Modifiable risk factors for lower-extremity injury: A systematic review and meta-analysis for the Female, Woman and Girl Athlete Injury Prevention (FAIR) consensus

Jackie L. Whittaker; Anu M. Räisänen; Chelsea Martin; Jean Michel Galarneau; Maitland Martin; Justin M. Losciale; Garrett S. Bullock; Marc-Olivier Dubé; Mario Bizzini; Matthew N. Bourne; H. Paul Dijkstra; Michael Girdwood; K. Alix Hayden; Martin Hägglund; Shreya McLeod; Nonhlanhla Sharon Mkumbuzi; Andrea Britt Mosler; Myles Calder Murphy; Grethe Myklebust; Merete Møller; Juliana Melo  Ocarino; Oluwatoyosi B. A. Owoeye; Debbie Palmer; Kati Pasanen; Ebonie Kendra Rio; Kristian Thorborg; Marienke van Middelkoop; Evert Verhagen; Stuart J. Warden; Matthew Whalan; Kay M. Crossley; Carolyn A. Emery

doi:10.1136/bjsports-2025-109902

Modifiable risk factors for lower-extremity injury: A systematic review and meta-analysis for the Female, Woman and Girl Athlete Injury Prevention (FAIR) consensus

Jackie L. Whittaker, Anu M. Räisänen, Chelsea Martin, Jean Michel Galarneau, Maitland Martin, Justin M. Losciale, Garrett S. Bullock, Marc-Olivier Dubé, Mario Bizzini, Matthew N. Bourne, H. Paul Dijkstra, Michael Girdwood, K. Alix Hayden, Martin Hägglund, Shreya McLeod, Nonhlanhla Sharon Mkumbuzi, Andrea Britt Mosler, Myles Calder Murphy, Grethe Myklebust, Merete MøllerJuliana Melo Ocarino, Oluwatoyosi B. A. Owoeye, Debbie Palmer, Kati Pasanen, Ebonie Kendra Rio, Kristian Thorborg, Marienke van Middelkoop, Evert Verhagen, Stuart J. Warden, Matthew Whalan, Kay M. Crossley, Carolyn A. Emery

Research output: Contribution to journal › Article › peer-review

Abstract

Objective Examine potentially modifiable risk factors (MRFs) for female/woman/girl athletes’ lower-extremity injuries.

Design Systematic review with meta- or semiquantitative analyses and Grading of Recommendations, Assessment, Development and Evaluation.

Data sources MEDLINE, CINAHL, APA PsycINFO, Cochrane Systematic Review Database, CENTRAL, SPORTDiscus, EMBASE, ERIC searched 30 October or 23 November 2023.

Eligibility Primary data studies with comparison group(s) assessing the association of MRFs for sport-related lower-extremity injury(s) with ≥1 female/woman/girl per study group.

Results Across 195 studies (n=115; 58.9% female/woman/girl-specific estimates) including 1 525 662 participants (2.4% females/women/girls), eight injury outcomes were assessed (n=75 general lower-extremity, n=3 groin, n=6 hip, n=17 thigh, n=88 knee, n=17 lower-leg, n=27 ankle, n=9 foot). Sixty-six MRF categories were identified. Substantial heterogeneity in MRFs and injury outcomes exists, with high risk of bias present in 37.4% of studies. Considering female/woman/girl specific estimates, we performed meta-analyses for 10 MRFs (body mass, x (BMI), weekly training distance, muscle strength, artificial turf, off-season plyometric training, readiness to return-to-sport, single-leg hop asymmetry, vertical drop jump peak knee flexion angle and ground reaction force) and semiquantitative analyses for 26 MRFs for a variety of injuries. Meta-analyses suggest no association between any lower-extremity strength outcome (g=0.01, 95% CI −0.11 to 0.14; I2=37.3%; very low certainty evidence) or artificial turf (Incidence Rate Ratio=0.97, 95% CI 0.88 to 1.07; I2=2.4%; low certainty evidence) and various lower-extremity injuries. Higher body mass (g=0.19, 95% CI 0.00 to 0.38; I2=71.7%) and/or BMI (g=0.22, 95% CI 0.09 to 0.36; I2=37.0%) are associated with several lower-extremity injuries (very low certainty evidence).

Conclusion This review synthesises a large body of exploratory research, exposes important knowledge gaps and provides a foundation for understanding MRFs for female/woman/girl athlete lower-extremity injuries.

PROSPERO registration number PROSPERO CRD42024486715.

Original language	English
Pages (from-to)	1-15
Number of pages	15
Journal	British Journal of Sports Medicine
Early online date	4 Sept 2025
DOIs	https://doi.org/10.1136/bjsports-2025-109902
Publication status	E-pub ahead of print - 4 Sept 2025

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10.1136/bjsports-2025-109902

WhittakerEtalBJSM2025ModifiableRiskFactorsAccepted author manuscript, 649 KBLicence: Creative Commons: Attribution (CC-BY)

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Whittaker, J. L., Räisänen, A. M., Martin, C., Galarneau, J. M., Martin, M., Losciale, J. M., Bullock, G. S., Dubé, M.-O., Bizzini, M., Bourne, M. N., Dijkstra, H. P., Girdwood, M., Hayden, K. A., Hägglund, M., McLeod, S., Mkumbuzi, N. S., Mosler, A. B., Murphy, M. C., Myklebust, G., ... Emery, C. A. (2025). Modifiable risk factors for lower-extremity injury: A systematic review and meta-analysis for the Female, Woman and Girl Athlete Injury Prevention (FAIR) consensus. British Journal of Sports Medicine, 1-15. Advance online publication. https://doi.org/10.1136/bjsports-2025-109902

@article{54bda493493441b8aff03931218aa110,

title = "Modifiable risk factors for lower-extremity injury: A systematic review and meta-analysis for the Female, Woman and Girl Athlete Injury Prevention (FAIR) consensus",

abstract = "Objective Examine potentially modifiable risk factors (MRFs) for female/woman/girl athletes{\textquoteright} lower-extremity injuries. Design Systematic review with meta- or semiquantitative analyses and Grading of Recommendations, Assessment, Development and Evaluation. Data sources MEDLINE, CINAHL, APA PsycINFO, Cochrane Systematic Review Database, CENTRAL, SPORTDiscus, EMBASE, ERIC searched 30 October or 23 November 2023. Eligibility Primary data studies with comparison group(s) assessing the association of MRFs for sport-related lower-extremity injury(s) with ≥1 female/woman/girl per study group. Results Across 195 studies (n=115; 58.9\% female/woman/girl-specific estimates) including 1 525 662 participants (2.4\% females/women/girls), eight injury outcomes were assessed (n=75 general lower-extremity, n=3 groin, n=6 hip, n=17 thigh, n=88 knee, n=17 lower-leg, n=27 ankle, n=9 foot). Sixty-six MRF categories were identified. Substantial heterogeneity in MRFs and injury outcomes exists, with high risk of bias present in 37.4\% of studies. Considering female/woman/girl specific estimates, we performed meta-analyses for 10 MRFs (body mass, x (BMI), weekly training distance, muscle strength, artificial turf, off-season plyometric training, readiness to return-to-sport, single-leg hop asymmetry, vertical drop jump peak knee flexion angle and ground reaction force) and semiquantitative analyses for 26 MRFs for a variety of injuries. Meta-analyses suggest no association between any lower-extremity strength outcome (g=0.01, 95\% CI −0.11 to 0.14; I2=37.3\%; very low certainty evidence) or artificial turf (Incidence Rate Ratio=0.97, 95\% CI 0.88 to 1.07; I2=2.4\%; low certainty evidence) and various lower-extremity injuries. Higher body mass (g=0.19, 95\% CI 0.00 to 0.38; I2=71.7\%) and/or BMI (g=0.22, 95\% CI 0.09 to 0.36; I2=37.0\%) are associated with several lower-extremity injuries (very low certainty evidence). Conclusion This review synthesises a large body of exploratory research, exposes important knowledge gaps and provides a foundation for understanding MRFs for female/woman/girl athlete lower-extremity injuries. PROSPERO registration number PROSPERO CRD42024486715.",

author = "Whittaker, \{Jackie L.\} and R{\"a}is{\"a}nen, \{Anu M.\} and Chelsea Martin and Galarneau, \{Jean Michel\} and Maitland Martin and Losciale, \{Justin M.\} and Bullock, \{Garrett S.\} and Marc-Olivier Dub{\'e} and Mario Bizzini and Bourne, \{Matthew N.\} and Dijkstra, \{H. Paul\} and Michael Girdwood and Hayden, \{K. Alix\} and Martin H{\"a}gglund and Shreya McLeod and Mkumbuzi, \{Nonhlanhla Sharon\} and Mosler, \{Andrea Britt\} and Murphy, \{Myles Calder\} and Grethe Myklebust and Merete M{\o}ller and Ocarino, \{Juliana Melo\} and Owoeye, \{Oluwatoyosi B. A.\} and Debbie Palmer and Kati Pasanen and Rio, \{Ebonie Kendra\} and Kristian Thorborg and \{van Middelkoop\}, Marienke and Evert Verhagen and Warden, \{Stuart J.\} and Matthew Whalan and Crossley, \{Kay M.\} and Emery, \{Carolyn A.\}",

year = "2025",

month = sep,

day = "4",

doi = "10.1136/bjsports-2025-109902",

language = "English",

pages = "1--15",

journal = "British Journal of Sports Medicine",

issn = "0306-3674",

publisher = "BMJ Publishing Group",

}

Whittaker, JL, Räisänen, AM, Martin, C, Galarneau, JM, Martin, M, Losciale, JM, Bullock, GS, Dubé, M-O, Bizzini, M, Bourne, MN, Dijkstra, HP, Girdwood, M, Hayden, KA, Hägglund, M, McLeod, S, Mkumbuzi, NS, Mosler, AB, Murphy, MC, Myklebust, G, Møller, M, Ocarino, JM, Owoeye, OBA, Palmer, D, Pasanen, K, Rio, EK, Thorborg, K, van Middelkoop, M, Verhagen, E, Warden, SJ, Whalan, M, Crossley, KM & Emery, CA 2025, 'Modifiable risk factors for lower-extremity injury: A systematic review and meta-analysis for the Female, Woman and Girl Athlete Injury Prevention (FAIR) consensus', British Journal of Sports Medicine, pp. 1-15. https://doi.org/10.1136/bjsports-2025-109902

TY - JOUR

T1 - Modifiable risk factors for lower-extremity injury

T2 - A systematic review and meta-analysis for the Female, Woman and Girl Athlete Injury Prevention (FAIR) consensus

AU - Whittaker, Jackie L.

AU - Räisänen, Anu M.

AU - Martin, Chelsea

AU - Galarneau, Jean Michel

AU - Martin, Maitland

AU - Losciale, Justin M.

AU - Bullock, Garrett S.

AU - Dubé, Marc-Olivier

AU - Bizzini, Mario

AU - Bourne, Matthew N.

AU - Dijkstra, H. Paul

AU - Girdwood, Michael

AU - Hayden, K. Alix

AU - Hägglund, Martin

AU - McLeod, Shreya

AU - Mkumbuzi, Nonhlanhla Sharon

AU - Mosler, Andrea Britt

AU - Murphy, Myles Calder

AU - Myklebust, Grethe

AU - Møller, Merete

AU - Ocarino, Juliana Melo

AU - Owoeye, Oluwatoyosi B. A.

AU - Palmer, Debbie

AU - Pasanen, Kati

AU - Rio, Ebonie Kendra

AU - Thorborg, Kristian

AU - van Middelkoop, Marienke

AU - Verhagen, Evert

AU - Warden, Stuart J.

AU - Whalan, Matthew

AU - Crossley, Kay M.

AU - Emery, Carolyn A.

PY - 2025/9/4

Y1 - 2025/9/4

N2 - Objective Examine potentially modifiable risk factors (MRFs) for female/woman/girl athletes’ lower-extremity injuries. Design Systematic review with meta- or semiquantitative analyses and Grading of Recommendations, Assessment, Development and Evaluation. Data sources MEDLINE, CINAHL, APA PsycINFO, Cochrane Systematic Review Database, CENTRAL, SPORTDiscus, EMBASE, ERIC searched 30 October or 23 November 2023. Eligibility Primary data studies with comparison group(s) assessing the association of MRFs for sport-related lower-extremity injury(s) with ≥1 female/woman/girl per study group. Results Across 195 studies (n=115; 58.9% female/woman/girl-specific estimates) including 1 525 662 participants (2.4% females/women/girls), eight injury outcomes were assessed (n=75 general lower-extremity, n=3 groin, n=6 hip, n=17 thigh, n=88 knee, n=17 lower-leg, n=27 ankle, n=9 foot). Sixty-six MRF categories were identified. Substantial heterogeneity in MRFs and injury outcomes exists, with high risk of bias present in 37.4% of studies. Considering female/woman/girl specific estimates, we performed meta-analyses for 10 MRFs (body mass, x (BMI), weekly training distance, muscle strength, artificial turf, off-season plyometric training, readiness to return-to-sport, single-leg hop asymmetry, vertical drop jump peak knee flexion angle and ground reaction force) and semiquantitative analyses for 26 MRFs for a variety of injuries. Meta-analyses suggest no association between any lower-extremity strength outcome (g=0.01, 95% CI −0.11 to 0.14; I2=37.3%; very low certainty evidence) or artificial turf (Incidence Rate Ratio=0.97, 95% CI 0.88 to 1.07; I2=2.4%; low certainty evidence) and various lower-extremity injuries. Higher body mass (g=0.19, 95% CI 0.00 to 0.38; I2=71.7%) and/or BMI (g=0.22, 95% CI 0.09 to 0.36; I2=37.0%) are associated with several lower-extremity injuries (very low certainty evidence). Conclusion This review synthesises a large body of exploratory research, exposes important knowledge gaps and provides a foundation for understanding MRFs for female/woman/girl athlete lower-extremity injuries. PROSPERO registration number PROSPERO CRD42024486715.

AB - Objective Examine potentially modifiable risk factors (MRFs) for female/woman/girl athletes’ lower-extremity injuries. Design Systematic review with meta- or semiquantitative analyses and Grading of Recommendations, Assessment, Development and Evaluation. Data sources MEDLINE, CINAHL, APA PsycINFO, Cochrane Systematic Review Database, CENTRAL, SPORTDiscus, EMBASE, ERIC searched 30 October or 23 November 2023. Eligibility Primary data studies with comparison group(s) assessing the association of MRFs for sport-related lower-extremity injury(s) with ≥1 female/woman/girl per study group. Results Across 195 studies (n=115; 58.9% female/woman/girl-specific estimates) including 1 525 662 participants (2.4% females/women/girls), eight injury outcomes were assessed (n=75 general lower-extremity, n=3 groin, n=6 hip, n=17 thigh, n=88 knee, n=17 lower-leg, n=27 ankle, n=9 foot). Sixty-six MRF categories were identified. Substantial heterogeneity in MRFs and injury outcomes exists, with high risk of bias present in 37.4% of studies. Considering female/woman/girl specific estimates, we performed meta-analyses for 10 MRFs (body mass, x (BMI), weekly training distance, muscle strength, artificial turf, off-season plyometric training, readiness to return-to-sport, single-leg hop asymmetry, vertical drop jump peak knee flexion angle and ground reaction force) and semiquantitative analyses for 26 MRFs for a variety of injuries. Meta-analyses suggest no association between any lower-extremity strength outcome (g=0.01, 95% CI −0.11 to 0.14; I2=37.3%; very low certainty evidence) or artificial turf (Incidence Rate Ratio=0.97, 95% CI 0.88 to 1.07; I2=2.4%; low certainty evidence) and various lower-extremity injuries. Higher body mass (g=0.19, 95% CI 0.00 to 0.38; I2=71.7%) and/or BMI (g=0.22, 95% CI 0.09 to 0.36; I2=37.0%) are associated with several lower-extremity injuries (very low certainty evidence). Conclusion This review synthesises a large body of exploratory research, exposes important knowledge gaps and provides a foundation for understanding MRFs for female/woman/girl athlete lower-extremity injuries. PROSPERO registration number PROSPERO CRD42024486715.

U2 - 10.1136/bjsports-2025-109902

DO - 10.1136/bjsports-2025-109902

M3 - Article

SN - 0306-3674

SP - 1

EP - 15

JO - British Journal of Sports Medicine

JF - British Journal of Sports Medicine

ER -

Modifiable risk factors for lower-extremity injury: A systematic review and meta-analysis for the Female, Woman and Girl Athlete Injury Prevention (FAIR) consensus

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