Men and Women Don’t Always Get the Same Running Injuries
As you know by now, if you have been reading my blog - there are a lot of things that can contribute to a running injury: training history, previous injuries, strength, recovery, nutrition, sleep, biomechanics, and what changed before the pain started.
Sex is another piece of that picture.
For a long time, sports medicine research was heavily weighted toward male athletes. We now have better data showing that although male and female runners may have similar overall rates of running-related injuries, the types of injuries they experience aren't always the same.¹
Similar Injury Rates, Different Injuries
A systematic review and meta-analysis of 38 prospective studies found overall injury rates of 20.8 injuries per 100 female runners and 20.4 per 100 male runners—essentially no difference in total injury occurrence between the sexes.¹
But when the researchers looked at specific diagnoses, the pattern changed.
Female runners had about twice the risk of bone stress injury, while male runners had nearly twice the risk of Achilles tendinopathy.¹
Bone stress injuries and Achilles tendinopathy weren't the only differences reported. The review also identified sex-specific patterns in several other diagnoses, including plantar fasciitis and some knee and lower-leg injuries.¹ The evidence for these conditions wasn't as consistent as it was for bone stress injuries and Achilles tendinopathy, but together these findings reinforce an important point: men and women may experience a similar overall number of running injuries while the distribution of those injuries can look different.
Bone Stress Injuries in Female Runners
Bone stress injuries are something I take seriously in every runner, but the higher rate among female runners should increase our awareness.
In the same review, female runners had roughly twice the risk of bone stress injury compared with males. Among younger runners, some studies reported a two- to 2.5-fold higher risk in female high school runners.¹
There isn't one explanation for this.
Bone health is influenced by training load, nutrition, energy availability, hormonal function, bone density, previous injury and other factors. In female adolescent runners, menstrual dysfunction and low bone mineral density have been associated with running-related injury and bone stress injury risk.²
This is why I don't want a young female runner with repeated bone injuries to simply hear, “You run too much.”
I want to know more.
How is she fueling? Has her menstrual cycle changed? Has training recently increased? Has she had a previous bone stress injury? What does her overall recovery look like?
Those questions can tell us a lot more than mileage alone.
Men Can Have REDs Too
This conversation has historically focused on women because of the Female Athlete Triad, but low energy availability and Relative Energy Deficiency in Sport (REDS) also occur in male athletes.
The running-injury literature recognizes REDs as relevant to both sexes, and low bone mineral density in male athletes has also been associated with bone stress injuries.¹˒³
So I don't assume a male runner with a bone stress injury is adequately fueled simply because he is male.
That is an important shift in how we think about runner health.
Men and the Achilles Tendon
The pattern looks different with the Achilles.
Male runners in the same meta-analysis had an estimated 1.86 times greater risk of Achilles tendinopathy than female runners.¹
We don't completely understand why.
Achilles tendinopathy is multifactorial. Training load, age, biomechanics, body composition, cumulative years of running and other factors may contribute. The authors also discussed hormonal influences, but they were careful to note that the increased risk in men cannot currently be explained by one mechanism.¹
Finding a difference between men and women doesn't automatically tell us what caused the injury in an individual runner.
How I Use This Information
I don't think women should be afraid of bone stress injuries or men should assume Achilles pain is inevitable.
I use sex as one part of a much larger clinical picture.
If a female distance runner develops focal shin or hip pain, I may have a lower threshold for considering bone stress injury and asking detailed questions about menstrual health, fueling and previous bone injuries.
If a male runner develops gradually increasing Achilles stiffness and pain, Achilles tendinopathy may move higher on my differential diagnosis.
But neither injury belongs exclusively to one sex. Women get Achilles injuries. Men get bone stress injuries.
Research gives us patterns across groups of runners. As clinicians, we can use those patterns to ask better questions while still evaluating the individual athlete standing in front of us.
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References
Hollander K, Rahlf AL, Wilke J, et al. Sex-specific differences in running injuries: a systematic review with meta-analysis and meta-regression. Sports Med. 2021;51:1011–1039. doi:10.1007/s40279-020-01412-7.
Tenforde AS, Sayres LC, McCurdy ML, Sainani KL, Fredericson M. Identifying sex-specific risk factors for stress fractures in adolescent runners. Med Sci Sports Exerc. 2013;45(10):1843–1851. doi:10.1249/MSS.0b013e3182963d75.
Tenforde AS, Parziale AL, Popp KL, Ackerman KE. Low bone mineral density in male athletes is associated with bone stress injuries at anatomic sites with greater trabecular composition. Am J Sports Med. 2018;46(1):30–36. doi:10.1177/0363546517730584.
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