The Ultimate Guide to Female Athletes and Knee Injuries

By Emily R Neff (Pappas), Ph.D student

Female athletes are more likely to suffer a knee injury than male athletes(1), especially during adolescence. But WHY? And what can the female athlete do about it?

This article helps you understand the deal with female athletes and their knees and how to reduce the risk of future knee injuries!

---

Female Athletes & Knee Pain: MYTHS BUSTED

When talking about female athletes & their knees, a lot of previously held misconceptions come into the conversation.

Myth 1: Females have wider hips (Q Angle), which puts more stress on their knees.

FALSE. 

• A study in 2000 (2)  demonstrated the size of the Q-angle has minimal effects on kinematic changes in the lower limb 

• A study in 2005 (3) concluded individuals with larger Q angles did not demonstrate a greater incidence of valgus than those with smaller angles. They actually found the OPPOSITE was true (smaller angles related to more valgus)

• A study in 2005 (4) concluded on average females and males vary in Q-angle measurements by only  2.3°  and that Q-angle was more related to height differences than to sex. 

Learn more on ACL Injuries & Anatomy here.

Myth 2: Females have hormones (especially around their menstrual cycles) that make their knees less stable 

FALSE

• A study in 2012 (5) demonstrated estrogen concentrations rose NON-SIGNIFICANTLY during puberty, but knee laxity (think knee stiffness)  in females was related to height changes. 

• A study in 2022 (6) demonstrated ligament laxity does not significantly change with varying estrogen and progesterone levels across the menstrual cycle 

• A review in 2018 (7) concluded natural estrogen cycling during the menstrual cycle actually leads to improved muscular repair, and stronger tendons, ligaments, and bones over time. 

Learn more on ACL Injuries & Hormones, here

So then, why are females more predisposed to knee injuries than male athletes?

And why is this difference in injury rates most pronounced during puberty (8)

Females Grow Differently

The difference in injury rates is directly correlated to the difference in growth observed between males and females.

When girls go through puberty, their bones grow at a MUCH faster rate than their muscles.

This is of course, due to their different hormonal makeup compared to boys

To accommodate this change, her ligaments (tissues that connect bone to bone) and tendons (tissues that connect bone to muscles) become more lax (think looser). 

This is NECESSARY to help make sure these tissues do not tear during growth.

Unfortunately for the active female, this makes her knee joint less stable.

And a less stable knee is more susceptible to forces experienced during running and jumping tasks. 

As a result, we see MORE INJURIES and poorer performance.

• A study in 2006 (9 )demonstrated over 2 years during puberty, females exhibit LESS POWER and poorer ability to absorb forces when landing compared to boys. 

This change is inevitable with growth when the athlete is only playing sports and not performing any physical training. 

But this does not mean your female athlete is destined to be injured. 

• In fact, a study in 2017 (10) demonstrated strength and neuromuscular training are the MOST EFFECTIVE in reducing injury risks in female athletes. 

More on this in a bit….

Common Knee Injuries for Female Athletes

• Patellofemoral joint injuries

• Patellofemoral Pain Syndrom (PFPS)

• Patellar Tendonitis

• IT Band Syndrome

• Osgood Schlatter’s Disease

• Tracking Issues 

• Posteriorlateral knee injury

• Anterior Cruciate Ligament (ACL) injuries

• Medial Collatoral ligament (MCL) injuries

• Posterior Cruciate Ligament (PCL) injuries 

• Meniscus Injury

Note ALL of these injuries (when non-contact) have the SAME CAUSE (overuse/ under preparation)

Meaning the female athlete’s tissues around her knees were not strong enough to handle all the running, jumping, cutting, kicking she was asking of her body. 

This is known as the Physical Stress Theory (11)

Unfortunately with growth, the increased instability associated with lax ligaments and tendons mean less capacity to handle athletic movement patterns.

Fortunately, these tissues are ADAPTABLE.

This means the female athlete DOES NOT have to be pre-disposed to knee injuries.

Preventing Knee Injuries

Like all body tissues, the tendons, ligaments, muscles, and bones are all responsive to progressive loading.

This means, overtime (with appropriate planning & rest periods) tendons & ligaments can grow STIFFER and muscles and bones can grow STRONGER & DENSER.

• A study in 2012 (12) demonstrated ACLs grow THICKER (increased cross-sectional area)  with Olympic Weightlifting Training that begins pre-puberty 

• A study in 2018 (13) demonstrated consistent strength training (2x/wk) can decrease overuse injury rates by 50%

• A study in 2013 (14) demonstrated training that includes strength and plyometrics can significantly decrease knee injury rates in both males and females, especially ACL injury rates. However, programs focusing only on balance, core strength, stretching, and agility have no effect. 

• A study in 2009 (15) demonstrated youth athletes can improve strength by 50% after just 8 to 12 weeks of well-designed 2x/wk resistance training leading to a significant reduction in overuse injuries 

• A study in 2016 (16) demonstrated >23 weeks of resistance training for 2x per week is the MOST EFFECTIVE training frequency to improve muscle strength and decrease injury rates in adolescent female and male athletes

• A study in 2013 (17) demonstrated neuromuscular training and plyometrics, when implemented during early adolescence, are significantly effective in preventing ACL injury rates in female athletes

• In 2004 the American College of Sports Medicine (18) recommends children engage in high-load resistance training to reduce injury risks, provided the program is designed and implemented by a strength and conditioning professional

The list goes ON and ON

What To Do When You Are Injured?

First, it is important to understand the difference between HURT and INJURED

Consider asking your athlete these questions

1. Does the feeling last longer than a day or two? Does it get WORSE or BETTER with time?

2. Does this feeling happen after specific drills or hard games?

3. Is this the first time you ever felt this? Or is this something you have experienced in the past?

4. What have you been doing leading up to this? Any changes in practice volume, competition levels, intensity of play, (think did she go from 0 to 100?)

5. Does it feel better or worse after you get moving? 

How you recover is directly related to the answers to these questions.

For instance, if the pain gets WORSE, its time to see a medical professional and work AROUND the injury in the meantime

Note this did not say WORK THROUGH. Work around means work your other limb, your core, and upper body.

Does it feel better as you get moving? Thats great! This means its best to slowly LOAD the knee with slow eccentrics and pauses to help build tolerance in the knee (of course in a program designed by an S&C professional) 

Remember, COMPLETE REST is a thing of the past. Your body needs MOVEMENT and BLOOD FLOW (learn more in this article) 

References

1. Hewett, T. E., Myer, G. D., & Ford, K. R. (2004). Decrease in Neuromuscular Control About the Knee with Maturation in Female Athletes. Journal of Bone and Joint Surgery. American Volume, 86(8), 1601–1608. https://doi.org/10.2106/00004623-200408000-00001

2. Heiderscheit, B.C. (2000). Influence of Q-angle on lower-extremity running kinematics. The Journal of Orthopaedic and Sports Physical Therapy, 30(5), 271–278. https://doi.org/info:doi/

3.  Pantano, K. J., White, S. C., Gilchrist, L. A., & Leddy, J. (2005). Differences in peak knee valgus angles between individuals with high and low Q-angles during a single limb squat. Clinical Biomechanics (Bristol), 20(9), 966–972. https://doi.org/10.1016/j.clinbiomech.2005.05.008

4. Grelsamer, R. P., Dubey, A., & Weinstein, C. H. (2005). Men and women have similar Q angles : A clinical and trigonometric evaluation. Journal of Bone and Joint Surgery. British Volume, 87(11), 1498–1501. https://doi.org/10.1302/0301-620X.87B11.16485

5. Wild, C. Y., Steele, J. R., & Munro, B. J. (2013). Musculoskeletal and Estrogen Changes during the  Adolescent Growth Spurt in Girls. Medicine and Science in Sports and Exercise, 45(1), 138–145. https://doi.org/10.1249/MSS.0b013e31826a507e

6. Maruyama, S., Sekine, C., Shagawa, M., Yokota, H., Hirabayashi, R., Togashi, R., Yamada, Y., Hamano, R., Ito, A., Sato, D., & Edama, M. (2022). Menstrual Cycle Changes Joint Laxity in Females-Differences between Eumenorrhea and Oligomenorrhea. Journal of Clinical Medicine, 11(11), 3222–. https://doi.org/10.3390/jcm11113222

7. Chidi-Ogbolu, N., & Baar, K. (2018). Effect of Estrogen on Musculoskeletal Performance and Injury Risk. Frontiers in Physiology, 9, 1834–1834. https://doi.org/10.3389/fphys.2018.01834

8. Shea, K. G., Pfeiffer, R., Wang, J. H., Curtin, M., & Apel, P. J. (2004). Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data. Journal of pediatric orthopedics, 24(6), 623–628. https://doi.org/10.1097/00004694-200411000-00005

9. Quatman, C. E., Ford, K. R., Myer, G. D., & Hewett, T. E. (2006). Maturation Leads to Gender Differences in Landing Force and Vertical Jump Performance: A Longitudinal Study. American Journal of Sports Medicine, 34(5), 806–813. https://doi.org/10.1177/0363546505281916

10. Nessler, T., Denney, L., & Sampley, J. (2017). ACL Injury Prevention: What Does Research Tell Us? Current Reviews in Musculoskeletal Medicine, 10(3), 281–288. https://doi.org/10.1007/s12178-017-9416-5

11. Mueller, M. J., & Maluf, K. S. (2002). Tissue Adaptation to Physical Stress: A Proposed “Physical Stress Theory” to Guide Physical Therapist Practice, Education, and Research. Physical Therapy, 82(4), 383–403. https://doi.org/10.1093/ptj/82.4.383

12. Grzelak, P., Podgorski, M., Stefanczyk, L., Krochmalski, M., & Domzalski, M. (2012). Hypertrophied cruciate ligament in high performance weightlifters observed in magnetic resonance imaging. International Orthopaedics, 36(8), 1715–1719. https://doi.org/10.1007/s00264-012-1528-3

13. Lauersen, J. B., Andersen, T. E., Andersen, L. B. (2018). Strength training as superior, dose-dependent and safe prevention of acute and overuse sports injuries: A systematic review, qualitative analysis and metaanalysis. British Journal of Sports Medicine, 52, 1557-1563. 

14. Voskanian, N. (2013). ACL Injury prevention in female athletes: review of the literature and practical considerations in implementing an ACL prevention program. Current Reviews in Musculoskeletal Medicine, 6(2), 158–163. https://doi.org/10.1007/s12178-013-9158-y

15. Dahab, K. S., & McCambridge, T. M. (2009). Strength training in children and adolescents: raising the bar for young athletes? Sports Health, 1(3), 223–226. https://doi.org/10.1177/1941738109334215

16. Lesinski, M., Prieske, O., & Granacher, U. (2016). Effects and dose–response relationships of resistance training on physical performance in youth athletes: a systematic review and meta-analysis. British Journal of Sports Medicine, 50(13), 781–795. https://doi.org/10.1136/bjsports-2015-095497

17. Myer, G. D., Sugimoto, D., Thomas, S., & Hewett, T. E. (2013). The Influence of Age on the  Effectiveness of Neuromuscular Training to Reduce Anterior Cruciate Ligament Injury in Female Athletes: A Meta-Analysis. The American Journal of Sports Medicine, 41(1), 203–215. https://doi.org/10.1177/0363546512460637

18. Kohrt, W. M., Bloomfield, S. A., Little, K. D., Nelson, M. E., & Yingling, V. R. (2004). American College of Sports Medicine Position Stand: physical activity and bone health. Medicine and Science in Sports and Exercise, 36(11), 1985–1996
    

ABOUT THE AUTHOR

In 2015 Emily opened Relentless Athletics to build a community for female athletes while educating their parents and coaches on the necessity of strength training and sports nutrition to optimize sports performance and reduce injury risks in the female athlete population.

Emily holds a M.S. in Exercise Physiology from Temple University and a B.S. in Biological Sciences from Drexel University. She is currently pursuing her Ph.D. at Concordia University St. Paul with a research focus on female athletes & the relationship between strength training frequency, ACL injury rates, and menstrual cycle irregularities (RED-s). Through this education, Emily values her ability to coach athletes and develop strength coaches with a perspective that is grounded in biochemistry and human physiology.

In 2020, Emily was an Adjunct at Temple University, instructing her own course on the current research behind female athlete development. Additionally, Emily has worked as a consultant in developing health education curriculums at the high school level.

Emily is passionate about developing young female athletes from middle school to college, assisting in ACL-R rehab, and developing more female strength coaches within the Relentless family while working on her Ph.D.

When she isn’t on the coaching floor or working in her office, she is at home with her husband Jarrod and their daughter Maya Rose, and, of course, their dog Milo (who has become the mascot of Relentless)!!