Context is queen: filling the gaping hole in Sports and Exercise Medicine research and practice

Sports and Exercise Medicine research largely excludes women cohorts. However, women’s biology influences the outcome of training programs and medical interventions. Still, the evidence pool is mainly void of specific data to design appropriate interventions. Nonhlanhla Mkumbuzi explores the gaps in research and discusses the inclusion of context as a critical determining factor when designing interventions in marginalized groups.

Athletics – World Athletics Championships – Doha 2019 – Women’s 800 Metres Final – Khalifa International Stadium, Doha, Qatar – Uganda’s Halimah Nakaayi competes. REUTERS/Ahmed Jadallah

Only 6% of Sports and Exercise Medicine (SEM) research is exclusive to women cohorts, and about 30% includes them(1). That means, 70% of the time, the development of training programs, clinical interventions, and policy is without consideration for women’s biology. While male biology is fairly consistent, the menstrual cycle hormonal fluctuations exclude women from SEM research. Though the primary function of the major hormones of the menstrual cycle is reproductive, they also influence other physiological systems such as the musculoskeletal and metabolic systems(2,3). These effects are considered confounders to research results; therefore, research is almost exclusive to male cohorts. Paradoxically, in the clinical application, SEM practice assumes consistent hormonal levels in designing training programs and other clinical interventions for female athletes. For the most part, SEM disregards hormonal fluctuations and uses male data for female athletes.

Women experience higher concussions and anterior cruciate ligament (ACL) injuries than men(4). In addition, for concussions, women present with different, more severe, and longer-lasting symptoms than their male counterparts in the same sport(4). However, as most research on concussion is exclusive to men, the clinical features, management, and return to play protocols are primarily derived from male data. Consequently, clinicians may consider female athletes to present with ‘atypical’ symptoms and ‘delayed’ healing, which leads to frustration. The menstrual cycle hormonal fluctuations affect every biological system, and clinicians should not ignore this when managing female athletes. A truly evidence-based SEM practice would not only acknowledge the sex differences in injury risk, performance, and recovery but also accommodate them in the description of clinical features, development of training plans, and interventions(see figure 1).

Gender tinted glasses

Hormonal fluctuations are not the only contributors to the sex-related differences in injury risk. Practitioners cannot separate the biological differences between men and women from the social and cultural contexts in which they exist. In this case, a gendered sports environment operates within a hegemonic masculine norm. A strong focus on the biomechanical ignores that men and women experience the sporting environment differently because they are male or female. While women may experience more concussions or ACL injuries than men, they do so in an environment that views them as fragile(4).

Figure 1: Evidence-based practice

Use research evidence, professional experience, knowledge of the participating athletes, and an intimate understanding of the sport’s needs to design interventions with real-world efficacy.

The same environment actively discourages women from resistance training, which is key to preventing and managing ACL injuries. Resistance training and the athletic body are considered too masculine and unacceptable for female athletes(5). Should an athlete get injured, the athlete’s and clinician’s gender determine the management, ultimately affecting their injury outcomes. Therefore, it is not just sex that affects performance and injury outcomes, but rather a bias of the management team. So while hormonal fluctuations may play a role in injury risk, this biology exists in a context that makes it more likely for women to get injured(5). Sports and Exercise Medicine needs to acknowledge the gendered environment in which female athletes play and consider this in the management of female athletes.

Reframing the weaker sex narrative is paramount to achieving optimal treatment outcomes. Female athletes aren’t physiologically inferior, but the services we provide for them and the development processes available may well be. It’s time to stop accepting the high frequency of female sports injury as inevitable and start challenging the system that causes it.

Racing to equality: closing the margins in SEM

Just as different genders experience the sporting environment differently, so do different races. Unfortunately, general health care and SEM marginalize and underrepresent people of color (POC)(6). The whole value chain of the sporting environment, from the research, participation, media coverage, remuneration, and SEM practice is racialized and operates within a hegemonic Caucasian norm. The majority of current evidence represents white males, and clinical practice does not acknowledge that the experiences of white males in the sporting environment are vastly different from those of other races.

Consequently, the management of athletes of color (AOC) deprives them of holistic management that considers their whole experience of the sport value chain. Taking a racial lens to SEM practice gives clinicians better insights into the life experiences, backgrounds, needs, and motivations of AOC. It allows them to validate these and accommodate them in clinical management. This is important as ethnicity affects health outcomes in general practice and sport(6).

As separate groups, women and POC are woefully underrepresented in SEM literature. Women and girls of color from low and middle-income countries such as sub-Saharan Africa are nigh invisible(7). Of the little SEM evidence on women and POC, even less is on women of color. For African women, in particular, their biology is ignored for the most part. In addition, SEM practice ignores their unique lived experiences, socio-economic, religious, cultural, and environmental circumstances.

Consequently, these athletes rely on the information on injuries, recovery, and training generated without their bodies or circumstances in mind. In addition, societal expectations, culturally driven perceptions, and (lack of) access to opportunities and financial support significantly influence these circumstances.

Biopsychosocial practice in SEM is everywhere and nowhere.

Intrinsic factors, such as physical and psychological readiness, influence an athlete’s ability to return to sport (see figure 2). However, systemic social factors such as income level, gender, and race supersede these intrinsic factors and shape an athlete’s reality and determine their access to sports development, funding, and medical resources. Despite SEM acknowledging this reality, it neglects the ‘non-physical’ factors(8). Thus, the biopsychosocial approach to sports medicine as a concept is simultaneously alive and dead(9).

Figure 2: The traditional biopsychosocial model

While the description of biological components of injury and performance (in males at least) is advanced, non-biological factors do not receive the same attention. To date, much of the current SEM evidence, and the interventions designed thereof, fail to account for the intersection of gender, race, culture, and economics — factors which compound the difficulties faced by, especially, female athletes, AOC, or those from low-income countries. Interventions that do not consider the intersection between biology and the lived contexts are likely to fail, with costly clinical implications.

Social sciences data provides ample evidence of the importance of understanding the non-physical aspects of injury and performance as they determine individual or population-level health outcomes. While the biology of injury might be similar, injuries have different implications in different contexts. For example, from a biomedical perspective, an ACL rupture in a male football player in Canada has similar tissue damage and clinical prognosis to that of a female football player in Zimbabwe. However, when clinicians consider context, these injuries present markedly different problems such as access to (or lack of) medical experts, financial support of the injured player, and socio-culturally driven perspectives towards the athlete, their choice of sport, and their injury. In addition, different psychological, social, and contextual factors influence all stages of recovery after injury(10,11). Hence, a better understanding of these factors at the time of injury and throughout injury rehabilitation could improve injury management protocols and long-term outcomes.


While SEM is trying to be more equitable and inclusive, clinical decision-making is still based on evidence generated from predominantly male, Caucasian, and high-income contexts and applied en masse to the rest of the world. Recognizing that the research that guides clinical decision making is within a particular socio-economic, religio-cultural, and environmental context, will not only help to identify the gaping holes in the current evidence base but will allow a better understanding of diverse athletes and their needs, especially those who are from systemically marginalized groups.

In conclusion, the current SEM practice is evidence-based. Unless one is female, a person of color, or from a low-income country. An evidence-based, biopsychosocial approach to SEM will acknowledge the complexity of athletes and their various contexts and the massive chasm in the current evidence. It needs to ask, “how?”, “for whom?”, and “under what circumstances?”(12).


  1. W in Sport Phys Act J. 2021
  2. Sports Med. 40(3):207-27
  3. Physiol. 2019. 9:1834
  4. International Olympic Committee- International Olympic Committee. 2015. Hoboken, New Jersey
  5. Br J Sports Med. 2021;55:984–990
  6. Br J Sports Med. 2021;55:526–527
  7. Br J Sports Med. 2021;55:1182–1186
  8. Sports Med. 2018; 48:2227–2234
  9. Br J Sports Med. 2021;55:462–467
  10. Br J Sports Med. 2020;54:1149–1156
  11. Br J Sports Med. 2016;50:537–544
  12. Br J Sports Med. 2021;55:1064–1065
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