Female Athletes and Concussions

Female Athletes and Concussions

Emily R Pappas M.S. Exercise Physiology

News flash: Men and women are different.


But did you know, when it comes to our brains, that contrast can be shown in over 100 different ways?


Research shows the electrical activity of the female brain, its metabolite chemistry, blood flow, structure, etc all contribute to the basic differences between it and its male counterpart.   


With this in mind, it just makes sense:

Females experience concussions differently than males.


Unfortunately, most of our data on sports-related brain injury comes from male athletes. Football, the sport with the highest risk of concussion in the United States, is a male dominated field.


Yet, with greater awareness being brought to female athletes, we’re realizing female athletes in sex matched sports of soccer, basketball, and softball/baseball have almost a 2x greater risk of sustaining a concussion over males (1).  


On top of this increased risk, when it comes to sports-related brain injury, the severity and recovery time for female athletes is also higher and longer compared to male athletes.


Concussions are an “unseen” injury. Unlike a torn tendon or a broken bone, it’s difficult for a coach, a trainer, or even a medical professional to know when it’s safe to get back into the game. We can’t create a blanket return-to-play protocol for all athletes, especially when the physical differences between male and female athletes is so great.


If you’re a female athlete, a coach, a trainer, or a parent looking for ways to prevent, identify, or recovery from a concussion, this resource is for YOU.


Read on to discover:


  • How female athletes are at HIGHER risk for concussion injuries

  • The SYMPTOMS female athletes with concussions experience that are DIFFERENT from male athletes

  • What RECOVERING from a concussion looks like

  • Your BEST practices for lessening risk of injury


The Surprising Facts: Concussions And The Female Athlete

New research emerges every day showing the surprising effects of concussions in female athletes. The biggest news? The frequency we get them.


Recent data suggests that in comparative sports, a female athlete may be up to 1.7x as likely to sustain a concussion than a male athlete.  (1)


Why the higher rate?


The jury is still out on that one.


We need more research to know for sure, but most studies suggest the primary suspects are:


What Exactly Is A Concussion?

When considering WHY the higher rates of concussions in females, it helps to understand what can actually cause a concussive injury:


Taken from BRAINLINE: Centers for disease control and prevention


“A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.”

–Centers for Disease Control and Prevention (2)


Because concussions are a “hidden injury”, we still have a lot to learn.


We DO know two things:


  1. Brain structure and function are altered during concussive events.  

  2. Some of the alterations can remain for extended periods of time (think months or even years).


The number of concussions, their severity, and duration of symptoms are predictors of a prolonged recovery (1)


Recurrent concussion is associated with increased odds of post-concussion syndrome (PCS)(4).


Unfortunately, female athletes seem to demonstrate greater impairments post concussion.


The obvious next question is….why?

How Female Athletes Experience Concussions Differently

Each brain is unique…and each injury is different. Studying concussions can be tricky because of these variances.


For females, it seems that not only do these unique traumatic brain injuries (tbi) occur more often, but also often result in exacerbated symptoms. (1)


Compared to male athletes, females athletes show greater impairments such as

  • Drowsiness

  • greater sensitivity to light

  • increased severity of headaches

  • greater difficulty concentration

  • higher levels of irritability and sadness.


Yet detecting these symptoms is pretty difficult if we solely rely on self-reporting.  By doing so, we’re collecting our data from an injured brain!


As teammates, coaches, and parents, we need to be aware of these symptoms. Changes in behavior could be key clues in recognizing injury- and aiding recovery.


Examples of these behaviors could be:

  • Withdrawn from social events

  • Unusually fatigued or lethargic

  • Change in work ethic

  • Skipping classes

  • Skipping lifts or training sessions

  • Mentally slower in processing information

  • More easily angered or disgruntled


Noticing these changes could be essential in preventing a premature return to play.


Because most female athletes experience a greater severity of symptoms when it comes to concussions, recovery time MUST be longer!!


Why Delay Return To Play?


Research supports that females take longer to recover from concussions than males.


Females remain symptomatic for 28 days on average compared to 11 days for males.


If females return to play too soon, they are at an increased risk of sustaining a different injury or increasing the severity of her existing concussion. (3)


However, complete rest is NOT the answer. A complete rest can be counter-productive to recovery (4). Most medical professionals recommend a graded return to play exercise program for females post concussion.


Stage Aim Activity Goal
1 Symptom-limited activity Daily activities that don’t provoke symptoms Gradual reintroduction to school/work
2 Light aerobic exercise Walking or stationary bike at slow speed Increase heart rate
3 Sport-specific exercise Jogging or Skating drills; no head impacts Add movement
4 Non-contact training drills Begin resistance training; increased level of sport play Exercise, coordination, increased thinking
5 Full contact practice Following medical clearance, participate in normal training Restore confidence and assess functional skills by coaching staff
6 Return to sport Normal game participation

*from: McCrory P, et al. Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838-847


The #1 goal of any return-to-play program?


To increase the amount of activities an athlete can perform WITHOUT provoking the symptoms. ‘


Females should progress along these stages based on her individual symptoms.


Returning to play too soon is a risk for any athlete, especially females. Slowed reaction times, decreased coordination and balance are the perfect recipe for longer lasting brain alterations or for sustaining a new injury (such as breaks, strains, or tears).


Can We Prevent Concussions?


As the rate of concussions increases in female athletes, we need to talk about ways to prevent them.


Unfortunately, even with increased attention to sport-related concussion in the scientific community, studies evaluating preventive interventions remain sparse. (5)


The research we do have on increasing cervical strength and decreasing concussion rates shows contradicting results.


What does this mean?  


Instead of thinking about your athlete and just her head, consider the ENTIRE athlete as a whole.


When researchers look at baseline imPACT testing for athletes (the test we use to assist in diagnosing a concussion), they found a predictive relationship between LOWER baseline scores and the relative risk of noncontact ACL injuries. (6)


With a lower baseline imPACT testing, they concluded athletes had a less neuromuscular control, resulting in poor balance and coordination.  These lacking attributes may cause the athlete to have worsened reaction time and motor coordination, especially in a fatigued state.


Therefore poor neuromuscular coordination put our athletes at HIGHER risk for injuries: such as an ACL tear or Concussions. (7)


Here’s how we can proactively combat this:


We know through strength training, athletes are able to improve their body awareness, strength, and neuromuscular coordination.


Concussive events appear to be MULTI-FACTORAL, with risk factors such as:

  • direct head impact events,

  • levels of fatigue or pain from previous injuries affecting body position,

  • reaction times,

  • movement patterns,

  • and nervous system motor control patterns.


Although strength training alone is not enough to help prevent concussive injuries, it can help!!


Athletes with higher levels of strength, body awareness, balance, and motor neuronal coordination are undoubtedly athletes who are better prepared when exposed to an activity where concussive events are possible. (7)



In Summary:

Although current studies may lack in the world of concussion prevention, they are numerous in demonstrating the higher rate of concussive occurrences in the female athlete population.


The female brain is unique from the male brain, and experiences concussive events differently.


Most females suffering from a concussions experience higher severity of symptoms that necessitates a longer return to play.


Research has demonstrated complete rest as being potentially harmful for the athlete.  Progressive exposure to sport related activity should be prescribed to each athlete individually.


Although concussive events are multifactorial, athletes who show higher imPACT baseline scores appear to have higher levels of muscular strength, balance, and coordination. These attributes are all positive characteristics that can be attained through strength training and help a female athlete decrease her risk of experiencing a concussion.


1. Harmon, Kimberly G., et al. “American Medical Society for Sports Medicine Position Statement.” Clinical Journal of Sport Medicine, vol. 23, no. 1, 2013, pp. 1–18., doi:10.1097/jsm.0b013e31827f5f93.

2. Centers for Disease Control and Prevention. (n.d.) Get a HEADS UP on Concussion in Sports Policies: Information for Parents, Coaches, and School & Sports Professionals.Centers for Disease Control and Prevention. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA.

3. Zuckerman, S. L., Yengo-Kahn, A. M., Buckley, T. A., Solomon, G. S., Sills, A. K., & Kerr, Z. Y. (2016). Predictors of postconcussion syndrome in collegiate student-athletes. Neurosurgical Focus, 40(4). doi:10.3171/2016.1.focus15593

4. Tremblay S, Pascual-Leone A, Theoret H. A review of the effects of physical activity

and sports concussion on brain function and anatomy. Intl J Psychophys. 2017; 9(5):1-9.14

5. Enniss TM, Basiouny K, Brewer B, et al. (2018). Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma Trauma Surgery & Acute Care Open 2018;3:e000153. doi: 10.1136/tsaco-2017-000153

6. Swank CB, Covassin T, Stearne DJ, Schatz P. The relationship between neurocognitive function and noncontact anterior cruciate ligament injuries. Am J Sports Med 2007;35(6):943-948.

7. Chorba RS, Chorba DJ, Bouillon LE, et al. Use of a functional movement screening tool to determine injury risk in female collegiate athletes. N Am J Sports Phys Ther 2010;5(2):47-54