Female participation in sport has been on the rise in Canada, and with it, concerns about injury. One of the greatest challenges has been that research on female athletes is sorely lacking, leaving millions of women and girls, coaches, parents, healthcare practitioners, and policymakers to rely on data and practice recommendations geared toward men and boys.

The International Olympic Committee (IOC)’s FAIR consensus statement, which was released at the beginning of December, aims to change this situation by providing best practices and policy and strategies.

It contains 56 recommendations that were informed by five systematic reviews and one scoping review. The latter synthesized evidence from more than 600 papers with more than 600,000 participants. The statement also relies on a concept-mapping project with 66 participants. It calls for the involvement of all sport stakeholders (eg, coaches, industry, parents, and athletes) to reduce female athletes’ risk for injury.

“The impetus was related to the lack of research focused on women and girls, the lack of recommendations that were female-specific, and the need to bring together the evidence to support female athletes globally for injury prevention,” FAIR co-author Carolyn Emery, PhD, professor of kinesiology at the Cumming School of Medicine and chair of the Sport Injury Prevention Research Centre, both at the University of Calgary in Calgary, told Medscape News Canada.

“We have increased participation rates for women and girls globally (we see that with the professionalization of many sports for women), and injury and concussion rates are reportedly high, even higher than for their male counterparts,” said Emery. “For example, we have some of the highest rates of concussion and injury in girls’ rugby compared with any other reported rates across all levels of play.”

Focus: Primary Prevention

The main objective of the recommendations was to focus on primary injury prevention, Emery explained. Strategies include the use of personal protective equipment (such as mouthguards, helmets, neck guards, and face shields in collision sports) and neuromuscular training (NMT). Warm-up using NMT focuses on strength, balance, and movement control. The statement recommends NMT for 10 minutes twice per week to prevent first-time injuries.

The evidence for NMT is strong. In one of the five systematic reviews or meta-analyses conducted for the statement, pooled data from six studies in 4799 females demonstrated with moderate-certainty evidence that NMT was associated with a 39% reduction in ankle strains. It found high-certainty evidence that NMT was associated with a significant 61% reduction in anterior cruciate ligament (ACL) injuries (n = 6492 females).

Solid research in NMT is only beginning to emerge, said Connie Klassen, a certified athletic therapist, director of prevention and wellness at Hockey Canada, and head athletic therapist for Ringette Canada in Calgary. Klassen emphasized that NMT, balance coordination, and strength and conditioning need to be age- and body development-appropriate to reflect how children develop. This principle is true even when the athlete enters her early twenties.

“We should be thinking about things like load modification when we are considering sports specialization at an early age and through rapid periods of growth and development,” she said.

The time spent in weekly competition (ie, absolute load), bone stress, and neck injuries are potentially modifiable risk factors that might have protected former international rugby player Kathryn Dane, PhD, a physiotherapist and postdoctoral fellow at the Sport Injury Prevention Research Centre. Dane started playing rugby on an all-boys team in County Fermanagh in Northern Ireland at the age of 8 years. Later, she played for numerous professional women’s rugby teams and eventually joined the Barbarians, a British-based invitational rugby club.

“I finished my career there off the back of my second ACL reconstruction surgery,” said Dane. “I’d also had a brain hemorrhage in the middle of my rugby-playing career.”

Dane said that NMT was not entirely missing during her time playing professionally; a lot of time during practice was spent on warm-ups and speed mechanics to prevent lower limb injuries such as hamstring strains.

“It wasn’t until the very end of my career that things like neck strengthening and neck stabilization to help build up the neck musculature [to prevent concussions] were included. If something like that had been introduced to me back when I was 8 years old playing with the boys, or even age 12 onward, it would have prevented some of those concussions I had in my career,” said Dane.

Health Equity

An important question raised by the recommendations is how the underrepresentation of females in research correlates not only with injury rates but also with policies that ideally create and foster positive environments.

“We need to build safe spaces for females in sport and exercise, not just from a physical perspective but also from a psychological perspective,” said Kimberly Coros, MD, a physical medicine and rehabilitation physician at Sinai Health in Toronto, sport and exercise medicine physician at the Canadian Sport Institute Ontario, and president of the Canadian Academy of Sport and Exercise Medicine.

Coros, whose patients are mostly female, said that she mostly sees adolescent girls in high-performance sports. Their presentations range from concussions and ACL injuries to hypermobility and stress-related bone injuries. Some of her patients have energy deficiencies resulting from factors such as disordered eating. Moreover, a significant proportion of her patients report sexual assault and unwanted attention, which cause many adolescent females to drop out of sports.

“It’s not just aesthetic sports like gymnastics, where there’s a subjective component to judging. I find that it’s more socially acceptable for predominantly male coaches to comment on their bodies. For example, they’re looking ‘too muscular,’ or there’s a weight target, which we know doesn’t play out from an evidence-based perspective,” she said.

Research on how gender might affect performance and injury is lacking. “When we look at recovery from injuries, we have to look at things like changes within different systems. How do hormones impact injuries and recovery? Have we looked at the recovery rates of men versus women? During recovery, are women in their menstrual cycle?” asked Klassen. “What role do anatomical differences play, especially related to ACL injuries in sports like basketball? We know that women’s basketball tends to see more knee injuries, and men’s basketball tends to see more ankle injuries,” said Coros.

“There’s so much that we don’t know; it’s a sort of biopsychosocial model where we don’t know how much biology, socialization, and gender roles play into the sport,” she added.

If anything, the FAIR recommendations have highlighted an unmet need in healthcare research overall: the lack of female-specific studies. “Research is only as good as the subject area and population being studied,” said Klassen. “We need to be better informed in these areas. At Hockey Canada, we’ve just embarked on conversations with women in our sports division on research opportunities,” she said.

The University of Calgary is also forging a path through its work in the community. Efforts at the elite level affect public health by “keeping kids playing sports they love, not only reducing injury rates and costs of injury, but also the consequences of injury, like posttraumatic osteoarthritis following ACL injury,” said Emery.

“The strength of our work is a tight connection with elementary, junior, and senior high schools, parents and coaches, referees, people who make decisions in sport, as well as youth. We really need the youth voice to be the center of this,” she said.

“The best injury is the one that never happens.”

The FAIR consensus was funded by the IOC. Emery, Dane, and Coros reported having no relevant financial relationships. Klassen reported being employed by Hockey Canada and being a contractor for Ringette Canada.

Liz Scherer is a health and medical journalist who frequently writes for Medscape News Canada and Medscape News Europe. She is an amateur athlete who has experienced several knee injuries.