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Kay Crossley Addresses the Perplexing Problem of Knee Injuries to Female Athletes

Noted physiotherapist and professor from Australia presents keynote address on opening day of 7th Annual Injury Prevention Symposium

June 7, 2023

VAIL/COLORADO SPRINGS, COLO. – Noted Australian physiotherapist and professor Kay Crossley, Ph.D., presented the keynote address and kicked off the 7th Annual Injury Prevention Symposium on June 7, 2023. The virtual event, co-hosted by Steadman Philippon Research Institute (SPRI) and the United States Olympic & Paralympic Committee (USOPC), is a two-day program featuring nearly 30 speakers from around the globe, focused on injuries and current methods of treatment and prevention.

Dr. Crossley focused on knee injuries to female athletes, a topic that has been a major concern for decades and one that has become more visible as women’s sports continue to grow worldwide in both participation and popularity, in part due to growing media coverage and exposure. 

“First, we want to look at the increasing sports participation by women and girls, particularly in our football (soccer) teams and professional sports,” said Dr. Crossley. “We know that being active in sport is great for the women and girls and they'll get a lot of health benefits both during their participation and beyond it.”

As is often the case with growth, it can lead to both good and less fortunate results. The bigger attendance figures and television ratings tend to attract more revenue, which leads to more opportunities for women to compete, the more stress placed on winning and, unfortunately, the potential for more injuries. 

Statistics show that women inherently seem to have more likely odds of sustaining knee injuries than their male counterparts.

“We've known for many years that there are systematic reviews showing that female athletes have two to five times higher risk than male athletes for ACL injury risk,” said Dr. Crossley.

It is not just the ACL injury that is of concern for women, but also the age that it most often occurs and the subsequent after-effects.

“We see that when someone tears their ACL, they're usually out of competitive sport for at least nine, but usually 12 months,” continued Dr. Crossley. “And that injury comes with a cost to a player of their enjoyment of their sport and, for some time for some players, also their revenue.

“But we also see long-term consequences,” added Dr. Crossley. “We know that 50% of people who tear their ACL will develop osteoarthritis within five to ten years. We also see sustained lower quality of life that exists for all of the studies. We see that following ACL reconstruction, women are three times more likely not to return to their sport and have a four times higher risk of re-injury than men. And because people are young when they tear their ACL, usually in their late teens or early 20s, they are developing this osteoarthritis and poor quality of life while they're still young adults.”

Suffering an ACL injury is just the start of the issue for many female athletes. The often long and difficult rehabilitation period may not be handled in the same way as a similar rehab for a male athlete, although greater funding and more attention on women’s sports in today’s world may be slightly narrowing that gap.

“At a leadership level, are women and men given equal opportunities and equal time for recovery and rehabilitation?” asks Dr. Crossley. “We know that in elite women's sport they have less time for injury recovery and rehabilitation.”

The differences that exist between women’s and men’s sports are well known, but many may result from a difference in funding. Growing support from fans and the media may help boost sport administrators to give women the same assistance in quick and efficient recovery and rehabilitation from ACL surgery, but that will require some time. In the meantime, the facilities and assistance needed for injured women athletes still lag behind.

The question remains, though, as to why women tend to suffer more ACL injuries than men.

“And it's probably more than just their hips and hormones,” noted Dr. Crossley about some of the physical differences between women and men. “There are lots of other factors that might influence their injury risk.

“Women may be more likely to be injured in sport because they jump and land differently, because they decelerate differently, because they tackle differently or because they have a lower level of strength and power,” offered Dr. Crossley. “What about their physical environment, their footwear, their playing surfaces, ground size, training facilities, their strength development, the coaching and training that's available to them and their socioeconomic status?”

Dr. Crossley answers her own questions and takes the discussion a step further.

“For example, if girls don't grow up jumping and landing, this might influence why they jump differently than boys do. Similarly, young girls don't traditionally tackle and play rough as young boys do, with both tackling and being tackled. Until recent years, they haven't played as much football, so they're less likely to develop the skills around decelerating, changing direction. We talked before about strength and power. We know that women have less access to female-specific footwear, particularly football boots. We know that playing surfaces can influence injury risk. And we also know that women are more likely to be asked to play on worse surfaces, which can increase your injury risk. Women often play on different ground sizes, have different team sizes, have worse training facilities, and have less exposure to training loads designed to make them resilient to injury.”

These social and environmental differences, combined with physical differences since birth, have given female athletes a much more challenging path than their male counterparts when it comes to avoiding all injuries, not just ACL tears.

“And at a leadership level, we can see how gender could influence the injury rates that exist today,” said Dr. Crossley. “Women are often given less time for injury prevention, less time on the training ground, less time to do their training and to practice their match play. They get less support from their medical and healthcare providers. Women are often given smaller grounds to play on. They have fewer subs, fewer players, and in some sports, there are different rules for girls and boys. So, there are lots of ways that the gendered environment can increase or change the influence and the risk.”

Dr. Crossley currently has studies underway in Australia as she and her colleagues try to find answers to these questions surrounding the higher number of knee injuries in female athletes than in men. As she nears the completion of these studies, she remains confident that some of the issues can be addressed.

“In summary, knee injuries are problematic for women and girls and they're more likely to have injuries than men and boys,” concluded Dr. Crossley. “They're burdensome for women more so than men. We can reduce knee injury and its burden for women by having a personalized approach that considers all levels of the socioecological framework, including the individual level, interpersonal level, environmental level and leadership. We need to address physical and non-physical factors. We need strategies to address any sociocultural factors, especially strategies to address gender inequity. 

“There are no simple answers, but we know that women athletes will continue to excel and that growing participation in women’s sports will help us find the answers to these injury problems that we are facing.”

For further information, contact Lynda Sampson, VP External Affairs (lsampson@sprivail.org, 970/479-1563)

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