August 2018

Gender, socioeconomics, specialization, and sports injury risk   

AAOS, AOSSM give back-to-school recs

By Hank Black

It’s back to school time, and orthopedic and sports medicine experts say some of the latest research at the intersection of sports and pediatric health could help practitioners minimize the risk of injury for their patients.

Experts from the American Academy of Orthopedic Surgeons (AAOS) and American Orthopedic Society for Sports Medicine (AOSSM), along with principal investigators of recent studies, highlighted the latest findings on the effect of gender, socioeconomic factors, and sports specialization on injury prevention and management of schoolchildren during a July 24 webcast, “Fall Forecast: Settling the Youth Sports Safety Score.”

They also presented recommendations from their OneSport Injury youth sports specialization campaign, initiated in spring 2018 to spread education about the dangers of early sports specialization.

The emphasis on injury prevention is important, investigators said, because some 60 million children aged 6 to 18 years participate in some form of organized athletics in the US.


Especially among youths, males and females have different risk factors for sports-related injuries, according to a review article.

Lead author Cordelia W. Carter, MD, director of NYU-Langone’s Health Women’s Sports Center and its Pediatric Sports Medicine Program at Hassenfeld Children’s Hospital in New York City, said gender-based variations in injury risk may be related to different anatomic and physiological characteristics of skeletal structure, muscle mass, ligament flexibility, and hormone levels.

“Understanding the sex-based differences can help orthopedic surgeons be better equipped to care for patients with these injuries and improve their treatment outcomes,” Carter said.

The review article noted:

  • Females’ relative energy deficiency compared with males produces a higher risk of stress fracture.
  • More than one third of girls do not take in sufficient nutrition to power their participation in high school sports, a factor that may be associated with menstrual dysfunction and bone stress injuries.
  • Females have a 2 to 8 times higher risk of anterior cruciate ligament injury than males in similar sports, and females are not as likely to return to participation in sports following such an injury.
  • Females have a higher incidence of concussion in soccer, basketball, and lacrosse.
Girls’ relative energy de ciency compared with boys creates a higher risk of stress fracture.

Socioeconomics and specialization

How does socioeconomic status (SES) play into specialization and injury risk? Neeru Jayanthi, MD, associate professor of orthopedics and family medicine at Emory University School of Medicine in Atlanta, recruited almost 1200 individuals aged 7 to 18 years for what he said was the first study of its kind.

The research group found athletes from higher-income families reported more serious overuse injuries than low SES families, potentially because higher SES athletes were more than twice as likely to greatly emphasize participation in a single sport.

Jayanthi said higher SES athletes also spent more time every week in organized sports with fewer chances to engage in free play. They also spent more time in individual sports, such as tennis and dance, as opposed to team sports. Jayanthi also is director of the Emory Sports Medicine Research and Education Program and its Tennis Medicine Program.

“We think it possible that injury risk happens not just from how much you play but rather how you spend that time—unorganized free play may potentially be protective of overuse injury,” he said. “We believe that this allows an environment where the child can be self-directed.”

OneSport Injury campaign

The AAOS and AOSSM OneSport Injury educational and awareness campaign presented during the webcast is designed to help “young athletes get the proper rest and recovery they need to participate in sports, reap the benefits of varied activities, and stay in the game for life,” said AAOS board member Elizabeth Matzkin, MD, chief of Women’s Sports Medicine and director of the Sports Medicine fellowship at Brigham and Women’s Hospital, and associate professor of orthopedic surgery at Harvard Medical School, both in Boston.

She noted that more than half of all sports injuries in middle and high school result from overuse. “Although we can treat most youth injuries, they can have consequences later in life, so it is vital to reduce or prevent incidence now and avoid the onset of chronic conditions,” she said.

Charles Bush-Joseph, MD, AOSSM past president, said more children younger than 12 years are playing a single sport and training year-round. “Children who do specialize are often more likely to develop overuse injures because of their repetitive movements, are stressed, and may even consider quitting a sport and losing the benefits,” said Bush-Joseph, professor of orthopedics at Rush University Medical Center and associate director of the Rush Orthopedic Sports Medicine Fellowship Program.

The webcast emphasized the following statistics on specialization, defined as intense year-round activity with more than eight months of training in a single sport at the exclusion of others:

  • Focusing on a primary sport is an independent risk factor for injury even when adjusted for age and weekly hours in total sports activity.
  • Emergency room data from 1990
    to 2014 showed children aged 12 to 17 years accumulated more than 70% of soccer injuries incurred annually and were more than 300% more likely to be injured than younger players.
  • Pitching more than 100 innings a year in youth baseball produced a significant increase in injury risk and loss of competition time among players aged 9 to 14 years.

Hank Black is a freelance medical writer in Birmingham, Alabama.


American Academy of Orthopedic Surgeons, American Orthopedic Society for Sports Medicine. Fall Forecast: Settling the Youth Sports Safety Score.
sportinjury-press-release/. Published July 24, 2018. Accessed September 18, 2018.

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