Unique health challenges of female athletes

Woman playing tennis

Just like male athletes, female athletes are prone to sports injuries. Due to their unique anatomy and physiology however, female athletes tend to get injured in different ways than their male counterparts.

Females have increased joint laxity, tend to have a wider pelvis, different femur shape and higher incidence of patella malalignment compared to males. These differences combine to change the biomechanics of the lower extremity, and make females prone to certain injuries and conditions. 

Natalie Ronshaugen, MD


ACL Tears

ACL tears in female athletes have unfortunately become one of the more common injuries we see. The incidence of non-contact ACL injuries is 2 to 8 times higher in female athletes than in male athletes participating in sports such as soccer and basketball. Female soccer players have the highest rate of ACL injuries, and in high level female soccer players, the incidence an ACL tear is 5% per year. This increase is due to risk factors we label as modifiable and nonmodifiable. Modifiable risk factors include how female athletes move compared to their male counterparts. For example, when females jump and land, they tend to land with the knee collapsed in which puts the ACL at higher risk of rupture. Nonmodifiable risk factors include anatomy and hormonal differences between females and males.

Patellofemoral Pain and Instability

Patellofemoral pain (also known as “runner’s knee”) is very common in female athletes and can occur in any sport. Females are 3 times more likely to suffer from patellofemoral pain (pain in the front of the knee) compared to males. 

Shoulder Instability

Females have a higher rate of atraumatic shoulder instability, whereas males have a higher rate of traumatic shoulder instability (dislocations). Increased hypermobility (flexibility) and greater shoulder range of motion in females contribute to the increased risk of shoulder dislocation without a trauma.


Concussions occur more often in females as compared to the same sport in males. Reasons for this are unclear, but weaker neck muscles are suspected to be a contributor. Girls are also more likely to rate their symptoms as more severe, though it is not clear if this is because their concussions are more severe or if they are more likely to report them than boys.

Iron Deficiency Anemia 

Iron is used in blood to carry oxygen molecules from the lungs to the tissue. Women loose blood, and hence iron, during menstruation. They need increased iron stores during pregnancy. Athletes need increased iron because they lose very small amounts of blood through break down during endurance sports, such as running. They also lose small amounts of blood through their intestines, sweat, and bladder. Because of this, female athletes are at increased risk of being anemic.


Formally known as the Female Athlete Triad, Relative Energy Deficiency in Sports (RED-S) is a constellation of symptoms presenting in an athlete who is not taking in adequate calories for their particular sport. Sometimes this is purposeful (in an effort to be thin) and is often found in sports such as gymnastics, figure skating and long distance running. Other times it is unintentional, where an athlete is not getting enough calories because they are working out more than they can take in. It can present in any age, but adolescents and young adults are at the highest risk.

The “female athlete triad,” was first coined in 1992 and was a syndrome of disordered eating, menstrual irregularity and osteoporosis. We now know that RED-S does not only affect females, but also males. It can cause problems with any organ system, even if menstrual irregularity and osteoporosis are not present.  RED-S can cause menstrual dysfunction, infertility and can lead to poor bone mineral density. 


RED-S is often diagnosed after an athlete has had one or more stress fractures, or when a female is having fewer periods than normal. It can also be diagnosed if someone has increasing injuries of any type, worsening coordination or sports performance, abnormal pubertal development, fatigue, depression, irritability or frequent illnesses. 


Early identification is important. Problems tend to be reversible when sufficient healthy calorie intake to support athletic performance is provided. This is generally achieved with the help of a dietician. They will help outline appropriate caloric and nutrient needs and figure out strategic ways of getting enough calories throughout the day. Some athletes may need to take a break from sports to recover their energy balance before returning to intense training. 

At Nebraska Medicine, we care about the unique health challenges of female athletes at every life stage. If you have concerns and need an appointment, we are here to help.

Article written by Natalie Ronshaugen, MD.