ACL injury basketballer

Social, not just biological factors, key in increased knee injuries among girls and women

Friday, 26 March 2021

The reason women are more prone to sports injuries has more to do with the social constructs around gender, and the subsequent gendered environment, than female biology, experts argue in a new paper in the British Journal of Sports Medicine (BJSM).

Current approaches to a common and debilitating knee injury that occurs more frequently
for women than men have focused for too long on biology at the expense of understanding social factors, the authors say.

Girls and women are said to be between three to six times more likely to suffer an anterior cruciate ligament (ACL) injury, where one of the key ligaments that helps to stabilise the knee joint is damaged. The devastating injury, which in extreme cases can be career ending for sports professionals, commonly occurs during sports that involve sudden changes in direction, such as netball, tennis, football, and basketball.

The difference in injury rates for men and women has not changed for two decades, but, the authors say, this might be partly due to how injury prevention and management has been approached to date. Writing in the BJSM they argue that much of the focus still centres on biological and hormonal factors, with little attention paid to how sex-based factors are affected by gender as a social construct, and might influence each other.

They suggest that gendered experiences matter in shaping girls’ and women’s participation in sport as well as disparities in injury outcomes. They demonstrate how this could play out across women’s lifetimes with gendered expectations of physical abilities (e.g. ‘throw like a girl’), to inequitable access to funding, training, and facilities for women’s sport (e.g. disparities in access to weight training). The authors point to the recent criticism that the USA’s National Collegiate Athletic Association (NCAA) received for not having an adequate facility for the women’s basketball teams to lift weights, in comparison to the men’s teams, as a prime example.

Finally, they argue that there may be a difference between post-injury rehabilitation for men and women recovering from an ACL injury. They say that these social and environmental factors play a much bigger role in how sports injuries occur than once thought, and urge that much more attention be given to these topics.

Dr Stephanie Coen, Assistant Professor in Health Geography at the University of Nottingham is a co-author of the paper, with Dr Joanne Parsons, Assistant Professor in the College of Rehabilitation Sciences at the University of Manitoba, and Dr Sheree Bekker, Assistant Professor in Injury Prevention at the University of Bath.

Dr Coen, an expert in gender-based analysis of health, with previous research into the gendered nature of gym environments said: “By extending the focus from individual bodies and biology to the gendered environments contextualising ACL injury, our approach identifies new opportunities to intervene and achieve better outcomes for girls and women, with implications beyond athletes. 

Stephanie Coen
As childhood and youth physical activity levels influence those in adulthood, the consequences of ACL injury can be lifelong and particularly concerning for girls and women who already participate in physical activity at lower rates than boys and men. There is a wider health equity issue at stake.
Dr Stephanie Coen, Assistant Professor in Health Geography at the University of Nottingham

Dr Sheree Bekker from the Department for Health at the University of Bath (UK) said: “We wanted to unpack the biases and assumptions that we were seeing in research into and practice around sports injuries in girls and women. Specifically, we wanted to challenge the increasingly pervasive idea that this is simply a problem for girls/women because they are inherently prone to injury just because of their female biology. Approaching ACL injury prevention and management from a strictly biological view can propagate sexism in sport with detrimental consequences for girls and women.”

Dr Joanne Parsons from the University of Manitoba, Canada added: “Over 20 years of research focussed on biological traits has failed to decrease the ACL injury rate in girls and women. To make a difference, we need to approach the problem in a different way. The recent challenges that the NCAA women’s teams faced with access to adequate training equipment is a perfect example of why we have to include society’s influence when talking about injury risk for girls/women.”

“Our research gives hope to potentially disrupting this injury cycle and reducing the disproportionate incidence of ACL injuries in women and girls. We need to now develop further research that works to identify ways to intervene in the gendered aspects of training, competition, and treatment environments contextualising ACL injury, and from there explore and test new approaches to ACL injury prevention and rehabilitation, such as addressing the gendered nature of weight rooms.
Dr Stephanie Coen

Story credits

More information is available from Dr Stephanie Coen in the School of Geography at the University of Nottingham at

Katie Andrews - Media Relations Manager for the Faculty of Social Sciences
Phone: 0115 951 5751

Notes to editors:

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