Introduction and Context
Upper‑extremity (UE) injuries—including shoulder, elbow and wrist/hand problems—are common in many female athletes, particularly in overhead and collision sports. However, most sport injury research historically underrepresents females and often mixes sexes in analyses. In response to this evidence gap, the FAIR (Female, Athlete Injury pRevention) consensus systematically reviewed interventions and potentially modifiable risk factors (MRFs) for upper‑extremity injury specifically focusing on female, woman and/or girl athletes. The systematic review and meta‑analysis by Heming et al., published in the British Journal of Sports Medicine (2025), used PRISMA and GRADE methodology to assess prevention strategies and MRFs in studies that included at least one female participant per group [1].
Why this matters now: rising female sports participation, sport specialization at younger ages, and sex‑specific anatomical and biomechanical factors mean that evidence tailored to female athletes is critical to meaningful prevention. The FAIR review consolidates what is known, what is uncertain, and where researchers and clinicians should prioritize action.
New Guideline Highlights
Major takeaways from the FAIR consensus (Heming et al., 2025):
– Shoulder‑specific exercise programmes (strength, stability/control and sport‑specific elements) appear to reduce shoulder injury rates in female athletes (pooled reduction ~51%; 95% CI 21–70% reduction) across three randomized/controlled studies in handball and volleyball players, but certainty of evidence is very low [1].
– Seven potentially modifiable risk factors for UE injury in female athletes were identified across studies: reduced range of motion (ROM), decreased shoulder muscle strength, high training load, scapular dyskinesis, high sport specialization, equipment differences, and lower sport‑specific conditioning. Most associations were limited by small numbers of female‑specific estimates and heterogeneity in outcomes and methods [1].
– The evidence base specific to female/woman/girl athletes is sparse: among 55 included studies (33,228 athletes), only 26% were female and only 17 studies provided female‑specific estimates [1].
Key clinical implication: Integrate shoulder‑focused strength and control programmes into training for female overhead athletes, while acknowledging the low certainty and the need for individualized assessment (range of motion, strength, scapular mechanics, training load) and ongoing monitoring.
Updated Recommendations and Key Changes
This FAIR work is not a guideline from a single society but a consensus synthesis translating current evidence into practical recommendations. Compared with prior broad sport injury prevention syntheses, the FAIR project:
– Prioritized female‑specific data and explicitly documented sex gaps in the literature.
– Focused on upper‑extremity injuries (most prevention research targets lower limb).
– Applied GRADE to rate certainty of effects and highlighted where evidence is very low.
Summary of changes (compared with the general injury prevention literature):
– New emphasis on shoulder exercise programmes for female handball and volleyball players as the best available preventive strategy for shoulder injuries in this group (very low certainty) [1].
– Identification and prioritization of seven MRFs specific to UE injuries in female athletes for targeted screening and intervention.
Evidence drivers for these updates include randomized trials of shoulder programmes in handball/volleyball and multiple cohort studies reporting sex‑specific measures for ROM, strength and scapular function.
Topic‑by‑Topic Recommendations
Below are the FAIR consensus practical recommendations, with the evidence rating assigned by the authors (GRADE where available). Note: many findings carry low or very‑low certainty, reflecting heterogeneity and limited female‑only data.
1) Prevention strategy: Shoulder‑specific exercise programmes
– Recommendation: Offer structured shoulder exercise programmes that include progressive strength, neuromuscular control/stability and sport‑specific elements to female overhead athletes (especially handball and volleyball).
– Evidence summary: Pooled data from three studies showed a 51% reduction in shoulder injury rates (RR 0.49; 95% CI 0.30–0.79), I2 0%.
– Certainty: Very low (downgraded for imprecision, limited studies specific to females and variable intervention content).
– Practical application: 10–20 minute sessions integrated 2–3× weekly into warm‑ups or conditioning; progress load and complexity across season.
2) Modifiable risk factor screening and management
– Reduced range of motion (ROM): Several studies associated less ROM with higher UE injury risk.
– Action: Screen key motions (shoulder external rotation, internal rotation, flexion); implement mobility and posterior‑capsule/stretching protocols where deficits are present.
– Lower shoulder muscle strength:
– Action: Baseline strength testing (isometric/resisted rotations, scapular stabilizers) and individualized strengthening programmes.
– Scapular dyskinesis:
– Action: Assess scapular control; prescribe motor control and scapular stabilization exercises; consider referral to physiotherapy for persistent dysfunction.
– High training load and load spikes:
– Action: Monitor training volume and intensity (session RPE, throws/contacts, competition minutes); avoid sudden workload increases; adopt periodization.
– High sport specialization:
– Action: Encourage diversified movement exposure in youth; delay intensive specialization where possible.
– Equipment differences:
– Action: Ensure sport‑specific equipment (e.g., ball size, racket grip, protective gear) is appropriate for athlete body size and sex‑appropriate differences when evidence exists.
– Less sport‑specific conditioning:
– Action: Provide conditioning that mimics sport demands (plyometrics, power, repeated‑effort capacity) and addresses shoulder endurance for overhead athletes.
3) Diagnostic criteria and injury definitions
– The FAIR review highlighted heterogeneity in outcome definitions; clinicians and researchers should use standardized, validated definitions when diagnosing UE injury (time‑loss vs medical attention vs tissue pathology) to improve comparability across studies.
4) Follow‑up and monitoring
– Use ongoing monitoring (training load, pain scores, functional testing) to guide return‑to‑play and to detect early signs of overuse injury.
5) Special populations
– Youth athletes: Pay attention to growth‑related vulnerability, gradually progress volume, and discourage early specialization.
– Elite vs recreational: Tailor programme intensity and specificity; elite athletes may need periodized prevention integrated into team medical plans.
Evidence Grades and Practical Summary (Bullet List)
– Shoulder exercise programmes (strength + stability + sport‑specific): Recommendation to implement in female handball and volleyball — effect size favorable; Certainty: Very low [1].
– ROM deficits: Associated with increased risk — low to very‑low certainty; screen and address deficits.
– Shoulder strength deficits: Associated with increased risk — low certainty; implement strengthening.
– Scapular dyskinesis: Associated with injury risk — low certainty; target motor control and stabilization.
– High training load / spikes: Likely increase risk (framework supported by broader literature) — moderate certainty from broader load literature (not female‑specific) [3].
– High sport specialization and inadequate sport‑specific conditioning: Associated with higher injury risk — low certainty; recommend diversification and conditioning.
– Equipment differences: Limited evidence – consider individual fit and sex‑specific adjustments where applicable.
Expert Commentary and Insights
Paraphrased insights from the FAIR consensus authors and broader expert opinion:
– ‘‘The biggest gap is not that we lack any interventions, but that we lack high‑quality, female‑specific trials across multiple sports with consistent outcome definitions.’’ — FAIR authors [1].
– ‘‘Shoulder programmes make physiological sense: strengthening rotator cuff and scapular stabilizers, improving neuromuscular control, and improving endurance should protect the joint during repetitive overhead tasks. The evidence is promising but not definitive in women; implementation is low risk and likely beneficial.’’ — sports medicine clinician commentary.
Controversies and open questions:
– How generalizable are the handball/volleyball shoulder programme findings to other sports (e.g., tennis, swimming, baseball/softball)? Evidence is currently limited.
– Optimal content, dose and delivery (team supervised vs coach led vs digital) of shoulder programmes remain uncertain.
– The interaction between sex‑specific anatomy/biomechanics and modifiable risk factors (e.g., hormonal influences on ligamentous laxity) needs more research.
Research priorities identified by FAIR:
– High‑quality randomized trials of standardized shoulder prevention programmes in diverse female sports.
– Prospective cohorts with pre‑season screening (ROM, strength, scapular function) and consistent injury definitions with female‑only reporting.
– Trials of load‑management strategies tailored to female athletes and youth.
Practical Implications for Clinicians, Coaches and Teams
For clinicians and athletic trainers:
– Incorporate brief, progressive shoulder programmes into preseason and in‑season training for female overhead athletes.
– Screen athletes for ROM, strength and scapular control at baseline; target deficits with individualized therapy.
– Monitor training load (session RPE, volume metrics specific to sport) and flag sudden increases.
For coaches and program directors:
– Embed 10–20 minute shoulder prevention sequences into warm‑ups 2–3× per week.
– Avoid early excessive specialization for youth athletes and encourage diverse movement skills.
– Ensure equipment is appropriate for athlete size and consider sex‑specific recommendations where available.
A brief clinical vignette:
Emma, a 16‑year‑old competitive volleyball player, presents for preseason screening. She reports intermittent posterior shoulder tightness but no current time‑loss injury. Baseline testing shows reduced shoulder external rotation on the dominant side, modest weakness in external rotators and subtle scapular upward rotation asymmetry. Following FAIR recommendations, her coach and physiotherapist implement a 12‑week shoulder programme (control and rotator cuff strengthening, scapular stabilization drills, sport‑specific throwing/overhead drills) done as a 15‑minute warm‑up 3× weekly. Training loads are monitored and graduated. Over the season, Emma reports less soreness and completes the season without shoulder time‑loss, illustrating feasible application of FAIR insights.
Limitations and Cautions
– Evidence certainty is low to very low for many findings; clinicians should use clinical judgment and individualize interventions.
– Most included studies had heterogeneous injury definitions, variable interventions and few female‑only analyses, limiting generalizability.
Conclusion and Future Directions
The FAIR consensus marks an important step toward female‑specific injury prevention for the upper extremity. The best current, albeit low‑certainty, evidence supports implementing shoulder‑focused strength and neuromuscular control programmes in female overhead athletes—especially handball and volleyball players. Clinicians should pair these programmes with targeted screening (ROM, strength, scapular function), careful training‑load management and attention to equipment and conditioning.
But the overarching message from FAIR is a call to action: we need more female‑specific, methodologically robust research with standardized injury definitions and consistent reporting to turn promising interventions into strong, evidence‑based practice.
References
1. Heming EE, Gibson ES, Friesen KB, Martin CL, Martin M, Asker M, et al. Prevention strategies and modifiable risk factors for upper extremity injury: a systematic review and meta‑analysis for the female, woman and girl Athlete Injury pRevention (FAIR) consensus. Br J Sports Med. 2025 Oct 24:bjsports-2025-109907. doi:10.1136/bjsports-2025-109907. Epub ahead of print.
2. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.
3. Gabbett TJ. The training‑injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50(5):273–280.
4. Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011;64(4):380–382. (See also: Guyatt G et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–926.)
5. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2003;11(2):142–151.
(Additional primary studies referenced within Heming et al. 2025 comprise the source evidence for these recommendations.)
