Why Are Female Athletes At A Higher Risk Of ACL Injuries?

IRA FLATOW: This is Science Friday. I’m Ira Flatow. Last year, during the NCAA March Madness tournament, photos and videos from inside the athlete’s weight rooms went viral. The images showed the difference between what was available to the men’s and women’s teams.

The men’s weight room was chock full of fitness training devices. For the female athletes, the only weights were six pairs of dumbbells. People were understandably mad. Women were insulted. The NCAA leadership apologized. And the women’s weight room was upgraded.

This was one of many examples of a harmful stereotype, a misconception about women in sports that has been around for, well, as long as I can remember. Strength training is for men, not for women. That kind of thinking is not only wrong, but can have serious consequences.

As research shows, female athletes are more prone to certain injuries. And a lack of strength training is a big reason why. Joining me to talk about this topic are two researchers who study gender differences in sports training, Joanne Parsons, a physical therapist and associate professor at the University of Manitoba in Winnipeg and Stephanie Coen, health geographer and associate professor at the University of Nottingham in England. Welcome both of you to Science Friday.

JOANNE PARSONS: Thank you so much for having us, Ira.

STEPHANIE COEN: Pleasure to be here.

IRA FLATOW: Nice to have you. Just a reminder that this conversation was recorded in front of a live Zoom audience. And if you want to learn more about how you can join a future recording go to sciencefriday.com/livestream. Joanne, let’s start with you. I know you both worked together on research about ACL injuries in women and girls. Let’s talk about what is an ACL? And why are ACL injuries? What are they?

JOANNE PARSONS: Sure, So ACL stands for anterior cruciate ligament. So it’s one of the main stabilizing ligaments in our knees. And it prevents kind of rotational movement in our knee. And we chose to study ACL injuries, or chose them as a good example in our paper, because they’re relatively common in sports from all levels, whether you’re a recreational athlete up to the elite levels.

And when they do happen, they are devastating. They can be life altering for people, not just the immediate pain and the lack of ability to participate in their sport. But people who experience this injury often have to have surgery. The rehabilitation, whether you have surgery or not, can take nine months or more.

And then you end up with increased risk of developing early onset osteoarthritis in your knee and having a joint replacement earlier in life. So very– a significant injury that does happen to a lot of girls and women, in particular.

IRA FLATOW: Well, how big of a gender difference is there with ACL injuries?

JOANNE PARSONS: Yeah, it does depend on the level that you’re playing, whether recreational or competitive sport. It also depends on the sport. So basketball and soccer tend to be higher risk sports. The risk can be anywhere between– it’s about 2 to 6 times higher injury risk in girls and women compared to boys and men. Yes, it is significant.

And just to give it kind of an individual risk example, a high school girl that plays basketball or soccer for one season, so let’s say three to four months-ish, we’ll have a 1% chance of rupturing their ACL, so not completely insignificant there.

IRA FLATOW: Stephanie, what did you find about why women– why women are more susceptible to ACL injuries?

STEPHANIE COEN: So what we’re trying to propose in the work that we’re doing is actually that we need to consider the kind of cumulative effects of gendered exposures over the life course in terms of shaping women and girls’ ACL injury risk. So we a lot about how sex-based biological factors may play into some of the sex-based or gender disparities that we see in terms of things like hormones and knee biomechanics.

But as Joanne said, this gender disparity has persisted. And it’s persisted for a long time. So part of what we’re trying to do in our work is to ask new questions about why this gender disparity in ACL injury might be occurring. And that might hopefully give us some new solutions in terms of how we can address this inequity.

So what we conceptualize is that we actually might consider the ways that women and girls are exposed to different gendered environments throughout our lifetimes, in ways that might shape how we move and use our bodies, in ways that might make us more susceptible to these particular types of injuries. So these kinds of social exposures might then play out over time, materially, in our bodies. And that might be part of why we see this kind of gender disparity.

And so in the work that Joanne, and I, and our colleague Sheree Bekker are doing, we’ve proposed kind of four environments where we might think about the way that this occurs. So we talk about the presport environment. So this is very early in life, where we’re socialized to move and use our bodies in highly gendered ways. We think about, for example, rough outdoor play for boys and indoor play for girls.

And then we move into the context of sport, whether it’s recreational or leisure sport, or more competitive sport, we can think about training environments like the gym, for example, and then as well, the competition spaces. So we might think about the different ways that perhaps women might be socialized to coping with and playing through pain. And then Joanne mentioned the complexities involved in rehabilitating an ACL injury after surgery, after intervention.

And so the rehabilitation environment is another place where we might think about why do we see different outcomes between women and men. And maybe we need to think about the gendered context of women’s lives. Women might have more caring responsibilities. And what does that mean for women’s capacities to complete a full course of rehabilitation or adhere to a rehabilitation regimen?

So what we’re trying to do is kind of say, here are a bunch of domains that we think might be having an impact. And we want to start asking those questions. It’s not that biology doesn’t matter, but actually what we want to consider is how do these social contexts, over time, materially play out in our bodies? Because if we can change aspects of our environments, that can have wide reaching impacts for populations of women and girls.

IRA FLATOW: Joanne, as a physical therapist, do you see a lot of misconceptions about why girls and women experience some sports injuries more than men and boys, I mean, in certain parts of their bodies, perhaps?

JOANNE PARSONS: Yes, absolutely. And Steph kind of alluded to this. Sport injuries and ACL injuries, in particular, have always been approached with a very biological viewpoint. So thinking that things like your anatomy, so women have wider hips, for example, hormonal changes during the month, physiology.

So the thought that women and men have different contraction rates with their muscles and different contraction patterns with their muscles. So those kinds of things are the causes of injury. So that the interesting thing is that there’s been literally tens of thousands of research studies done since the 1990s.

When the first studies about ACL injury and the injury rate disparity between girls and boys came out, tens of thousands of research studies, but that injury rate disparity has not changed. And so we have to be missing something. There has to be more to the story than that. And that’s what Steph is talking about, considering the gendered aspects of our lives and how that might affect our injury risk.

And even one thing beyond that, too, is that not only are the current approaches not working, they’ve got us to a certain place, for sure. But it’s not working– it’s not only not working, but it could introduce other risks and potential harms. For example, a couple of years ago, a paper came out that suggested that physicians recommend oral contraceptives to all girls competing in sport to reduce ACL injuries.

And we don’t believe that that’s a realistic approach or even an ethical approach. So we need to challenge these misconceptions and ask new questions. And we have our first question from our Zoom audience. Let’s go to Lauren. Hi, Lauren. You have a question about a personal injury. Go ahead.

AUDIENCE: Hi, Ira. So yeah, I tore my ACL when I was 16. So it’s been probably 20 years now. It’s been a while, playing soccer. And I just want to preface this with I grew up in Texas. And the doctor told me that while I was very thin, I had wide, baby making hips. So he wasn’t surprised that I tore my ACL. And that phrase has stuck with me for 20 years. And I’ve always wanted to know, is there any validity to that at all?

IRA FLATOW: Oh, that’s a great question. Because we’ve heard that so many times before, right Joanne, right Stephanie?

JOANNE PARSONS: Absolutely. That is one of the go-to reasons that you’ll see on social media in– when it’s written about in news articles from, unfortunately, from healthcare professionals. And no, there’s almost no validity to that, I’m going to say. And I’m sorry you had that experience, first of all. That’s not a good, positive experience to have when you’ve just experienced this huge, life altering injury.

There may be a slight contribution of anatomy to ACL injury risk. But it would be so minute, it is not the driving force of why our young girls– and usually, it’s women or girls between the ages of 13 and 17. That’s the highest rate of injuries that happen in girls and women, at that age.

It’s such a small contribution that– I’m never going to say no validity, because I’m a scientist, and that can never really be proven. But I would say very, very little validity to, unfortunately, what your physician had told you.

STEPHANIE COEN: Yeah, definitely. I also just wanted to jump in on that and just say that I think that is such an illustrative example of how sexism is kind of baked into our current paradigm around thinking about ACL injury. Kind of blaming women’s bodies as being somehow inherently risky. So that’s part of what we’re trying to do with this work, is to kind of counter that and offer other plausible ways and mechanisms that we need to explore that might be shaping these outcomes. So thanks for that question, Lauren.

IRA FLATOW: Stephanie, though, your research does make a distinction between sex and gender. Can you walk us through that?

STEPHANIE COEN: So this is one of those cases in science and in research where we’re often constrained to operationalizing things in sometimes oversimplified ways. And this is, arguably, the case with sex and gender, in which sex is generally thought of as pertaining to biological characteristics, so hormones, genes, reproductive anatomy that distinguish maleness and femaleness in very binary ways, sometimes.

And gender is thought of as a social phenomenon. That’s about how we identify as men, women, gender diverse people, the roles that society ascribes to us, and how gender is institutionalized and structures society. But theories and evidence, now, really show us that, of course, both of these are complex. And neither is actually binary.

So in our work, we draw on theories from the field of social epidemiology that further challenge the binary distinction as well between sex and gender. So this challenging that binary between the biological and the social. And actually suggests that we need to understand sex and gender as entangled.

So that means that we can’t neatly distinguish between the biological and the social. But that we have to understand them as having interactive relationships, which may actually be difficult to tease out in practice. It’s complex stuff. But this line of thinking takes as a starting point that gendered life experiences have material effects on the body. So that’s where this untangling of the biological and the social comes into play. And that’s what we’re trying to open up with this line of thinking that we are exploring around ACL injury.

IRA FLATOW: This is Science Friday from WNYC Studios. We’re on a Zoom meeting talking with Joanne Parsons and Stephanie Coen, who are both studying ACL injuries in women and sports training. So Joanne, I’m going to give you a magic wand. I know you need one. And if you could fix hypergendered exercise, what would your ideal form of nongendered sports conditioning look like?

JOANNE PARSONS: Oh, that’s a good question, maybe a loaded question. The first thing I’d get rid of is gender reveal parties. But that’s for another conversation, perhaps. I would say that our work is not necessarily about nongendered conditioning. It’s about creating equitable opportunities.

Rather than equality, we’re talking about equitable opportunities. So that we’re meeting people where they’re at. We’re providing each individual person with what they need, regardless of their sex/gender. But having said that, we do know that there are gendered environments in sports. So the weight room is the perfect example.

You used the NCAA example, which we constantly go back to as well, because it’s so high profile. And there is some research, as well, that shows us that the types of exercises that are prescribed by coaches during warm-ups can be different depending on whether the coach is a man or a woman and whether the athletes are women or men.

And the thing about specific to ACL injuries that’s interesting is that there’s been a push in the last few years to develop specific injury prevention programs for women and men, so separate programs that are different. And our feeling is that sex specific programming may knowingly or unknowingly, really, embed and perpetuate these stereotypes and differences that already disadvantage girls and women.

So we think that before we assume that training for ACL injury prevention needs to be different for girls and women or boys and men, we need information as to what already exists. We actually don’t have a great idea about the gendered environments that exist in sport and how that may relate to injury risk for the ACL. And so I wouldn’t say that we would– nongender exercise, we need the information first to figure out what’s already happening. And then, where do we need to go from there?

IRA FLATOW: And so Stephanie, how do we make strength training more inviting for both women and girls?

STEPHANIE COEN: So I think we need to, as we’ve kind of been touching on in this conversation, sort of move away from a focus on fixing women, the example that Joanne gave about oral contraceptives as an intervention, to thinking more comprehensively about how we can change our environments and intervene in the gendered relations that disadvantage women in physical activity and sport. And so I would situate strength training environments within this kind of wider context.

So there’s work that needs to happen within training environments, strength training environments, but it is also the sort of bigger project. And I think sometimes when we think about the bigger project, it can be daunting in terms of how do we actually do that. But I do think there are a few things we could do within training environments, or strength training environments specifically.

So one thing is I think women’s strength training begets women’s strength training. So in some of the work that I’ve done around gym environments, women commented to me that not seeing women in particular sections of the gym, like the free weight section, signaled to them that it wasn’t a space for women. It wasn’t a space where women were welcome. So I think we need to insert women and gender diverse role models in those spaces.

And I also think that there’s work that shows that a lot of strength and conditioning coaches are men. So when it comes to more competitive athletes, I think we need to think about how do we support more women in getting into those strength and conditioning leadership positions.

IRA FLATOW: And I think that’s where we’re going to have to stop, because we have run out of time. Some great talk here. Thank you both for taking time to be with us today. And thank you all on Zoom. Joanne Parsons, physical therapist, associate professor at the University of Manitoba in Winnipeg, Canada. Stephanie Coen, health geographer, associate professor at the University of Nottingham in the UK. Thank you both for taking time to be with us today.

JOANNE PARSONS: Thank you so much.

STEPHANIE COEN: Thank you.

IRA FLATOW: You’re welcome.

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