The injury prevention gap
When an adolescent female athlete tears her ACL during competition, the injury is usually understood as an individual medical event. The athlete is evaluated, imaging is ordered, treatment is discussed, and rehabilitation begins. But the circumstances surrounding that injury are rarely limited to the moment when the ligament failed. Whether the athlete had participated in an evidence-based neuromuscular warm-up, whether her coaches had received meaningful injury-prevention education, whether an athletic trainer was available to evaluate her, and whether her school had a structured system for managing the injury can all shape the likelihood of prevention and the quality of recovery that follows.
That broader context matters because girls' participation in organized sports has expanded dramatically. More than 3.5 million girls participated in high school sports during the 2024-25 school year, according to the National Federation of State High School Associations, as total high school sports participation surpassed 8.2 million student-athletes. The growth represents one of the major successes of American youth athletics, but participation has expanded faster than the medical and educational infrastructure surrounding it in many communities. The result is a system in which access to competition may be widespread while access to evidence-based prevention, athletic training, rehabilitation, and gender-informed medical care remains highly variable.
What the evidence says
Research has identified meaningful sex-based differences in the incidence, presentation, and recovery of several sports injuries. Evidence-based neuromuscular training programs have also demonstrated reductions in injury risk among young female athletes. The central implementation challenge is ensuring that these strategies become routine parts of youth sports rather than optional additions that depend on individual coaches or schools.
Why girls face different injury risks
Female athletes do not experience sports injuries for a single reason, and describing girls as simply being "more injury-prone" obscures the interaction between biological development, biomechanics, training exposure, sport demands, and environmental factors. During adolescence, rapid changes in height, strength, body composition, coordination, and neuromuscular control can alter how an athlete lands, decelerates, changes direction, and absorbs force. Researchers have studied differences in lower-extremity alignment, ligament characteristics, joint laxity, muscular strength, and movement patterns as potential contributors to the elevated risk of certain injuries among female athletes.
The ACL provides one of the clearest examples. Depending on the sport, age group, and study population, adolescent female athletes have been reported to experience ACL injuries at rates substantially higher than their male counterparts, with commonly cited estimates ranging from two to eight times the rate observed among boys in comparable sports. In high school soccer, published injury surveillance has found substantially higher ACL injury rates among girls than boys. These differences do not mean that every female athlete has the same risk profile or that an ACL injury is inevitable. They indicate that prevention strategies need to account for the characteristics of the athletes they are intended to protect rather than assuming that a program developed around a predominantly male research population will automatically provide equivalent protection.
The same principle applies beyond the knee. Female athletes experience higher reported concussion rates than male athletes in comparable sports, and studies have found differences in symptom burden and recovery following concussion. Possible explanations include differences in neck strength, head and neck biomechanics, reporting behavior, hormonal factors, and other physiological characteristics, although researchers continue to investigate the mechanisms involved. The important point for schools is not that every sex-based difference has already been completely explained. It is that enough evidence exists to justify more deliberate research, education, and medical protocols designed with female athletes in mind.
The research has not always reflected the athletes on the field
One of the structural problems behind inconsistent injury protocols is the historical imbalance in sports medicine research. A 2022 evidence review examining the representation of female athletes in research informing influential concussion consensus and position statements found substantial underrepresentation of non-male athletes. That does not mean existing concussion guidelines have no value for girls, but it does raise a fundamental question about how confidently generalized recommendations can account for differences in symptom presentation, recovery, and risk.
Research gaps become particularly consequential when they move from academic literature into everyday medical decision-making. A clinical recommendation may be written broadly for "athletes," then interpreted by a coach, athletic trainer, physician, or parent as applying equally to everyone. When the underlying research population does not adequately represent female athletes, however, the system can miss important differences. Better representation in research is therefore not an academic exercise; it is part of building medical guidance that reflects the athletes actually receiving care.
The athletic trainer divide
The availability of trained sports medicine professionals is another major dividing line between youth sports programs. Fewer than half of U.S. high schools employ a full-time certified athletic trainer, and research examining secondary-school athletic training services has documented substantial differences in access depending on school and community characteristics. In a well-resourced program, an athlete who sustains a knee injury or shows signs of a concussion may receive immediate evaluation and have a defined pathway for referral, follow-up, and return to participation. In a school without an athletic trainer, a coach may be the person making the first decision about whether an athlete should continue playing, go home, or seek medical attention.
Coaches are not failing because they are not physicians. They are being placed in situations where the expectations of the role can exceed the medical training available to them. A coach can be highly experienced, attentive, and deeply committed to athlete safety while still lacking the specialized knowledge required to recognize the difference between ordinary soreness and a developing stress injury or between a minor collision and a concussion requiring further evaluation. The appropriate response is not to turn coaches into medical professionals, but to establish clear education, referral pathways, and access to qualified personnel so that coaches know what they should recognize and when responsibility needs to transfer to a medical professional.
Prevention programs work, but implementation is the problem
The evidence supporting neuromuscular injury prevention is stronger than the inconsistent adoption of these programs might suggest. Structured programs that incorporate strength, plyometric training, balance, landing mechanics, and movement control have been shown to reduce the risk of ACL and other lower-extremity injuries among young female athletes. Programs such as FIFA 11+ and related neuromuscular approaches demonstrate that prevention can be incorporated into regular training rather than requiring a separate medical program that athletes must attend outside practice.
The difficulty is translating that evidence into routine behavior. Recent implementation research has identified barriers including limited practice time, competing coaching priorities, insufficient training, inconsistent organizational support, and difficulty maintaining adherence. A coach may understand that a prevention program is effective and still struggle to deliver it consistently when practice time is limited or when the program has not been integrated into the team's established routine. This is why simply distributing an injury-prevention manual is unlikely to solve the problem. Effective implementation requires training, repetition, accountability, and institutional support.
Note
The distinction between knowing what works and consistently implementing what works is central to the female athlete injury-prevention problem. Schools should evaluate not only whether they have a prevention program, but whether coaches and athletes are actually using it throughout the season.
Injury prevention is also an equity issue
The quality of an athlete's prevention and recovery experience can depend heavily on the resources available to her school and family. A student at a well-funded school may have access to an athletic trainer, strength and conditioning staff, physical therapy referrals, rehabilitation equipment, and specialized orthopedic care. A student at an under-resourced school may have none of those resources immediately available and may rely on a parent to determine where to seek care after an injury.
Those disparities can influence outcomes even when the initial injury is identical. Families with limited transportation may struggle to attend repeated physical therapy appointments. Parents working hourly jobs may have difficulty taking time away from work for medical visits. Specialized orthopedic services may be farther away or more difficult to access. Rehabilitation equipment and follow-up care can create additional costs long after an athlete leaves the field.
This means that sports injury prevention cannot be separated from broader questions of school funding and healthcare access. The biological risk may be distributed across athletes, but the ability to prevent, diagnose, and recover from injury is not.
The psychological cost of losing a season
For adolescent athletes, the consequences of injury extend beyond physical limitations. Sport can be closely connected to friendship, identity, confidence, routine, and a sense of accomplishment. When an athlete is suddenly removed from that environment, the disruption can affect school life and social relationships as well as physical activity.
The psychological effects vary from athlete to athlete, and an injury should not automatically be treated as a mental health crisis. But prolonged rehabilitation, uncertainty about returning to competition, fear of re-injury, and separation from teammates can create meaningful emotional challenges. Athletes who have built much of their identity around sport may also struggle with the sudden loss of a role that previously structured much of their daily life.
That is why return-to-sport programs should not be understood solely as a series of physical benchmarks. An athlete may regain measurable strength while still lacking confidence in the injured limb or feeling unprepared for the psychological demands of competition. A comprehensive recovery system should account for both dimensions.
The equipment question
The sports-equipment market offers parents and athletes another potential response to injury risk. Braces, sleeves, specialized footwear, and other protective products can have legitimate roles in specific circumstances, particularly when they are recommended as part of an individualized medical or rehabilitation plan. But equipment should not be treated as a substitute for strength development, neuromuscular training, appropriate workload progression, or medical evaluation.
Parents should therefore ask what a particular product is designed to accomplish, what evidence supports its use, whether it is appropriate for the athlete's specific injury history, and whether wearing it could alter movement in ways that need to be considered. A product marketed as providing broad protection against complex injuries deserves particular scrutiny. Prevention is rarely a single piece of equipment; it is the cumulative effect of appropriate training, preparation, education, medical oversight, and recovery.
Caution
Protective equipment should not be used to justify continuing through unexplained or persistent pain. When an athlete develops recurring pain, swelling, instability, neurological symptoms, or other concerning changes, the priority should be appropriate evaluation rather than finding equipment that allows continued participation.
What a better system looks like
A stronger youth sports injury-prevention system would begin by treating prevention as part of athletic infrastructure rather than an optional service. Schools could establish standardized prevention expectations across sports, require meaningful continuing education for coaches, improve access to certified athletic trainers, centralize injury reporting, and periodically review injury data to identify patterns that individual teams might otherwise miss.
The system should also distinguish between universal standards and sport-specific needs. A soccer team, basketball team, cross-country team, and competitive cheer program do not expose athletes to identical demands, so they should not be expected to use identical prevention programs. The common standard should be that each program uses evidence-informed strategies appropriate to its athletes and sport, that coaches understand how to implement those strategies, and that administrators have a way to determine whether implementation is actually occurring.
This is the gap that G-MIP, alongside resources available through preventsportsinjury.com, is designed to address: not by replacing athletic trainers, physicians, coaches, or existing prevention programs, but by helping translate sports medicine research into systems that schools and teams can actually use. G-MIP empowers young female athletes with practical, research-backed injury-prevention resources and works to make evidence-based practices easier to implement consistently across the environments where girls train and compete. Through workshops, digital resources, and practical tools for schools, coaches, and athletes, the platform focuses on the often-overlooked distance between knowing that a prevention strategy works and making that strategy part of everyday practice. That distinction matters because the strongest research has limited value if it remains in academic journals while coaches continue to improvise warm-ups, athletes receive inconsistent education, and schools lack a common framework for identifying and addressing risk. The broader objective is to help build a system in which prevention is not dependent on whether a particular coach happens to know the latest research or whether a family can afford specialized guidance, but is instead embedded into the ordinary structure of adolescent sports.
From evidence to routine
The most important change may be the simplest: injury prevention needs to become ordinary. It should happen before practice, not only after an injury. It should be included in coach education, not left to whichever coach happens to seek out the latest research. It should be supported by athletic departments, not treated as an individual athlete's responsibility. And when an injury occurs, the athlete should enter a defined medical and rehabilitation pathway rather than having to navigate the system herself.
Girls' sports have already demonstrated that participation can grow on a national scale. The next question is whether the infrastructure surrounding those athletes can become equally ambitious. The evidence increasingly identifies where the risks are, which prevention strategies can help, and where existing systems fall short. The remaining challenge is implementation: making sure that what researchers know reaches the field, the gym, the weight room, and the sideline consistently enough to make a difference.
References
- D’Lauro, Christopher, et al. “Under-Representation of Female Athletes in Research Informing Influential Concussion Consensus and Position Statements: An Evidence Review and Synthesis.” British Journal of Sports Medicine, 2022.
- Eason, Christianne M., et al. “Factors Influencing Athletic Training Services in California Secondary Schools: A 5-Year Update.” Journal of Athletic Training, 2024.
- Lutz, Destiny, and Carla van den Berg. “Dissemination and Implementation of Injury Prevention Interventions: A Scoping Review for the Female, Woman and/or Girl Athlete Injury Prevention (FAIR) Consensus.” British Journal of Sports Medicine, 2024.
- Mitchell, Joshua, et al. “Epidemiology of Meniscal Injuries in US High School Athletes Between 2007 and 2013.” Knee Surgery, Sports Traumatology, Arthroscopy, 2016.
- Munoz-Plaza, Corrine, et al. “High School Basketball Coach and Player Perspectives on Warm-up Routines and Lower Extremity Injuries.” Sports Medicine – Open, 2021.
- Musko, Patryk A., and Andreas K. Demetriades. “Are Sex Differences in Collegiate and High School Sports-Related Concussion Reflected in the Guidelines? A Scoping Review.” Brain Sciences, 2023.
- National Federation of State High School Associations. “Participation in High School Sports Hits Record High with Sizable Increase in 2024-25.” 2025.
- Sarmiento, Kelly, et al. “Youth and High School Sports Coaches’ Experience with and Attitudes about Concussion and Access to Athletic Trainers by Sport Type and Age of Athlete Coached.” Journal of Safety Research, 2019.