What I Wish I Would Have Known as a Female Athlete

Yes, it is my job as a physical therapist to fix the injured, but I also feel a duty to help prevent musculoskeletal injuries from occurring in healthy populations. I was 14 years old the first time I tore my ACL and meniscus. I grew up playing basketball, baseball, and soccer, but was only exposed to injury prevention and specific strengthening after my first knee surgery. Even playing varsity basketball in high school, there was no strengthening program we followed specific to injury prevention. My coach would lead us to the weight room and my teammates and I would end up doing skull crushers, which does nothing for the lower extremity (obviously). This does not come at any fault to the coaches because unfortunately, there is a knowledge gap, especially with female athletes.

Anatomically, females generally have shorter legs, smaller ligaments, smaller muscle cross-section, more joint laxity, and a wider pelvis resulting in knee valgus or “knock-knees.” There are also conditions that females experience that our male counterparts will not such as menstruation and bone density issues due to the presence of estrogen. On average, menstruation begins between 10 and 15 years of age, which is right when female athletes begin to ramp up sport-specific training. We learn about periods and how our body shape might change, but no one ever talked about my joints becoming more lax or my risk of sport injury increasing. More importantly, no one ever told me what I could do to prevent these injuries from occurring.

Some of the most common injuries seen in female athletes are patellofemoral (knee) pain, ACL tears, ankle sprains, and stress fractures. Patellofemoral pain syndrome (PFPS) involves your patella (knee cap) and your femur (thigh bone) and is one of the most common causes of anterior knee pain. PFPS is about twice as common in women, and mainly affects young active women. There are many risk factors for developing PFPS such as poor patellar tracking, pelvic malalignment, muscle weakness or dysfunction, muscle and soft tissue tightness on the outside of the knee, altered lower extremity biomechanics, and training errors or overuse. During pre-season training, we used to run the bleachers to get in shape. The forces transmitted through your kneecap when going up stairs is three times your body weight. Now imagine running up and down the stairs for extended periods of time without the proper pelvic stability. I can promise you, your knees are probably not going to be happy. Do not take pain lightly – cut back on your mileage at the first sight of pain and make sure you are wearing good shoes. The best way to prevent PFPS is to address the risk factors listed above. These assessments are best performed by qualified sports medicine professionals or physical therapists, and highlight the importance of injury prevention screenings.

Weak Tight
Hip abductors Hamstrings
Deep hip rotators Quadriceps
Quadriceps Iliotibial band (ITB)
Core Calves
Table 1: Example of commonly weak vs. tight muscles in those at risk for developing PFPS


The next topic is something I am very familiar with. ACL tears. Between 14 and 20 years of age, I tore my ACL four times and underwent a total of five knee surgeries. Unfortunately, these numbers aren’t a rarity for female athletes. Females show a sharp increase in the incidence of ACL tears during puberty due to the resulting ligamentous laxity, which is why prevention is so important. Surprisingly, around 70% of ACL tears happen from non-contact injuries. Risk factors for ACL tears include high BMI, asymmetry between the right and left lower extremity, core and pelvic weakness, hip and ankle joint tightness, decreased neuromuscular control of the knee, and movement dysfunctions. Weakness in your core abdominal and hip musculature can lead to pelvic drop, increased internal rotation of your femur, knee valgus (knock-knees), external rotation of your tibia (lower leg bone), and over-pronation of your foot and ankle. I know there are a lot of big words in that last sentence, but you can probably sense that those are all bad things that lead to increased tension through your ACL.  Additionally, multiple studies have shown that a poor hamstring to quadriceps strength ratio is a significant risk factor for ACL injury. Female athletes generally have much weaker hamstrings than quadriceps, so it is important to strengthen both. Now let’s talk about tightness. Each joint in our body is generally suited for either mobility or stability. For example, the pelvis should be stable, the hips should be mobile, the knees should be stable, and the ankle should be mobile. If your hips or ankles are tight, your body is going to get the mobility from somewhere—and usually it comes at the expense of the stable knee. Once you have normalized your mobility, you have to learn how to jump, land, decelerate, and cut properly. Try this out in front of a mirror: are you able to jump up and land with your knees aligned over your 2nd toe, or do your knees collapse in towards each other? Next try jumping on one leg. If you are not able to land on one leg without your knee collapsing, you are at a huge risk for an ACL injury.

Ankle sprains are another largely prevalent injury among female athletes, and most commonly seen in soccer players. The Journal of Bone and Joint Surgery released a meta-analysis in 2017 concluding that prevention programs are effective at reducing the risk of ankle injuries by up to 40% in soccer players. The studies reviewed included neuromuscular training, proprioceptive training, strengthening, and stretching exercises in their prevention protocols. Proprioception is your joint’s ability to determine its position in space and the main way to train this is through single leg balance drills. Once you can balance on one leg for at least 30 seconds you can progress to standing on a variable surface (i.e. foam, pillow), with your eyes closed, or with arm or head movements. Neuromuscular training is the ability to maintain stability during more advanced movement patterns and is crucial before transitioning to jumping, cutting, and landing. It’s scary how most female athletes are thrown into jumping and cutting at full speed before they can even balance on one leg without falling over, isn’t it? As far as strength, it is most important to strengthen your gastroc (calf) and your peroneal muscles to optimize ankle stability and prevent your ankle from turning out after landing awkwardly. After you sprain your ankle even once, you slowly stretch out your lateral ligaments and are prone to recurrent ankle sprains. Unfortunately, ligaments are like laffy taffy, and cannot tighten up after they have been stretched. If your ligaments don’t do a good job of stabilizing your joint, your muscles are next in line, which is why they have to be strong. As far as stretching, you need to have to good calf mobility. Try this—put a piece of tape four inches away from a wall. Place your toes on the tape, and attempt to touch your knee to the wall, keeping your heel flat on the ground. If you cannot reach the wall from four inches, you do not have sufficient ankle mobility to run, squat, or play without increasing stress through the ankle (and knee).

The last pathology I am going to cover is stress fractures. Stress fractures account for up to 20% of all injuries treated in sports medicine clinics. The risk factors for stress fractures are low body mass index (BMD), menstrual irregularities, late period onset, dietary insufficiency, biomechanical abnormalities, and training errors. The female athlete triad is a well-known concept that has evolved over the last 20 years and describes the connection between energy availability, decreased BMD, and menstrual irregularities. Energy availability is the amount of caloric energy remaining after exercise energy expenditure. The female athlete triad is very real. Young girls, and especially young athletic girls, experience a lot of pressure as far as body image is concerned. Fad diets and diet pills are on the rise and are a scary combination with growing women who are expending a lot of energy on practices, games, and training. If a female athlete does not intake enough calories to cover her expenditure, her body will take energy at the expense of her overall health. Two of the most common examples are an athlete with a stable body weight but no period and an athlete with chronic stress fractures. Take care of your body girls!

One of the most common questions I am asked is “so…when should I stretch?” Female athletes (ESPECIALLY if you are on your period) should leave static stretching to after training/practices/games. Try not to sit down and statically stretch your hamstrings while you talk to your teammates for 3 minutes before practice. Your muscles need to be ready to move and protect your joints, so don’t relax them too much before you play. Dynamic stretching is better before training/practices/games to get blood flowing to your muscles so they are ready to go. Think high knees, high kicks, twisting lunges, etc.

All sports medicine professionals, coaches, and athletes need to be aware of the risk factors and pathologies to effectively prevent injuries. A few of the most important take home points are:

  • Have a pre-season physical by a qualified movement specialist (like a PT)!
  • Strengthen smart. Stretch smart. Train smart.
  • Avoid overuse. Try to take at least one season off so your body can recover.
  • Don’t fad diet. Don’t overly restrict your eating. Don’t skip meals. Don’t take diet pills, laxatives, diuretics, etc while you are training.
  • Talk to your coach(es) about injury prevention programs for the injuries we discussed in this blog.


Marley Lefelar, PT, DPT



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