Female athletes at higher risk of concussion than males

Thursday, May 2, 2013 | 6:00 a.m. CDT; updated 11:06 a.m. CDT, Friday, May 3, 2013
After suffering four concussions, former Missouri women's soccer player Jessica Gwin decided to quit playing the sport. This portrait, taken March 11, was made using a technique where a flash was fired multiple times during a single exposure.

COLUMBIA — Former Missouri soccer player Jessica Gwin often wonders whether the trouble she has remembering things is a result of being in tougher classes or from the concussions she suffered playing soccer.

“It’s a hard line to draw, whether my classes were getting harder or if there really were effects,” Gwin said. “Sometimes I think there are days when I could remember things like this — memorizing and such.”

ACL tears, eating disorders and the 'Triad'

Female athletes are four to eight times more prone to ACL (anterior cruciate ligament) tears than male athletes. They're also more likely than nonathletes and most male athletes to be calorie deficient and to have an eating disorder, which can lead to a condition termed Female Athlete Triad by the American College of Sports Medicine. The term was coined in the 1990s and describes the interplay between energy availability, menstrual function and bone health.

The condition starts when the female athlete doesn’t eat enough, and the low caloric intake results in irregularities in her menstrual cycle. The short-term effects are just as harmful as the long-term effects. There’s an increased risk of stress fracture, poorer performance and a diminished ability to recover from workouts and competition. The long-term effects include a loss in hormones, and that leads to weaker bones and more severe osteoporosis and bone loss later in life.

“It’s about the overall caloric intake,” said Kathryn Ackerman, co-director of the Female Athlete Program at Boston Children's Hospital. “Girls must take in the appropriate calories, fat, protein and carbs. It’s everything.”

MU's athletics department is educating its athletes on proper nutrition with information about how to grocery shop and cook. This is especially important for female athletes who are concerned about eating too much or those who have a misconception about increased protein consumption,  said Jana Heitmeyer, MU director of sports nutrition and a former college gymnast. 

“I don’t necessarily want them counting calories because I don’t want to do that personally,” Heitmeyer said. The focus instead is on whether the plate is balanced. "Are you getting the nutrients you need every meal?”

To lower the risk of injuries and other health problems, female athletes need to eat the right amount of protein and calories for their workout, Heitmeyer said.

“We’re also asking our bodies to do a lot of really crazy stuff, and if we have a bunch of the wrong type of weight, we could potentially be injured,” she said.

Female athletes are also somewhere between four and eight times more likely to suffer an ACL injury,  Ackerman said. That's because females are built for greater flexibility and rely less on their hamstring in movements. The hamstring does not act as quickly or powerfully in females as in males, putting more stress on the knee ligaments.

Ackerman says the key to preventing ACL injuries in girls is teaching better strengthening techniques for the hamstring and how to jump and land to reduce stress on the ligament.

Female athletes are also at an excessively high risk for eating disorders as they try to maintain weight and stay in playing shape.

“Everyone’s at risk, but females are more susceptible than males,” Ackerman said about the potential to develop an eating disorder. “And athletes even more so than regular people.”

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Gwin, 22, played soccer for 13 years, including two seasons with Missouri’s women’s soccer team. She has suffered several head injuries, including three sports-related concussions. She also suffered a concussion when she was 5 and ran into a wall while playing with her brother. She cut her soccer career short two years ago after a hit late in her sophomore season at Missouri while playing Texas A&M. Gwin was slide tackled and took a blow to the neck.

“When you’re 20 years old and you’ve spent your whole life working for this, it’s kind of hard to know that you have to make a mature decision, which was one of the hardest parts,” Gwin said.

The complexity of the decision was compounded by a lack of certainty, she said. “If you have someone who has had recurring ACL tears, they can show you on an MRI that their ACL is severely injured, and you can feel that your knee is unstable, but with concussions, once the symptoms subside you don’t really know,” Gwin said.

Women in sports seem to be suffering more concussion than males, according to a study published in the Journal of Athletic Training. In addition to having a higher risk for concussion, women could also be susceptible to longer-lasting symptoms.

Kathryn Ackerman, co-director of the Female Athlete Program at Boston Children’s Hospital, said that in all sports, concussion is more prevalent in women than in men. “The symptoms may last longer, and there may be more severe symptoms,” she said.

But the why is still unknown. “It’s definitely still murky, and we have to do more research,” she said.

 A blow to the head

Gwin’s soccer career began in first grade as a recreational league soccer player at age 7. It wasn’t until high school that she suffered her first sports-related concussion. An opponent's knee collided with her face, and she was incoherent for 45 minutes. After asking her the same questions repeatedly, her father took her to the hospital.

“When you see any athlete take a hit, you realize that they can really get hurt,” her father, Will Gwin, said.  “Then when you see one of your own children, it strikes even more fear. It does really affect you and make you concerned.”

Gwin's second concussion came while playing at a summer soccer camp at the University of Tennessee. She decided to keep playing after she was kicked in the head. After the game, the camp trainer took her to the hospital to be examined. Gwin said she’s unsure whether the concussion occurred as a direct result of the hit or from continuing to play after the collision.

She got her third concussion when she was hit in the neck during the last home game of her sophomore season for Missouri  in a game against Texas A&M. She doesn’t remember the collision but remembers continuing to play. She decided to take herself out of the game when she couldn’t make sense of the score.

“I realized if I couldn’t keep track of the score, I couldn’t keep balls from going in the goal,” Gwin said.

After the game, she met with the team doctor, Matt Thornburg, who referred her to a neuro sports clinic at the University of Michigan in Ann Arbor, Mich. After two weekends of cognitive testing, Gwin felt better, though there still wasn’t enough data to predict how she might be affected long term.

On the long drive back from Michigan, Gwin and her parents decided it was best for her not to return to playing soccer.  

“We always want to make sure that in the end she is a healthy, young adult and she can have a positive impact on the world,” Missouri women's soccer coach Bryan Blitz said. “Knowing what our value system is, it was an easy choice to make, but it was a hard process.”

The lack of scientific certainty made the decision to forgo training even more difficult, Gwin said. Her parents were relieved she wouldn't be putting herself at risk of more injuries. But they were sad that their daughter could no longer play the sport she loved so much.

That’s the bind for parents: weighing the fun their children are having against the risk of serious injuries.

Many say the key is teaching coaches, parents and players more about concussion. Blitz said his plan for injury prevention relies on the education of players and their families, emphasizing communication between the victim and the medical personnel to help prevent long-term effects from repeated head trauma.

“We are beginning to hear a lot about traumatic brain injuries in the news, and the first thing is people aren’t necessarily educated about them,” Gwin said. “Obviously, if someone’s brain has been affected, it is going to change their behavior, and that’s just something I have just begun to learn.”

Is gender a factor?

Here's what the study published in the Journal of Athletic Training found: In girls high school soccer, 36 concussions were reported per 100,000 “athlete exposures” in the sport. As defined in the study, one “athlete exposure” is each time an individual player takes part in a game or practice. In boy’s high school soccer, concussions accounted for just 22 of every 100,000 athlete exposures.

The numbers were similar in basketball, with female athletes having three times the concussion incidence of their male counterparts, with 21 concussions per 100,000 athlete exposures for women compared with 7 per 100,000 for men.

In its latest consensus statement on concussion, the British Medical Journal — after considering input from doctors with expertise in research and treatment of concussion — said the published research on whether gender is a possible modifier in the management of concussion is inconclusive. But there was agreement that gender might be a risk factor for concussion and its severity.

Ackerman believes the paucity of research on female concussions could have a simple explanation: Professional sports with males are more popular and make more money than do female sports. In turn, more money goes toward research.

“The attention on male professional athletes brings it more attention,” she said. “I think a lot of the funding for research is for male athletics.”

Ackerman and the Boston Children’s Hospital are set to host a conference on health concerns for female athletes on June 8 and 9, the first conference of its kind.

“I think it’s huge,” Ackerman said of the conference. “We wanted to do this because when we go to conferences, female athletes get about an hour of a two-day conference. There’s so much more to cover out there.”

The future

At 9, McKynleigh Jackson has never had a concussion or serious injury. As an athlete, she plays football with her brother, Kole, as well as basketball and soccer.

“My daughter is pretty hard-core in her sports,” said Catherine Miller, McKynleigh’s mother.

Miller said no release was required for Jackson to play for the Columbia Youth Football League, though they did “a really good job” educating parents and coaches about the risks of concussion. She said she was not aware of the heightened risk that her daughter faced playing sports.

“I’d still let her play,” Miller said.

As a parent, she said she would prefer to get her daughter checked regularly to make sure she's OK as she progresses in her athletic life than hold her back from sports.

When she has children of her own, Gwin said she will not let the potential for injuries keep them from playing sports.

“Sports have taught me a lot of lessons throughout life,” Gwin said. “Not just how to kick a ball up and down a field, but mental discipline, self esteem and confidence and multi-tasking. Skills that maybe I would have developed outside of it, but I also learned a lot about people and how to work with others.”

Supervising editor is Katherine Reed.

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