July 08, 2016
5 min read

Consider overuse injuries in female youth athlete

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Since passage of Title IX in 1972, a comprehensive federal law that required gender equity in every education program or activity receiving federal funding, the societal norms in sports have changed. Female participation in athletics is at an all-time high.

Current estimates are almost 15 million girls in the United States between the ages of 8 years and 17 years participate in organized sports each year, playing on at least one team or one club. Almost 50% of girls are on teams by 6 years old and one-third of girls will play on three or more teams per year between third grade and fifth grade. Basketball and soccer remain the most popular competitive sports for girls, followed by track and field, volleyball, swimming, tennis and softball. With increased sports participation, there has been an associated increase in sports injuries, especially injuries related to overuse or fatigue.

Incidence of injuries

Anthony A. Romeo

To prevent youth musculoskeletal injuries, we need to understand the incidence and situations in which these injuries occur. Injuries, such as tears of the ACL and elbow medial collateral ligament, are often the most studied and best understood. These are also the types of injuries on which parents, teachers, coaches and athletes focus. Many prevention programs have been developed, including the Sports Trauma and Overuse Prevention program of the American Orthopaedic Society for Sports Medicine and ACL injury neuromuscular prevention programs. However, there are a number of other injuries that are less understood, especially for athletes of softball, volleyball, swimming and gymnastics.

Participating on multiple teams or multiple training programs simultaneously is a growing concern for all athletes. Youth athletes are at particular risk of sustaining overuse injuries that occur with year-round participation in a single sport. Up to 27% of boys and girls who quit sports will do so because of injury or other health problems.

The mechanisms by which gender affects injury risk are likely multifactorial and certainly not well-understood. Several authors have suggested different movement patterns as possible reasons for differences in injury patterns. For example, the biomechanics of a windmill softball pitch differ substantially from the biomechanics of an overhead baseball pitch. Likewise, the difference in injuries sustained among athletes in these sports is remarkable. Unfortunately, most published literature discusses throwing injuries only as these relate to the overhead throw/pitch, with little evidence-based data available to guide clinicians and coaches on the risks associated with windmill pitching.

Rachel M. Frank
Rachel M. Frank

In 2015, Schroeder and colleagues reported the rates and types of high school overuse injuries between 2006 and 2012. They found an overall overuse injury exposure rate of 1.5 per 10,000 athletic exposures. Girls had greater rates of overuse injuries compared to boys. The highest rates of injuries were found among female track and field athletes and female field hockey players.

Yang and colleagues found that among competitive collegiate athletes, acute injuries are more common in male athletes and overuse injuries are more common in women and girls athletes. Sports associated with the highest rates of overuse injuries in women and girls included field hockey, soccer, softball and volleyball. Explanations for the increased overuse injury rates in females may include physiologic differences in hormones, muscle mass relative to overall body weight, ligament/tendon composition, nutrition and role of menarche, although to date, there remains a paucity of correlative data. There also may be critical differences in the psychological aspect of injury reported by women and girls, especially for overuse injuries, although these data are sparse.

Critical problem

Lack of knowledge about overuse injuries in female athletes remains a critical problem. Without it, the development of prevention and treatment strategies aimed at reducing the incidence of overuse injuries is highly unlikely. An improved understanding of the incidence, prevalence, severity and mechanism of youth musculoskeletal injuries in female athletes will allow clinicians to counsel patients and families and ultimately develop programs to reduce and prevent the injuries. Programs to train female athletes to jump and land with better technique and efficiency have shown remarkable decreases in knee injuries.


An opportunity for future research efforts, which will directly impact this at-risk patient population, is to establish a pitch count for female athletes who participate in sports that require repetitive motions leading to overuse injuries, particularly softball. Volleyball also may benefit from this approach as the number of swings or hits from front row players is not monitored. Pitch counts have been successful guidelines to limit injuries in male youth athletes so it is feasible to apply a similar strategy for female youth athletes. The findings from the research likely will provide insight into the epidemiology of other injuries known to be more prevalent in female athletes, including stress fractures, ACL injuries, patellofemoral-related injuries and other injuries as sequelea of the female athlete triad.

Optimal playing environment

As orthopedic surgeons and other health care professionals have done for male youth athletes, it is imperative to ensure a safe and optimal playing environment for female youth athletes. All athletes should enjoy and benefit from sport without the risk of overuse injuries resulting from lack of knowledge, guidelines and prevention strategies.

Girls and boys do not have the same sports injuries. Future investigations are needed to develop a more thorough approach to these differences and to improve prevention strategies and outcomes of surgical intervention.

Disclosures: Romeo reports he receives royalties, is on the speaker’s bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed. Frank reports no relevant financial disclosures.