How Sex-Related Differences Impact Sports Injuries

Kids playing soccer.

Fifty years after the passage of Title IX, which mandated equal opportunities for males and females in sports, doctors and researchers are still learning about anatomical and physiological differences between boys and girls and how they may affect young athletes. Research is also revealing how warm-ups and nutrition can help address these differences and reduce the risk of injury.

Arvind Balaji, MD, a Stanford pediatric sports medicine specialist who sees patients in Pleasant Hill, in partnership with John Muir Health, took us through some of the most common injuries that can be caused in part by anatomical and physiological differences between boys and girls. Dr. Balaji also discusses how sex-related differences can impact sports injuries in a HealthTalks podcast.

Listen to the HealthTalks Podcast, How Sex-Related Differences Impact Sports Injuries with Arvind Balaji, MD.

Knee and hip injuries

Athletes with female anatomy can have a higher risk of knee and hip injuries, especially after going through puberty. That’s because during puberty, girls develop a wider pelvis and hips, which creates a wider angle between the hips and knees. When an athlete with female anatomy pivots quickly on a soccer field, for example, this wider angle can put more pressure on her knees. Studies also show that female anatomy includes a thinner anterior cruciate ligament (ACL), which can tear more easily.

Doctors and researchers suspect that these differences contribute to higher rates of ACL injury among athletes with female anatomy.

“Research shows us that girls tear their ACL more frequently than boys, even if they’re playing the exact same sport with the exact same rules,” Dr. Balaji said. “We see many ACL injuries in soccer players, and they’re not contact or collision injuries, but injuries that happen when a player is trying to change direction quickly.”

These injuries can also require longer healing times and more rehabilitation for athletes with female anatomy.

“Athletes with female anatomy may require a longer rehabilitation to improve hip and core strength,” Dr. Balaji said. “We treat and rehab all athletes the same, but those with female physiology may need a longer amount of time.”


Studies show that kids and teens with female anatomy tend to get more concussions than those with male anatomy, even if they are playing the same sport with the same rules, Dr. Balaji added. Researchers are still exploring why this is the case.

Athletes with female anatomy also take longer to recover from concussions than athletes with male anatomy, but new research offers a way to address this inequity.

“New research shows that if we can get girls to a medical provider that can accurately diagnose their concussion and get them into the appropriate rehab program as fast we do with boys, they will recover in about the same time as boys,” Dr. Balaji said. “Female athletes may have different symptoms that are not as easily recognized. That’s something we can work on as a community: coming together, recognizing all athletes’ symptoms, and getting them to someone who can help them.”

Warm-ups and preseason training

Targeting warm-up and training routines to address these anatomical and physiological differences can also help prevent injuries.

“To help reduce the risk of ACL injury, for example, there are many different knee injury prevention programs that parents can look up online,” Dr. Balaji said. “They can help condition and strengthen the hip, knee, and core muscle groups and help young athletes be better prepared for the sport they’re going to play—before the season starts and during the season. These types of training programs have been proven to have profound impact on reducing the risk of injuries, especially for girls.”

Nutrition also plays a role

Proper nutrition and hydration can help ensure that all young athletes have the energy they need to perform their best and stay healthy. Before puberty, the nutritional needs for both sexes are roughly equal. Once puberty begins, those needs start to diverge.

“Boys usually require a higher caloric intake, especially more protein, as they tend to add more muscle mass during puberty,” Dr. Balaji said. “If boys aren’t getting enough calories, they might seem extra-tired and have trouble focusing in class. This can happen to both sexes but might be more prominent in boys.”

And for young athletes with female anatomy, the risks of poor nutrition may be even higher.

“During adolescence, everyone is building up their bone density, and it peaks in our early 20s,” Dr. Balaji said. “Girls who aren’t taking in enough calories or the right nutrients may permanently lose some of their bone density, which makes their bones more vulnerable to fractures. And if girls are overexercising and undereating, they may also lose their periods, which can reduce estrogen and also lead to fractures.”

Bone health problems and lack of a menstrual period, along with disordered eating, make up the female athlete triad. Dr. Balaji said that athletes who participate in sports that emphasize a lean physique, such as cheer, gymnastics, and track and field, may be at a higher risk of developing these conditions.

Dr. Balaji recommends that athletes with female anatomy consume roughly 2,200 calories a day, while athletes with male anatomy may need closer to 2,800, including a balance of protein, carbohydrates, fats, micronutrients, and vitamins like calcium, vitamin D, and iron. He also recommends that athletes drink 5 to 8 ounces of water for every 20 minutes of vigorous exercise. Many sports drinks have excess sugar, so look for electrolyte solutions that are low in sugar.

Injuries becoming more inclusive

Despite the differences, with sports becoming so much more competitive and young athletes playing equally hard, Dr. Balaji said he’s seeing injuries trend increasingly similar for all.

“I’m finding that our children’s injuries are becoming more inclusive,” he said. “Depending on the specific sport they play, and as the level of competition accelerates, children’s injuries are more similar than different. Keep in mind that children can develop different problems at different ages, and be mindful of warming up, proper training, good nutrition, and taking off one to two days a week to rest.”

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