Kantaros E & Borgstrom H
DOI: 10.53646/jwsm.v1i1.3
Published online: Sept 26, 2021
2769-4895 Ó Journal of Women’s Sports Medicine
- 30 -
Sex-specific Differences in Perceived Injury Management and
Prevention in High School Student-Athletes
Eve Kantaros, Haylee Borgstrom, MD MS
1,2
1
Massachusetts General Hospital, Sports Medicine Division, Harvard Medical School,
Boston, Massachusetts USA
2
Spaulding Rehabilitation Hospital, Department of PM&R, Harvard Medical School,
Boston, Massachusetts USA
BACKGROUND: Sport-related injuries are common among high school student-athletes with specific
sex disparities in injury risk. Many of these injuries may be avoidable with the use of injury prevention
programs (IPPs). Sex differences in injury management and return to sport are not well understood.
PURPOSE: To determine sex-specific differences in self-reported injury management and prevention
strategies in high school student-athletes.
DESIGN: Cross-sectional, survey-based study.
METHODS: An anonymous 13-item electronic survey was distributed to all students in a private high
school in December 2019 with responses recorded over a one-month study period. Primary outcomes
were sex-specific differences in self-reported outcome measures assessing student-athlete experience
during injury recovery and familiarity with IPPs. Groups were evaluated via descriptive statistics and
differences between groups were compared.
RESULTS: From a total of 190 responses, 106 were included in the analysis (63F, 43M, mean age 16.7
years). Female athletes reported decreased exposure to injury prevention training (44.4% vs 69.8%,
p=0.01) and practice-based utilization of IPPs (23.8% vs 55.8%, p=0.001) compared to male athletes.
Overall, reported utilization of IPPs was low regardless of sex at less than 40% for all athletes. Nearly 85%
of female athletes compared to 51% of male athletes felt they could benefit from IPPs (p=0.001), yet fewer
than half of female athletes reported ever having training in injury prevention. There were no statistically
significant differences in measures of injury management or return to sport between sexes. Females
reported similar major impact of injury on life and future plans compared to male athletes.
CONCLUSIONS: Male athletes were 1.6x more likely to report injury prevention training and 2.4x more
likely to report practice-based utilization of IPPs compared to female athletes. Sex-specific differences in
injury management and return to sport were not identified. Better incorporation of IPPs, specifically at
the high-school level, may help to address sex disparities in preventable sport-related injuries and allow
student-athletes to maximize the myriad benefits of sport participation.
BACKGROUND
Subsequent to the enactment of Title IX in 1972,
participation in high school athletics has increased
by over 10-fold for girls compared to less than 2-fold
for boys
1
. As of 2018-2019, females accounted for
43% of high school and 44% of collegiate student-
athletes
1, 2
. In addition, the opportunities to compete
across a wide variety of sports is also growing with
increasing female representation in more classically
male-dominated sports, such as ice hockey and
wrestling
3
. Sport-related injuries are common in
both male and female high school student-athletes
with an injury rate of 2.29 per 1,000 athlete
exposures across nine major sports over the 2018-
2019 season
4
. Among sex-comparable sports
including soccer, basketball, volleyball,
baseball/softball, swimming and diving, track and
field, cross-country, and tennis, injury rates are
higher for high school girls compared to boys with
the lower extremity being the most commonly
Kantaros E & Borgstrom H
DOI: 10.53646/jwsm.v1i1.3
Published online: Sept 26, 2021
2769-4895 Ó Journal of Women’s Sports Medicine
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injured body region
4, 5
. Additionally, high school
girls are more likely to suffer a severe lower
extremity injury resulting in greater than three
weeks of time loss or medical disqualification than
boys
5
. Recognizing sex differences for specific
preventable injuries along with structural,
biomechanical, neuromuscular, and hormonal risk
factors is imperative to mitigating injury risk
6-9
.
Injury prevention programs (IPPs) are exercise-
based, proactive interventions designed to decrease
avoidable sport-related injuries by improving
modifiable risk factors such as core stability,
dynamic lower extremity alignment, eccentric
strength, proprioception, balance, and
neuromuscular control
10-12
. Despite demonstrated
benefits related to both injury prevention and
performance, IPPs are not widely utilized at the
high school level and, when implemented,
adherence is often suboptimal
13
. Sport-related
injuries not only impact athletic performance and
cardiovascular health, but impede athletes from
gleaning potential benefits related to higher
academic achievement, advanced educational
opportunities, skilled workforce employment, and
improved mental health and social interaction
14-16
.
Thus, athletes, coaches, and sports medicine
providers alike should prioritize injury prevention
in order to maximize student-athlete potential in
both sport and life.
The purpose of this study is to identify sex-
specific differences in perceived management and
prevention of injuries in high school student-
athletes who have experienced significant sport-
related injuries. Specifically, we aim to determine
differences in athlete support during injury
recovery, exposure to preventative exercise, and
utilization of IPPs between sexes that may
contribute to known sex disparities in sport.
METHODS
In December 2019, an anonymous electronic
survey was developed to gauge perceptions of
sport-related injury management and prevention
among high school student-athletes. The survey
contained 13 questions, including basic
demographic information (age, gender, sport,
injury, time to diagnosis, and time to recovery) and
self-reported outcome measures related to the
student-athlete’s experience during injury recovery
and exposure/access to injury prevention programs
via primarily binary response format. The survey
was reviewed for objectivity and clarity by the
Head Athletic Trainer at a local private high school
prior to distribution. Participants were recruited via
email distribution of the electronic Google Forms
survey link to all students in the private high school
as well as through two common social media
platforms. The survey link was emailed twice over
the study period from December 6th, 2019 - January
8th, 2020. Informed consent was implied by
completion of the survey. Retrospective analysis of
the anonymous dataset was deemed exempt from
institutional review board (IRB) approval.
Statistical analyses were performed with IBM
SPSS® Statistics software platform. Independent
samples t-tests were used to evaluate for sex-
specific differences in demographic data between
groups. Pearson’s chi-squared tests were used to
evaluate for sex-specific differences in categorical
outcome measures for injury management and
prevention between groups. P-value of less than
0.05 was considered statistically significant.
RESULTS
Overall, there were a total of 190 anonymous
electronic responses collected over the one-month
study period. Of these, a total of 106 responses (63F,
43M, mean age 16.7 years old) were included in this
study. Responses were excluded for incompleteness
(n=2), participant not of high school age (n=23), and
lack of prior injury resulting in one or more months
away from sport (n=59). Participant demographics
and injury characteristics are presented in Table 1.
The most common sports resulting in injury were
soccer, lacrosse, and basketball for female athletes
and ice hockey, soccer, and volleyball for male
athletes. Approximately 13% of athletes reported
injuries from more than one sport. The most
commonly injured body region was the knee
followed by the ankle for both female and male
athletes. Time to diagnosis was reportedly less than
3 days for 38% of all athletes and less than 2 weeks
for nearly 75% of athletes. Average time to recovery
from all reported injuries was approximately 4
months. There were no significant differences in
mean age, time to diagnosis, or time to recovery
between sexes.
Most athletes, regardless of sex, reported that
they generally felt encouraged to return to sport
after injury recovery (85.7% female vs. 93.0% male;
p=0.24). While there appeared to be a trend toward
more female compared to male athletes reporting
they had been suggested to stop playing their sport
Kantaros E & Borgstrom H
DOI: 10.53646/jwsm.v1i1.3
Published online: Sept 26, 2021
2769-4895 Ó Journal of Women’s Sports Medicine
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entirely, or retire, due to injury (39.7% vs. 25.6%,
respectively), this difference was not statistically
significant (p=0.13).
Table 1. Participant demographics & injury
characteristics by sex
Female
Male
Sex
Total (%)
63 (59.4)
43 (40.6)
Age, years
Mean ± SD
16.6 ± 1.1
16.9 ± 1.5
Sport (% by sex)
Soccer
15 (20.6)
6 (11.3)
Lacrosse
12 (16.4)
5 (9.4)
Ice hockey
4 (5.5)
12 (22.6)
Volleyball
7 (9.6)
6 (11.3)
Basketball
8 (11.0)
4 (7.6)
Field hockey
7 (9.6)
1 (1.9)
Cross country
4 (5.5)
4 (7.6)
Softball/baseball
2 (2.7)
4 (7.6)
Football
0 (0.0)
5 (9.4)
Track & field
2 (2.7)
2 (3.8)
Other
12 (16.4)
4 (7.6)
Total
73 (57.9)
53 (42.1)
Injury body region (% by sex)
Knee
19 (28.4)
10 (20.8)
Ankle & foot
16 (23.9)
9 (18.8)
Wrist & hand
9 (13.4)
8 (16.7)
Concussion
7 (10.5)
5 (10.4)
Shoulder
5 (7.5)
4 (8.3)
Leg/shin
6 (9.0)
3 (6.3)
Hip
4 (6.0)
0 (0.0)
Back
0 (0.0)
4 (8.3)
Thigh
0 (0.0)
3 (6.3)
Other
1 (1.5)
2 (4.2)
Total
67 (58.3)
48 (41.7)
Time to diagnosis (% by sex)
Less than 3d
23 (36.5)
17 (39.5)
3d-1wk
11 (17.5)
7 (16.3)
>1wk
10 (15.8)
6 (14.0)
>2wks
18 (28.6)
11 (25.6)
Time to recovery, months
Mean ± SD
4.1 ± 3.1
3.8 ± 2.9
Importantly, the reported major impact of
injury on life or future plans was similar for both
sexes (p=0.54). In terms of injury prevention
programs (IPPs), there were significant sex-specific
differences. While nearly 70% of male athletes
reported training focused on injury prevention,
only 44% of female athletes reported similar
exposure (p=0.01). Similarly, female athletes were
less than half as likely to report inclusion of
preventative exercise as part of practice, with
overall low occurrence for both sexes (23.8% female
vs. 55.8% male, p=0.001). Only 24% of all athletes
reported incorporation of IPPs into their high
school sport programs. More female athletes felt
they could benefit from inclusion of preventative
training in a practice setting (84.1% female vs. 51.1%
male, p=0.001).
DISCUSSION
To our knowledge, this is the first study to
investigate sex-specific differences in perceived
injury management and prevention among high
school student-athletes. In the present study, male
athletes were 1.6 times more likely to report injury
prevention training and 2.4 times more likely to
report inclusion of IPPs into a practice setting
compared to female athletes. Fewer than half of
females reported ever having training in injury
prevention. Among all athletes, only 36.8%
reported inclusion of preventative exercise into a
practice setting, and only 24% as part of high school
level sport. Within this context, our findings
specifically highlight deficiencies in utilization of
IPPs for high school student-athletes regardless of
sex with further emphasis on the reported disparity
for female compared to male athletes.
These findings are of great clinical importance
given well-established epidemiologic research
demonstrating high sport-related injury rates
among both female and male high school athletes
5,
17
, with further increased risk for lower extremity
and knee injuries among female athletes
5, 18, 19
.
Anterior cruciate ligament (ACL) injuries in
particular are 2-4 times more common in female
compared to male athletes
18, 19
with peak incidence
occurring in high school years
20
. Similarly, among
our study population, lower extremity injuries were
most common for both sexes with knee injuries
accounting for 28% of female and 21% of male
injuries. Additionally, injuries were most common
in cutting/pivoting sports.
Many of these injuries may be avoidable with
the use of IPPs. The efficacy of IPPs has been
repeatedly demonstrated in terms of improved
biomechanical factors as well as translation into
decreased risk for a variety of sport-related injuries,
Kantaros E & Borgstrom H
DOI: 10.53646/jwsm.v1i1.3
Published online: Sept 26, 2021
2769-4895 Ó Journal of Women’s Sports Medicine
33
Figure 1. Self-reported outcomes for sport-related injury management and exposure to
preventative exercise (*, p<0.01; **, p<0.001).
including overall injury risk as well as lower
extremity, hamstring, knee, ACL, and ankle specific
injury risk
10-12, 17, 21-30
. Additionally, implementation
of IPPs in high school-aged athletes has been shown
to result in greater biomechanical improvements
compared to middle school-aged athletes
21
and
greater reduction in injury risk compared to college
or professional athletes
25
. This emphasizes the
importance of targeting high school-aged athletes
for preventive exercise, especially given peak
incidence of certain injuries, including ACL injuries,
during high school years
20
.
Underutilization of IPPs likely stems from
multiple causes. In a recent survey-based study of
440 intercollegiate female student-athletes, a vast
majority (over 85%) understood that women are at
higher risk for preventable ACL injuries, and nearly
90% reported they would perform injury
prevention exercises daily if it would decrease their
risk for ACL injury; however, only 33% noted
familiarity with ACL-specific IPPs and only 15%
had ever performed these types of exercises
31
.
These findings indicate that a deficiency in athlete
education and awareness likely contributes to
underutilization of IPPs. In parallel, 84% of the
female athletes in the present study felt they could
benefit from incorporation of preventative exercise
into a practice-based setting, yet only 44% had ever
been exposed to preventative exercise and only 24%
had ever practiced IPPs. While significantly fewer
male athletes felt they could benefit from practice-
based IPPs, possibly reflecting increased training
and experience with performing these types of
exercises compared to female counterparts, a
majority (51%) still preferred to incorporate IPPs
into practice.
Additional barriers to successful
implementation of IPPs are numerous. Coaches are
an integral part of IPP utilization
32
, and coach-led
IPPs have been demonstrated to be equal in efficacy
yet superior in feasibility to IPPs with mixed
leadership including coaches, trainers, physical
therapists, and physicians
33
. Among high school
and adolescent coaches, logistical factors (IPP
complexity/inflexibility, lack of sport-specific IPP,
lack of time, venue constraints, weather), athlete-
related factors (player engagement, maturity level),
and educational factors (lack of IPP awareness and
expertise) are cited as barriers to use
13, 34-37
.
Furthermore, a complex interplay of institutional
and organizational influences, sport- and/or
regional-specific culture, and socioeconomics has
been implicated in affecting successful
implementation of and adherence to IPPs
38
.
Even in cases when IPPs are implemented, low
adherence to these programs may limit their success
38, 39
. Among high school soccer and basketball
coaches, only 21% reported IPP implementation
and of those only 43% adhered to the IPP as
designed
13
. Specific factors that coaches feel would
increase IPP utilization and adherence include:
increased access to education and training
resources, sport-specific IPPs, emphasis on both
injury prevention and sport performance, support
from other coaches, club/organizational adoption
of IPPs, ease of use (2-3 days weekly, no more than
15-20 minutes), and modifiability to increase athlete
motivation (competitive elements, paired exercises,
etc)
34-37
. Another potential athlete-specific factor
Kantaros E & Borgstrom H
DOI: 10.53646/jwsm.v1i1.3
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2769-4895 Ó Journal of Women’s Sports Medicine
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related to IPP adherence is athlete sex. Interestingly,
exercise fidelity, or performing the exercise
correctly, has been demonstrated to be higher in
adolescent female compared to male athletes
39
. Sex-
specific differences in sport psychology may be of
importance related to this finding as female
adolescent athletes endorse higher levels of
perceived injury risk with sport and lower levels of
risk taking behavior compared to male athletes
40
,
potentially improving their adherence to IPPs. This
may be another explanation for the sex disparity in
preference for incorporation of IPPs into a practice
setting identified in this study.
In terms of the sports medicine provider’s role
in enhancing coaching education and
implementation of IPPs, it is imperative that the
provider “speak[s] the same language as the coach”
and “proposes rather than imposes” in order to
optimize delivery and receptiveness of IPP
information, facilitate dialogue, and allow for
collaboration if needed
32
. While coaches often note
preference for sport-specific IPP, the use of
generalized compared to sport- or athlete-specific
IPPs has not been well studied
26
. There is, however,
limited evidence supporting similar improvements
with a generalized compared to individualized IPP
among high school and pre-high school athletes
21
.
It is likely that feasibility of generalized IPPs is far
greater especially at this competition level, and this
knowledge may empower coaches to feel confident
in adopting a generalized program rather than none
at all. Additionally, while elite level athletes,
coaches, and physical therapists primarily value
sport performance
41
, high school female athletes
report the most important factor influencing
willingness to perform an IPP is decreased injury
risk rather than improved performance
42
.
Regardless, it is important to highlight that in
addition to notable reduction in injury risk, IPPs
often lead to improvements in various performance
metrics, including strength, explosiveness, balance,
and proprioception
10
. Furthermore, it is important
for all members of the sports medicine team to
acknowledge the complex interplay of additional
factors implicated in successful implementation of
and adherence to IPPs, including institutional and
organizational influences, sport- and/or regional-
specific culture, and socioeconomic elements
38
.
This study did not demonstrate significant sex-
specific differences in outcomes related to injury
management or return to play, including time to
diagnosis, time to recovery, feeling of
encouragement to return to sport after injury
recovery, or suggestion to retire from sport due to
injury. There is sparse literature investigating sex
differences in injury management and return to
sport in athletes. Sport-related concussion has the
most robust evidence demonstrating longer time to
recovery and return to sport in female compared to
male athletes. This finding has been associated with
many sex-specific differences including neck
strength, self-reported symptomology, severity of
neurologic deficit, rate of neurocognitive recovery,
hormonal factors, social and behavioral norms, and
more
43-45
. There is strong advocacy for further
research and development of injury prevention,
treatment, and return to sport protocols that
consider sex differences in an effort to improve
outcomes for all athletes with sport-related
concussion
45
.
In contrast, much remains unknown regarding
potential sex disparities in treatment and recovery
following musculoskeletal injuries. One study
found that male athletes returned to sport at
approximately twice the rate of female athletes at
one year post-ACL reconstruction
46
. Sex-specific
differences in objective measurements of knee
function or self-reported outcome measures that
may have helped to explain this finding were not
reported. Also post-ACL reconstruction, sex
differences in psychological factors related to
recovery and return to sport have been described in
high school athletes
47
, suggesting that sex-specific
approaches beyond rehabilitation protocols may be
warranted. Further, while sex bias among clinicians
has been demonstrated to affect management of
other medical conditions, the potential effect that
bias may have on sport-related injury and recovery
is largely unknown. A single vignette-based study
demonstrated racial and social class biases among
Division 1 sports medicine providers regarding
perception of increased pain tolerance after ACL
injury in black and low socioeconomic status
athletes, but bias was not demonstrated based on
sex
48
. Decreased satisfaction with sports medicine
care has been reported among female compared to
male collegiate athletes
49
, though this is not well
supported and may be related to participation in
lower-profile sports with decreased access to
athletic trainers
50
. Much work remains to be done
to better define sex differences in injury
management and return to sport after
musculoskeletal injury.
Finally, one-third of all athletes in the present
study reported major impact of injury on their
future plans and/or life goals with no difference
Kantaros E & Borgstrom H
DOI: 10.53646/jwsm.v1i1.3
Published online: Sept 26, 2021
2769-4895 Ó Journal of Women’s Sports Medicine
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between sexes. This further reinforces the fact that
female athletes value sport participation as much as
their male counterparts. With continually growing
opportunities for female athlete sport participation
in addition to known benefits beyond that of
cardiovascular fitness, including psychosocial,
educational, and socioeconomic benefits
14-16
, young
women are motivated to pursue higher levels of
sport competition. As sports medicine providers,
recognizing the importance of injury prevention is
key in allowing young athletes—both female and
male—to reach their full athletic potentials, which
may in turn have life-long benefits beyond athletics.
This prospective, cross-sectional, survey-based
study has multiple limitations inherent to its study
design, including risk for response and recall bias.
Athletes without prior injury history may have been
less likely to respond, and it is possible that those
athletes may have had increased exposure to IPPs.
To this effect, female athletes who were excluded
due to lack of significant injury more commonly
reported prior injury prevention training (77% vs
44%) and incorporation of preventative exercises
into practice settings (63% vs 23%) compared to
female athletes included in the study population,
though this finding is of limited relevance due to
low sample size (n=16) and frequent incomplete
survey responses. Additionally, the survey tool was
initially designed in an effort to inform a journalistic
endeavor with primarily binary response options.
Inclusion of Likert scales would have allowed for
increased granularity in responses, enhancing
detection of relationships of smaller effect size and
overall strength of associations. Given concern for
anonymity, additional participant demographics,
including ethnicity, socioeconomic status, and high
school funding were not collected and may have
independent influence on access to preventative
exercise. Recruitment was primarily focused on
students at a single private high school which limits
generalizability across publicly funded schools.
CONCLUSION
This study identifies a lack of exposure to
preventative exercise and IPP implementation in all
high school student-athletes, while emphasizing
greater deficiencies in injury prevention strategies
among female compared to male athletes. Given
known sex-related disparities including increased
injury risk and severity for high school girls
compared to boys, along with proven benefit of
IPPs, these findings highlight the need for better IPP
utilization. Sex-specific differences in injury
management and return to sport were not identified
in this study and remain largely unknown for most
sport-related injuries. Future research should focus
on improving injury prevention education,
addressing known barriers to IPP implementation
to allow for better adoption at the high school level,
and investigating sex differences in injury
management and return to sport with the goal of
providing more equitable care and reducing
preventable injury in all athletes.
Conflict of Interest Statement
The authors report no conflict of interest with the
contents of this manuscript.
Corresponding author
Haylee Borgstrom, MD MS
Spaulding Rehabilitation Hospital
Department of Physical Medicine and
Rehabilitation, Harvard Medical School
300 1
st
Avenue, Charlestown, MA 02129, USA
P: 617-952-5243
F: 617-952-5934
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