This article discussed the anatomic, physiologic, hormonal, and psychosocial factors unique to the female athelte that can affect a female athlete’s injury risk and rehabilitation trajectory. A review of considerations unique to different stages of life in the female athlete and a discussion of the prevalence of certain injuries in female athletes are discussed. The purpose of this narrative review is to highlight how understanding the unique characteristics of the female athlete can allow for optimization of rehabilitation protocols.
Key points
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Increased participation of females in sport has led to an increase in injuries and the need for rehabilitation protocols targeting the unique characteristics of female athletes.
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A paradigm shift is required to understand the physiologic, anatomic, and hormonal factors that impact a female athlete’s predisposition to and recovery from injury.
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Female athletes’ physiology fluctuates depending on age, life circumstances (eg, pregnancy), and their menstrual cycle; therefore, rehabilitation considerations must evolve through a female athlete’s lifespan.
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Rehabilitation of injuries for female athletes often involves a multidisciplinary approach that incorporates strength training, nutrition, and psychological readiness.
Introduction/background
Since the passing of Title IX in 1972, female participation in sport has grown at an exponentially large rate. In marathon and ultramarathon events, female participation has increased by at least 50% over the past 40 years with females surpassing males in some age groups. In the 2022 to 2023 school year, 3,328,180 females participated in high school sports in the United States. For collegiate athletics, in 2023, the number of female athletes increased to 226,212, compared with approximately 30,000 in 1972. Female athletes are more likely than male athletes to specialize in and undertake a high competition volume, both of which predispose them to overuse injuries. As the trend of increased female participation in sports continues, it is imperative that medical professionals have a thorough understanding of the health considerations unique to female athletes.
This article will discuss the anatomic, physiologic, hormonal, and psychosocial factors unique to the female athlete, review considerations unique to different stages of life in the female athlete, provide a current assessment on injury prevalence, and discuss specific considerations for the rehabilitation of several common conditions to identify how an understanding of characteristics unique to female athletes can guide optimization of rehabilitation protocols.
Gender differences affecting performance and rehabilitation
Anatomic/Mechanical
The differences in female musculoskeletal anatomy compared with males can affect the performance and rehabilitation outcomes ( Table 1 ). , Notably, female’s reduced height and center of gravity confer an advantage in sports requiring balance. The differences of greatest impact are those related to a higher risk of injury in females compared with males (see specific injuries later).
| Females Compared with Males | Injury and Rehabilitation Implications | |
|---|---|---|
| Anatomic/Mechanical |
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| Physiologic |
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| Neuromuscular |
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Physiologic
There are several physiologic parameters to consider when treating and rehabilitating the female athlete (see Table 1 ). The overall reduced blood volume, reduced vital capacity, and reduced V o 2max in females lends to a lower ceiling on their aerobic capacity compared with males. , , The differences in energy metabolism also has implications for how to adequately fuel female athletes compared with males. ,
Neuromuscular
There are several sex differences related to neuromuscular control of joints, which are thought to relate to injury incidence and prevalence (see Table 1 ). Neuromuscular training programs targeting these deficits are important to be considered in the rehabilitation of the female athlete.
Hormonal
Hormonal control and secretion play an intricate role in the functioning of the neuromusculoskeletal system. Sex hormones, in particular estrogen, progesterone, and testosterone, affect several parts of this system both in basal secretion and related to the female menstrual cycle and reproduction ( Tables 2 and 3 ). , , Other important players in this system include the hormones relaxin, growth hormone, and insulin-like growth factor 1. Important factors to keep in mind when planning the rehabilitation of a female athlete include estrogen’s effect on bone density, ligamentous laxity, and reduced tendon stiffness.
| Hormone | Estrogen | Progesterone | Testosterone |
|---|---|---|---|
| Effects on the female body |
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| Stage | Premenstruation | Menstruation | Late Follicular/Ovulation (Higher Estrogen) | Mid-Luteal (Lower Estrogen) |
|---|---|---|---|---|
| Effects on the female body |
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Menstrual cycle
Female athletes must uniquely consider the hormonal fluctuations that accompany the menstrual cycle. The effect that the eumenorrheic menstrual cycle has on female athlete performance, injury risk, and rehabilitation potential is still being fully elucidated, but it seems that injury burden is higher in the late follicular and ovulatory phases ( Fig. 1 , see Table 3 ).
Perturbations in the menstrual cycle, commonly due to relative energy deficiency in sport (RED-S) and low energy availability (LEA), lead to oligomenorrhea or amenorrhea. Menstrual dysfunction often impacts injury severity, sexual function, fertility, bone health, cognitive function, and mood. , There are a paucity of studies investigating how menstrual dysfunction affects healing and recovery from exercise and injury, except as it relates to bone stress injuries (BSIs). ,
Relative energy deficiency in sport and low energy availability
Historically, LEA was classified under the diagnosis of Female Athlete Triad, which encompasses a syndrome of (1) disordered eating, (2) reduced bone mineral density (BMD), and (3) menstrual dysfunction. , LEA has now been found to affect other body systems and terminology has transitioned to that of RED-S to better encompass the comprehensive and multisystem effects of energy deficiency. Most often RED-S is associated with menstrual dysfunction and impaired bone health but additionally has “other endocrine and metabolic effects, growth and development disruptions, cardiovascular system disturbances, gastrointestinal slowing, hematological and immunologic adaptions, and mental health disorders.”
Regardless of syndrome naming, RED-S and LEA are very common among female athletes. In a cohort of elite female athletes between ages 15 and 32, 40% exhibited at least 2 symptoms of RED-S. Disordered eating among female athletes is as high as 62% with an up to 5 times greater prevalence than male athletes. RED-S and LEA more often affect athletes who participate in “lean” or “weight-sensitive sports,” like dance, gymnastics, running, and figure skating. It is important to optimize energy availability during the rehabilitation of female athletes as RED-S and LEA may curtail injury healing efforts.
Mental health considerations
Competing in sport presents a unique set of psychological challenges for the female athlete, including risk of suffering from anxiety, depression, body image issues, and interpersonal violence. Anxiety and depressive disorders are higher among female versus male athletes and show an equal or greater prevalence compared with nonathlete females. , , Specific review of body image dissatisfaction reveals a higher trend among female athletes, particularly in leanness or esthetic-based sports, as they balance the pressure of aspiring to the “ideal” body for healthy sport participation versus per societal standards. , , Athletes also experience pressure from social media and societal influences that often present a curated version of the “ideal” body. , Additionally, sport-related abuse, also known as interpersonal violence, comes in many forms, including psychological, sexual, physical, financial, and neglect types. , Female athletes experience abuse at higher rates compared with male athletes, with sexual violence estimated to be 4 times as common.
It is furthermore important to consider minoritized female populations based on race, ethnicity, disability, and socioeconomic status who are especially vulnerable to psychological stressors on and off the field. , Greater psychological distress among female athletes is exacerbated by factors such as injury, performance pressure, financial hardship, gender inequality, sexual abuse, interpersonal violence, media sexualization and social media abuse, body image concerns, and family planning. , , , An especially important stressor for physicians to consider is the negative effect that injury has on athlete’s mental health. , Therefore, it is important to ensure that the mental health of an athlete is optimized and that an athlete feels psychologically safe throughout the rehabilitation process. The medical team should consider psychological readiness in the return to play decision and can help in supporting positive factors like self-esteem, internal locus of control, and athletic identity while disbanding negative factors like kinesiophobia and fear of reinjury. Rehabilitation from pelvic floor dysfunction may be a necessary part of the treatment of female athletes who have experienced abuse.
Female athletes by age/stage of life
Pediatric/Adolescent
Youth athletes are participating in sports at an earlier age and with greater intensity than ever before. Much research involving young athletes has revolved around the detrimental effects of early sport specialization, which is more common in females. Risk of injury is higher in female athletes who specialize earlier on, likely due in part to the development of motor and coordination deficits with changes in center of gravity and limb length during puberty. This highlights the importance of integrating early strength training and neuromuscular control programs for this population to reduce future injury burden. Detecting menstrual cycle irregularities in female youth athletes is crucial, but it may be difficult to elicit irregularities in those who are around pubertal age. Menstrual irregularities affecting bone density accrual are particularly problematic in this population, as they may lead to lower bone density in adulthood.
Recommendations for treating and rehabilitating pediatric/adolescent female athletes:
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Maintain a regular sleep-wake cycle—goal of around 9 to 10 hours of sleep per night reduces injury and improves performance.
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Optimize nutrition (fuel to maintain menses)—adequate carbohydrates, protein, and fat, as well as micronutrients like calcium, Vitamin D, and iron are essential.
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Delay sport specialization (until after puberty)—maintain 1 to 2 nonpractice days weekly and 3 months per year free of organized sport. ,
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Participate in regular resistance training program fitted to biological age and psychosocial maturity.
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Supervise rehabilitation and strength training programs—to ensure proper technique and safe progression.
Pregnancy
The female body undergoes several anatomic and physiologic changes during pregnancy which increase the risk of musculoskeletal injury and affect their ability to remain active. Remaining physically active during pregnancy is highly recommended, although modifications may be necessary for the health of the mother and fetus. Pregnant females experience soft tissue edema, ligamentous laxity, weight gain, and a shift in center of gravity leading to greater lumbar lordosis and stress on the low back and peripheral joints. , As a result, pregnant athletes often experience nonspecific low back pain and pelvic girdle pain, including sacroiliac joint and pubic symphysis dysfunction, hip pain, and compression-related peripheral neuropathies.
Recommendations for treating and rehabilitating pregnant athletes:
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Perform both regular aerobic and anaerobic exercises as long as there are no contraindications (contraindications include: persistent bleeding, cardiovascular disease, restrictive lung disease, multiple gestation, cervical insufficiency, preeclampsia, and premature contractions).
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Avoid exercise in the supine position after 20-week gestation.
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Avoid activities with the risk of falling or collision, at high altitude, in extreme heat, and scuba diving.
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Optimize pelvic floor strength to prevent urinary incontinence and low back pain.
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Consider use of a sacroiliac joint belt and/or acupuncture for the treatment of pelvic girdle pain. ,
Postpartum
Following childbirth, the postpartum period of a female’s life poses its own unique challenges regarding rehabilitation and return to activity. Physiologic changes of pregnancy may persist for up to 6 weeks postpartum and, subsequently, females often experience similar musculoskeletal complaints as during pregnancy. , Most recommend pelvic floor strengthening (Kegel exercises and core strengthening) begin immediately postpartum. , Early return to sport may be associated with an increased risk of sustaining ligamentous and/or bony injury, particularly sacral stress fractures, and breastfeeding requires extra nutritional energy that can predispose to the development of LEA and RED-S. It is also important to note other social factors that may impede return to sport and increase injury risk postpartum, including access to childcare, lack of sleep, lack of maternal leave benefit, and loss of financial earnings through missed work/competition.
Recommendations for treating and rehabilitating postpartum athletes:
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There is no specific guideline for timing to return to activity and it should be individualized and gradual. Return to running postpartum should be guided by passing medical and impact screening milestones, healing completely from birth injuries, obtaining an adequate duration and quality of sleep, having adequate breast support, and being mentally ready for the task. ,
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Optimize pelvic floor and core strength to prevent urinary incontinence, pelvic floor dysfunction, low back pain, and diastasis recti. ,
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Optimize hip and knee stabilizer strength to prevent musculoskeletal injury related to return to activity.
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Maintain adequate nutrition and hydration, particularly calcium intake, to potentially reduce risk of BSI with increasing exercise. , ,
Postmenopausal
Postmenopausal female athletes face similar considerations to those that are pregnant and postpartum in that hormonal fluctuations affect exercise abilities and injury risk. This period is associated with reductions in bone mass, lean muscle mass and strength, and flexibility, as well as weight gain and increase in fat percentage due in part to reduced metabolic rate and proportion of type II muscle fibers. , The reduction in bone mass is especially pertinent given the accompanying withdrawal in estrogen with menopause. Of particular importance is the risk of LEA and BSI in this population given an already hypo-estrogenic state and lack of ability to use loss of menstruation as a detection tool for RED-S and LEA. To lessen performance decline and prevent injury, some propose a greater emphasis on nutritional intake for the masters athlete, particularly a higher protein diet and considering timing of nutrient intake. , It is also important to consider that nutrient deficiencies are more common in older females, particularly Vitamin D, Vitamin B6 and B12, iron, and calcium. ,
Recommendations for treating and rehabilitating postmenopausal athletes:
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Nutritional history and counseling is especially important in this population as their requirements for protein, Vitamin D, and omega 3 fatty acids are higher.
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Consider the use of hormone replacement therapy for prevention and treatment of low BMD and chronic tendinopathies. , ,
Rehabilitation considerations for injuries common in female athletes
Anterior Cruciate Ligament Tear
Anterior cruciate ligament (ACL) tears are 10 times more likely in females, and females are between 2 and 8 times more likely tear their ACL through a “noncontact” mechanism of injury when compared with males. , Inherent anatomic, biomechanical, and hormonal factors unique to female athletes contribute to their increased risk of ACL injury ( Table 4 ). , , Preventative rehabilitation that is individualized, sport-specific, and encompasses a combination of strengthening, plyometrics, proximal control, and balance/neuromuscular control exercises are beneficial but adherence is often poor. ,
Related posts:
Rehabilitation Considerations in Women with Traumatic Brain Injury
Cardiac Rehabilitation for Women with Heart Disease
Rehabilitation Considerations for Women with Spinal Cord Injury
Pelvic Pain and Pelvic Floor Disorders in Women
Reproductive and Sexual Health Considerations for Adolescent Females with Disabilities
Osteoporosis Issues Regarding Rehabilitation in Women
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