What type of study is this?

This is a Systematic Review study (also classified as: Meta-Analysis).

September 10, 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

Key Points

Higher body mass and BMI are associated with several lower-extremity injuries, indicating important risk factors to monitor.
Meta-analyses of 10 modifiable risk factors found no significant associations with strength outcomes, suggesting uncertainty in prevention strategies.
The review highlights 66 modifiable risk factor categories, pointing out substantial heterogeneity in how injuries are assessed.
Significant bias is present in over one-third of studies, indicating a critical need for improved research methodologies.

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; I 2 =37.3%; very low certainty evidence) or artificial turf (Incidence Rate Ratio=0.97, 95% CI 0.88 to 1.07; I 2 =2.4%; low certainty evidence) and various lower-extremity injuries. Higher body mass (g=0.19, 95% CI 0.00 to 0.38; I 2 =71.7%) and/or BMI (g=0.22, 95% CI 0.09 to 0.36; I 2 =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.

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