Sex-Based Differences in Common Sports Injuries

Cordelia W. Carter, MD; Mary Lloyd Ireland, MD; Anthony E. Johnson, MD; William N. Levine, MD; Scott Martin, MD; Asheesh Bedi, MD; Elizabeth G. Matzkin, MD


J Am Acad Orthop Surg. 2018;26(13):447-454. 

In This Article

Abstract and Introduction


The patient's sex plays an important role in mediating the risk for, and experience of, disease. Injuries of the musculoskeletal system are no exception to this phenomenon. Increasing evidence shows that the incidence, clinical presentation, and treatment outcomes for male and female patients with common sports injuries may vary widely. Stress fracture, which is associated with the female athlete triad, is a sports injury with known sex-based differences. Other common sports-related injuries may also have distinct sex-based differences. Understanding these differences is important to optimize each patient's musculoskeletal care.


At the end of the 20th century, the National Institutes of Health (NIH) implemented a series of policy changes that substantially increased the proportion of females participating in NIH-funded clinical trials.[1] These changes have had the desired result of improving our understanding of sex-based differences that exist in clinical medicine. More recently, the NIH has focused on ensuring that preclinical trials include both male and female cells and animals in the laboratory.[1]

The musculoskeletal system is rife with sexual dimorphism. One example is that males have greater bone mass, greater muscle mass, and greater lean mass than do females. Various sex-based differences in injuries and diseases of the musculoskeletal system have been described, including differences in osteoporotic hip fractures and osteoarthritis of the knee and the carpometacarpal joint of the thumb.[2]

Most of the existing data regarding sex-based differences in the incidence of sports injuries are from the pediatric literature. One recent epidemiologic study of sports-related injuries (SRIs) in Canadian children and adolescents reported that males are more frequently injured during sports participation than females are. Males comprised 71% of SRIs in this study, reporting higher injury rates in 11 of the 13 sports investigated.[3] A more recent study of children aged 5 to 17 years in the United States described the type, location, and chronicity of SRIs as a function of sex.[4] The authors noted that females are more likely than males to have overuse injuries; for example, females are three times more likely than males to develop patellofemoral knee pain. Males are markedly more likely than females to sustain acute, traumatic injuries such as sports-related fractures.[4]

Mounting evidence exists supporting the concept that the incidence, clinical presentation, and functional outcomes for male and female patients with sports injuries may profoundly differ. By improving our understanding of these sex-based differences, orthopaedic surgeons may be better equipped to care for patients with common sports injuries and improve treatment outcomes. For example, the intraoperative choice of an anterior cruciate ligament (ACL) autograft is a notable factor in determining return-to-sport and reinjury rates, especially for adolescent females with high quadriceps to hamstring strength ratios. Investigating this and similar hypotheses in a systematic fashion may lead to the development of sex-specific treatment algorithms that may optimize clinical outcomes.

Here, we review the current literature on sex-based differences for five commonly occurring SRIs: stress fracture, ACL injuries, femoroacetabular impingement (FAI), shoulder instability, and concussion.