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Women Are at Higher Risk for Concussions Due to Ball or Equipment Contact in Soccer and Lacrosse

Ling, Daphne I. PhD; Cheng, Jennifer PhD; Santiago, Kristen BA; Ammerman, Brittany BA; Jivanelli, Bridget MLIS; Hannafin, Jo MD; Casey, Ellen MD

Clinical Orthopaedics and Related Research: October 17, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/CORR.0000000000000995
Diversity and Disparities in Orthopaedic Surgery: PDF Only

Background There is ample evidence to suggest sex- and gender-based differences in the incidence of sports-related concussions. The mechanisms of concussion may vary between male and female athletes and contribute to this observed difference. Understanding the underlying etiology by pooling data from primary studies across different settings and sport types will inform interventions that can reduce concussion rates.

Questions/purposes Specifically, we asked: (1) In which sports are female athletes less likely to experience concussions from player contact? (2) In which sports are female athletes more likely to experience concussions because of ball or equipment contact?

Methods PubMed, EMBASE, and Cochrane Library databases were searched to identify articles published from January 2000 to December 2018. Ten studies met the inclusion criteria, which were studies that reported concussion incidence by mechanism for both male and female athletes. Exclusion criteria included non-English studies, conference abstracts, and studies on non-sports related concussions. The sports represented by the 10 studies included ice hockey (n = 4), soccer (n = 5), basketball (n = 4), baseball/softball (n = 4), and lacrosse (n = 5). The rate ratio was calculated as the incidence rate in female athletes/male athletes for each concussion mechanism or activity. Data were pooled using the DerSimonian-Laird random-effects model. Study quality was assessed with the Newcastle-Ottawa Scale.

Results Female athletes were at lower risk of player-contact-induced concussions in lacrosse (pooled rate ratio 0.33 [95% CI 0.25 to 0.43]; p < 0.001), basketball (pooled rate ratio 0.86 [95% CI 0.76 to 0.97]; p = 0.01), ice hockey (pooled rate ratio 0.64 [95% CI 0.56 to 0.73]; p < 0.001), soccer (pooled rate ratio 0.70 [95% CI 0.66 to 0.75]; p < 0.001), and soccer heading (pooled rate ratio 0.80 [95% CI 0.72 to 0.90]; p < 0.001); in these sports, men were at higher risk of concussions from player contact. Female athletes were more likely to experience concussions because of ball or equipment contact in lacrosse (pooled rate ratio 3.24 [95% CI 2.10 to 4.99]; p < 0.001), soccer (pooled rate ratio 2.04 [95% CI 1.67 to 2.49]; p < 0.001), and soccer heading (pooled rate ratio 2.63 [95% CI 1.84 to 3.77]; p < 0.001).

Conclusions The mechanism or activity underlying concussions differs between male and female athletes across different sports. This finding remains the same regardless of whether there are rule differences between the men’s and women’s games. The implementation of other interventions are required to further ensure player safety, including protective head equipment, concussion prevention training, or rules limiting player contact in the men’s game.

Level of Evidence Level III, retrospective study.

D. I. Ling, J. Hannafin, Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA

D. I. Ling, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA

J. Chang, K. Santiago, B. Ammerman, E. Casey, Physiatry Service, Hospital for Special Surgery, New York, NY, USA

B. Jivanelli, Kim Barrett Memorial Library, Hospital for Special Surgery, New York, NY, USA

D. I. Ling, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA, Email:

Each author certifies that neither she, nor any member of her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that her institution waived approval for the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at the Hospital for Special Surgery, New York, NY, USA.

Received June 04, 2019

Accepted September 20, 2019

© 2019 Lippincott Williams & Wilkins LWW
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