840809
research-article2019
NASXXX10.1177/1942602X19840809NASN School NurseNASN School Nurse
Sex Differences in Common
Sports-Related Injuries
Elizabeth Matzkin, MD
Kirsten Garvey, MS, BA
Sex plays a role in mediating different
susceptibilities and outcomes of disease
and injury. Sports injuries are included
in this phenomenon, as recent research
demonstrates that males and females show
differences in incidences of varying injuries,
presentations of injury, and treatment
outcomes. Incidence of certain sports
injuries like anterior cruciate ligament
injury or patellofemoral pain syndrome
may vary widely between male and female
athletes, with female athletes being more
susceptible to anterior cruciate ligament
injury and patellofemoral pain syndrome.
Treatment outcomes for males and females
may also vary widely. For example, males
have a higher risk of recurrent shoulder
instability compared with females. These
variances among incidence and outcome
following certain injuries highlight the
necessity of understanding these differences
to provide quality care. It is especially
important for the school nurse to be aware
of these sex differences as they are well
positioned to make youth athletes and
their families aware of the varying injury
susceptibilities among them.
Keywords: sex differences; youth
sports; youth sports injuries; injury
prevention; sports safety
A
fter recognizing the importance of
understanding sex differences in
 health, the National Institutes of Health
DOI: 10.1177/1942602X19840809
For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav.
© 2019 The Author(s)
implemented changes to support the
increased participation of females in the
National Institutes of Health clinical trials.
Additionally, this effort was extended to
preclinical trials and basic science research
by ensuring the inclusion of both male and
female animals and cells in laboratory
investigations (Clayton & Collins, 2014).
Not surprisingly, this effort spurred
investigations into sex-based differences
within the musculoskeletal system. For
example, males have greater bone density,
muscles mass, and lean mass than their
female counterparts. Anatomy differences,
hormones, and genetics all play a role in
differential injury and disease patterns of
the musculoskeletal system between sexes.
Recognition of these differences between
males and females and their varying
responses to treatment are critical when
aiming to optimize care for these patients
(Wolf, Cannada, Van Heest, O’Connor, &
Ladd, 2015).
There is mounting evidence to support the
idea that the incidence, clinical presentation,
and functional outcomes for male and
female patients with sports injuries may
differ greatly. This article aims to evaluate
sex differences among three common sports
injuries—namely, anterior cruciate ligament
(ACL) injury, patellofemoral pain syndrome
(PFPS), and shoulder instability.
Anterior Cruciate Ligament
Injury
There is abundance of data that
demonstrate that female athletes are
Healthy Communities
particularly susceptible to ACL injury.
The female athlete carries a four to six
times increased risk for ACL injury
compared with male athletes (Ramirez,
Baldwin, & Franklin, 2014). Risk factors
for ACL injury have been described as
either nonmodifiable or modifiable.
Nonmodifiable factors include anatomic,
structural, and hormonal factors, while
modifiable factors include neuromuscular
and biomechanical factors. Expert
opinion is that modifiable risk factors
may be the driving force for higher
incidence of noncontact ACL injuries
among female athletes (Griffin et al.,
2006). For example, differences in
landing patterns among the sexes have
been described as predictive for ACL
injury. Females tend to demonstrate
valgus collapse and increased abduction
movements of the knee, both of which
are predictive of ACL injury (Franklin,
2017). Nonmodifiable risk factors also
highlight the differences between male
and female athletes. For example, sex-
based differences in bone anatomy of
the knee have been described. These
include differences in femoral condyle
shape, hip version, and length of the
femur compared with pelvic width.
However, no causal relationship between
these factors and ACL injury has been
proven. The changing levels of sex
hormones throughout the menstrual
cycle has been theorized to correlate
with ACL injury; however, the data are
insufficient, and determinations cannot
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Month 2019  |  NASN School Nurse  
 be made about the menstrual cycle and
risk of ACL injury in females (Sutton &
Bullock, 2013).
Treatment options and outcomes after
ACL injury may also differ between males
and females. A study by Brophy et al.
(2012) followed soccer players for 7
years after ACL reconstruction and found
that females were more likely than their
male counterparts to require additional
surgery and were less likely to return to
play. A meta-analysis of 13 studies found
no difference among contralateral ACL
rupture, graft failure, or patient-reported
outcomes between males and females.
However, the authors concluded that
more high quality studies are needed to
draw stronger conclusions (Magnussen
et al., 2012). Evidently, more research is
needed on potential sex-based
differences in risk factors, treatment, and
outcomes for athletes with ACL injuries.
Patellofemoral Pain Syndrome
PFPS is one of the most common
causes of knee pain and is
disproportionately more common in
females relative to males. PFPS is anterior
knee pain that results from the
imbalance of forces that control patellar
tracking during knee flexion and
extension. The incidence of this
syndrome is significantly higher in
females, and young females who
regularly participate in running, and
jumping activities may be particularly at
risk (Vora, Curry, Chipman, Matzkin, &
Li, 2017). A study at the U.S. Naval
Academy conducted by Boling et al.
(2010) found that females were 2.23
times more likely to develop PFPS
compared with males.
Researchers suggest that there are
biomechanical and anatomical factors
that may lead to the increased incidence
of PFPS in females compared with males.
These factors include differences
between males and females on measures
of Q angle, dynamic lateral patellar
tracking, and lower extremity muscle
strength. Q angle is defined as the angle
between the line connecting the anterior
superior iliac spine to the center of the
patella and the extension of the line
from the center of the patella to the tibial
2  NASN School Nurse | Month 2019
tubercle. A high Q angle increases the
amount of force on the lateral patella
onto the lateral femoral condyle and may
be a risk factor for patellofemoral pain
(Vora et al., 2017). Normal patellar
tracking, which characterizes dynamic
patellofemoral alignment throughout
knee flexion and extension, is critical for
a healthy joint. Dynamic patellar
maltracking is a risk factor more
prevalent in females than in males that
affects load transmission on the joint
(Carlson et al., 2017; Vora et al., 2017).
On measures of strength, females have
been reported to be significantly weaker
than males on measures of quadriceps,
hip external rotation, hip extension, and
hip abductor strength (Boling et al.,
2010). These deficits are theorized to be
risk factors for PFPS and, therefore, may
contribute to the higher incidence of
PFPS in females.
When understanding the etiology of
PFPS, many studies have focused on
neuromuscular imbalances and
biomechanical abnormalities. However,
activity level and overuse may be an
important factor in the development of
PFPS. For example, Thomeé, Renström,
Karlsson, and Grimby (1995) found that
all female patients who reported
symptoms of an insidious onset had
been involved in temporary overuse or a
period of increased physical activity.
Researchers still struggle to understand
the definitive causes of PFPS because it
is multifactorial in nature. It is clear that
females present with PFPS more
commonly than do males, and this may
be due to many factors, including lower
extremity malalignment, patellofemoral
tilt, muscle imbalances, and other soft
tissue abnormalities. Further research is
necessary to better understand this
complex disorder in both males and
females.
Shoulder Instability
The glenohumeral joint is the most
mobile of the major joints and its stability
depends on a combination of soft tissue
restraints, dynamic muscular forces, and
bony anatomy. The shoulder joint is a
“ball and socket” joint and comprises the
humeral head (“ball”) and the glenoid
(“socket”). The socket is very shallow
compared with other ball and socket
joints like the hip. The labrum acts as a
bumper around the rim of the glenoid to
stabilize the humeral head. In shoulder
dislocations, the ball (i.e., humeral head)
comes off the socket (i.e., glenoid) either
anteriorly or posteriorly, typically tearing
the labrum in the process (AOSSM
SPORTS TIPS, 2008). Owens, Campbell,
and Cameron (2014) investigated the role
of bony anatomy in providing shoulder
stability and found that a patient whose
glenoid is tall and thin has a higher risk
of instability than one whose glenoid is
short and wide. Glenoid morphology
differs greatly among males and females,
females have smaller glenoids and higher
inclination angles, meaning the glenoid is
more oval in shape for females and more
round in males (Owens et al., 2014).
Innate female anatomy demonstrates that
females should have higher rates of
instability than males, and in combination
with females’ increased shoulder range of
motion and greater prevalence of
generalized ligamentous laxity, these
likely contribute to higher rates of
atraumatic shoulder instability in this
population (Carter et al., 2018). Sex-based
anatomic differences are well described
for atraumatic shoulder instability;
however, little information is available
regarding sex differences among
treatments and functional outcomes in
atraumatic shoulder instability.
In general, the incidence of traumatic
shoulder instability is relatively low, with
0.08 to 0.24 dislocations occurring per
1,000 persons per year (Owens, Dawson,
Burks, & Cameron, 2009). Research has
revealed that traumatic dislocations occur
twice as often in males as in females.
Reportedly, males are 2.6 times more
likely to present to the emergency
department with a shoulder dislocation
than are females (Zacchilli & Owens,
2010). Additionally, the male population
has shown an increased risk of
developing recurrent shoulder instability
after an initial traumatic dislocation.
Robinson, Howes, Murdoch, Will, and
Graham (2006) found that male sex and
younger age were independently
predictive of recurrent instability. The
 Table 1.  Sex Differences in Common Sports Injuries and Associated Risk Factors
Injury Type Sex Differences Modifiable Risk Factors Nonmodifiable Risk Factors

ACL injury 4 to 6 times increased risk for Neuromuscular control, valgus Bony anatomy, hormonal,
female athletes compared with landing patterns, muscular generalized joint laxity
male counterparts imbalances

PFPS Incidence is significantly higher in Lower extremity neuromuscular Patellar tracking/patellofemoral

females compared with males imbalance, activity level, overuse malalignment, Q angle

Shoulder instability Traumatic dislocations occur twice Unknown Generalized ligamentous laxity,
as often in males as in females glenoid morphology

Note. ACL = anterior cruciate ligament; PFPS = patellofemoral pain syndrome.

risk of recurrent instability was lower for
females of all age-groups compared with
their age-matched male counterparts
(Robinson et al., 2006). There has been
little investigation to date on possible
sex-based differences in outcomes after
surgical treatment of traumatic or
recurrent shoulder instability. Therefore,
further research is necessary to best
understand how athletes’ sex affects their
risk of shoulder instability as well as
treatment outcomes.
Conclusion
Sex-based differences are common in
musculoskeletal disease and injury. ACL
injury, PFPS, and shoulder instability are
three common sports injuries that reveal
sex-based differences (see Table 1). The
incidence of ACL injury remains
markedly higher in female athletes than
in male athletes. PFPS is another
musculoskeletal disorder that is present
more commonly in females than in
males. There are also sex-based
differences among both traumatic and
atraumatic shoulder instability. Females
are more susceptible to atraumatic
instability due to their anatomically
smaller glenoid, increased shoulder
range of motion, and greater prevalence
of generalized ligamentous laxity.
Traumatic shoulder dislocations,
however, are more common in males
than in females and males have
increased risk for recurrent shoulder
instability.
It is critical that we continue to
investigate sex-based differences in
common sports injuries because a
patient’s sex will likely affect his or her
outcome. As we enhance our
understanding of the differences among
patients and the role these differences
play, we will continue to optimize the
patients experience of, and treatment
outcomes for, various musculoskeletal
diseases including ACL injury, PFPS, and
shoulder instability. For those of us caring
for youth athletes, the most important
thing we can do is start to recognize that
sex differences in musculoskeletal injuries
exist. For the school nurse, it is critical to
understand what risk factors and injury
patterns are more common in females
than in males. When evaluating young
athletes for injury, the school nurse
should keep in mind the increased
incidence of ACL rupture and PFPS in
females and the increased incidence of
shoulder instability in males. The school
nurse is uniquely poised to make
teachers, coaches, and athletic trainers
aware of the differences in injury risk
between male and female youth athletes.
Resources
The school nurse can refer to the STOP
Sports Injuries website to utilize valuable
educational resources that are both sport
specific and injury specific. STOP Sports
Injuries was initiated in 2007 by the
American Orthopedic Society for Sports
Medicine (“STOP Sports Injuries | Sports
Injury Prevention,” n.d.). ■
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Elizabeth Matzkin, MD
Chief of Women’s Sports Medicine
Brigham and Women’s Hospital
Department of Orthopaedic Surgery
Boston, MA
Elizabeth Matzkin, MD, is an
orthopedic sports medicine surgeon
with clinical interests focused on
prevention, management, and
surgical treatment of sports-related
injuries.
Kirsten Garvey, MS, BA
Clinical Research Coordinator
Brigham and Women’s Hospital
Department of Women’s Sports Medicine
Kirsten is a clinical research
coordinator at Brigham and
Women’s Hospital in the
Department of Women’s Sports
Medicine with research interests in
patient outcomes and sex
differences in sports-related injuries.