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


Concussions sustained during athletic participation have become increasingly common; the CDC reported that 249,000 children (aged ≤19 years) were treated in an emergency department for sports-related concussion in 2009.[53] This new wealth of experience treating young athletes with concussions led some investigators to hypothesize that sex-based differences exist in both the incidence of and the symptomatology after a sports-related concussion.[54] In a recent study, Zuckerman et al[55] demonstrated a higher incidence of concussion in females participating in sports such as soccer, basketball, and lacrosse. Large epidemiologic studies have consistently found that female athletes sustain markedly more concussions than male athletes; in some studies, the number of concussions sustained by female athletes is double the number sustained by male athletes.[54,56] These differences are most commonly seen in sports such as basketball, soccer, and volleyball.[54,56] Some authors have additionally demonstrated that female athletes sustain more severe concussions than do males, with greater deficits in cognitive function reported and a longer recovery period required than their male counterparts.[57–59]

Why females seem to have a higher risk of sustaining a concussion compared with males remains uncertain. Several theories have been posited and primarily focus on anatomic and biomechanical differences: first, females typically have more slender necks and smaller heads compared with males and thus experience greater reactive forces when head trauma is sustained. Biomechanical studies have demonstrated that females can experience nearly 50% more head acceleration during head trauma than males.[54,60] Although it has also been theorized that a female's relatively weak neck musculature may provide less protection against concussion than a male's neck musculature, recent research suggests that dynamic cervical stabilization responses may play a larger role than neck strength in mitigating head impact severity.[61] Finally, in addition to the sex-based differences in anatomy and biomechanics that likely mediate an athlete's experience of concussion, hormonal differences between males and females may also play a role. Studies have shown that estrogen has differential effects on the brain after trauma, with animal studies suggesting a greater detrimental effect of estrogen in females.[54,62]

It has also been argued that the documented differences between the sexes with regard to concussion incidence and severity may simply be the product of reporting bias. Male athletes may be more likely than female athletes to hide concussions and fail to report them for fear of not being able to continue playing or to participate in sports.[63] Gender stereotypes may reinforce this behavior, with boys wanting to appear "manly" after sustaining a concussion and "toughing it out."

Much remains to be elucidated regarding sex-based differences in concussion incidence and severity. Ultimately, team physicians should have a high index of suspicion for concussion with any head trauma sustained in sports, regardless of the athlete's sex.