

Lower-extremity injury prevention interventions include neuromuscular training-based injury prevention programs (NMT) that include balance, strength, agility, and/or running/movement/cutting drills, personal protective equipment (PPE), policy/rule changes, and injury management (12-16). While some information is known concerning the efficacy of NMT programs (17-19), these data are inconsistent. There is currently little-known concerning PPE, policy/rule changes, or injury management. The absence of detailed information has limited clinical interpretation and application of injury-prevention strategies in female/woman/girl sports. Analyzing existing female/women/girl-specific data could enhance the understanding of the effectiveness of lower-extremity injury prevention strategies for female/woman/girl athletes and enable sport partners—such as athletes, coaches, clinicians, parents, and community sport organizations—to implement evidence-informed best practices and policies for injury prevention.

How did we study this?

We reviewed and included 82 studies and performed a meta-analysis on studies that specifically reported the effects of female/woman/girl NMT training on lower extremity injury. Of note, 7% of all studies did not report the number or % of sex or gender when female/woman/girl and male/man/boy athletes were included. There was not sufficient data to perform meta-analysis for PPE, policy/rules, or injury management.  

What did the study find?

Across the 82 studies, a total of 154,561 participants (84,915 females/women/girls, 55%) were included. Neuromuscular-based training programs [(NMT) n=60, 73%] were the most frequently studied prevention strategy, followed by personal protective equipment (PPE) (n=9, 11%), policy/rules change (n=4, 5%), and 6 (7%) education. Of note, 7% of all studies did not report the number or % of sex or gender when female/woman/girl and male/man/boy athletes were included. There was not sufficient data to perform meta-analysis for PPE, policy/rules, or injury management. 

  • There was low certainty of evidence from 9 studies that NMT training programs with a minimum dose of 10 minutes twice weekly, reduced female/woman/girl athletes’ lower extremity injuries by 19%
  • There was moderate certainty of evidence from 6 studies that NMT training programs reduce ankle sprains by 39%.
  • There was high certainty of evidence from 6 studies that NMT training programs reduce anterior cruciate ligament injuries by 61% (Figure 1).

Figure 1

What are the key takeaways?

  • Neuromuscular training programs that include at least 10 minutes of exercise twice per week, progressing from bilateral to single-leg activities and incorporating balance, lower-limb strength, agility, and directional changes, are effective in reducing ankle sprains and anterior cruciate ligament (ACL) injuries among female/woman/girl athletes of all ages. 
  • Due to the relatively low resource demands of neuromuscular injury-prevention programs, there is significant potential for national and international policy initiatives to mandate their widespread adoption in female/woman/girl athlete sports. 
  • Current evidence is limited regarding strategies to prevent lower-extremity injuries in female/woman/girl athletes beyond the knee and ankle, as well as the effectiveness of interventions such as rule modifications, protective equipment, or educational approaches.
Authors:

Garrett S. Bullock [1,2]

Jackie L. Whittaker [2,3] 

Maitland Martin [2]

Chelsea L. Martin [4]

Carolyn A. Emery [2]

Affiliations

  1. Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
  2. Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.
  3. Department of Physical Therapy, University of British Columbia, Vancouver, Canada
  4. Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, USA

References

  1. Emery CA, Meeuwisse WH, McAllister JR. Survey of sport participation and sport injury in Calgary and area high schools. Clinical journal of sport medicine 2006;16(1):20-26.
  2. Roos KG, Marshall SW, Kerr ZY, et al. Epidemiology of overuse injuries in collegiate and high school athletics in the United States. The American journal of sports medicine 2015;43(7):1790-97.
  3. Richardson A, Clarsen B, Verhagen E, Stubbe JH. High prevalence of self-reported injuries and illnesses in talented female athletes. BMJ open sport & exercise medicine 2017;3(1):e000199.
  4. Tenan MS. Quantifying emergency department visits from sport and recreation: focus on the lower extremity and knee, 1997–2009. Journal of Athletic Training 2016;51(4):309-16.
  5. King D, Hume PA, Hardaker N, et al. Sports-related injuries in New Zealand: National Insurance (Accident Compensation Corporation) claims for five sporting codes from 2012 to 2016. British journal of sports medicine 2019;53(16):1026-33.
  6. Ross AG, McKay MJ, Pappas E, et al. Direct and indirect costs associated with injury in sub-elite football in Australia: a population study using 3 years of sport insurance records. Journal of science and medicine in sport 2022;25(9):743-49.
  7. Richmond SA, Fukuchi RK, Ezzat A, et al. Are joint injury, sport activity, physical activity, obesity, or occupational activities predictors for osteoarthritis? A systematic review. journal of orthopaedic & sports physical therapy 2013;43(8):515-B19.
  8. Whittaker JL, Woodhouse L, Nettel-Aguirre A, Emery C. Outcomes associated with early post-traumatic osteoarthritis and other negative health consequences 3–10 years following knee joint injury in youth sport. Osteoarthritis and cartilage 2015;23(7):1122-29.
  9. Ezzat AM, Brussoni M, Mâsse LC, Emery CA. Effect of anterior cruciate ligament rupture on physical activity, sports participation, patient-reported health outcomes, and physical function in young female athletes. The American journal of sports medicine 2021;49(6):1460-69.
  10. Filbay SR, Skou ST, Bullock GS, et al. Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus. British Journal of Sports Medicine 2022;56(24):1465-74.
  11. Bruder AM, Culvenor AG, King MG, et al. Let’s talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes. British journal of sports medicine 2023;57(10):602-10.
  12. Emery CA, Roy T-O, Whittaker JL, et al. Neuromuscular training injury prevention strategies in youth sport: a systematic review and meta-analysis. British journal of sports medicine 2015;49(13):865-70.
  13. Herman K, Barton C, Malliaras P, Morrissey D. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC medicine 2012;10:1-12.
  14. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British journal of sports medicine 2014;48(11):871-77.
  15. Yang J, Marshall SW, Bowling JM, et al. Use of discretionary protective equipment and rate of lower extremity injury in high school athletes. American journal of epidemiology 2005;161(6):511-19.
  16. McBain K, Shrier I, Shultz R, et al. Prevention of sport injury II: a systematic review of clinical science research. British journal of sports medicine 2012;46(3):174-79.
  17. Crossley KM, Patterson BE, Culvenor AG, et al. Making football safer for women: a systematic review and meta-analysis of injury prevention programmes in 11 773 female football (soccer) players. British journal of sports medicine 2020;54(18):1089-98.
  18. Emery CA, van Den Berg C, Richmond SA, et al. Implementing a junior high school-based programme to reduce sports injuries through neuromuscular training (iSPRINT): a cluster randomised controlled trial (RCT). British journal of sports medicine 2020;54(15):913-19.
  19. Slauterbeck JR, Choquette R, Tourville TW, et al. Implementation of the FIFA 11+ injury prevention program by high school athletic teams did not reduce lower extremity injuries: a cluster randomized controlled trial. The American Journal of Sports Medicine 2019;47(12):2844-52.


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