Q: Very interesting article. As a (female) former high school and collegiate cross-country and track athlete, I experienced many of the same struggles as the young woman described in this article. In the running world, overuse injuries, such as stress fractures and tendonitis, are more common than ACL ruptures, though the emotional turbulence surrounding injury is devastating to any dedicated athlete.

I was also compelled by the article's suggestion that female athletes may have a higher tolerance for pain than their male peers. Are there many empirical studies that back up that assertion? From an anecdotal standpoint, I have always thought that to be true; I've endured multiple stress fractures and even severe gastrointestinal internal bleeding, all of which I have trained and competed through to the surprise of my family/doctors.

Nevertheless, I still think that girls will always be striving that much harder to prove themselves in athletics. In running, the male high school and college cross-country stars always get more attention than the females; they are the ones setting course records. Girls will never be as “fast” and we will always be thinking of other ways to make up for it, including pushing ourselves to unhealthy extremes. — L.M., New York (Go to Comment)

A: The question of pain tolerance is intriguing. It is difficult to research because you cannot, of course, put people in pain for the sake of a study. Some research that I've seen observes subjects do such things as put their hands in hot water and take them out when it gets too uncomfortable, which seems pretty artificial. I found the military research more relevant — the studies that showed women in basic training to be both more vulnerable to certain injuries, but also tougher. It took a bigger injury to knock them out of the service than it did for men, who left with lesser maladies.

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Consider those findings alongside this comment from Brandy, from Plano, Tex. (Comment #254), a scholarship soccer player who retired after a series of injuries and has, at 38, endured a dozen surgeries. (Or 13; she lost count.) “While I was playing soccer when I was young I did not think past the goal of winning and being the best. NOTHING prepares you for a life of constant pain or what that really means. When you are young you think you are invincible. Women are made differently than men physically and emotionally — women tend to take on the responsibility for everything themselves and put their health at risk not to let anyone down. Girls look to seek their coaches' and teammates' approval. That can result in putting their body at risk for permanent damage.”

This rings true to me based on my own research over the course of two years, and my understanding of related social-science research: Female athletes deeply bond with team and teammates. They feel a sense of duty and may be less motivated by visions of personal glory. Are they more willing than male athletes put themselves at risk for the sake of team? This would be difficult to measure, but I think it's possible, and I was told that this was the case by athletic trainers and coaches. It is certainly something parents ought to consider when their daughters are injured but insist on playing through the pain. It is a parent's job to be the one who looks 10 or 20 years down the road, because a teenager certainly will not.

Another person who commented on this forum, Sara from California, wrote of her back injury and her “somewhat excessive activity” and offered what I thought was a terrific comment: “'No pain no gain' is a lethal motto to the competitive girl who is willing to play through injuries. Myopic young athletes need to have parents and coaches advise them not to play when they are injured. Little injuries can become long-term health threats when ignored and not cared for. We don't give significant weight to the consequences when we are in the moment and in a competitive environment. Coaches and parents need to listen to their players' injury complaints, and consider them four times as serious as the athlete says.”


Q: The thing we should worry about most with girls is the evidence showing a far higher rate of concussive brain injury, often causing permanent loss of some part of brain function. This a huge problem for all athletes, as many coaches are either unaware or ignore the risk of repetitive brain injury; however, the problem is worse for girls. One solution — better protective gear (helmets for soccer players) and rules changes that prevent behavior that can cause brain injury.

Girls can and should have the opportunity to pursue the fun and passion of competitive sports. We as adults should make sure that today's child/teen doesn't unnecessarily pay for that fun with a lifetime of brain damage or pain. — Doug G, San Francisco (Go to Comment)

A: Concussions are a cause for concern in both male and female athletes, because, like A.C.L. injuries, they can involve serious long-term consequences. And, like A.C.L. injuries, women seem to be more susceptible to them. Female collegiate soccer players suffer concussions at essentially the same rate as male football players, which is notable since football is a far more violent sport. (Yes, there are plenty of collisions in soccer, but multiple collisions occur on every play in football.)

The rates of concussion in women's collegiate ice hockey are so off the charts — twice the rate of football — that one researcher said to me that he believed the sport should be suspended until someone develops a plan on how to lower them. I realize that kind of statement sounds wildly impolitic — shouldn't females have the right to play ice hockey? — but if you were the parent of a girl playing in college, or a younger daughter just getting into the sport, wouldn't you want the issue of concussions squarely addressed and aggressively researched?


Q: A significant difference in officiating has to be partly responsible for the frequency and severity of injury to women in sports. It is especially true in women's basketball where, compared with the men's programs, much more contact is allowed without fouls being called. We know men won't watch if they think the women are playing like “girls.” — OJ, Atlanta (Go to Comment)

A: This is a great comment. I sat courtside at the N.C.A.A. women's Final Four in Boston in 2006 and was appalled at the rough play. Dribblers racing up the court with the basketball were consistently and blatantly pushed from behind with no fouls called. Offensive players working for position under the basket were hacked and shoved in a manner that no N.B.A. referee would permit, even if it were Shaquille O'Neal whom a defender was trying to push out of the way. In 2008, a television commenter working one of the women's Final Four games commented that the overly physical game seemed more like rugby than basketball.

While watching women's collegiate soccer with Holly Silvers, a Santa Monica physical therapist and A.C.L. researcher, she gasped on several occasions after referees failed to call what in her mind were obviously dangerous plays. (Holly knows soccer; she played it herself at a high level, and has worked with the top American women players.)

I don't think lax officiating is a primary cause of injuries in women's sports. But after seeing it time and time again, it did make me wonder if there was some misguided notion out there that in the new world of women's sports, the enforcement of a safe game and the calling of reasonable fouls might be considered by some to be turning the clock back.


Q: I was interested in your comments on the apparent effect of hormones on increased injury in girls. Is there any research (or even theories) on how birth control pills might affect young women who play sports? — kjsp94, San Francisco (Go to Comment)

A: There have been studies on when in a woman's cycle she may be most vulnerable to A.C.L. and other types of injuries — all of it, so far, inconclusive. Obviously, this research sits right smack in the middle of a treacherous intersection, right where science and modern sensibilities intersect. I did not come across any 12-year-olds being encouraged by coaches to take birth-control pills. That, too, would be far out ahead of any research — as well as inappropriate and appalling. But knowing what I do of the youth sports culture, it would not shock me if it in fact occurs.



Q: Why shouldn't women, if it is what they choose, put their sport over their health? Men make millions doing it, yet you are concerned about women doing the same thing? Is it because they can't make money at it? Are you trying to protect the 'weaker' sex? Isn't it a personal choice no matter what the gender issue/vulnerability is?

You confused two very serious issues: a woman's sport injuries and her right to that risk. That's why “We” no longer make those choices for her, Title 9 guarantees that protection. — sinabean1010, San Francisco (Go to Comment)

A: A great many comments like this came in, from both men and women, and to be honest, I don't fully understand them as a response to the article. Yes, injuries are part of every sport. But they are not the point of the sport. Nor should they be a badge of honor.

As for women making their own choices, even unhealthy choices, yes, they have every right. My concern is mainly with children and adolescents who are being overplayed and undertrained and my concern is more with girls because the out-of-control youth-sports culture is taking a greater toll on them — a toll that is still not fully understood.

Several people wondered why I chose to write about girls and injuries rather than boys and football, so I'll address that: It's been well known for a long time that football is a dangerous game. Parents choose to let their kids play, or not. But at least in football, the dangers and physical toll are acknowledged — and no coach or league official would consider having a team of children play five full-length games over the course of three days. But that occurs all the time in girl's soccer, basketball and other high-injury sports.

The point of Title IX was not to have generations of girls grow into adult women who limp around like they played a decade in the N.F.L. In better moments, surgical scars and lifelong pain may seem like a cost worth paying for all the high moments of an athletic youth. But in reality, pain and lack of mobility is devastating — physically and emotionally. I am not positing a binary choice: either play and accept serious injury, or don't play. The third and best option is to redesign training and the sports culture to produce fewer injuries.


Q: There are a variety of programs that have been developed to help reduce the risk of ACL injuries by teaching female athletes how to improve movement flaws. It is unfortunate that the only program mentioned in this article was the PEP program. There are other commercially available programs such as SportsMetrics and more recently the G.O.A.L.S. Training Series. The PEP program was successful in reducing ACL injury risk in younger female soccer players, but has not been as successful with more advanced/older athletes (i.e., college players). In fact despite all of the media and scientific attention this particular injury has received a recently published study in the American Journal of Sports Medicine indicated that ACL injury rates have remained steady for the past 13 years in female college athletes suggesting that the current injury prevention methods are failing for a substantial number of advanced/elite athletic women. This might be a result. — JDV, Canada (Go to Comment)

A: There are many other programs beside PEP, but I highlighted that one because it is easily implemented by any coach who is determined to make injury prevention a priority. Most of the others that I'm aware of are variations on the same theme: enhancing girls' strength, especially in the core, and modifying their movement patterns.

Also, you are absolutely right that A.C.L. injury rates among women in college have not fallen despite the greater awareness over the last decade, but in my estimation the reason for that is that prevention programs are not in wide enough use — not that they've been proven ineffective. Also, it must be pointed out that even in a college program determined to institute A.C.L. and other injury-prevention efforts, they are working with young women who have well-established movement patterns, have likely been overplayed for years and may enter college with pre-existing injuries and/or chronic pain. The most effective time to intervene and truly cut into injury rates is with much younger girls, preferably before they reach their teens.

The words of Sandra Shultz, an athletic trainer and professor at the University of North Carolina in Greensboro, are worth repeating. She said she'd like to be able to tell all young girls: “Before you engage in a sport, I am going to teach you how to move. And I am going to give you strength.”


Q: Follow the money. Why do kids do it? Why do parents allow it or encourage it? It's about college scholarships. My daughter played rec soccer, travel soccer and school ball from age 4. She burned out at 13. Parents badgering coaches about where to showcase their daughter's for the right high school so they can get to the right college. In the last two weeks I Know of a 14 yo who broke her clavicle, an 18 year old who sprained her ankle again and has had so many sprained ankles she lost count. Why? They need to get a college scholarship. — Paul Lakeman, Dover, DE (Go to Comment)

A: Any kid playing primarily for a college scholarship should quit. In most sports, there are a small number of full scholarships available that go to the top sliver of national-level players. Partial scholarships — also exceedingly hard to land — probably won't equal the money that parents have already shelled out for club fees, sports tutoring, sports travel and equipment. The youth-sports industry perpetuates the fantasy of college scholarships. Tournaments, many of them called “college showcases,” fill up hotel rooms and restaurants in host communities. There is every reason to scale down these tournaments — where kids are overplayed and injured — but an economic disincentive to doing so.


Q: Where to start? I'm an orthopedic surgeon and I see this scene played out in my office every day .... After 22 years of practicing orthopedic surgery, I find myself giving a little lecture to more and more patients, young and old, about what the human body is really meant to do. If you consider the human organism, we were hunter gatherers. Females began having babies when they reached puberty and they died young...in childbirth. Believe me I was happy for the right to choose when and if I wanted to have children and for the option to choose my destiny. But we have to remember we might live to be 100 years old and very few of our bodies were meant to make it that long. ACL surgery and total knee replacements can only do so much to relieve our pain and suffering. Taking care of our bodies from the get go helps.

We have also done something else to women which puts them at a distinct disadvantage. At the same time we've encouraged them to be athletic, we've also demanded that they be skinny. Sometimes I see waif-like girls in my office who claim to be major athletes. They have no muscle definition and I would rather see them modeling than going back to soccer. Body aesthetics are still very important to girls and thick muscular bodies in women are not yet the standard desired form. Sometimes during the course of rehabilitation following an ACL reconstruction, I can convince a young woman to “get after it” and get strong. It's interesting to see the transformation. And sometimes they're even apologetic and embarrassed about the weight gain.

I don't have any answers. The P.E.P. program and other programs like it are a good start. I don't see how identifying body types more likely to be injured will be helpful. — Barbara Bergin, Austin, Texas (Go to Comment)

A: Thank you for this vivid view from the trenches. The points you make about body aesthetics and female athletes are vitally important, and they are ones I picked up during my research. I met teenage girls who wanted to be strong on the playing field, but feared that dedication in the weight room would make them look “manly.” A 15-year-old girl involved in elite sports, pushing herself academically and trying to find her niche socially has a lot of mixed messages to sort out and needs the help of every available adult, including a thoughtful doctor if she is lucky enough to have one.

As to what occurs after she is injured and, specifically, if it is an A.C.L. rupture: A surgeon who puts a teenage girl's knee back together is already dealing with a frightened young woman. She's in pain, and bereft at having temporarily lost her sport and perhaps her identity. So the doctor, quite understandably, wants to be as reassuring as possible. He or she says the knee will be as good as new and that after rehabbing the patient will be fine. What he does not often point out is what Dr. Bergin has stated here — that the younger a patient is, the more years of active sports she has in front of her and the more likely she is to suffer this injury again, to the repaired knee or the other one.

This means that doctors, as gently as possible, ought to level with patients and their parents — not to scare them off the field of play, but to scare them into A.C.L.-injury-prevention programs and saner sports schedules.

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