Sex-Related Differences in the Incidence, Severity, and Recovery of Concussion in Adolescent Student-Athletes Between 2009 and 2019

Hannah TC, Li AY, Spiera Z, Kuohn L, Dai J, McAuley F, Ali M, Durbin JR, Dreher N, Marayati NF, Gometz A, Lovell M, Choudhri T. Am J Sports Med. 2021 Jun;49(7):1929-1937. doi: 10.1177/03635465211008596.

Take-Home Message

Female athletes have a higher chance of concussion and greater severity scores post-injury; however, males and females recovered at similar rates.


Females have a higher incidence of concussion when compared with their same sport male counterparts. However, sex differences in concussion severity, recovery, and risk of sustaining multiple concussions have not been thoroughly evaluated. Clinicians could use this information to educate athletes about risk, determine best practices to minimize this risk, and determine rehabilitation strategies.

Study Goal

The authors evaluated sex-related differences in concussion incidence, severity, and recovery following a concussion in a large cohort of young athletes.


A total of 11,563 baseline ImPACT tests were conducted between 2009 to 2019 (~15 years of age; 34% female). Medical professionals followed a standardized protocol and determined a concussion injury if at least 2 of the 5 ImPACT composite scores (e.g., verbal memory, reaction time) deviated more than 80% from baseline. The authors calculated the post-injury severity index by comparing baseline and post-injury composite scores. Among ~25% of the sample with a concussion, the authors had enough data to define recovery as the time when someone had no more than 1 composite score that deviated from baseline.


Overall, participants 12 to 22 years of age completed 5,216 post-injury tests (33% female). Of these, 1,296 participants had sufficient data to assess recovery. At baseline, females had better verbal memory, processing speed, and reaction time but reported more symptoms and had lower visual memory. Females had a 62% higher odds of concussion compared to males and reported greater post-injury severity. The higher post-injury severity index was primarily from poor processing speeds and more symptom reporting. Based on ImPACT scores, females recovered slightly slower than males (~9 vs. ~8 days); however, this may be influenced by other factors (e.g., initial severity score, age, history of concussion or learning disability).


Ultimately, the researchers demonstrated that sex differences existed at baseline and post-injury testing. Furthermore, females had a greater risk of concussion than males even after controlling for demographic factors. Much of the severity difference came from the symptom reporting. Specifically, females reported more post-concussion migraine and neuropsychiatric problems like anxiety and depression, which are treatable with therapy or therapeutic agents. Therefore, the authors highlighted that monitoring for these symptoms could help clinicians optimize management strategies to enhance patient outcomes. The authors also demonstrated that we need to better understand if sex differences in concussion recovery really exist and why. Hopefully, this study will spark other researchers and clinicians to report whether they observe similar findings when they compare athletes within a specific sport and have more standardized follow-up assessments without ~75% of people missing data.

Clinical Implications

Medical professionals should recognize that females may be at a greater risk of suffering not only more concussions but more severe concussions. Therefore, evaluating prevention programs for their sport could be advantageous. Further, clinicians should monitor patients for migraine symptoms and neuropsychiatric problems to enable more individualized treatment approaches to rehab and referral to other healthcare team members.

Questions for Discussion

Do you see your female athletes sustain more frequent and more severe concussions? Would you utilize ImPACT to determine symptom clusters or evaluate severity? Why or why not?

Related Posts

  1. Does Sex and Contraception Influence Concussion Recovery?
  2. A Closer Look At Concussions 2016-2020: Increasing Prevalence and Sex Differences
  3. Proposed Answer to Most Common Concussion Question: How many Days Until I can Play?  

Written by: Jane McDevitt
Reviewed by: Jeffrey Driban