A female-athlete injury consensus finds almost nothing rated above low certainty

Three papers underpinning a new consensus on injury prevention in female, woman and girl athletes appeared in the British Journal of Sports Medicine this month [s1][s2][s3]. Read together, they are less a set of recommendations than a formal accounting of how little the field can currently say with confidence.

The lower-limb review

The first review examined modifiable risk factors for lower-extremity injury [s1]. It covered 195 studies with 1,525,662 participants, across eight injury outcomes: 75 studies on general lower-extremity injury, 88 on knee, 27 on ankle, 17 on thigh, 17 on lower leg, 9 on foot, 6 on hip and 3 on groin [s1].

Then the number that frames everything else in it: females, women and girls made up 2.4% of those 1,525,662 participants [s1]. Of the 195 studies, 115 — 58.9% — reported estimates specific to female, woman or girl athletes [s1].

Across 66 identified categories of modifiable risk factor, the authors were able to meta-analyse 10 using female-specific estimates and assess 26 more semiquantitatively [s1]. High risk of bias was present in 37.4% of studies [s1].

The pooled results are mostly null. There was no association between any lower-extremity strength outcome and injury (g = 0.01, 95% CI −0.11 to 0.14; I² = 37.3%; very low certainty evidence), and none between artificial turf and lower-extremity injury (incidence rate ratio 0.97, 95% CI 0.88 to 1.07; I² = 2.4%; low certainty) [s1]. Higher body mass (g = 0.19, 95% CI 0.00 to 0.38; I² = 71.7%) and higher BMI (g = 0.22, 95% CI 0.09 to 0.36; I² = 37.0%) were associated with several lower-extremity injuries, again at very low certainty [s1].

The strength result deserves emphasis because it runs against a widely held assumption. In the female-specific estimates available, muscle strength did not predict lower-limb injury. That is not evidence that strength is irrelevant — the confidence interval is narrow around zero but the certainty rating is very low, and the studies are heterogeneous. It is evidence that the assumption has not been demonstrated in this population.

The concussion review

The second review looked at prevention strategies and modifiable risk factors for sport-related concussion and head acceleration events [s2]. It included 108 studies: 67 evaluating a prevention strategy — 25 on equipment, 21 on policy or rule changes, 11 on management and 10 on training — and 41 evaluating potential modifiable risk factors, covering 34 distinct factors across nine categories [s2].

Of those 108 studies, 40 (37%) included female-, woman- or girl-specific estimates: 19 of the 67 prevention studies and 21 of the 41 risk-factor studies [s2]. That left enough female-only data for exactly three meta-analyses [s2].

Headgear was associated with 30% lower concussion rates in adolescent female and girl lacrosse and soccer players (IRR 0.70, 95% CI 0.50 to 0.99; very-low certainty) [s2]. The upper bound of that interval is 0.99 — the result clears statistical significance by a hair, at the lowest certainty grade.

Eyewear use was not protective (IRR 1.08, 95% CI 0.69 to 1.68; very-low certainty) [s2]. Concussion rates did not differ between artificial turf and grass (IRR 0.95, 95% CI 0.62 to 1.45; very-low certainty) [s2] — consistent with the lower-limb review's null turf finding, from a separate literature [s1].

The authors' conclusion is that evidence for prevention strategies and modifiable risk factors in female, woman and girl athletes is limited, with the single exception of very-low-certainty support for headgear in adolescent lacrosse and soccer [s2].

What the experts think is fixable

The third paper approaches the same problem from the other direction. Rather than pooling published studies, it used mixed-methods concept mapping with 66 experts — athletes, coaches and carers; clinicians; sports science and high-performance professionals; administrators; and researchers — who generated, sorted and rated statements in response to a single prompt about which gender- and sex-specific factors contribute to injury risk in female, woman and girl athletes [s3].

The exercise produced 101 unique statements grouped into 10 clusters [s3]. The largest were lack of evidence for, and implementation of, gender- and sex-appropriate injury prevention (20 statements) and inequitable organisational funding and support (17), followed by sex-related factors (14) and gendered expectations to conform to athletic ideals and norms (10) [s3]. Others covered gendered harassment and social biases (9), gendered health (8), athletes' lack of and access to resources (7), the gendered sport environment (7), lack of knowledge and expertise among support staff (6) and gendered communication (3) [s3].

The cluster rated most important and most modifiable was not the largest one. It was lack of knowledge and expertise among support staff [s3].

How to read this set

The honest summary is that a consensus process assembled the available evidence and found that most of it does not meet the standard needed to make recommendations. Almost every pooled estimate across both reviews carries a very-low or low certainty rating [s1][s2]. The reviews are useful precisely because they document that, rather than converting weak evidence into confident guidance.

The 2.4% figure [s1] is the structural explanation. A literature built overwhelmingly on male participants cannot answer questions about female athletes by reanalysis; it can only be supplemented by new studies designed for the purpose. Both reviews end by calling for exactly that [s1][s2].

What to watch

The FAIR consensus statement itself, which these three papers are built to inform, and whether it issues practice recommendations despite the certainty ratings — or declines to, and says why.

Sources

• Modifiable risk factors for lower-extremity injury: a systematic review and meta-analysis for the FAIR consensus — British Journal of Sports Medicine, 2025-09-04
• Prevention strategies and modifiable risk factors for concussion: a systematic review and meta-analysis for the FAIR consensus — British Journal of Sports Medicine, 2025-09-19
• Gender- and/or sex-specific considerations for sport-related injury: a concept mapping approach for the FAIR consensus — British Journal of Sports Medicine, 2025-09-16