Female Athletes and Sports Injuries

Beth Shubin Stein, MD, discusses the most common types of injuries among female athletes and how they can advocate for better treatment

Field and court sports provide the highest risk for injury in female athletes, says Dr. Beth Shubin Stein, Associate Professor of Orthopedic Surgery and Sports Medicine at the Hospital for Special Surgery in New York. When it comes to the type of injury, Dr. Shubin Stein says female athletes are most susceptible to knee and shoulder injuries—and even have an increased risk for some of these injuries compared to male athletes. While prevention programs aimed at educating female athletes about the prevalence of these injuries and how to best train to reduce their risk have popped up in recent years, there is still work to do.

Dr. Shubin Stein recently spoke with us about the differences in treatment between male and female athletes, the most common type of injury female athletes face and the role concussion plays in women’s athletics.

Equal Care for Female Athletes

Treatment of female athletes has improved significantly in the past couple of decades, Dr. Shubin Stein says. “In the last 15 to 20 years, we’ve seen a huge shift toward more aggressive care for the female athlete,” she says. “That’s because, in this generation, we have seen nearly equal sports participation amongst women and men as they grow up.”

Dr. Shubin Stein says she always advises her female patients to speak up if something doesn’t seem right when they are being treated for an injury. “Women need to be their own best advocates,” she says. “If what they’re told on the sidelines or even in the doctor’s office does not make sense, or they’re told that it’s time to return to sport and something doesn’t fit, they should say, ‘I’m not comfortable. Something is off.”

The Prevalence of Knee Injuries in Female Athletes

When comparing women’s soccer, tennis and basketball players to men’s soccer, tennis and basketball players, the risk to the female knee is four to nine times greater than it is to the male knee, Dr. Shubin Stein says.

The anatomy of the female knee and the way in which women land, cut, pivot and jump contribute to this increased risk of knee injury. More specifically, female athletes have a higher incidence of ACL injuries than male athletes in the same sports, according to a 2012 study published in Research In Sports Medicine.

Dr. Shubin Stein says prevention programs have been created to mitigate the risk female athletes face regarding knee injury. This is an area experts have tried to create more awareness about, especially in youth athletics. But incorporating these risk prevention programs in youth athletics is still a challenge. “Unfortunately, most of the schools that would benefit from it don’t have the finances to get the athletic trainers who could actually help them,” Dr. Shubin Stein says. “But the awareness is there.”

Concussion Risk in Female Athletes

For female athletes, the greatest risk for concussion occurs in soccer and lacrosse, Dr. Shubin Stein says. This year, female lacrosse players have the option to wear helmets for the first time. Previously, there were no protective helmets for women, Dr. Shubin Stein says. Men, on the other hand, have always worn protective helmets during lacrosse.

Dr. Shubin Stein says she believes newer and stricter policies that came out regarding concussion in the past few years have created more awareness for concussion not only in athletes but health care providers, as well.

“When my patients and I speak, and we talk about the injury at hand, if it had anything to do with their head, I make sure that they’ve either seen a neurologist or have an appointment to see a neurologist to be evaluated,” she says.

Dr. Shubin Stein believes this increased awareness about concussion will make treatment of it gender-neutral in the future. “I think we will see that concussion is treated aggressively both between men and women. The focus now is more equal in terms of how we treat our young athletes,” she says. “I don’t think that was true 25 years ago, but it has become true within the last decade.”

Beth Shubin Stein, MD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class Scientific Advisory Board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

Returning the Athlete to Competition After a Concussion

Amaal Starling, MD, shares the five steps every coach and parent should follow

The importance of a safety protocol for a possible concussion seems common knowledge, but Dr. Amaal Starling says as recently as six years ago, when she’d ask coaches about their team’s post-head injury protocol, they’d say, “Oh, we pull [athletes] off the field and we’ll ask them a question or two, and then we watch them for a couple of minutes. It was very unstructured, which leaves room for error and missed diagnoses,” says Dr. Starling, Assistant Professor of Neurology at the Mayo Clinic in Phoenix and member of the International Concussion Society’s Scientific Advisory Board.

Relying on an injured athlete to self-report is dangerous, because, “when you’re concussed, you’re confused, and when you’re concussed, you’re not playing at your best,” which can lead to unsafe play and risk of subsequent head injuries. This is why Dr. Starling advocates for schools, youth athletic organizations and professional teams to set a standard structured protocol for concussed athletes to follow prior to returning to play. “If you think about life in general, really important emergencies always have a specific structured protocol,” she says. “Policemen, firemen and emergency medical services have a protocol to approach emergencies. When patients come in concerned about a possible stroke, as neurologists we have a specific protocol to assess, diagnose and treat as rapidly as possible. This is important in emergencies and time-sensitive conditions including head injuries.”

While protocols should be allowed some flexibility according to age, sport and level of play, Dr. Starling believes a standard concussion and return-to-play protocol should include the following:

1. Pre-concussion education

“Protocol should start even before a head injury occurs,” Dr. Starling says, calling for concussion education for athletes, parents, coaches, administrators, nurses and counselors. In order for any concussion program to exist—at a school or on a sports team—there has to first be an awareness of the injury itself and an understanding of the symptoms and risks. To successfully and safely rehabilitate an athlete, “concussion education is really the first start,” says Dr. Starling.

2. Pre-game brain function testing

Dr. Starling believes that brain function should be measured as a part of any athlete’s annual physical, which examines the heart, lungs, muscles and bone health but tends to leave out the brain. The King-Devick eye movement test is easily applied (versions of the test can be downloaded and administered on a tablet) and provides baseline information so that when another test is administered post injury, abnormalities in eye movement coordination, attention, concentration and language may objectively suggest a brain injury or concussion immediately post injury.

3. When in doubt, check them out

The moment a parent or coach suspects a potential head injury based on the hit or athlete’s behavior, the athlete should be immediately removed from play to reduce the risk of subsequent head injury. If a well-validated sideline tool like the King-Devick test shows abnormal objective results or there are any symptoms and signs concerning for a concussion, it’s time to see a concussion specialist. “[The visit] should occur within a week of injury so that we can administer appropriate tests and provide recommendations for management including returning to learn/school and returning to physical activity,” Dr. Starling advises. At return-to-play clinics like the one at Mayo, doctors administer various objective tests to provide a comprehensive clinical picture of the patient in order to treat physical, cognitive, emotional and sleep symptoms.

4. Wait for the all clear

Whether on the sideline or in a clinic, concussed athletes need to be completely symptom-free at rest and with full exertion in order to return to contact play. “They must have completed an exertion protocol where we have them exercise, raise their heart rate, complete balance and movement work without any return of symptoms,” says Dr. Starling.

5. Post-game discussion

“The last and very crucial step is to have a discussion with the athlete and parents about returning to sports, particularly if there is a history of prior concussions,” says Dr. Starling. A concussed athlete faces an increased likelihood of future concussions occurring, which brings risk of a longer recovery for subsequent head injuries. Coaches, parents and athletes should review safety measures and future protocol in case there is another injury.

Dr. Starling would like to see sports programs at every level equip themselves with a checklist for concussions.  “I hope that we have more standardized protocols so that every potentially concussed athlete is evaluated in a structured fashion and thus has the best chance of immediate identification and diagnosis, appropriate recovery and continued participation in sports,” she says.

Amaal Starling MD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

Action Plan: What to Do After a Player Sustains a Head Injury

Follow the Return to Play protocol to ensure players are ready to return to activity

If one of your players experiences a head injury during practice or a game, you should first consult the Return to Play protocol that is set in place by the league or the school. All 50 states have Return to Play laws, but schools, sports leagues and organizations adopt them differently, according to the CDC. If a specific plan isn’t in place—or it doesn’t seem thorough enough—consult the CDC’s guidelines, which are a good benchmark for responding to a concussion.

You can ensure your athlete will be safe, healthy and ready to return to play at the appropriate time by following this protocol after a head injury:

Remove the Athlete from the Activity or Game

Be on the lookout for early and common symptoms of a concussion, such as a headache, dizziness, difficulty concentrating, confusion, sensitivity to light, blurry vision, irritability and nausea, according to The Cleveland Clinic.

Keep the Athlete Out of Play

The player should refrain from activity for the remainder of the day of the incident—at least. Do not allow the player to return until he or she has been cleared by a health care provider. Returning the player to activity before he or she has been seen by a medical professional may aggravate the injury and delay recovery.

Know When to Call an Ambulance

If a player demonstrates any of the dangerous symptoms associated with a concussion—such as loss of consciousness, a seizure, one pupil larger than the other or trouble recognizing people or places, according to Rush University Medical Center—call an ambulance right away.

Inform the Player’s Parents of the Head Injury

If the child’s parents or guardians are not at the game or practice, contact them immediately to let them know about the injury and suspected concussion. Provide them with any informational materials you have about concussions, and refer them to additional online resources such as CDC’s HEADS UP Resource Center or the Sports Concussion Resources from the American Academy of Neurology.

Give a Detailed Recording of the Injury to the Health Care Provider

The health care provider will want to know things such as what caused the injury, how forceful the blow was and if the player sustained any loss of consciousness, memory loss or seizures. You should also mention if the player has had previous concussions.

Wait for Clearance

The most vital step after a player sustains a head injury is waiting to return a player to activity until a health care provider has cleared him or her to return to the playing field.

The CDC notes that you should get written instructions from the player’s health care provider before returning him or her to play. Ask the health care provider for information on when to return the athlete to play, and how you as a coach can ensure he or she will be returning safely.

If a player has undergone a concussion, you should follow the American Academy of Pediatrics’ recommended set of guidelines before returning the athlete to play. As part of this protocol, youth athletes begin with minimal, light activity and gradually progress through six stages of activity until they are fully ready to re-enter game play.

For more information on concussion signs, symptoms and safety, visit our resource library.

Encouraging Young Athletes to Speak Out After Head Injuries

Tips For Coaches to Better Recognize and Treat Concussions

Young athletes often push themselves to be “tough” and avoid showing weakness. While grit is a valuable quality on and off the field, insecurity can prevent young players from being honest with their coaches or other adults after an injury. As role models and team leaders, coaches have the power to break down these barriers and create a team culture where athletes feel comfortable seeking appropriate treatment for their injuries.

Here are tips to help coaches show their athletes the importance of speaking openly and honestly about head injuries on the field.

Teach the Symptoms

Young athletes might be hesitant to speak to an adult if they’re not sure whether their injury is severe, or may be a concussion. Coaches can relieve some of that anxiety by discussing common signs, symptoms and misconceptions about concussions and head injuries with players and their parents. Explain that concussions are serious brain injuries that can be caused by even a minor blow. Contrary to popular belief, people don’t have to be knocked unconscious to be experiencing a concussion.

Common symptoms of concussion include headache, blurred vision, nausea, unconsciousness and trouble paying attention, according to the Centers for Disease Control. But athletes should also know that everyone has different concussion symptoms, and some may take days to appear. Concussion symptoms can last up to two weeks for many people, or even longer for about 20 percent of people with concussion, according to the Mayo Clinic.

If a player experiences any kind of head injury, encourage him or her to consult a doctor, and to be on the lookout for any unusual symptoms for several days after the injury. When young know the warning signs to watch for after a head injury, they can feel more confident seeking help from a coach or parent, and getting the medical care they need, to safely return to play as soon as they’re ready.

Understand the Effects

Young athletes may dismiss the seriousness of a head injury if they don’t understand the reality of concussion. Explaining the the long- and short-term effects of concussions can encourage them to exercise more caution and feel more comfortable speaking out. While it is important not to frighten younger children about their risks of injury in sports or other high-energy activities, kids are especially susceptible to concussions as their brains develop, and communication barriers make their injuries more difficult to diagnose: so make it clear that it’s important they tell you if they bump their heads during play.

With older kids and teens, be straightforward about the real risks of untreated concussions, which can have severe, long-term effects on their lives. Ignoring concussion symptoms can make them worse and lead to lasting side effects like post-traumatic headache. Concussions can also put young people at risk for developing neurodegenerative disease, like Alzheimer’s, later in life, according to the Mayo Clinic.

Recovery from concussion can take longer in teens and young children than in adults, according to the CDC, and continuing to participate in sports while concussed can delay healing even longer. During recovery, people with concussion may see their symptoms worsen when they exercise or do activities that require concentration, like schoolwork. Seeking help after a head injury, and avoiding re-injury after a concussion, are the most important things a young athlete can do to keep themselves healthy in the future.

Show Them Their Health Comes First

It’s important to reassure young athletes—clearly and often—that their health is more important than a game. If you suspect your players might dismiss concussion symptoms out of fear they’ll lose their place on the team or let down their teammates, make it clear that their well-being is your to priority. Avoid pressuring players to return to play after an injury, even if their injuries are less severe than head trauma, to reinforce this message.

On the flipside, coaches can foster a culture of concussion awareness by supporting children and teens who alert adults about potential head injuries. Having to sit out due to a concussion shouldn’t be seen as a punishment; combat the potential stigma of sitting out by including injured players in team conversations and off-the-field events. If an athlete or parent decides the child shouldn’t return to the sport after a concussion, help the team understand why, and encourage them to be understanding.

Coaches play a key role in creating a team culture where young athletes feel encouraged to put their health first. Combatting this stigma is especially important when it comes to concussions, which can have immediate and long-term effects on a young athlete’s health. Talking about the effects of concussions, educating players on signs to look out for, and reinforcing the message that athletes’ health comes first will encourage young people to speak out when they suspect they might have a concussion.

Looking for more information to better understand and reduce concussions in youth sports? Visit the Concussion.org resource library for tools to educate coaches, parents and athletes on concussion signs, symptoms and safety.

What Every Coach Needs to Know About Concussion Safety

From high school soccer to Little League, here is what coaches can do to make sports safer.

The positive impact coaches can make in the lives of young athletes is incredible. From hard work and discipline to demonstrating the value of teamwork, a good coach can be an instrumental element of childhood development. But as a coach, one of the most important aspects of running a team is creating a safe environment on and off the field—especially when it comes to concussions.

Because coaches are on the front lines, here is what coaches can do to promote concussion safety.

Explain the Symptoms

Oftentimes, children aren’t aware that some of the symptoms they might be experiencing are actually a serious brain injury. According to the Mayo Clinic, clear indicators of concussion are dizziness, confusion and a headache. If players have a more solid idea as to concussion symptoms, they will be more likely to notify you of a problem. Since 90% of concussions take place without the athlete losing consciousness, having the players report their own injuries can take away a lot of the guesswork.

Encourage Open Communication

It is not uncommon for children to be nervous about speaking up about a head injury, anxious about appearing weak or letting down their teammates by being taken out of the game. In fact, as many as seven in 10 young athletes with a possible concussion reported playing with concussion symptoms, according to the Centers for Disease Control and Prevention. The CDC advises offering positive reinforcement for athletes who report concussion symptoms.

Educate the Parents

It’s important to ensure that parents and coaches are both in sync when it comes to safe play and concussion reporting. Children should feel that concussion symptoms are to be taken seriously both on the field and at home. Make sure that parents know that concussions don’t just occur in contact sports like football. In fact, research published in the British Journal of Sports Medicine found that while most concussions happen in football, hockey and rugby, they also occur in sports like soccer, lacrosse and baseball. Have a conversation with the parents regardless of the perceived concussion risk.

Enforce the Rules of the Game

In concussions reported among high school athletes, as many as 25 percent were the result of aggressive or illegal play, notes the CDC. Work with parents and players alike to ensure that all teammates follow regulation rules, such as avoiding illegal activity like striking other players in the head, using their helmet to contact other athletes and colliding with unprotected opponents.  As a coach, you can lower your players’ concussion risk by following advice about sports conduct.