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

Femoroacetabular Impingement

FAI is a condition characterized by bony abnormalities around the hip that may cause labral tearing and damage to the articular cartilage, especially in young athletes.[35,36] Because the etiology of FAI is poorly understood, the effect of specific sports activities is unclear. Research has indicated that repetitive hip motion may lead to irregular bone formation, particularly in younger athletes as their physeal plates close.[37] Alternatively, athletes may have the same prevalence of radiographic FAI as the general population, yet become symptomatic because of increased stress through the hip.[36,38,39]

Sex-based differences in the acetabular and femoral morphology have been identified in patients with FAI.[40] Although pincer lesions occur equally in males and females, cam- or combined-type morphologies are more prevalent in males.[36] When cam morphology is present in patients with hip pain, males have larger alpha angles; in a recent study, Nepple et al[41] reported average alpha angles of 70.8° and 57.6° in symptomatic males and females, respectively (Figure 1). A study of large cohort of patients with symptomatic FAI assessed with CT suggested that females have increased femoral and acetabular anteversion with milder cam-type morphology, whereas males have more restricted motion and larger and broader cam-type morphology.[42] In addition to increased hip anteversion,[43–46] females also have a higher prevalence of acetabular dysplasia compared with males. In their recent series, Kapron et al[38] identified dysplasia in 21% of collegiate female athletes. This finding is relevant for surgical planning because overresection of a pincer lesion can result in instability.[47]

Figure 1.

Radial reformatted MRI demonstrating the method of assessing the alpha angle in femoroacetabular impingement. It is measured by drawing a best-fit circle on the femoral head (a); a line from the center of the femoral head that bisects the femoral neck (b); and a line from the center of the femoral head to the location where the femoral head no longer follows a circular contour (c).

Symptoms of FAI and labral tears include intermittent anterior hip or groin pain, locking, and popping. Activities requiring hip flexion or pivoting often elicit symptoms in both male and female athletes.[36] Kapron et al[38] found that, in female athletes only, the response to impingement testing did not correlate well with the presence of radiographic FAI. On presentation, females reported worse function and decreased activity, despite a greater hip range of motion than that of males. Interestingly, this finding does not seem to correlate with the severity of the disease because males often have larger cartilage defects and labral tears[41] (Figure 2). Although females present earlier in the disease process than males do, males are more likely to undergo bilateral surgery within 2 years.[48]

Figure 2.

Intraoperative photograph of the hip demonstrating a labral tear extending into the chondrolabral junction. This pattern of injury is more commonly seen with cam lesions.

Of note, symptoms of FAI can be seen in females with minimal bony abnormalities. This occurrence may be attributed to physiologic differences such as increased laxity, less muscle mass, and overall greater range of motion compared with males.[43,45] Awareness of alternate etiologies of pain, particularly in females, such as stress fractures, iliopsoas dysfunction, sacroiliac pathology, ovarian cysts, and endometriosis, is important. Management of confirmed FAI does not differ between males and females because a nonsurgical approach, including physical therapy, activity modification, and anti-inflammatory medication, is recommended as first-line treatment.[35,36] Typically, surgical intervention entails some combination of labral repair, acetabular osteoplasty, and femoral osteoplasty that can be conducted arthroscopically. Surgical techniques are not sex dependent; however, careful consideration of the underlying bony abnormalities is essential in determining appropriate resection.[35,36] Prognosis after surgery is favorable, with return to play reported in 73% to 92% of patients.[49,50] Markedly improved functional outcome scores after hip arthroscopy have been reported, with no difference between sexes in patients aged <45 years.[51,52]

Further investigation of sex-based differences in the clinical presentation, relevant anatomy, and surgical management of FAI is necessary to elucidate factors markedly associated with patient outcomes. For example, recognizing that females have higher rates of pelvic anteversion coupled with greater ligamentous laxity might suggest that surgical osteoplasty would be beneficial in this population, even in the setting of radiographically smaller impingement lesions. Rigorous scientific investigation that either confirms or refutes this type of clinical hypothesis is needed.