athletics
CENTER FOR RESEARCH ON GIRLS
A SERIES OF RESEARCH AND INFORMATIONAL PUBLICATIONS BY LCRG
“Putting the world’s best research to work for girls.”
by Tori S. Cordiano, Ph.D. and Lisa Damour, Ph.D.
PROTECTING THE FEMALE ATHLETE: RESEARCH ON CONCUSSIONS, ACL INJURIES AND NUTRITION Participation in athletics contributes to health but can, for girls, pose some special challenges.
GIRLS AND CONCUSSIONS Girls show higher rates of concussion than boys participating in the same sports Research1 consistently indicates that girls experience more concussions and show worse outcomes2 than boys in similar sports, including soccer and basketball, though the rates at which they differ vary. A sport-related concussion (SRC) may include immediate, short-lived neurological impairment and longer-term effects such as disorientation or confusion, impaired balance, slower reaction time, impaired verbal learning and memory, among others.3 Diagnosis and treatment of concussion is complicated by the fact that symptoms are often subtle and difficult to detect, can be non-specific to concussion and might not present immediately following the injury.4
Girls’ impact and recovery from concussion Though young children do not show significant sex differences in their rates of concussion, severity of symptoms or recovery time, sex differences in these areas begin to emerge around puberty.5 In addition to longer general recovery time from concussion, female athletes also show poorer visual memory6 and greater declines in simple and complex reaction times following concussion and more subjective and objective concussion effects.7 Research has begun to explore factors that may contribute to these differential effects of concussion.
athletics:
PROTECTING THE FEMALE ATHLETE: RESEARCH ON CONCUSSIONS, ACL INJURIES AND NUTRITION
What accounts for sex differences in concussion? While the research in this area is still developing, researchers have identified certain factors that likely contribute to sex differences in concussion. These include: • Anatomical differences, including structure of the neck and blood flow in the brain, may increase female athletes’ susceptibility to concussion and help explain differences in symptom severity and recovery time.8 • Hormones likely play a role, though their impact is difficult to study due to fluctuations during females’ menstrual cycles. Research into the effect of hormones on concussion is in the preliminary stage.9 GIRLS AND ACL INJURIES Girls are more likely than boys to rupture an ACL The ACL stabilizes the knee and connects the femur to the tibia. Devastating injuries to the anterior cruciate ligament (ACL) can occur while playing sports—such as soccer and basketball—that require cutting, rapid deceleration and jumping. Girls are at least three times as likely10 as boys to sustain non-contact ACL injuries.
Several factors contribute to girls’ vulnerability to ACL injuries Research11 suggests several factors may make girls more prone to ACL injuries than boys. First, girls generally show decreased neuromuscular control, such as relying on quadriceps muscles rather than hamstring muscles during movements like pivoting, landing and stopping.12, 13 Second, girls tend to show greater hamstring flexibility during and after puberty, while boys’ hamstring flexibility declines during that same developmental period.14 Increased hamstring flexibility can lead to decreased dynamic control of the knee, and weaker hamstring muscles can affect the coactivation of hamstring and quadriceps muscles necessary for protecting the knee during movement. Finally, anatomical differences related to the angle at which the tibia meets the femur increase girls’ susceptibility15 to ACL injuries. Particularly during puberty, as growth spurts lead to a changing center of mass and challenged muscular control, anatomical differences become a factor in girls’ ACL injuries.
Preventing ACL injuries in female athletes Neuromuscular training and plyometric exercise programs that condition girls to use specific muscle groups to stabilize their knees have been found to reduce ACL injuries in female athletes.16, 17 These programs help to reduce strain on the ACL by improving girls’ balance and strength18 and by teaching girls the biomechanics19 of movements that will protect their knees. Research suggests that beginning these interventions during early adolescence may provide the most benefit for injury prevention.20
NUTRITION FOR FEMALE ATHLETES How much should young female athletes eat? Athletes need enough calories and nutrients to support critical biological processes, daily living activities and exercise training. Commonly, sports nutrition assesses an athlete’s energy availability (EA), which is the “energy available for metabolic processes, after accounting for dietary energy intake and physical activity energy expenditure.”21 Chronic low EA can cause delayed puberty, menstrual irregularities, bone damage, shortness of stature and increased risk of injury.22 Energy intake to meet the athlete’s need can decrease the risk of injury in young athletes.23 The specific caloric demands needed to maintain adequate EA vary across young female athletes and depend on metabolic rate, training volume, training intensity and the shifting nutritional demands of pubertal development.24
What should young female athletes eat?25 Carbohydrates maintain energy during exercise and replace energy stores after exercise • Protein provides the basic elements that build and repair tissue • Dietary Fats provide energy and essential fatty acids and help the body absorb fat-soluble vitamins • Vitamins and Minerals support energy production, bone strength, immune function, cellular repair and muscle restoration and development. Key vitamins and minerals (listed below) may be low in the diets of female athletes, especially those who restrict energy intake or avoid meat, fish, poultry and dairy products. • B-vitamins aid energy production and cellular repair • Vitamin D supports bone health, muscle function and boosts the immune system • Calcium is essential to building and repairing bone tissue, maintaining bone mineral density and preventing stress fractures • Iron helps deliver oxygen throughout the body and is key to the enzymes involved in energy production • Zinc supports growth, muscle health and energy production. •
The Female Athlete Triad26 The Female Athlete Triad is a term used to refer to three interrelated health problems sometimes seen in female athletes: low energy availability, menstrual disturbances and impaired bone health. The loss of bone mass is especially concerning during girls’ peak bonebuilding years which begin during puberty. Low energy availability (EA) can result from restricting calories or from having a decreased appetite due to following a high fiber diet or engaging in high intensity exercise. In addition to being associated with abnormal menstruation, increased risk for stress fractures and poor bone health, low EA also links to hormonal disruptions and impaired immune functioning.
PROTECTING THE FEMALE ATHLETE: RESEARCH ON CONCUSSIONS, ACL INJURIES AND NUTRITION [endnotes]
1
Kerr, Z. Y., Chandran, A., Nedimyer, A. K., Arakkal, A., Pierpoint, L. A., & Zuckerman, S. L. (2019). Concussion incidence and trends in 20 high school sports. Pediatrics, 144(5).
2
McGroarty, N. K., Brown, S. M., & Mulcahey, M. K. (2020). Sport-related concussion in female athletes: a systematic review. Orthopaedic journal of sports medicine, 8(7), 2325967120932306.
17
Willadsen, E. M., Zahn, A. B., & Durall, C. J. (2019). What Is the Most Effective Training Approach for Preventing Noncontact ACL Injuries in High School–Aged Female Athletes?. Journal of sport rehabilitation, 28(1), 94-98.
18
Griffin, L.Y. et al. (2006). Understanding and preventing noncontact anterior cruciate ligament injuries. The American Journal of Sports Medicine, 34, 1512-1532.
3
Halstead, M. E., Walter, K. D., Moffatt, K., LaBella, C. R., Brooks, M. A., Canty, G., . . . & Stricker, P. R. (2018). Sport-related concussion in children and adolescents. Pediatrics, 142(6).
19
Mandelbaum, B.R. et al. (2005). Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. The American Journal of Sports Medicine, 33, 1003-1010.
4
National Collegiate Athletic Association (2014). Guideline 21: Sport-Related Concussion. In 2014-2015 NCAA Sports Medicine Handbook (pp. 56-64).
1
5
Stephenson, K., Womble, M. N., Frascoia, C., Eagle, S. R., Covassin, T., Kontos, A. P., ... & Elbin, R. J. (2023). Sex differences on the concussion clinical profiles screening in adolescents with sport-related concussion. Journal of athletic training, 58(1), 65-70.
Myer, G.D., Sugimoto, D., Thomas, S. & Hewett, T.E. (2014). The influence of age on the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: A meta-analysis. The American Journal of Sports Medicine, 41, 203-215.
21
Sims, S. T., Kerksick, C. M., Smith-Ryan, A. E., Janse de Jonge, X. A., Hirsch, K. R., Arent, S. M., ... & Antonio, J. (2023). International society of sports nutrition position stand: Nutritional concerns of the female athlete. Journal of the International Society of Sports Nutrition, 20(1), 2204066.
22
Williams, N. I., Statuta, S. M., & Austin, A. (2017). Female athlete triad: future directions for energy availability and eating disorder research and practice. Clinics in sports medicine, 36(4), 671.
23
Hecht, C., Bank, N., Cook, B., & Mistovich, R. J. (2023). Nutritional Recommendations for the Young Athlete. Journal of the Pediatric Orthopaedic Society of North America, 5(1), 599.
24
Hecht, C., et al. (2023).
25
American College of Sports Medicine, American Dietetic Association & Dieticians of Canada (2000). Joint position statement: Nutrition and Athletic Performance. Medicine & Science in Sports & Exercise, 32, 2130-2145.
6
7
Koerte, I. K., Schultz, V., Sydnor, V. J., Howell, D. R., Guenette, J. P., Dennis, E., ... & Lin, A. P. (2020). Sex‐related differences in the effects of sports‐related concussion: a review. Journal of neuroimaging, 30(4), 387-409. Covassin, T., Savage, J. L., Bretzin, A. C., & Fox, M. E. (2018). Sex differences in sportrelated concussion long-term outcomes. International journal of psychophysiology, 132, 9-13.
8
Stephenson, K., et al. (2023).
9
Goeckner, B. D., Huber, D. L., Van Bortel, K., Gill, J. M., Mannix, R., Master, C. L., ... & CARE Consortium Investigators. (2024). Progesterone and Estradiol Levels Associated with Concussion and Clinical Outcomes and Recovery in Female Athletes and Cadets. Medicine and science in sports and exercise.
10
The female ACL: Why is it more prone to injury? J Orthop. 2016 Mar 24;13(2)
11
Bram, J. T., Magee, L. C., Mehta, N. N., Patel, N. M., & Ganley, T. J. (2021). Anterior cruciate ligament injury incidence in adolescent athletes: a systematic review and meta-analysis. The American journal of sports medicine, 49(7), 1962-1972.
26
Kussman, A., & Nattiv, A. (2020). The female athlete triad. Mental Health in the Athlete: Modern Perspectives and Novel Challenges for the Sports Medicine Provider, 127-147.
12
Hewett, T.E. & Myer, G.D. (2005). Reducing knee and anterior cruciate ligament injuries among female athletes. The Journal of Knee Surgery, 18, 82-88.
27
13
Kasmi, S., Zouhal, H., Hammami, R., Clark, C. C., Hackney, A. C., Hammami, A., . . .& Ounis, O. B. (2021). The effects of eccentric and plyometric training programs and their combination on stability and the functional performance in the post-ACLsurgical rehabilitation period of elite female athletes. Frontiers in Physiology, 12, 688385.
American Academy of Pediatrics (September, 2016). State Advocacy Focus: Concussion Management: Return to Play. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/ Concussion.pdf
28
Noyes, F.R. & Barber-Westin, S. (2018). ACL injuries in the female athlete: Causes, impacts, and conditioning programs, second edition. New York: Springer Heidelberg.
29
LaBella, C.R., Hennrikus, W. & Hewett, T.E. (2014). Anterior cruciate ligament injuries: Diagnosis, treatment, and prevention. Pediatrics, 133, e1437-e1450.
30
Castle, J. (2015). Eat like a champion: Performance nutrition for your young athlete. New York: American Management
14
Hewett, T.E., Myer, G.D. & Ford, K.R. (2006). Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors. The American Journal of Sports Medicine, 34, 299-311.
15
Hewett et al. (2006).
16
Foss, K. D. B., Thomas, S., Khoury, J. C., Myer, G. D., & Hewett, T. E. (2018). A school-based neuromuscular training program and sport-related injury incidence: a prospective randomized controlled clinical trial. Journal of athletic training, 53(1), 20-28.
athletics: PROTECTING THE FEMALE ATHLETE: RESEARCH ON CONCUSSIONS, ACL INJURIES AND NUTRITION
RESOURCES FOR PARENTS, COACHES AND ATHLETES Resources RETURN TO PLAY AFTER A CONCUSSION27 This fact sheet, produced by Children’s Hospital Colorado, provides information, guidelines and helpful links for additional guidance. https://www.childrenscolorado.org/conditions-and-advice/sports-articles/sports-injuries/concussion/ play-after-concussion/
ACL INJURIES IN THE FEMALE ATHLETE, SECOND EDITION28 This book provides helpful information to guide training techniques toward reducing and preventing ACL injuries in female athletes.
ANTERIOR CRUCIATE LIGAMENT INJURIES: DIAGNOSIS, TREATMENT, AND PREVENTION29 This clinical report, provided by the American Academy of Pediatrics, provides accessible, up-to-date information for parents regarding ACL injuries in children and teens. http://pediatrics.aappublications.org/content/133/5/e1437
EAT LIKE A CHAMPION: PERFORMANCE NUTRITION FOR YOUR YOUNG ATHLETE30 This research-driven, practical book addresses the nutritional needs of athletes aged eight through eighteen.
FIND A NUTRITIONIST The “Find an Expert” section of the Academy of Nutritionist and Dietetics website lists Registered Dietician Nutritionists by location and area of expertise. https://www.eatright.org/find-a-nutrition-expert
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