LIFELONG FEMALE FOOTBALL PLAYER HEALTH AND THE IMPORTANCE OF THE ATHLETE VOICE
Written by Jane Thornton, Canada
10-Jul-2023
Category: Sports Medicine

Volume 12 | Targeted Topic - Women's Football | 2023
Volume 12 - Targeted Topic - Women's Football

– Written by Jane Thornton, Canada

 

INTRODUCTION

Women’s football participation is on the rise around the world, and encouragingly, so is research into female athlete health. Astonishingly, this is a relatively recent change, and much of the available evidence is still in its infancy. A key priority of the FIFA Medical Commission is to “protect and improve the health of all who play football, from grassroots to elite level worldwide”. Women have specific health considerations which can shape injury and illness experience, prevention, and treatment. For example, female football players are at higher risk of anterior cruciate ligament (ACL) injury and early knee osteoarthritis (OA) than their male counterparts1,2. Risks of concussion are also higher, potentially increasing the likelihood of adverse cognitive and neuropsychological outcomes3.  Recently, attention has been paid to the female athlete sport environment as well, which affects both sport exposure and health outcomes4. Clearly, there is more work to be done and new opportunities to explore.

To tackle the gap in injury prevention research for female football players, we can turn to the well-established theoretical framework outlined by van Mechelen5. Injury prevention begins with establishing the extent of the injury problem (step 1), establishing the etiology and mechanism of injury (step 2), introducing preventative measures (step 3) and assessing the effectiveness of repeating step 1 (step 4). Integrating the athlete voice and context into this model6 is key to guiding more context-sensitive studies and providing new insights.

When we engage the voices of those most impacted by healthcare, research, policy development and implementation, new insights emerge. Athletes’ perspectives are critical as they bring ‘lived expertise’ that complements the scientific and medical expertise of others on the team7. This aim of this article is to provide an overview of female football player health across the lifespan and emphasize the importance and contribution of the athlete voice in bridging the data gap.

 

FEMALE ATHLETE HEALTH ACROSS THE LIFESPAN

Female athlete injury rates and health outcomes are influenced by biological and sociocultural processes. Circulating endogenous and exogenous concentrations of ovarian hormones influence most systems in the body including metabolism, respiration, the immune response, cognitive, gastrointestinal, and cardiovascular health, autonomic regulation, and genitourinary function8. A recent supplement to the International Olympic Committee consensus statement on methods for recording and reporting epidemiological data on injury and illness in sport identified 10 domains of female health for categorising health problems according to biological, life stage or environmental factors that affect female athletes: menstrual and gynaecological health; preconception and assisted reproduction; pregnancy and perinatal; postpartum; menopause; breast health; pelvic floor health; breastfeeding, parenting and caregiving; mental health; and sport environments9 (Moore et al.) . While football-specific research is lacking in many of these areas, new insights are emerging in a few key areas that will be highlighted in this paper – namely, musculoskeletal, reproductive, cardiovascular, cognitive, and mental health.

 

MUSCULOSKELETAL HEALTH

Severe injury is one of the main reasons for an athlete to retire (23-30% of players)10,11. Female football players have 1.5 times greater injury risk compared to males12, and at least twice the anterior cruciate ligament (ACL) injury risk1. The main risk for early onset (or post-traumatic) knee osteoarthritis (OA) is previous sport-related knee injury13-18. In studies involving male football players (or where gender was not reported), there is a high prevalence of OA in the hip, knee and/or ankle19,20. Half of retired female football players will develop knee OA by age 5021, and earlier in those who have sustained a knee injury22.

The reasons behind these injury rates are multifactorial and include disparities in access to and experiences with sport and training4. One example is resistance training: although an important component of prevention and rehabilitation, girls and women participate at a much lower rate than boys and men23 due to concerns of becoming too ‘bulky’ and muscular, even with an understanding that it may be performance-enhancing. Female athletes may have different treatment success rates as well: one study demonstrated that women have greater knee laxity, lower patient reported knee function, less chance of returning to sport, and a more frequent need for revision surgery after ACL reconstruction compared to their male colleagues24. These factors necessitate further investigation into improved prevention and treatment strategies.

 

REPRODUCTIVE HEALTH

Menstrual cycle and performance

Ovarian hormone profiles influence health and performance across the life span8. Athletes are generally able to excel during all phases of their menstrual cycles but there may be subtle changes that occur and/or individual variability. A recent systematic review and meta-analysis indicated that exercise performance might be trivially reduced during the early follicular phase of the menstrual cycle, compared to all other phases25. Authors maintain that as a result of the trivial changes, general guidelines on exercise performance across the menstrual cannot yet be formed.  When performance is a priority, an individualised approach might be appropriate.

 

Alterations in menstrual cycle

Menstrual cycles can be altered intentionally (e.g., via exogenous hormones) or secondary to other causes (through low energy availability, other health conditions, or life stage transitions such as pregnancy or menopause). The most comprehensive systematic review to date on hormonal contraception and performance concluded that oral contraceptive pills might minimally decrease athletic performance, however, evidence was not strong enough to draw practical conclusions for the female athlete population26. If there is a secondary disturbance in menstrual function, the causes may be multifactorial. Among Olympic competitors, polycystic ovarian syndrome (PCOS) is the most frequent underlying cause of menstrual dysfunction (due to high circulating androgens)27. Menorrhagia, or heavy menstrual bleeding, is also relatively common28, where optimizing pain relief and identifying sequelae such as iron deficiency are important to ensure physical performance is not compromised.
Athletes have higher rates of oligo- and amenorrhea than the general population as well. Functional hypothalamic amenorrhea is a diagnosis of exclusion and may be linked to Relative Energy Deficiency in Sport (RED-S), a consequence of low energy availability that can impact both male and female athletes’ physical and psychological health long-term29,30. Athletes with RED-S can suffer disruptions in cardiovascular, gastrointestinal, musculoskeletal, haematological, metabolic, endocrine, immunological, and psychological function31. In female athletes this may result in menstrual dysfunction, with unknown impacts on long-term fertility. Independent of menstrual dysfunction, low energy availability can negatively and irreversibly affect bone mass accrual, leading to premature osteopenia and osteoporosis32.

An estimated 70% of elite athletes suffer with >1 symptom of RED-S33. A recent study in Polish female football players documented low energy availability in 20 of 31 players34, and 24% of Norwegian elite female football players surveyed met diagnostic criteria for eating disorders39. Importantly, RED-S can go unrecognised, and many athletes do not receive appropriate education or treatment. We do not know if experiencing RED-S increases injury risk, or the effects on BMD, fertility, and mental health long-term.

 

Pregnancy and Postpartum

Elite female athletes are now becoming pregnant more often during their sporting careers.  Two recent reviews35,36 suggest that women who do so have healthy pregnancies and babies, but many wait to have children until after they have retired from elite sport.  To date, there is no empirical evidence examining the impact of elite sport participation on (in)fertility, pregnancy and postpartum outcomes, postpartum return to sport (RTS) rates, or age at menopause37. The long-term impact of RED-S on reproductive health in elite athletes is unknown. This lack of knowledge makes it difficult for athletes to make informed decisions about their reproductive health and for healthcare providers to provide meaningful advice. 

In general, elite athletes return to physical activity early in the postpartum period and may have an increased risk of injury. Urinary incontinence is also common symptom after childbirth and can impact activity levels. Return to sport and/or activity models have been proposed38,39 which generally include advice on graduated return to running after the first 6-12 weeks with sport-specific training to follow. A systematic review involving postpartum elite athletes detected no decreases in postpartum performance in elite athletes, and improved performance in some cases40.

 

CARDIOVASCULAR (CV) HEALTH

Football confers wide-ranging benefits for cardiovascular health. Elite female football players have a superior cardiovascular health profile compared to untrained controls41. Recreational football training in women aged 18-65 years provides optimal stimuli for cardiovascular, metabolic, and musculoskeletal fitness42.

The relationship between the intense training and competition of elite sports like football and the long-term consequences on CV health, however, is not well established. Male endurance athletes have higher rates of atrial fibrillation (AF), arrhythmias and other cardiac findings17,43. In contrast, one study examining sex differences in AF rates in cross-country skiers demonstrated that female skiers had lower incidence of AF and stroke than the general population43. A recent meta-analysis on the long-term health of over 165,000 elite athletes (84.4% male) concluded there is insufficient data available to delineate cancer and cardiovascular mortality outcomes in elite female athletes44. The impact of intense football training on the female athlete heart is currently unknown.

 

COGNITIVE HEALTH

Female athletes are more susceptible to concussion and report more symptoms when they are concussed than male athletes45,46,47. Female football players outperform the general population in cognitive testing48,49, yet retired players with a history of multiple concussions and frequent heading have lower verbal memory and fluency performance than age-matched controls3. Current RTS guidelines may not adequately consider sex and gender differences50. Women may also be at higher risk of neurocognitive disease than men51. Further studies are required to assess short and long-term risks of concussion and evaluate the need for specific RTS guidelines.

 

MENTAL HEALTH

The prevalence and associations of depression and anxiety in female players is largely unknown22,52, but one study reported a similar prevalence to the age- and sex-matched general population53. The prevalence of depressive symptoms is influenced by personal and sport-specific variables. Mental health may be influenced by playing position, level of play, and experience of conflict22. Half of the players attributed ‘conflicts with coach/management’ as an important reason for their low moods, followed by ‘low in performance/injury’ and ‘too little support/acknowledgement by the coach’. In line with experiences of people who have lived in conflict, abuse and harassment and poor mental health are inextricably linked53-55. When former international level female rowers and rugby players were asked about harassment and abuse in their sports, 79% recalled witnessing or experiencing at least one form during their career. We do not yet have similar data on female football players. Eating disorders56 and addictions are common in elite sport, yet little is known about the long-term rates and their effects. Transition out of sport may be accompanied by a profound loss of identity and self-efficacy; when it comes to mental health, a career/lifespan approach should be adopted so that players can thrive.

 

THE ATHLETE VOICE

Through the voices of the female athletes themselves we can appreciate how best to prioritize injury and illness prevention research and optimize health and performance. It is important to incorporate athlete context into injury and health assessments as it affects all aspects of an athlete’s career as well as prevention and treatment outcomes.

Athletes report that their environments make a large impact on their health, particularly the amount of support they are likely to receive. Qualitative work conducted with male and female rowers showed that their lived experience of low back pain was influenced by a pervasive culture of secrecy around symptoms as they didn’t want to be viewed as a “weakness”57. In environments where openness was encouraged by support staff, rowers reported better outcomes.

Female athletes can provide insights into essential types of support across the athlete lifespan. For athlete mothers, they report needing more support for breastfeeding, parenting and caregiving. They highlight the many significant decisions athletes must make as they navigate pregnancy alongside elite sport participation, including lack of time, training “new” bodies, injuries and a safe RTS, breastfeeding while training and navigating motherhood and sport58. Athlete-mothers can also provide clear recommendations for policy and research to better support following generations59.

This is also the case regarding transition out of elite sport. Athletes provide learned expertise for injury prevention even after their careers are over36 and context as to how they reframe their injury experiences. In one survey of retired female rowers and rugby players, most rated their current health as above average or excellent and would compete at the same level again if given the choice36.

Given the complex nature of sports injuries and illnesses, additional qualitative research methodologies are recommended to gain insight into the ‘ecological system’ of the athlete and a more comprehensive understanding of the many aspects of health5. This has yet to be investigated in many of the key areas listed above.

 

FUTURE RESEARCH

The field of women’s health and sport and exercise medicine is ripe with opportunity. In MSK health, key research gaps include the impact of elite football participation on long term outcomes including OA, and improved ACL prevention and treatment strategies. The association between elite football participation, concussion history and cognitive function is a critical area to study. Furthermore, key research gaps in mental health for female athletes include the impact of football participation on mental health outcomes, the prevalence of eating disorders and addictions, and mediators of these relationships (e.g., physical activity, experiences of abuse and harassment, relationship with coaches/teammates/support staff).  The prevalence of cardiac conditions such as atrial fibrillation, cardiomyopathies, and heart disease warrants further attention. Finally, key research gaps in reproductive health for female athletes include the effect of elite football participation on the prevalence of RED-S, and the long-term effects of RED-S on fertility rates and bone health.

 

CONCLUSION

We should do our best to protect the health of our female athletes and bridge the female athlete data gap. Our female athletes of today deserve our attention, our scientific rigor, data, support to achieve their goals. There is so much powerful physiology to study, so many strengths of the female athlete and no more time to waste. By improving the quality and quantity of female football player health data, we can better focus our preventative efforts, so that more current, former, and future female football players can more fully experience the positive outcomes associated with sport and make football a lifelong joy.

 

Jane Thornton M.D., Ph.D.

Olympian (Rowing)

 

Clinician Scientist | Schulich School of Medicine & Dentistry

 

Sport Medicine Physician | Fowler Kennedy Sport Medicine Clinic

 

Western University | London, Ontario CANADA

 

Contact: jane.s.thornton@gmail.com

 

References

1.Montalvo AM, Schneider DK, Silva PL, et al. 'What's my risk of sustaining an ACL injury while playing football (soccer)?' A systematic review with meta-analysis. Br J Sports Med. 2019;53(21):1333-1340. doi:10.1136/bjsports-2016-097261

2.Prien A, Junge A, Brugger P, et al. Neurocognitive Performance of 425 Top-Level Football Players: Sport-specific Norm Values and Implications. Arch Clin Neuropsychol. 2019;34(4):575-584. doi:10.1093/arclin/acy056

3.Prien, A. The Other Side of the Medal: Health Issues In Retired Elite Female Football Players and Cues for Prevention. Chapter 6. Vrije Universiteit Amsterdam, the Netherlands, 2020.

4.Parsons JL, Coen SE, Bekker S. Anterior cruciate ligament injury: towards a gendered environmental approachBritish Journal of Sports Medicine 2021;55:984-990.

5.van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med. 1992;14(2):82-99. doi:10.2165/00007256-199214020-00002

6.Bolling C, van Mechelen W, Pasman HR, et al. Context Matters: Revisiting the First Step of the 'Sequence of Prevention' of Sports Injuries. Sports Med. 2018;48(10):2227-2234. doi:10.1007/s40279-018-0953-x

7.Thornton JS, Richards D. Learning from ‘lived expertise’: engaging athletes and patients in sport and exercise medicine research and policyBritish Journal of Sports Medicine 2023;57:189-190.

8.Elliott-Sale KJ, Minahan CL, de Jonge XAKJ, Ackerman KE, Sipilä S, Constantini NW, Lebrun CM, Hackney AC. Methodological Considerations for Studies in Sport and Exercise Science with Women as Participants: A Working Guide for Standards of Practice for Research on Women. Sports Med. 2021 May;51(5):843-861. doi: 10.1007/s40279-021-01435-8. Epub 2021 Mar 16. PMID: 33725341; PMCID: PMC8053180.

9.Moore et al. under review

10.Grygorowicz M, Michalowska M, Jurga P, et al. Thirty Percent of Female Footballers Terminate Their Careers Due to Injury: A Retrospective Study Among Polish Former Players. J Sport Rehabil 2019;28(2):109-14.

11.Prinz B, Dvorak J, Junge A. Symptoms and risk factors of depression during and after the football career of elite female players. BMJ Open Sport Exerc Med 2016;2(1):e000124

12.Brophy RH, Schmitz L, Wright RW, et al. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med 2012;40(11):2517-22.

13.Roos EM. Joint injury causes knee osteoarthritis in young adults. Curr Opin Rheumatol 2005;17:195–200.

14.Gouttebarge V, Inklaar H, Backx F, et al. Prevalence of osteoarthritis in former elite athletes: a systematic overview of the recent literature. Rheumatol Int 2015;35:405–418

15.Iosifidis MI, Tsarouhas A, Fylaktou A. Lower limb clinical and radiographic osteoarthritis in former elite male athletes. Knee Surg Sports Traumatol Arthrosc 2015;23:2528–2535.

16.Fernandes GS, Parekh SM, Moses J, et al. Prevalence of knee pain, radiographic osteoarthritis and arthroplasty in retired professional footballers compared with men in the general population: a cross-sectional study. Br J Sports Med. 2018;52(10):678-83.

17.Driban JB, Hootman JM, Sitler MR, et al.  Is participation in certain sports associated with knee osteoarthritis? a systematic review. J Athl Train 2017;52:497–506.

18.Melekoğlu T, Sezgin E, Işın A, et al. The Effects of a Physically Active Lifestyle on the Health of Former Professional Football Players. Sports (Basel). 2019;7(4):75. Published 2019 Mar 28. doi:10.3390/sports7040075

19.Kuijt MT, Inklaar H, Gouttebarge V, et al. Knee and ankle osteoarthritis in former elite soccer players: a systematic review of the recent literature. J Sci Med Sport 2012;15(6):480-7.

20.Gouttebarge V, Inklaar H, Backx F, et al.  Prevalence of osteoarthritis in former elite athletes: a systematic overview of the recent literature. Rheumatol Int 2015;35:405–418

21.Prien A, Boudabous S, Junge A, et al. Every second retired elite female football player has MRI evidence of knee osteoarthritis before age 50 years: a cross-sectional study of clinical and MRI outcomes. Knee Surg Sports Traumatol Arthrosc. 2020;28(2):353-362. doi:10.1007/s00167-019-05560-w

22.Lohmander LS, Ostenberg A, Englund M, et al. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players 12 years after anterior cruciate ligament injury. Arthritis Rheum 2004;50:3145–3152.

23.Bennie JA , De Cocker K , Teychenne MJ , et al . The epidemiology of aerobic physical activity and muscle-strengthening activity guideline adherence among 383,928 U.S. adults. Int J Behav Nutr Phys Act 2019;16:34.doi:10.1186/s12966-019-0797-2 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30999896

24.Tan SHS , Lau BPH , Khin LW , et al . The importance of patient sex in the outcomes of anterior cruciate ligament reconstructions: a systematic review and meta-analysis. Am J Sports Med 2016;44:242–54.doi:10.1177/0363546515573008 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25802119

25.McNulty KL, Elliott-Sale KJ, Dolan E, Swinton PA, Ansdell P, Goodall S, Thomas K, Hicks KM. The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis. Sports Med. 2020 Oct;50(10):1813-1827. doi: 10.1007/s40279-020-01319-3. PMID: 32661839; PMCID: PMC7497427.

26.Elliott-Sale KJ, McNulty KL, Ansdell P, Goodall S, Hicks KM, Thomas K, Swinton PA, Dolan E. The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis. Sports Med. 2020 Oct;50(10):1785-1812. doi: 10.1007/s40279-020-01317-5. PMID: 32666247; PMCID: PMC7497464.

27.Hirschberg AL. Female hyperandrogenism and elite sport. Endocr Connect. 2020 Apr;9(4):R81-R92. doi: 10.1530/EC-19-0537. PMID: 32197237; PMCID: PMC7159262.

28.Bruinvels G, Burden R, Brown N, Richards T, Pedlar C. The Prevalence and Impact of Heavy Menstrual Bleeding (Menorrhagia) in Elite and Non-Elite Athletes. PLoS One. 2016 Feb 22;11(2):e0149881. doi: 10.1371/journal.pone.0149881. PMID: 26901873; PMCID: PMC4763330.

29.Ackerman KE, Holtzman B, Cooper KM, et al. Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport. Br J Sports Med. 2019;53(10):628-633. doi:10.1136/bjsports-2017-098958

30.Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48(7):491-497. doi:10.1136/bjsports-2014-093502

31.Mountjoy M, Sundgot-Borgen J, Burke L, et al. IOC consensus statement on relative energy deficiency in sport (RED-S) update. Br J Sports Med 2018; 52(11):687-97.

32.Thein-Nissenbaum J. Long term consequences of the female athlete triad. Maturitas. 2013;75(2):107-112. doi:10.1016/j.maturitas.2013.02.010

33.VanBaak K, Olson D. The Female Athlete Triad. Curr Sports Med Rep 2016;15(1):7-8

34.Dobrowolski H, Włodarek D. Low energy availability in group of Polish female soccer players. Roczniki Państwowego Zakładu Higieny 2020;71(1), 89–96. https://doi.org/10.32394/rpzh.2020.0106

35.Wowdzia J, McHugh T, Thornton J, et al. Elite Athletes and Pregnancy Outcomes: A Systematic Review and Meta-Analysis. [published online ahead of print, 2020 Sep 11]. Med Sci Sports Exerc. 2020;10.1249/MSS.0000000000002510

36.Thornton, J., Rosen, C., Davenport, M., Mountjoy, M. L., Dorian, P., Gouttebarge, V., Breau, B., Pila, E., Reilly, K., Yuan, J., Mok, K., Di Ciacca, S., Speechley, M., & Crossley, K. (2023). Beyond the medals: A cross-sectional study exploring retired elite female athletes’ health. BMJ Open Sport & Exercise Medicine, 9(1), e001479. https://doi.org/10.1136/bmjsem-2022-001479

37.Bø K, Artal R, Barakat R, et al. Exercise and pregnancy in recreational and elite athletes: 2016/2017 evidence summary from the IOC expert group meeting, Lausanne. Part 5. Recommendations for health professionals and active women. Br J Sports Med. 2018;52(17):1080-1085. doi:10.1136/bjsports-2018-099351

38.Deering, R. E., Christopher, S. M., & Heiderscheit, B. C. (2020). From Childbirth to the Starting Blocks: Are We Providing the Best Care to Our Postpartum Athletes? Journal of Orthopaedic & Sports Physical Therapy, 50(6), 281–284. https://doi.org/10.2519/jospt.2020.0607

39.Donnelly, G. M., Moore, I. S., Brockwell, E., Rankin, A., & Cooke, R. (2022). Reframing return-to-sport postpartum: The 6 Rs framework. British Journal of Sports Medicine, 56(5), 244–245. https://doi.org/10.1136/bjsports-2021-104877

40.Kimber, M. L., Meyer, S., Mchugh, T.-L., Thornton, J., Khurana, R., Sivak, A., & Davenport, M. H. (2021). Health Outcomes after Pregnancy in Elite Athletes: A Systematic Review and Meta-analysis. Medicine & Science in Sports & Exercise, 53(8), 1739–1747. https://doi.org/10.1249/MSS.0000000000002617

41.Randers MB, Andersen LJ, Orntoft C, Bendiksen M, Johansen L, Horton J, Hansen PR, Krustrup P. Cardiovascular health profile of elite female football players compared to untrained controls before and after short-term football training. J Sports Sci. 2013;31(13):1421-31. doi: 10.1080/02640414.2013.792950. Epub 2013 Jul 8. PMID: 23829646.

42.Krustrup P, Helge EW, Hansen PR, Aagaard P, Hagman M, Randers MB, de Sousa M, Mohr M. Effects of recreational football on women's fitness and health: adaptations and mechanisms. Eur J Appl Physiol. 2018 Jan;118(1):11-32. doi: 10.1007/s00421-017-3733-7. Epub 2017 Nov 21. PMID: 29164325.

43.Elliott AD, Linz D, Verdicchio CV, et al. Exercise and Atrial Fibrillation: Prevention or Causation? Heart Lung Circ. 2018;27(9):1078-1085. doi:10.1016/j.hlc.2018.04.296

44.Runacres A, Mackintosh KA, McNarry MA. Health Consequences of an Elite Sporting Career: Long-Term Detriment or Long-Term Gain? A Meta-Analysis of 165,000 Former Athletes. Sports Med. 2021 Feb;51(2):289-301. doi: 10.1007/s40279-020-01379-5. Epub 2020 Dec 24. PMID: 33368029; PMCID: PMC7846545.

45.Mollayeva T, El-Khechen-Richandi G, Colantonio A. Sex & gender considerations in concussion research. Concussion 2018;3(1):CNC51.

46.Gupte R, Brooks WM, Vukas RR, et al. Sex differences in traumatic brain injury: What we know and what we should know. J Neurotrauma Published Online First: 2019 Jul 19. doi: 10.1089/neu.2018.6171.

47.Merritt VC, Padgett CR, Jak AJ. A systematic review of sex differences in concussion outcome: What do we know? Clin Neuropsychol 2019;33(6):1016-43.

48.Prien A, Junge A, Brugger P et al. Neurocognitive Performance of 425 Top-Level Football Players: Sport-specific Norm Values and Implications. Arch Clin Neuropsychol. 2019 Jun 1;34(4):575-584. doi: 10.1093/arclin/acy056. PMID: 30165564.

49.Prien A, Besuden C, Junge A, et al. Cognitive Ageing in Top-Level Female Soccer Players Compared to a Normative Sample from the General Population: A Cross-sectional Study. J Int Neuropsychol Soc. 2020;26(7):645-653. doi:10.1017/S1355617720000119

50.Bretzin AC, Covassin T, Wiebe DJ, et al. Association of sex with adolescent soccer concussion incidence and characteristics. JAMA Netw Open 2021; 4:e218191.doi:10.1001/jamanetworkopen.2021.8191pmid:http://www.ncbi.nlm.nih.gov/pubmed/33904911

51.Scheyer O, Rahman A, Hristov H, et al. Female sex and Alzheimer's risk: the menopause connection. J Prev Alzheimers Dis 2018;5:225–30.doi:10.14283/jpad.2018.34pmid:http://www.ncbi.nlm.nih.gov/pubmed/30298180

52.Junge A, Prinz B. Depression and anxiety symptoms in 17 teams of female football players including 10 German first league teams. Br J Sports Med. 2019;53(8):471-477. doi:10.1136/bjsports-2017-098033

53.Vertommen T, Schipper-van Veldhoven N, Wouters K, et al. Interpersonal violence against children in sport in the Netherlands and Belgium. Child Abuse Negl. 2016;51:223-236. doi:10.1016/j.chiabu.2015.10.006

54.Timpka T, Janson S, Jacobsson J, et al. Lifetime history of sexual and physical abuse among competitive athletics (track and field) athletes: cross sectional study of associations with sports and non-sports injury. Br J Sports Med. 2019;53(22):1412-1417. doi:10.1136/bjsports-2018-099335

55.Timpka T, Spreco A, Dahlstrom O, et al. Suicidal thoughts (ideation) among elite athletics (track and field) athletes: associations with sports participation, psychological resourcefulness and having been a victim of sexual and/or physical abuse [published online ahead of print, 2020 Feb 26]. Br J Sports Med. 2020;bjsports-2019-101386. doi:10.1136/bjsports-2019-101386

56.Sundgot-Borgen J, Torstveit M. The female football player, disordered eating, menstrual function and bone health. Br J Sports Med 2007;41(suppl 1), i68–i72. https://doi.org/10.1136/bjsm.2007.038018

57.Wilson F, Ng L, O'Sullivan K, et al. 'You’re the best liar in the world’: a grounded theory study of rowing athletes’ experience of low back painBritish Journal of Sports Medicine 2021;55:327-335.

58.Davenport MH, Nesdoly A, Ray L, et alPushing for change: a qualitative study of the experiences of elite athletes during pregnancyBritish Journal of Sports Medicine 2022;56:452-457.

59.Davenport MH, Ray L, Nesdoly A, Thornton J, Khurana R, McHugh TF. We're not Superhuman, We're Human: A Qualitative Description of Elite Athletes' Experiences of Return to Sport After Childbirth. Sports Med. 2023 Jan;53(1):269-279. doi: 10.1007/s40279-022-01730-y. Epub 2022 Jul 28. PMID: 35900698; PMCID: PMC9331002.

 

Header image by Games Boyes (Cropped)


Share

Volume 12 | Targeted Topic - Women's Football | 2023
Volume 12 - Targeted Topic - Women's Football

More from Aspetar Journal

Sport and Society
PUSHING FOR A CHANGE IN WOMEN’S SOCCER

Written by – José M. Oliva-Lozano, Celeste Dix, Rick Cost, Frank Wijbenga, George Chiampas, USA

Interview
JILL ELLIS

Interview by – Monique Fischer, Switzerland

Editorial
FROM OUR EDITOR

Written by – Dr. Omar AlSeyrafi.

Latest Issue

Download Volume 13 - Targeted Topic - Sports Medicine in Athletics | 2024

Trending

Editorial
FROM OUR EDITOR
Editorial
FROM OUR GUEST EDITORS
Interview
WAYDE VAN NIEKERK
Sports Medicine
MANAGEMENT OF HAMSTRING AND RECTUS FEMORIS TENDON INJURY IN ELITE TRACK AND FIELD ATHLETES
Sports Medicine
MANAGING RECTUS FEMORIS INJURIES IN ELITE TRACK AND FIELD

Categories

Member of
Organization members