Female high school soccer injuries presenting to US emergency departments: A 10-year analysis of national injury data

Jennifer Yu; Avanish Yendluri; Julian V. Javier; Sohan S. Shah; Jeffrey Yu; Dennis M. Bienstock; Christon Darden; Salvatore Capotosto; Rachel M. Frank; Theodore J. Ganley; Robert L. Parisien

doi:10.1016/j.jor.2025.08.017

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69 (); 324-328

doi:

10.1016/j.jor.2025.08.017

Female high school soccer injuries presenting to US emergency departments: A 10-year analysis of national injury data

Jennifer Yu^a,, Avanish Yendluri^a, Julian V. Javier^a, Sohan S. Shah^b, Jeffrey Yu^c, Dennis M. Bienstock^a, Christon Darden^a, Salvatore Capotosto^a, Rachel M. Frank^d, Theodore J. Ganley^e, Robert L. Parisien^a

a Icahn School of Medicine at Mt. Sinai, USA

b Union College, USA

c Touro College of Osteopathic Medicine - Harlem, USA

d University of Colorado School of Medicine, USA

e Children's Hospital of Philadelphia, USA

⁎Corresponding author: Jennifer Yu. jennifer.yu@icahn.mssm.edu

Received: 2025-6-24, Accepted: 2025-8-11, Published: 2025-8-12

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Female athletes are underrepresented in sports injury research, especially regarding soccer-related injury patterns in adolescent females. This study analyzes injury trends among high school-aged female soccer players to address injury risks in this population. We hypothesize that soccer-related injuries in high school-aged females most commonly involve the head or lower extremities, with incidence decreasing over time due to improved prevention measures.

The National Electronic Injury Surveillance System (NEISS) was queried for soccer-related injuries in females aged 14–18 from 2014 to 2023. Demographics, injury sites, and diagnoses were analyzed. National estimates (NEs) were calculated using NEISS statistical weights. Linear regression evaluated trends over time.

From 2014 to 2023, an estimated 227,217 soccer-related injuries occurred in high school-aged females (7248 NEISS cases). Strains/sprains were the most common diagnosis (NE = 96,619, 33.2 %), followed by head injuries and concussions (NE = 57,311, 19.7 %). The head was the most frequently injured body part (21.1 %), followed by the ankle (20.6 %) and knee (15.7 %). Injuries significantly declined over time (p < 0.05). Notably, injuries decreased by 53.4 % from 2019 to 2020 but rose by 57.7 % from 2020 to 2021.

There was a significant decline in female high school soccer injuries from 2014 to 2023, with head and lower extremity injuries being most common. The high frequency of head injuries emphasizes the importance of concussion baseline testing and treatment protocols. The decline in injuries, particularly head injuries, may reflect the effectiveness of prevention strategies implemented during the study period.

This study highlights the need for targeted prevention strategies, including baseline concussion testing, protective gear, and improved training practices. The decline in injury rates suggests the positive impact of safety measures while identifying areas for further improvement to ensure player safety.

Keywords

Soccer

Injuries

Sports medicine

Fractures

NEISS

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1 Introduction

According to the National Federation of State High School Associations (NFHS), 42 % of high school athletes in 2023 were female.¹ However, this percentage is not proportionately reflected in sports medicine and injury prevention research Female athletes have been historically underrepresented in studies that guide clinical care, including those related to musculoskeletal injury and sports-related concussion.^2–4 For example, a review of concussion literature found that 40.4 % of studies completely excluded female participants, despite evidence that female athletes are at greater risk of concussions and experience more prolonged post-concussion symptoms than their male counterparts.⁵,⁶

The high school female athlete is of particular interest due to unique vulnerabilities during adolescence. Concussion symptoms are frequently underreported in this population,⁷ and conditions such as the Female Athlete Triad Syndrome, characterized by low energy availability, menstrual dysfunction, and low bone mineral density, remain underdiagnosed.⁸;³

Among high school girls' sports, soccer is the 3rd most popular sport in the US, with 377,838 participants in 2023, representing 46 % of all high school soccer players.¹ Notably, girls’ soccer has the highest reported rate of concussion among all high school female sports.⁹ Given both the popularity of soccer and the known injury risks among female athletes, there is a critical need for updated and sex-specific epidemiologic data. While prior studies have used the NEISS database to report broad trends in sports-related injuries among youth athletes, they often include mixed-sex populations or group multiple sports together, limiting sport- and sex-specific insights.⁹,¹⁰; In contrast to prior work, our analysis includes a more granular breakdown of injury diagnoses and body parts, expanding on previous studies, as well as examining trends across the pandemic period. The purpose of this study is to characterize the recent trends and patterns of soccer-related injuries among female high school athletes to inform risk management, prevention, and support strategies in this population.

2 Methods

2.1

2.1 Database

The National Electronic Injury Surveillance System (NEISS) is an open-access database managed by the U.S. Consumer Product Safety Commission. It comprises anonymized data from over 100 emergency departments across the country. Each case in the dataset is assigned a statistical sample weight according to the hospital, enabling the estimation of national injury numbers from the raw NEISS case data.

2.2

2.2 Data extraction

NEISS was retrospectively queried for all musculoskeletal and head soccer injuries for high school-aged females (age 14–18, inclusive), that took place between January 1, 2014 and December 31, 2023 using the “Soccer” code. An ED narrative is provided for each case in the NEISS dataset describing how the injury occurred. Narratives were reviewed to exclude cases that clearly involved multiple sports or were unrelated to soccer-specific activity. There were 8848 total cases of female high school-aged soccer-related injuries extracted from 2014 to 2023 through the query. The patient's demographic information (age, race), injury location, diagnosis, and discharge disposition were available for each case.

2.3

2.3 Exclusion criteria

Injuries that were not musculoskeletal or of the head were excluded using a combination of NEISS diagnosis/body part codes and manual narrative review (chest pain, syncope, heat exhaustion/dehydration). This narrowed down the dataset to 7248 total cases.

2.4

2.4 Statistical analysis

The analysis included descriptive statistics reported with the raw number of cases and with the NEISS-provided statistical weights given by the Consumer Product Safety Commission for each case, allowing calculation of a national estimate. These weights were applied following standard NEISS methodology; however, no additional adjustments for complex survey design elements (clustering, stratification) were made. To evaluate whether fluctuations in participation influenced observed injury trends, annual female high school soccer participation data were obtained from the National Federation of State High School Associations (NFHS) for the years 2014 through 2023. These data were reviewed to assess potential variability in the athlete population over time. As participation numbers remained relatively stable across the study period, no adjustments were made to account for participation in the primary trend analyses. Linear regression was utilized to assess trends in injuries during the study duration. Year of injury was the independent variable, and frequency of injuries was the dependent variable. Injury trends were also stratified by age and diagnoses. The p-value, regression coefficient (β), and a 95 % confidence interval (CI) were reported when statistically significant (p < 0.05). Python 3 with the pandas and scipy data analysis libraries was utilized to analyze the data.

3 Results

There were 227,217 nationally estimated soccer-related injuries for high-school aged females (7248 NEISS cases) that presented to US EDs from January 1, 2014 to December 31, 2023. The average age was 15.5 ± 1.2 years. Injuries affecting 14-year old females (NE = 60,610, 26.7 %) were most frequent, followed by 15-year old females (NE = 58,598, 25.8 %), then 16-year old females (NE = 48,792, 21.5 %), 17-year old females (NE = 41,205, 18.1 %) and finally 18-year old females with the lowest proportion (NE = 18,012, 7.9 %).

Linear regression analysis of annual injuries revealed a significant decrease in injuries between 2014 and 2023 (p < 0.01; R² = 0.74, β = −2066.84; 95 % CI: [−3060.99 to −1072.68]) (Fig. 1). The significant decrease in injuries was apparent across all ages assessed except for those aged eighteen: 14 (p < 0.01), 15 (p = 0.01), 16 (p < 0.001), 17 (p < 0.01), and 18(p = 0.07) (Fig. 2). Moreover, the number of overall female high-school aged soccer-related injuries that presented to US EDs in 2023 was 48.8 % less than in 2014. A decrease in injuries was seen among all age groups in 2020 during the COVID-19 pandemic, with an overall decrease of 51.6 % of injuries from 2019.

Nationally estimated soccer-related injuries for high school-aged females from 2014 to 2023. The red trendline represents a significant overall decline in injury counts over the 10-year period. Abbreviations: NE - national estimate.

Nationally estimated soccer-related injuries for high school-aged females from 2014 to 2023 stratified by age 14–18. Across all years, younger athletes experienced higher injury counts, with a general decline in injuries observed over time for each age group. A sharp drop is evident in 2020, likely reflecting reduced athletic activity during the COVID-19 pandemic.

Strains/sprains were the most common diagnosis (NE = 88,221, 38.8 %), followed by concussions and closed head injuries (NE = 54,496, 24.0 %) (Table 1). Contusions/abrasions and fracture injuries accounted for 17.3 % and 13.4 % of all injuries, respectively. The ankle was by far the most common body part to sustain a strain/sprain, accounting for 48.5 % of all strains/sprains, followed by the knee (22.0 %). Contusions/Abrasions were most commonly sustained to the knee (13.5 %), the lower leg (13.3 %) and the foot (11.6), while fractures most commonly affected the wrist (20.1 %), lower arm (13.0 %) and ankle (12.4 %).

Table 1 Injury incidence among high school-aged female soccer players stratified by diagnosis and body part affected, based on NEISS data from 2014 to 2023.

	Category	NEISS Cases	National Estimate	%
	Strain/Sprain	2831	88221	38.8
	SRC/CHI	1766	54496	24.0
Diagnosis	Contusions/Abrasions	1129	39381	17.3
	Fracture	1056	30361	13.4

	Head	1830	57503	25.3
	Ankle	1570	49091	21.6
Body Part	Knee	977	30012	13.2
	Wrist	410	13924	6.1
	Lower Leg	330	10294	4.5

The head was the most commonly injured body part overall, accounting for 25.3 % (NE = 57,503) of all injuries, followed by the ankle (NE = 49,091, 21.6 %) (Table 1). The knee and wrist accounted for 13.2 % and 6.1 % of injuries, respectively, followed by the lower leg, accounting for 4.5 % of all injuries.

Linear regression analysis of yearly trends for the 4 most common injury diagnoses between 2014 and 2023 showed significant decreases in strains/sprains (p < 0.001; β = −852.6; 95 % CI: [−1233.0, −472.2]), SRC/CHI (p = 0.0026; β = −-513.4; 95 % CI: [−789.1, −237.7]), and contusions/abrasions (p < 0.001; β = −-535.7; 95 % CI: [−761.1, −310.4]). However, no significant decreases in annual fractures (p = 0.062) were observed within this time period, suggesting that these serious injuries remained prevalent in US EDs (Fig. 3).

National estimates for the 4 most common soccer-related female high-school aged injury diagnoses reported at US emergency departments between 2014 and 2023.

In the study, only 0.8 % (NE = 1814) of patients were admitted. 98.5 % (NE = 223,734) of patients were treated and released, while 0.37 % (NE = 836) left without treatment.

4 Discussion

This study assessed the frequency and distribution of soccer-related injuries among high school-aged female athletes presenting to US EDs from 2014 to 2023. Overall, there was a significant decline in reported injuries over time, particularly among athletes aged 14–17(Figs. 1 and 2). Muscle strains and sprains accounted for the largest proportion of injuries, followed by contusions, abrasions and SRC/CHI. Fracture rates remained relatively stable throughout the study period. Notably, despite muscle strains and sprains being the most common diagnoses, the head was the most frequently injured body part.

Age-stratified analysis (Fig. 2) revealed a consistent decrease in injury frequency with increasing age – injuries were more frequent at age 14 compared to age 18. This pattern aligns with growth-related literature on Peak Height Velocity (PHV), which typically begins around age 11 and completes by age 18. During this period, imbalances between muscle strength and flexibility can increase susceptibility to injury and temporarily reduce athletic performance. These biomechanical vulnerabilities may contribute to the higher injury rates observed among younger female athletes in our sample.¹¹,¹²

Injury rates were lowest during the COVID-19 pandemic (2020–2021), likely due to widespread cancellations of practices and competitions.¹³ Girls’ soccer has been shown to have significantly higher injury rates in games compared to practices, and the reduction in competition during the pandemic decreased exposure risk.¹⁰ Surveys from this period revealed that weekly training hours for high school athletes dropped from over 15 to approximately 8 h for the majority of respondents, over half of whom were female.¹⁴ Additionally, mandated quarantines affected over 20 % of student athletes, further limiting their participation.¹³

The post-pandemic increase in injury rates likely reflects both the return to full athletic participation and the effects of deconditioning – a decline in physical fitness due to reduced training during lockdown.¹⁶ This phenomenon has been documented in other athletic populations. Kremen et al. observed elevated injury rates among college athletes post-pandemic, particularly in soccer¹⁵ Similarly, Seshadri et al. reported a threefold increase in injury rates in the German Soccer League upon resumption of play.¹⁷ These findings support the hypothesis that abrupt resumption of high-intensity activity after prolonged inactivity may elevate injury risk.

Despite the observed decline in female soccer injuries presenting to EDs, overall ED visits in the U.S. have increased over the same period.¹⁸ With 20 % of ED cases involving musculoskeletal complaints, the rise of orthopedic urgent care centers may be diverting lower-acuity sports injuries away from EDs. These centers offer faster access to care and have become the preferred option for many injured athletes, potentially contributing to the observed decline.¹⁹,²⁰ In contrast, ED visits for fractures remained consistent, likely reflecting the more severe and painful nature of these injuries, prompting patients to seek immediate emergency care.

Our findings that sprains/strains and SRC/CHI were the most common diagnoses are consistent with prior literature. Pizarro et al. (2015–2019) reported that the head/face, ankle, and knee were the most commonly injured body parts, with sprains/strains and concussions comprising the leading diagnoses in female high school soccer players.¹⁰ The high prevalence of ankle injuries can be attributed to the biomechanical demands of soccer, as the ankle bears significant ground reaction forces and is prone to reinjury. Additionally, collagen remodeling during physeal growth may increase ankle vulnerability during adolescence.²¹

Given the prevalence of injury, especially among younger female athletes, injury prevention strategies should be integral to soccer training programs. McGuine et al. found that high school basketball, soccer, and volleyball female athletes who lacked formal training—such as instruction on proper jumping and landing techniques or structured warm-up routines—experienced a 3.6-fold increase in injury rates compared to those who received training and were more prone to ACL (noncontact) injuries.²² A prospective study by Junge et al. demonstrated that preventive interventions can effectively reduce the incidence of soccer injuries, particularly among youth teams with lower skill levels.²³ While contact injuries are harder to prevent structured training can substantially reduce overuse injuries and lower ED presentation rates among high school female athletes.

4.1

4.1 Limitations

While this study offers valuable insight into the epidemiology of soccer-related injuries among high school-aged female athletes, several limitations should be considered. First, the NEISS database includes only injuries reported to US EDs, excluding those treated in outpatient clinics, urgent care centers, or those that went unreported entirely. Although NEISS is nationally representative, sampling error remains possible. Second, injuries were identified based on NEISS product codes and narrative descriptions, which are subject to potential miscoding, resulting in the inclusion of injuries that are not strictly soccer-related. While manual narrative review was conducted to remove unrelated cases, exclusion of relevant cases due to inconsistent documentation was possible. Third, the dataset does not provide information on whether injuries occurred during games, practices or informal play, limiting our ability to distinguish context-specific risk factors. Additionally, NEISS does not capture the severity of injuries beyond the initial diagnosis and ED disposition, preventing stratification of injuries by clinical impact or time lost from sport. The study also excluded cases where the diagnosis was cardiac-related, heat exhaustion/dehydration, or not musculoskeletal or head-related using a combination of NEISS diagnosis/body part codes and manual narrative review. While the study aimed to focus on orthopedic and biomechanical injuries, the exclusion of non-traumatic conditions – such as heat-related illness, syncope, or cardiac complaints – may omit certain exertional events that occur during soccer participation. These were excluded due to their differing pathophysiology and management approaches, which fall outside the scope of mechanical injury surveillance. Additionally, while concussion and closed head injuries were retained given their biomechanical origin and established relevance in sports injury epidemiology, particularly among female athletes, the exclusion of other systemic medical events represents a limitation in capturing the full spectrum of soccer-associated presentations.

5 Conclusion

There is an overall decreasing trend in female high school soccer injuries presented to the US emergency departments. While this may be partly due to improvement in injury prevention, the saturation of patients in US emergency rooms have caused orthopedic urgent care centers to open and reduce the burden on emergency rooms. It is important to emphasize that strains/sprains and concussions/closed head injuries were the two most common injury diagnoses. This study focused on the epidemiology of injuries among female high school soccer players, aiming to raise awareness about reducing preventable injuries in youth sports. While preventing contact injuries remains challenging, implementing a well-designed training program focused on injury prevention is essential for minimizing the incidence of non-contact injuries.

IRB

IRB approval was not required for this manuscript as only publicly available data was included in the investigation.

Author contributions

Yu, Yendluri, Javier, Shah, Yu: Conceptualization, Data curation, Formal analysis, Writing - original draft.

Bienstock, Darden, Capotosto: Writing - original draft, Writing - review & editing.

Ganley, Frank, Parisien: conceptualization, Writing - review & editing, Supervision.

Disclosures

The following individuals have no conflicts of interest or sources of support that require acknowledgement: Jennifer Yu, Avanish Yendluri, Julian V. Javier, Sohan Shah, Jeffrey Yu, Dennis M. Bienstock, Christon Darden, and Salvatore Capotosto.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Patient Consent

Not required.

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