Cross-posted with permission from On The Issues Magazine.

Prior to the 1960s, women and girls heard a steady banter when it came to sports: Don’t participate. Of course, not everyone listened, and those who insisted on taking part were warned to tread lightly lest the running, throwing, jumping, and lifting irreparably harm their bodies and interfere with their ability to bear children.

Now, women actively pursue a huge variety of vigorous physical activities—from competitive sports to demanding dance, fitness, and recreational regimens. Studies for the 2009 to 2010 year reveal that 3,172,637 girls participated in high school athletics; another 184,426 took part in championship college sports (compared to 4,455,740 and 245,875 males, respectively). And then there are nonstudents, the millions of women and girls who run, bike, or go to the gym for Pilates, yoga, and other classes.

While just about everyone agrees that female participation in athletic endeavors is great news, the down side is that sports injuries are on the rise since women—like men—often get hurt when they exert themselves. In addition, their differing anatomical construction means that attention to certain vulnerabilities needs to be addressed in sports training, fitness activities, and coaching—and by medical specialists.

The most common injuries faced by girls and women may not seem obvious at first glance. For example, tears to the knee’s anterior cruciate ligament, or ACL, are five times more common in girls and women than they are in men and boys. Other common injuries include stress fractures, concussions, shoulder injuries, and damage to joints and cartilage.

Bodily Vulnerabilities

Certified Athletic Trainer Stacy Struble, Head Athletic Trainer of Club Sports and Campus Recreation at the University of San Diego, has served as a trainer with the USA Softball National Women’s Team and US Soccer Federation. She describes a key difference between men’s and women’s bodies that contributes to ACL tears:

“Our pelvis is wider and deeper in order to accommodate for carrying and birthing children. The accommodation causes our hips to be wider set than our knees in what is called a ‘Q’ angle. While this in itself is not the sole cause of an increase in ACL injuries in women, it is cause for concern and must be recognized and dealt with” by sports professionals.

Dr. Catherine Robertson, Assistant Clinical Professor of Orthopedic Surgery at the University of California, San Diego, agrees. “We don’t want to pretend that there are no differences between male and female bodies or athleticism, or in terms of risks,” she says. “The question is how we address them. Yes, our wider pelvis is one factor leading to ACL tears, but it’s also true that women tend to have more flexibility and better balance than men. Most men do better in upper body strength.” Both she and Struble stress proper warm-up exercises as key to injury prevention. At the same time, everyone involved in sports understands that it is impossible to prevent all injuries and accidents.

In fact, most people are shocked to learn that airborne endeavors—leaping, jumping and flying over bars—cause the most serious injuries to women and girls who participate in high school and college athletics. In the nearly three decades from 1982 to 2010, the greatest percentage of catastrophic or disabling injuries to females occurred in gymnastics. According to research by the National Center for Catastrophic Sports Injury (NCCSI), the most dangerous sports for females are not football or ice hockey—the sports that are most perilous for males—but cheerleading. What’s more, the National Center found that high school cheerleading accounted for 65.1 percent of all serious female sports injuries—including concussions, dislocations, lacerations, and soft-tissue damage—between 1982 and 2007; in the most recent year for which statistics are available, 2009-2010, 78 school cheerleaders reported serious impairments as a result of their squad’s activities. Even more shocking, there were two cheerleading fatalities that year.

Dr. Frederick Mueller, director of NCCSI, cites 26,786 emergency room visits by cheerleaders in 2007 alone. The reason, he says, is a shift in what cheerleaders do. “In the 1960s, cheerleaders were shaking pom-poms, and the only stunt they performed was a short jump off the ground,” he wrote in the Journal of Athletic Training. Not so today. Mueller states that contemporary cheerleaders are high-level acrobats who generally perform on wooden or concrete floors. “It is a competitive contact sport that involves all kinds of gymnastic stunts, pyramids, and partnering as well as throwing flyers high in the air and catching them,” he concludes.

Faced with these daunting injuries, sports and health practitioners agree that the best way to prevent injuries lies in training, instilling a rigorous regard for warm-up exercises, healthy habits, and appropriate self-care in all participants. Both coaches and players need to follow these rules, they say. “Some coaches think about the technical aspects of their sport, the hitting and scoring, but don’t necessarily pay attention to injury prevention. Youth coaches have the potential to have the highest impact on young athletes. They teach kids good habits and techniques. If they teach prevention—beginning with warm-up exercises—the child will be more likely to have longevity in the sport,” trainer Stacy Struble says.

Warming Up and Cooling Down

Dr. Catherine Robertson also stresses the importance of educating coaches. “When coaches see data that says that if you spend 15 minutes a day on warming up, you have a lower risk of athletic injuries, you’ve given them a compelling reason to build in warm-ups,” she says. “What’s harder is keeping up the enthusiasm since warm-ups don’t completely eliminate impairments.”

In addition, she continues, female athletes need to take basic self-care seriously. “Women and girls often feel as if they need to present a front of invulnerability. We have a kind of warrior woman mentality, but we need to learn that it’s okay to admit when something is wrong and strike a balance between being strong and letting injuries heal,” she adds.

Peter Cirolia, a kinesiologist and personal trainer in Westchester County, New York, specializes in treating sports injuries among women and girls. “Most girls are not taught to stretch before competing. They’re told, ‘Lets go,’ and they start running around the track when they’re not warm, or just go and start the game. I talk to the parents of each kid and emphasize that if they don’t stretch they’ll eventually have problems. A 10 to 15 minute stretch can release muscles that are spasmed or contracting; it further releases the pull on hamstrings, spine, knees, and hips.

“Women often don’t build up the correct muscles around their joints,” he continues. “If I see them because they’re feeling pre-ACL-tear pain or discomfort in their knees, the right exercises can usually prevent the tear from happening by building up the strength of the surrounding muscles. If I see her post-tear and she has to have surgery, I can design exercises to help with the pain.”

Cirolia underscores the interplay of proper warm-ups and nutrition with all of his clients—regardless of whether they’re seasoned athletes or neophytes. He further warns against the use of protein shakes or meal bars in lieu of food. “Protein powder has fewer benefits than protein from actual food. When I say this people’s faces drop. I try to nip fallacies in the bud with young girls, teaching them to eat the fruit, vegetables, protein, and carbohydrates their bodies need,” he says. He also cautions young athletes about the relationship between nutrition and menstruation, since excessive exercise and poor eating habits can cause the body to stop producing estrogen, the hormone needed for ovulation. Low estrogen levels have been linked to bone loss, which increases the risk of fractures and causes other serious health problems as women age.

The same conditions apply to the dance world, where athletic ability is translated into art, and bodily wear-and-tear can be rigorous. Dr. Chloe Bland, a developmental psychologist, danced with a regional ballet company in upstate New York from 1989 to 1993. “Ballerinas get caught up in proving how tough they are and how much pain they can take,” she begins. “I remember when I first started to do point, and we’d take off our shoes after class to compare how much our feet had bled.” Although Bland now considers this behavior absurd, at the time the desire to continue dancing made ignoring the pain a given.

Coupled with rigid weight requirements and the understanding that they’re in a time- limited career, Bland reports that professional dancers typically feel extremely pressured when they get hurt or become ill. While members of her troupe were technically allowed to take time off for serious injuries, they were simultaneously encouraged to return as soon as possible. “At one point I had tendonitis and a pulled groin muscle but I never stayed out,” she admits.

Still, Bland notes that athletic activities, including dance, offer valuable benefits to girls and women, especially by boosting serotonin levels. “Higher serotonin increases the experience of joy and pleasure and can help you overcome sadness or depression. Just moving a muscle can change your thoughts,” she notes.

In the end, it’s a question of balance, figuring out the best ways to integrate movement into everyday life so that it is not a chore, but a source of enjoyment. Indeed, with appropriate care, women can stay in the game well into old age. “Things like loss of flexibility and strength, joint stiffening, and weakening were always assumed to be inevitable, but they’re not,” adds Dr. Catherine Robertson. “Exercise can ameliorate the changes that have traditionally been viewed as part of female aging. There’s no reason women can’t be active in their 60s, 70s, 80s and beyond.”