Cultural Influences on Injury Risk

If you have listened to my podcast or seen one of my lectures over the years, you have heard me give my opinions regarding why female athletes have a higher incidence of ACL injuries.

I usually open with this statement:

I think that the increased rate of ACL injury in female athletes could be due predominantly to cultural reasons.

What does that even mean?

First, a little disclaimer. There has been SOME written out there about there being cultural influences on the support of women’s sports. Most have been in the past year and most, but not all, seem to focus predominantly on financial investment in female athletes.

The discussion there is about how controlling interests skimp on female athletes. They are underpaid and undersupported. We see huge discrepancies in things like equipment access. This blew up in the NCAA Division I Basketball Championship bubbles where the men had state of the art weight room equipment, and the women got…a few light dumbbells and some yoga mats.

People were rightfully outraged. I was personally outraged. Let me make this statement as clear as I can:

Female athletes require equal support in order to play at equal levels

Except this conversation is actually a little different than what I’m actually talking about in this post. I’m asking for people to think a little deeper along this line of reasoning. What I am actually saying is that cultural expectations about women, held by societies as a whole (men and women), could explain a lot about what we see in ACL injury rates.

In other words, all investments being equal, we still have a culture problem.

Capacity plus experience

In my view, there is a simple injury prevention equation that requires having the necessary capacity to do the job (having enough “strength”), and experience accessing that capacity. In other words, a large load demand is presented to the athlete, and the athlete, as a complex organism, says, “I recognize this load and know what to do with it.”

A lot of people see this as “coordination training” – teaching athletes to jump/land/cut in specific ways. Maybe, but I have some doubts. I think that the loads experienced in that kind of training are typically too light to be meaningful and the benefits may be accidental. In my opinion, the easier strategy is to get the athletes to have experience pushing close to their max intensities on a regular basis. This means getting in the weight room and pushing some heavy weights. And then go bang around on the court/field/pitch.

This is actually different than just being stronger. I don’t think that strength, in and of itself, is protective. I believe that working on exploring and pushing one’s strength, is. Again, basic strength, and experience working near their limits.

Now at this point you may be raging about whether or not this is a viable injury prevention program. I’m not asking you to believe me on this concept, that would be another blogpost, but rather just to consider that this is at least possible. Now follow me just a little further.

Little boys vs little girls

Think about what is culturally acceptable for little boys to be doing while they are growing up. Running, jumping, wrestling, “rough-housing”, etc.

What about little girls? Even if they participate in these activities, is this kind of behavior encouraged?

What are little boys developing with all of this? Progressive capacity plus experience. By the time a typical boy has reached adolescence, how many exposures to high intensity load demands have they experienced? How many exposures does the typical girl have? Could this have an effect on the difference in injury rates in male vs female high school athletes? Is it fair to expect a female athlete to make up this difference in the month before their first season of playing their first sport?

“But female athletes land differently than males!”

Ok but have you ever wondered why? Does it not seem odd to you that millions of years of evolution results in a genetic predisposition for women to move in a way that causes a severe injury? What other kind of injury is gendered like this? I’m sorry but something seems…weird here.

Do you think that there could be a cultural reason for landing like that? Let me ask you this: Do women sit differently than men? Knees together vs knees apart. Have you ever heard of “man-spreading” where men are seen on mass transit with their knees wide apart? Women, on the other hand, tend to sit with their knees together.

Do women sit like that because of genetics? I would seriously doubt that. Women are taught from a young age that it is inappropriate do anything with their knees apart. Men are not taught that.

Remember, human movement is rooted in context. Do you think that it is possible that there is some little unspoken voice in a woman’s head that was ingrained over the years to say, “Keep those knees close to midline, ladies!”? Compound that with the capacity plus experience issue that I discussed earlier. Now perform on a volleyball court in front of a bunch of spectators.

(SIDE NOTE: Looking to see if there is a correlation between sitting style and landing mechanics would be an interesting study…)

Now I’m not saying that this is 100% the cause of that landing position. I’m saying that it is *possible* that this drives a trend in female movement. I think that it is reasonable to suggest that discouraging rough-housing and encouraging “knees together” specifically in young girls creates an additional injury burden on female athletes as an entire group.

Genes vs memes

Memes are very important here. No, I’m not talking about “lol cats”. The word “meme” was actually coined in 1976 by Richard Dawkins of all people. The word is actually based on the word “mimeme” which means “imitated thing”. Dawkins shortened it to “meme” to be thought of as something that acts like a gene. It is metaphorically coded into your cultural DNA. Like a cultural gene.

A meme is a cultural trait that is handed down through generations through norms of the society to which the individual belongs. To apply it here, it is possible that landing like that is not “in her genes” so to speak, but actually in her memes. So the difference is not genetic, it is cultural.

Now let’s take it to the weight room

I have been extremely honored to work with many elite collegiate and professional athletes, both men and women. Across the board, I see a very common and disturbing trend. Even when given access to the exact same facilities and staff, men and women have very different experiences.

In general, men get into the weight room and are pushed hard, both internally and externally. They grab heavy weight. Someone, whether a teammate or a coach, gets hyped up and pushes them mentally. There’s growling. There’s grunting. There’s hooting. There’s hollering. There’s slamming weights on the ground. All of this is not only acceptable; it is encouraged.

With women, the expectation is lower. WAY lower. Some aren’t expected to go into the weight room AT ALL. When they do, the exercises are often low weight and high rep. If a woman exerts herself to the point that she grunts, she is often embarrassed. If the weight is so heavy that it slams to the ground at the end of the lift, she is often worried that she is disturbing others in the weight room. When she gets into a deep squat, is there an unspoken voice telling her to “hold those knees in”?

If I could give a crude example of the sharp contrast here. When an athlete farts during a max effort lift in the weight room, the reactions in the room are dramatically different if the athlete is male or female. Does that have an effect on that athlete’s willingness to maximize effort?

It is less likely that a coach or teammate will get hyped up and encourage a female athlete to really push herself. Coaches who buck these trends are often told, “Stop treating them like men. Remember that they are women.” Women are treated as somehow fragile. Unfortunately this is what is expected.

And so we end up with light dumbbells and yoga mats and think that this is all a female athlete needs…

What do you think her risk of injury is when she is exposed to an unusual load during a game or match? What is her capacity and her experience with these forces? They may have equal experience in sport, but I suspect that men have more experience with max threshold loads because of these norms.

All of that seems very wrong to me. Setting expectations, prescribing heavy weights, aiming at lofty benchmarks of performance, and challenging someone to really push their physical limits is not “treating someone like a man.” It is treating someone like and athlete.

A couple of things that I’m not saying

I’m not saying that all ACL injuries are strictly due to this. Men obviously also suffer ACL injuries without these cultural drivers. There are also women who grew up rough-housing and have always rejected gender norms who have torn their ACLs, often multiple times. Also, shit happens. My main point is that it is very plausible that this is something that is having a causal effect on the significantly higher incidence rate in female athletes, and that this is beyond just genetic predisposition. I suspect that this cultural influence is a bigger driver than most people think.

I’m also not saying that it is somehow “wrong” for someone to culturally embrace a more feminine-stereotyped movement style or mannerisms in their daily lives, be they female or male. Culture plays a huge role in society and people should not be shamed for how they express themselves. It just might not be optimal when it applies to high intensity sport or training, assuming that they would like to participate in those things.

I’m also not saying that using a valgus knee position is always inherently bad. I’ve written before that valgus itself is only problematic in certain situations and may otherwise be a normal variation of movement. I actually believe that correcting all incidents of valgus would result in decreased performance, assuming it is even possible to truly correct it. What I am talking about in this current post are some of the possible reasons for the trend towards valgus specifically in female athletes in these extreme and complex situations that result in ACL injury.

Finally, not all coaching styles work for all athletes. What is really motivating for one, could be downright abusive for another. But this should be based on the individual preferences of the athlete and not some arbitrary gender norm. Motivation should be maximized in whatever form that means for the individual athlete.

What should we do about this?

Should we be forcing little girls to go bang around and sit with their legs wide apart like uncultured men? I don’t think that that‘s the answer. But I do think that we should make a point not to discourage girls from more intense physical play. Make sure that they know that is very ok, appropriate, and normal for them to participate in such activities at a high intensity.

All children should be taught basic, universal cultural norms that make society more pleasant for everyone. Things like proper table manners or not sitting like some kind of caveman in public. But, they should also be taught to let those norms fall away in the sporting environment. In other words, it is not only acceptable but actually encouraged to grunt and growl in a weight room if you feel so inclined, man, woman, or non-binary. It’s actually one of the great things about sport.

Supporting a child’s understanding of their culture’s norms is not inherently a bad thing. I don’t want parents to get the idea that their daughter’s ACL injury is somehow due to bad cultural parenting on their part. The specific cause of any one person’s ACL injury is very complicated.

I am optimistic that more and more girls are participating in sports at a younger age. This is great! We as a society need to support them to forget gender when they get out there, and just be athletes. A lot of this is happening already, but I feel that we need to be more intentional in this way of thinking. In my opinion, this will benefit not only injury rates, performance, and mental health of the individual, but will benefit society as a whole as well.

If you are a coach or other professional supporter of sports, treat female athletes like athletes. Athletes are strong, powerful, and fierce with very high-performance ceilings and they should be treated as such, regardless of gender. Female athletes deserve the same support as their male counterparts. They should be held to similar standards and expectations. Setting the expectations of weight room norms – for example “You might fart and that’s ok” – is extremely important.

Anecdotally, I can say that women’s programs that I have consulted with who have greatly increased the intensity of simple, classic lifts in the weight room (squats, etc) have seen dramatic decreases in knee injuries. This has also correlated with new coaches who adopt this general coaching mentality of intensity and accountability. Interestingly, these coaches often tend to be female athletes themselves, and they tend to nod their heads vigorously in agreement when I express these general thoughts to them.

In the literature we have seen injury prevention programs having an effect on ACL injury incidence, but I wonder how much of this is due to offsetting some of these cultural effects more than truly correcting a “coordination issue” that is genetically driven. Injury prevention programs are a good start, but I think what we really need is a culture change from top to bottom.

FINAL NOTE: Most of my commentary is around the gender norms of a society, not an individual’s gender. Gender is a societal construct that is very fluid for individuals. It is a spectrum that is more like a color wheel than a linear slider. It should not be conflated with body parts, procreation, or what people chose to do in the privacy of their own bedrooms.

In summary…

• Cultural expectations and experiences may have an influence on ACL injuries
• Little boys and little girls get difference exposure to, and encouragement for, physical play
• Memes can be just as powerful as genes
• Men and women often have different experiences in the weight room
• Athletes are athletes regardless of gender and should be treated as such
• Injury prevention programs are a good start, but I think what we really need is a culture change
• You might fart and that’s ok

Featured image is “Jump!” by MFer Photography