How Tongue Position and Jaw Function May Improve Strength, Balance, and Breathing

Part 1 of the Improving Force Production and Movement From Head to Toe Series

Written by Michael Crawley, BSc, BPT, CSCS

Introduction

When people think about improving strength and force production, attention is usually directed toward the obvious areas: the legs, hips, trunk, and shoulders. Rarely does anyone consider the tongue or jaw.

At first glance, this seems reasonable. The tongue is typically associated with speech, swallowing, and airway function rather than athletic performance. However, emerging research suggests that tongue position, tongue strength, and jaw function may influence force production, balance, coordination, and respiratory mechanics.

While strength is often viewed as a product of the arms, legs, and trunk, force is rarely generated by a single muscle or body part. Instead, it is transferred throughout the body as multiple regions work together. Understanding these connections may provide additional opportunities to improve performance, movement quality, and long-term health.

This article is the first in a series examining how different regions of the body contribute to force production and movement quality. We will begin at the top, exploring the tongue and jaw, before working downward through the diaphragm and foot.

Series Breakdown

This series will explore three often-overlooked contributors to force production, movement quality, and long-term function:

1. The tongue and jaw

2. The diaphragm and bracing

3. The foot and pressure distribution

Together, these concepts provide additional tools that may help an individual break through a plateau in a lift, improve their strategies to strength train, or attenuate some of the deficits and systemic problems which develop with age.

The Tongue & Jaw: Pressure and Position

The embryological development and anatomy of the tongue can shed light on how it is a forgotten piece in strength training and human function beyond mastication and speech. The tongue consists of intrinsic and extrinsic muscle connections. This allows an intricate dance where the complex can adapt its activation and position differently during breathing and swallowing (Fregosi and Ludlow 2014).

The tongue has the same neural origins as the hyoid bone and associated musculature involved in head and neck stabilization. The hyoid bone is a floating bone acting as an interface for the origin of the tongue and connector of important neck and jaw muscles.

There is a functional relationship between the tongue and diaphragm, demonstrated through the coordinated activation of specific extrinsic tongue muscles during respiration (Sokoloff 2004). As a result, tongue function can influence how easily air moves through the airway and how efficiently we breathe. This will really be hammered home in Part 2 regarding the diaphragm and bracing.

The tongue and jaw do not operate independently. Resting tongue position helps influence both jaw alignment and head posture, with the ideal resting position being the tongue gently placed against the roof of the mouth.

The jaw is also closely connected to the neck and upper body through muscles, nerves, and connective tissues (Silveira et al. 2015). Because of these connections, changes in jaw position can influence how the head, neck, and shoulders work together.

This is important because force is rarely generated by a single muscle or body part. Instead, it is transferred throughout the body as multiple regions work together. The tongue and jaw may seem far removed from exercises such as squats, deadlifts, or carries, but their connections to the neck and upper body suggest they can still influence posture, stability, and force production.

The image below highlights some of the tissues that link the jaw, neck, and shoulder region. Next, we will discuss how tongue function changes over time and why this may be particularly important for the older athlete.

Importance of Tongue Function in the Older Athlete

When most people think about age-related muscle loss, they think of weaker legs, reduced grip strength, or difficulty getting up from a chair. What is often overlooked is that the tongue also loses strength and muscle mass with age.

This decline in tongue function has been associated with several important health concerns, including impaired swallowing, increased risk of aspiration, and poorer balance (Bordoni et al. 2018). In other words, tongue function may influence much more than speech or eating.

For older athletes and gym-goers, this creates an interesting opportunity. Maintaining tongue strength and awareness may be a simple strategy to support both performance and long-term health. While it is unlikely to be the most important piece of the puzzle, it may be one of the easier ones to address. Similar to strength training itself, small improvements maintained over time can have a meaningful impact on long-term health, balance, and independence.

This could be as simple as applying firm tongue pressure to the roof of the mouth during heavier lifts or practicing proper resting tongue position while performing breathing exercises and warm-up activities.

Evidence of Tongue Pressure and Strength Performance

At this point, it is reasonable to ask whether tongue position and tongue pressure actually influence strength and movement, or whether this is simply an interesting anatomical discussion.

While the research in this area is still developing, several studies have demonstrated improvements in force production, balance, and movement performance when tongue position or tongue stimulation is altered.

Some examples include:

• Saito et al. (2022) demonstrated that the rate of force development (RFD) of tongue pressure was strongly correlated with knee extensor strength and single-leg stand time in adults over 65.

• di Vico et al. (2013) found that tongue position significantly impacted knee flexor strength test performance. Participants generated approximately 30% greater force when the tongue was pressed against the roof of the mouth compared to a resting position.

• Wildenberg et al. (2010) found improvements in balance and postural sway following external tongue stimulation in older adults.

Taken together, these findings suggest that tongue function may influence more than just speech, swallowing, and breathing. It may also play a role in force production, balance, and coordination.

This does not mean tongue position should become the primary focus of a training program. Rather, it may represent another small but useful strategy that can be incorporated alongside sound strength training principles.

The diagram below demonstrates the recommended tongue position, with the tongue resting against the roof of the mouth and the tip sitting just behind the upper front teeth. The next question is why these changes might influence performance in the first place.

Why Might the Tongue and Jaw Influence Performance?

At this point, the obvious question is: why would tongue position or jaw activity affect strength, balance, and movement quality in the first place?

The honest answer is that we do not know exactly. While the relationship between tongue position and breathing is well established, the mechanisms behind its apparent influence on force production and coordination are still being investigated.

Several theories have been proposed, including changes in nervous system activation, interactions between cranial nerves involved in coordination, and connective tissue links between the tongue, neck, and chest (Bordoni et al. 2018). Regardless of the exact mechanism, multiple studies have demonstrated improvements in strength, balance, and movement performance when tongue position, tongue pressure, or jaw activity are altered.

Similar findings have been reported with jaw clenching. Research has demonstrated improvements in force production, grip strength, jumping performance, rowing strength, and balance when a jaw clench is incorporated during testing (Allen et al. 2017; Buscà et al. 2016; Alghadir et al. 2015).

However, there is an important trade-off. Unlike tongue position, excessive or habitual jaw clenching can contribute to issues such as teeth grinding (bruxism) and temporomandibular joint (TMJ) irritation. For that reason, I generally place greater emphasis on tongue position and tongue strength than aggressive jaw clenching. The potential benefits appear similar, while the downside risk is lower.

The broader lesson is that force production is not simply a function of the muscles directly involved in a lift. The body operates as an integrated system, and seemingly small factors such as tongue position, breathing strategy, and jaw position may influence how force is generated and transferred throughout the body.

This is one reason why movement assessments should look beyond individual muscles and joints. At Avos Strength, our assessment process examines how multiple systems work together to influence movement quality, performance, and long-term function.

Summary

The tongue and jaw may influence more than speech, swallowing, and chewing. Research suggests they can also affect breathing, balance, coordination, and force production.

While these factors are unlikely to be the primary drivers of performance, they represent simple strategies that may improve movement quality and strength expression when combined with sound training principles.

For older adults, maintaining tongue function may also have benefits beyond the gym, supporting balance, respiratory function, and overall quality of life.

Takeaways

• Pressing the tongue firmly against the roof of the mouth may help improve force production during strength exercises.

• Resting the tongue gently against the roof of the mouth can support an open airway and efficient breathing during mobility, warm-up, and recovery work.

• Jaw clenching may improve strength, jumping performance, and balance, but excessive or habitual clenching can contribute to jaw irritation and teeth grinding.

• If choosing between the two strategies, tongue position is likely the lower-risk and more practical place to start.

• These concepts should be viewed as small pieces of the puzzle, not replacements for sound strength training, recovery, and exercise technique.

Next Up

In Part 2, we will move one step lower and examine the diaphragm, breathing, and bracing.

Topics will include:

• Basic diaphragm anatomy and function

• The relationship between breathing and trunk stability

• Bracing strategies for strength training performance

• Practical applications for both performance and long-term health

References

Alghadir, A. H. et al. 2015. Effect of three different jaw positions on postural stability during standing. Funct Neurol 30(1), pp. 53-57.

Allen, C. et al. 2017. The Effects Of Jaw Clenching And Jaw Alignment Mouthpiece Use On Force Production During Vertical Jump And Isometric Clean Pull. Journal of Strength and Conditioning Research 32, p. 1. doi: 10.1519/JSC.0000000000002172

Bordoni, B. et al. 2018. The Anatomical Relationships of the Tongue with the Body System. Cureus 10. doi: 10.7759/cureus.3695

Buscà, B. et al. 2016. Effects of Jaw Clenching While Wearing a Customized Bite-Aligning Mouthpiece on Strength in Healthy Young Men. The Journal of Strength & Conditioning Research 30(4).

di Vico, R. et al. 2013. The acute effect of the tongue position in the mouth on knee isokinetic test performance: a highly surprising pilot study. Muscles Ligaments Tendons J 3(4), pp. 318-323.

Fregosi, R. F. and Ludlow, C. L. 2014. Activation of upper airway muscles during breathing and swallowing. J Appl Physiol 116(3), pp. 291-301. doi: 10.1152/japplphysiol.00670.2013

Miró, A. et al. 2023. Acute effects of jaw clenching while wearing a customized bite-aligning mouthguard on muscle activity and force production during maximal upper body isometric strength. Journal of Exercise Science & Fitness 21(1), pp. 157-164. doi: https://doi.org/10.1016/j.jesf.2022.12.004

Saito, S. et al. 2022. Relationship between Rate of Force Development of Tongue Pressure and Physical Performance. J Clin Med 11(9). doi: 10.3390/jcm11092347

Silveira, A. et al. 2015. Jaw dysfunction is associated with neck disability and muscle tenderness in subjects with and without chronic temporomandibular disorders. Biomed Res Int 2015, p. 512792. doi: 10.1155/2015/512792

Sokoloff, A. J. 2004. Activity of tongue muscles during respiration: it takes a village? Journal of Applied Physiology 96(2), pp. 438-439. doi: 10.1152/japplphysiol.01079.2003

Wildenberg, J. C. et al. 2010. Sustained cortical and subcortical neuromodulation induced by electrical tongue stimulation. Brain Imaging Behav 4(3-4), pp. 199-211. doi: 10.1007/s11682-010-9099-7

Why Your Training Program Won’t Work Without Sleep, Nutrition, and Recovery

Why Your Training Program Won’t Work Without Sleep, Nutrition, and Recovery

Written by Evelyn Calado, MKin, CSCS, RKin

One of the hardest things for coaches to accept is this:

You can write the most detailed, individualized, evidence-informed training program possible, and it still may not work if the big rocks are not in place.

I’ve seen this over and over again throughout my coaching career.

The athlete is committed.
They show up consistently.
They follow the sets, reps, tempos, and rest periods.
They train hard.
They genuinely want results.

But outside the gym?

They’re sleeping five hours a night.
Their stress is through the roof.
They barely drink water.
Their nutrition is inconsistent.
They rely on caffeine to survive the day and supplements to try to “fix” the problem.

At some point, the body stops being able to recover.

And recovery is where adaptation actually happens.

You Don’t Get Better During Training

Training is the stimulus.

Recovery is where the body adapts.

That means if you’re constantly exhausted, under-fueled, dehydrated, stressed, or running on poor sleep, your body has a much harder time repairing tissue, building muscle, improving conditioning, regulating hormones, and recovering from the demands of training.

This is one of the reasons why two people can follow the exact same program and get completely different results.

The program matters.

But the foundation matters more.

This is also why progress in strength, muscle growth, and conditioning often takes longer than people expect. Adaptation requires recovery capacity. How Long Does It Take to See Results from Training

Sleep Is One of the Biggest Performance Enhancers We Have

This is probably the most common issue I see.

People want better energy, better recovery, improved body composition, more muscle mass, lower pain levels, and better athletic performance, but they’re sleeping poorly every single night.

If you constantly wake up throughout the night, struggle with insomnia, or spend most of your day exhausted, your recovery capacity drops significantly.

Sleep impacts:

• Recovery from training

• Muscle repair and growth

• Hormonal regulation

• Mood and mental health

• Pain sensitivity

• Cognitive function

• Energy levels

• Immune function

You cannot out-train chronic poor sleep.

And no supplement stack is going to replace it.

Recovery Is More Than Just Taking a Rest Day

A lot of people think recovery simply means taking a day off from training.

But recovery is much bigger than that.

Recovery includes:

• Sleep quality

• Nutrition

• Hydration

• Stress management

• Recovery between training sessions

• Nervous system regulation

• Overall lifestyle habits

You cannot continuously add more stress to the system without giving the body the resources it needs to recover and adapt.

Sometimes the issue is not the program itself.

Sometimes the body simply has no remaining capacity to tolerate additional stress.

Stress Is Still Stress

This is another major piece people underestimate.

Your body does not separate “life stress” from “training stress.”

Heavy training is a stressor.
Long work hours are a stressor.
Financial pressure is a stressor.
Relationship issues are a stressor.
Anxiety is a stressor.

It all contributes to your total stress load.

One book I often recommend is the Why Zebras Don't Get Ulcers by Robert Sapolsky, which discusses how humans often stay stuck in a chronic fight-or-flight state.

A lot of people are constantly “on.”

Their nervous system never really gets a chance to downshift.

Then they wonder why they feel exhausted, inflamed, sore, unmotivated, or unable to recover.

Nutrition Is Not Optional

You cannot build a high-performing body without giving it the raw materials it needs.

Protein matters.
Micronutrients matter.
Overall calorie intake matters.
Hydration matters.

If most of your diet consists of highly processed foods, takeout, chips, candy, and energy drinks, your recovery, energy levels, body composition, and performance are going to suffer.

That does not mean you need to eat “perfectly.”

But your body still needs adequate nutrients and amino acids to:

• Build and maintain muscle

• Recover from training

• Support connective tissue health

• Improve body composition

• Regulate energy levels

• Support overall health and longevity

Supplements can support a good foundation.

They cannot replace one.

Creatine is great.
Protein powder can be helpful.
Certain supplements absolutely have value.

But supplements cannot compensate for chronic sleep deprivation, poor nutrition, dehydration, and unmanaged stress.

If you want a deeper breakdown on the supplements that actually matter most for recovery and performance, check out The Only Two Supplements Most Athletes Actually Need.

Hydration Is More Important Than People Think

This is another one that gets overlooked constantly.

The number of people I meet who drink one or two glasses of water per day is honestly surprising.

Many people function almost entirely on coffee and caffeine.

Hydration impacts:

• Performance

• Recovery

• Energy

• Cognition

• Joint comfort

• Muscle function

• Cardiovascular function

Even mild dehydration can negatively affect how you feel and perform.

Coaches Cannot Do The Work For You

As coaches, we can guide you.
We can educate you.
We can build individualized programs.
We can adjust your training loads.
We can help create structure and accountability.

But we cannot sleep for you.
We cannot manage your stress for you.
We cannot hydrate for you.
We cannot make your nutritional choices for you.

If we see you twice per week in person, that’s two hours out of a 168-hour week.

The other 166 hours matter.

A lot.

This is one of the reasons why our initial assessment process focuses on more than just exercises and sets and reps. Understanding lifestyle, recovery, stress, injury history, and daily habits matters when building an individualized plan. What Actually Happens During an Initial Assessment?

The Big Rocks Come First

People often search for advanced solutions before they’ve mastered the fundamentals.

They want the perfect program.
The perfect supplement stack.
The perfect recovery gadget.
The perfect optimization strategy.

Meanwhile:

• They sleep poorly

• They are chronically stressed

• They barely eat protein

• They drink almost no water

• They recover inconsistently

The basics are not boring.

The basics are foundational.

And honestly, these “big rocks” are not just important for performance or body composition goals. They are fundamental for living a healthier, more energetic, and more resilient life.

That’s one of the reasons why strength training and recovery habits become increasingly important as we age. Strength Training for Longevity: Staying Active, Capable and Competitive as You Age

Training matters.
Strength matters.
Conditioning matters.

But none of it works as well if the foundation underneath it is unstable.

Get the big rocks in place first.

Everything else works better after that.

At Avos Strength, we focus on individualized coaching that takes into account your training history, recovery capacity, lifestyle, stress levels, and long-term goals. Training is important, but sustainable progress comes from addressing the full picture.

If you’re looking for guidance with strength training, recovery, performance, or long-term health, you can learn more about our coaching and assessment services here.

Frozen Shoulder: Unravelling the Complexities and Providing Clarity

Written by Michael Crawley, BSc, BPT, CSCS

Nearly 100 years ago, Earnest Codman coined the term “frozen shoulder” and highlighted three clinical issues (Salamh et al. 2025):

• Difficult to define

• Difficult to treat

• Difficult pathology to explain to patients

Those three points still hold true today.

Multiple structures and pathological findings have been implicated in the development of frozen shoulder. This includes the accumulation of immune system mediators, thickening of ligaments, and altered collagen translation (Pandey and Madi 2021). Clinically, this presents as a shoulder with reduced range of motion in both active and passive flexion, abduction, and external rotation (as seen in the image below).

Figure 1: Reduced Shoulder range of motion (ROM) with frozen shoulder

The Real Impact of Frozen Shoulder

A scoping review examining how people experience and live with frozen shoulder demonstrates how debilitating and impactful the condition can be. King and Hebron (2023) identified five major themes:

1. “Dropping me to my knees, due to the pain”

2. Struggle for normality

3. Emotional change for self

4. Challenges through the healthcare journey

5. Coping & adapting

This highlights that frozen shoulder is not just a physical limitation. It can significantly alter how someone functions and experiences their daily life.

Unfortunately, frozen shoulder demonstrates a bias towards a particular demographic. Females in the 40–60 age category take the brunt of diagnoses. To rub salt in the wounds, females are more likely to experience a more prolonged and symptomatic course compared to male counterparts.

Types of Frozen Shoulder

Frozen shoulder can be broadly classified into two categories (Pandey and Madi 2021):

Primary:
A stiff shoulder developing with no known cause. However, there are commonly linked conditions, most notably diabetes mellitus and thyroid dysfunction. The incidence of frozen shoulder can reach as high as 30% in individuals with diabetes.

Secondary:
A stiff shoulder with an underlying cause such as direct trauma (e.g. a fall), infection, or inflammatory conditions.

The Three Stages of Frozen Shoulder

Frozen shoulder follows a series of stages, delineated by changing symptoms (Date and Rahman 2020). While approximate timelines are often attached, there is significant variability, and for some individuals, full resolution may not occur within 3–5 years.

Freezing Stage (Stage 1: 2–6 months)

• Predominantly characterised by moderate to severe pain and partial restriction of ROM

• Early stages may present with pain and only terminal loss of ROM

This stage can be confused with rotator cuff tendinopathy. However, ROM does not progressively worsen in tendinopathy, whereas it continues to worsen with each follow-up in frozen shoulder.

Frozen Stage (Stage 2: 4–12 months)

• Characterised by both pain and stiffness in varying proportions

• Early phase tends to be more pain-dominant

• Later phase becomes more stiffness-dominant

Thawing Stage (Stage 3: 6–26 months)

• Characterised by minimal pain

• Gradual resolution of stiffness

• Progressive return of movement

Pathologically, this reflects a gradual reduction in inflammation and restoration of movement.

Treatment and Management Across the Stages

What actually works, and when it matters

The research on the effectiveness of treatments for frozen shoulder remains conflicting. However, a conservative approach is typically recommended as the starting point (Date and Rahman 2020).

Common interventions include:

• Analgesics

• Physiotherapy

• Intra-articular injections

• Suprascapular nerve block

Early Stage: Movement Within Tolerance

In the early stage of frozen shoulder, gentle stretching and mobility exercises within a pain-free range are advised (Date and Rahman 2020).

Creativity can play a key role here, as Louis Gifford, the brilliant pain specialist, stresses. In his book Aches and Pains, he explains how adjusting body position can influence the amount of pain-free range available to a limb.

The videos below demonstrates this concept. The key idea is simple:

• The arm can move relative to the body

• Or the arm can stay fixed while the body moves around it

Shoulder Range of Motion Wall Drills:
https://youtu.be/9_GwO7r24hM

Passive and active-assisted exercises can also be incorporated. These reduce the working stress on affected structures, allowing the humerus to move through range without generating or exacerbating pain.

Active Assisted and Passive Shoulder:
https://youtu.be/072jZDVW-ac

As Pain Settles: Introducing Strength

As pain begins to reduce and become more manageable, strengthening exercises can be introduced.

Here, the principle that “the dose and position make the poison” becomes particularly relevant.

Using isometrics in varying positions and directions allows for global loading through the shoulder while staying within tolerable limits.

Entry Level Isometric:
https://youtu.be/mDzgyyKlzZo

Later Stages: What Are Mobilisations Actually Doing?

Mobilisations performed by a physiotherapist in the later stages have shown some utility. However, the mechanism behind their effectiveness is contested.

For many years, the prevailing thought was that inferior mobilisation directly impacted the shoulder joint capsule. However, Jeremy Lewis, a well-known Australian shoulder specialist, has pointed out that a physiotherapist would need to generate approximately 600kg of force to meaningfully affect the capsule.

I am not aware of many Canadians with a 600kg deadlift.

The best approach at this stage would be to continue to progress strength training through pain free range.

Injections and Medical Management: Timing Is Key

Outside of physiotherapy, injections and pharmacological treatments are often used.

Nonsteroidal anti-inflammatories have shown little impact in the case of frozen shoulder. Intra-articular steroid injections, however, have demonstrated positive effects, particularly when used at the right time.

Again, Jeremy Lewis stresses that these injections must be used in the early stages, when pain is highest. This reinforces the importance of early and accurate diagnosis.

A similar pattern is seen with suprascapular nerve blocks, which can also have a positive effect on pain relief when applied early (Date and Rahman 2020).

Surgical Options: Often Less Helpful Than Expected

Surgical options are available, but often yield little additional benefit.

Beard et al. (2018) found no clinically significant benefit of shoulder arthroscopy compared to sham surgery. This was further supported by the large UK FROST trial (Corbacho et al. 2021), which reported that early physiotherapy was more cost-effective and accessible compared to invasive and costly surgical approaches.

Interestingly, manipulation under anaesthetic, which previously had negative connotations, has shown some efficacy. This likely relates to the reduction of muscle guarding and tension that can develop with frozen shoulder. When under anaesthetic, this guarding effect is temporarily removed.

Looking Beyond the Shoulder

An important point that is often not expressed or evaluated in the research is that frozen shoulder may be a sign of broader health issues, stemming from multiple systems in the body.

In many cases, it can act as a wake-up call to incorporate strength and conditioning into your lifestyle and address other health metrics.

You may not be able to train the affected side in the same way, but there are still many full-body exercises that can be performed without exacerbating the shoulder:

• Towing a sled

• Belt squat

• Walking lunges

• Step-ups

Why This Matters

There are three key reasons why this approach is important:

1. Approximately 1 in 5 people go on to develop similar symptoms in the opposite shoulder (Pandey and Madi 2021)

2. Sedentary individuals are more likely to receive a frozen shoulder diagnosis

3. Well-designed strength and conditioning programs can positively influence the systems linked to frozen shoulder development, including endocrine, immune, and cardiovascular systems

Deeper Dive into Causation and Management

Recent research has continued to highlight the multi-faceted nature of frozen shoulder and the challenges associated with its management (Navarro-Ledesma 2025a).

This is not a condition driven by a single structure or isolated tissue. Instead, it reflects the interaction of multiple systems within the body.

The diagram below highlights this well. Rather than being caused by one specific issue, frozen shoulder appears to sit at the intersection of several physiological systems, all of which can influence one another.

Estrogen and Menopause

One of the more consistent patterns seen in the research is the increased prevalence of frozen shoulder in peri-menopausal women. This has led to estrogen being identified as a key player in its development (Wend et al. 2012).

As shown in figure below, estrogen has effects that extend well beyond the reproductive system. Its influence spans multiple systems that are directly relevant to frozen shoulder.

Neuroendocrine System

Declining estrogen levels can influence the nervous system through several mechanisms, impacting pain thresholds, resilience to stress, and central sensitisation.

A useful way to think about this is the “fire alarm” analogy.

You leave the bacon on the grill too long and the fire alarm goes off because of the smoke. There is no fire, but the system reacts as if there is.

With reduced estrogen levels, the threshold for triggering that “alarm” can become lower. The result is an amplified pain experience, even when the underlying tissue irritation may not fully justify it.

Metabolic System

Estrogen also plays a key role in fat metabolism, glucose regulation, and resistance to oxidative stress.

When these systems are disrupted, it can create an internal environment where tissue repair is compromised. This contributes to fibrosis, which is a hallmark of frozen shoulder.

Immune System

The same pattern continues within the immune system.

Declining estrogen levels tend to promote a more pro-inflammatory state. Immune system mediators accumulate within the tissues involved in frozen shoulder, and when combined with metabolic dysfunction, this can further drive the condition.

Targeting the System, Not Just the Shoulder

The research highlights how frozen shoulder is influenced by multiple systems, not just the shoulder itself. As a result, management is not limited to physiotherapy or surgical intervention alone.

There are a number of factors that could be explored here, but for the purpose of this piece, three of the more relevant and actionable areas will be discussed below.

Strength and Conditioning

Well-designed and properly implemented strength and conditioning programs have demonstrated positive impacts on estrogen levels, muscle mass, and fat mass in menopausal women (Razzak et al. 2019).

As mentioned previously, even with an impacted and painful shoulder, this does not mean avoiding training altogether or waiting for full resolution before doing anything.

The whole-body and multi-system benefits of strength training can influence long-term outcomes indirectly. While the shoulder itself may be limited, the broader physiological adaptations still matter.

Nutrition

Diet quality also plays a meaningful role.

A nutritional approach centred around higher-quality, minimally processed foods has been shown to impact symptom severity in individuals with frozen shoulder (Hamed-Hamed et al. 2026).

In practice, the decision to implement a structured strength training program often leads to improvements in other lifestyle behaviours, including dietary choices.

In the same way that hormonal, metabolic, and immune factors can drive the development of frozen shoulder, lifestyle decisions can push back against these drivers. This not only has the potential to improve current symptoms, but also to reduce the likelihood of future development.

Sleep and Circadian Rhythm

Circadian rhythm and sleep regulate inflammatory processes, hormonal release, and tissue repair (Navarro-Ledesma 2025a).

These are central to both general health and the development and recovery of frozen shoulder, as well as adaptation to strength training and exercise.

This is where the entanglement of systems becomes more apparent.

Bringing It Together

Sleep, exercise, and nutrition can be thought of as a three-legged stool. Each supports the others, and removing one weakens the entire system.

Addressing these factors will not provide an immediate solution to frozen shoulder. However, they can set the conditions for recovery and reduce the likelihood of recurrence, particularly when considering that approximately 20% of individuals will experience similar symptoms in the opposite shoulder.

Summary and Takeaways

Frozen shoulder is a systems issue, not just a joint problem

Frozen shoulder is not a local condition. It can have significant and long-term effects on both physical and psychological well-being.

In some cases, it can be so debilitating that it alters how an individual functions day to day. That may sound hyperbolic, but when revisiting the five themes outlined earlier, alongside the number of systems involved, it becomes more understandable.

Approaching treatment with a reductionist lens, relying solely on an injection or a home exercise program, is akin to using a hammer where a scalpel is required. This sentiment is supported in a recent review by Brindisino et al. (2026).

Effective management requires a more nuanced and personalised approach that considers the multiple drivers involved:

• Hormonal (endocrine)

• Immune system (autoimmune / inflammatory)

• Strength, mobility, and capacity

• Cardiovascular health

• Pain psychology (sensitisation and emotional drivers)

• Structural factors

• Circadian rhythm and sleep

Key Takeaways

• General strength training can still be completed and is beneficial with a frozen shoulder diagnosis

• Surgical interventions are often unwarranted and do not demonstrate superior outcomes

• Frozen shoulder is multi-factorial, and lifestyle factors such as exercise, nutrition, and sleep play a critical role in both management and risk reduction

References

Beard, D. J. et al. 2018. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet 391(10118), pp. 329-338. doi: 10.1016/S0140-6736(17)32457-1

Brindisino, F. et al. 2026. Beyond the capsule: an integrated perspective on the wide world of frozen shoulder. A collaborative viewpoint. Pain Management, pp. 1-20. doi: 10.1080/17581869.2026.2636725

Corbacho, B. et al. 2021. Cost-effectiveness of surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder : an economic evaluation of the UK FROST trial. Bone Jt Open 2(8), pp. 685-695. doi: 10.1302/2633-1462.28.Bjo-2021-0075.R1

Date, A. and Rahman, L. 2020. Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies. Future Sci OA 6(10), p. Fso647. doi: 10.2144/fsoa-2020-0145

Hamed-Hamed, D. et al. 2026. Impact of nutritional profile on pain and functionality in patients with frozen shoulder: a cross-sectional observational study. Frontiers in Medicine Volume 13 - 2026,  doi: 10.3389/fmed.2026.1785577

King, W. V. and Hebron, C. 2023. Frozen shoulder: living with uncertainty and being in “no-man’s land”. Physiotherapy Theory and Practice 39(5), pp. 979-993. doi: 10.1080/09593985.2022.2032512

Navarro-Ledesma, S. 2025a. Frozen Shoulder as a Systemic Immunometabolic Disorder: The Roles of Estrogen, Thyroid Dysfunction, Endothelial Health, Lifestyle, and Clinical Implications. J Clin Med 14(20),  doi: 10.3390/jcm14207315

Navarro-Ledesma, S. 2025b. Frozen Shoulder as a Systemic Immunometabolic Disorder: The Roles of Estrogen, Thyroid Dysfunction, Endothelial Health, Lifestyle, and Clinical Implications. Journal of Clinical Medicine 14(20), p. 7315. 

Pandey, V. and Madi, S. 2021. Clinical Guidelines in the Management of Frozen Shoulder: An Update! Indian J Orthop 55(2), pp. 299-309. doi: 10.1007/s43465-021-00351-3

Razzak, Z. A. et al. 2019. Effect of aerobic and anaerobic exercise on estrogen level, fat mass, and muscle mass among postmenopausal osteoporotic females. Int J Health Sci (Qassim) 13(4), pp. 10-16. 

Salamh, P. et al. 2025. An international consensus on the etiology, risk factors, diagnosis and Management for individuals with Frozen Shoulder: a Delphi study. J Man Manip Ther 33(4), pp. 309-320. doi: 10.1080/10669817.2025.2470461

Wend, K. et al. 2012. Tissue-Specific Effects of Loss of Estrogen during Menopause and Aging. Frontiers in Endocrinology Volume 3 - 2012,  doi: 10.3389/fendo.2012.00019

You Should Not Get Injured During a Training Session

Written by Evelyn Calado, MKin, CSCS, RKin

If you leave a training session injured, something has gone wrong.

That is not normal. It should not be expected. And it is not part of “training hard.”

I have been in this industry for over a decade, and I have seen far too many situations where clients get hurt in the weight room. Not because of bad luck, but because of poor decisions.

The Gym Should Be One of the Safest Places You Train

Think about it.

The weight room is a controlled environment.

• You control the load

• You control the movement

• You control the pace

• You control the rest

Compare that to sport, where there are opponents, unpredictable movements, and variables you cannot control.

In theory, your injury risk in the gym should be extremely low.

That does not mean training is easy. You should still be challenged. You should still push your limits.

But it should be done in a controlled and intentional way.

Where Things Go Wrong

Most training-related injuries are not random. They come from avoidable mistakes.

1. Ego-Based Training

This is one of the biggest issues.

A client walks in, maybe they look strong or athletic, and the session becomes about proving something. The load goes up too quickly, technique breaks down, and fatigue is ignored.

That is how people get hurt.

2. No Plan

This is more common than people think.

Clients come in and have no idea what they are doing that day. The trainer is choosing exercises on the spot with no structure, no progression, and no record of previous sessions.

Without a plan, there is no progression. Without progression, there is no direction. And without direction, you are just accumulating risk.

3. Poor Exercise Sequencing

Fatigue matters.

If someone is pushed to the point of exhaustion through their legs and core, and then asked to perform a heavy compound lift, that is a problem.

That is not “hard training.” That is poor decision-making.

4. Ignoring the Individual

Not every client should move the same way.

Mobility, injury history, movement patterns, and training experience all matter. If those are ignored, you are forcing someone into positions they are not prepared for.

That is where breakdown happens.

Soreness Is Not the Goal

Another misconception is that a good session should leave you unable to move.

If your trainer’s goal is to completely destroy you, that is a red flag.

• You should not struggle to sit at your desk

• You should not be unable to walk for days

• You should not feel worse instead of better

Anyone can make you tired.

It takes skill to build a program that challenges you, progresses you, and still allows you to function.

What Good Training Actually Looks Like

Good training is not random. It is structured.

• There is a clear plan

• There is progression over time

• Your loads and performance are tracked

• Exercises are selected for a reason

• Intensity is managed, not guessed

You are pushed, but within your capacity.

You improve, without being completely broken down in the process.

Playing the Long Game

At Avos Strength, the focus is simple:

Train. Play. Repeat.

The goal is not to win a single session. The goal is to keep you training consistently, improving over time, and continuing to do the things you enjoy.

That means:

• Checking your ego at the door

• Building progressively

• Respecting your current capacity

• Training with intention

The Bottom Line

The gym should not be where you get injured.

Can things happen occasionally? Yes. But injuries should be rare, not expected.

If you have worked with a trainer and felt unsafe, unsupported, or left sessions worse than when you walked in, that is not something you should accept.

You deserve better coaching than that.

Osteopenia and Strength Training for Women: What Happens Before Menopause

Written by Evelyn Calado, MKin, CSCS, RKin

There is a persistent misconception that bone loss is something that “just happens” after menopause. By the time many women start thinking seriously about bone density, the process of loss is already well underway.

Osteopenia and strength training are directly linked, yet most women are not told how early bone loss actually begins.

Bone health is not a passive outcome of aging. It is an active, dynamic process shaped by hormones, mechanical loading, and energy availability across the entire female lifespan.

Understanding osteopenia requires understanding one central principle: bone is living tissue, constantly undergoing remodeling through the opposing actions of osteoblasts and osteoclasts.

Bone Remodeling: The Balance Between Formation and Breakdown

At any given moment, your skeleton is not static. It is metabolically active.

• Osteoblasts are responsible for bone formation

• Osteoclasts are responsible for bone resorption

In a healthy system, these processes are tightly coupled. Bone that is broken down is replaced with new, strong bone. The integrity of your skeleton depends on the balance between these two forces.

Estrogen plays a critical regulatory role in maintaining this equilibrium.

Estrogen as a Regulator of Bone Turnover

Estrogen is not just a reproductive hormone. It is deeply involved in musculoskeletal health.

It functions, in part, by:

• Inhibiting excessive osteoclast activity

• Supporting osteoblast survival and activity

When estrogen levels are stable, bone turnover remains balanced. But when estrogen becomes low or erratic, this regulatory system begins to fail.

Estrogen does not “leach calcium from bone.” Its decline removes inhibitory control over osteoclasts, allowing bone resorption to outpace formation.

The result is a gradual reduction in bone mineral density, what we clinically recognize as osteopenia, and eventually osteoporosis if left unchecked.

Perimenopause: The Underappreciated Inflection Point

Much of the conversation around bone health focuses on postmenopause. However, perimenopause is a critical and often overlooked phase.

This is not simply a state of low estrogen. It is a state of hormonal volatility.

During perimenopause:

• Estrogen levels fluctuate unpredictably

• Progesterone exposure becomes inconsistent

• The coordination of tissue remodeling processes becomes impaired

These fluctuations influence:

• Bone turnover

• Muscle protein synthesis

• Recovery capacity

The net effect is a physiological environment that becomes increasingly catabolic, meaning tissue breakdown can begin to exceed tissue formation.

This is why bone density decline can begin before menopause is complete.

The Muscle–Bone Unit: Why Strength Matters

Bone does not exist in isolation. It is functionally linked to muscle through what is often referred to as the muscle–bone unit.

When muscle contracts, it exerts mechanical force on bone. This mechanical strain is the primary stimulus for bone adaptation.

Without sufficient loading, the body interprets bone as metabolically expensive and unnecessary, and osteoclastic activity increases accordingly.

Strength training directly targets this system.

Through high-load resistance exercise:

• Muscle force increases

• Mechanical strain on bone increases

• Osteoblast activity is stimulated

• Bone mineral density is preserved or improved

This is not a marginal effect. It is one of the most powerful non-pharmacological interventions available for maintaining skeletal integrity.

If you are unsure where to start, this is exactly where an individualized approach matters. [Start with an Initial Assessment]

Why Endurance Alone Is Not Enough

Many active women assume that being “fit” is sufficient to protect bone health. However, endurance training does not provide the same osteogenic stimulus as resistance training.

In fact, without adequate nutrition and strength work, high volumes of endurance exercise can:

• Increase cortisol and systemic stress

• Contribute to low energy availability

• Impair bone formation

Bone health requires specific, targeted mechanical loading, not just general activity.

Why Strength Training Is Essential for Women’s Bone Health

Dr. Stacy Sims is explicit. Strength training is not optional for women. It is a lifelong requirement.

General recommendations include:

• At least 2 to 3 strength sessions per week

• Emphasis on heavy resistance, not just light weights

• Inclusion of compound lifts and power-based movements

This becomes even more critical during perimenopause and beyond, when:

• Muscle mass becomes harder to maintain

• Hormonal support for tissue repair declines

• The risk of accelerated bone loss increases

Strength training is not simply about preserving aesthetics or performance. It is about maintaining structural integrity.

For most people, this requires structure, progression, and accountability. [Explore Personal Training Options]

The Compounding Effect of Muscle Loss

Muscle loss and bone loss are interconnected.

As muscle mass declines:

• Mechanical loading on bone decreases

• Bone formation signals weaken

• Risk of fragility increases

Hormonal environments during this phase can also increase muscle protein breakdown, making it harder to maintain lean mass without intentional intervention.

This creates a feedback loop:

Less muscle leads to less bone stimulus, which leads to weaker bone and higher injury risk.

Strength training interrupts this cycle.

Bone Health Is Built, Not Preserved

One of the most important reframes is this:

You are not trying to hold on to bone. You are trying to continually build and reinforce it.

Bone is responsive tissue. It adapts to the signals it receives.

• If the signal is inactivity, bone loss occurs

• If the signal is chronic stress without adequate fuel, bone loss occurs

• If the signal is heavy loading with adequate nutrition, bone strength improves

Perimenopause does not mark the end of this adaptability. It simply raises the stakes.

Final Thoughts

Osteopenia is not an inevitable consequence of aging. It is, in large part, the result of mismatched physiology, where hormonal changes are not met with appropriate mechanical and nutritional support.

Estrogen may set the stage, but behavior determines the outcome.

Strength training, done consistently and with sufficient intensity, provides the necessary stimulus to:

• Maintain bone mineral density

• Preserve lean muscle mass

• Counteract the catabolic shifts of hormonal fluctuation

For women entering perimenopause, this is not optional. It is essential.

And the earlier this foundation is built, the more resilient the system becomes over time.

This is why most of the women we work with are already incorporating structured resistance training before these changes begin. [Learn More About Hybrid Coaching]

Source

Dr. Stacy Sims, ROAR

ACL Injury Risk in Female and Youth Athletes: What Actually Matters (Part 2)

Written by Michael Crawley, BSc, BPT, CSCS

Anterior cruciate ligament injuries are a significant issue in sport, particularly among female and youth athletes. Female athletes have a significantly greater incidence of ACL injury compared to males, with research suggesting the risk may be between 2 and 8 times higher depending on the population studied (Herzberg et al. 2017).

A number of factors have been proposed to influence this increased risk. These include both extrinsic factors such as playing surface, and intrinsic factors such as biological, structural, and physical characteristics. This article focuses on the intrinsic side of the equation.

If you have not read Part 1, where we break down how ACL injuries occur and what influences risk more broadly, you can start here: ACL Injuries: How They Occur, Who Is at Risk, and Why Training Quality Matters

The key intrinsic factors that may influence ACL injury risk in the female athlete include:

• hormonal influences

• biomechanics and structural considerations

• strength and neuromuscular control

It is also important to recognize that surgery is not the only solution following an ACL injury. The appropriate approach depends on the athlete’s age, injury severity, and the presence of additional damage such as meniscal or cartilage involvement. Graft selection is also influenced by these factors and plays an important role in long-term outcomes.

Menstruation and Hormones

The menstrual cycle consists of three phases, each characterized by fluctuations in key hormones including estrogen, progesterone, and luteinizing hormone (Wojtys et al. 2002).

• Follicular phase: approximately 9 days

• Ovulatory phase: approximately 5 days, marked by peaks in estrogen and luteinizing hormone

• Luteal phase: approximately 14 to 15 days, with elevated progesterone

Research in this area remains mixed. However, several studies have reported a higher incidence of ACL injuries during the ovulatory phase compared to other phases (Wojtys et al. 2002; Herzberg et al. 2017).

Wojtys et al. (2002) demonstrated a higher number of ACL injuries, marked as X on the figure above, in a group of young female athletes during the ovulatory phase. The mechanisms behind this relationship are varied and often disputed. At the neurological level, Kumar et al. (2013) demonstrated reduced reaction time to visual and auditory stimulus between the follicular and luteal phases.

From a structural perspective, the ACL contains estrogen receptors, and cell culture research has demonstrated that estrogen can influence the ligament’s collagen composition. It is proposed that this may increase knee joint laxity. Maruyama et al. (2021) examined knee laxity across the menstrual cycle and found increased anterior knee laxity during the ovulatory phase.

However, this difference was only observed when participants were grouped into those with genu recurvatum and those without it, meaning athletes whose knees hyperextend 10 degrees or more versus those who do not. This adds another layer of complexity, as it suggests that biomechanical factors such as hyperextension may interact with hormonal factors such as higher estrogen levels rather than acting independently.

Relaxin is another important peptide hormone that has been specifically linked to injury risk in female athletes. It appears to work synergistically with estrogen, contributing to changes in ligament laxity (Berger et al. 2023; Parker et al. 2024).

Relaxin exerts its effects in two key ways:

• increases type 1 collagen degradation

• suppresses collagen synthesis

Given that ligaments are composed of approximately 40 to 50 percent type 1 collagen, this provides a plausible mechanism by which relaxin may influence ACL integrity. Alterations in the collagen structure of the ligament are one proposed explanation for increased laxity and injury risk.

Parker et al. (2024) also highlight a practical consideration. Relaxin levels tend to peak around days 21 to 24 of the menstrual cycle. In a coaching setting, this may present as an athlete reporting unexplained musculoskeletal discomfort around the knee without a clear training-related cause. This is not something to overreact to, but it can serve as a useful opportunity for education, monitoring, or short-term modification of training.

Across the cycle, these hormonal fluctuations may contribute to changes in reaction time, ligament laxity, and available joint range of motion. While some research has explored the use of oral contraceptives to regulate these hormonal variations and potentially reduce ACL injury risk (Herzberg et al. 2017), the quality of evidence remains low and is often confounded by multiple variables.

More importantly, as Parker et al. (2024) point out, oral contraceptives are not without trade-offs. While they may influence hormones such as relaxin and estrogen, there are more accessible and lower-risk interventions available. For most young female athletes, this is not where the focus should be.

Which leads into the next major factor: strength and neuromuscular training.

Strength and Neuromuscular Training

As female participation in sport has increased over the past few decades, there has been a corresponding increase in injury rates. At the same time, training age and exposure to structured strength and conditioning within a gym setting has generally lagged behind that of male athletes.

Well-rounded strength and conditioning is not only a tool to support and improve performance in sport. It can have a profound effect on robustness and coordinative qualities, helping to mitigate injury risk.

For a deeper look at how strength training should be structured for younger athletes, see: Building a Strong Foundation: The Crucial Role of Youth Strength and Conditioning

In young female athletes, several characteristics have been associated with increased ACL injury risk (Collings et al. 2022):

• lower strength ratios between hip adductors and abductors

• reduced trunk control

• higher countermovement peak force values

This highlights the importance of a complete strength and conditioning plan. As young athletes improve jumping ability and increase power output, the risk of ACL injury and other issues such as patellofemoral pain may also increase (Myer et al. 2015; Collings et al. 2022).

Training for these athletes must address several components:

• maximal strength and power

• jumping and landing mechanics and technique

• strength capacity

• energy system development

Sugimoto et al. (2016) demonstrated that neuromuscular programs that include a combination of strength training, jumping, trunk control, and coordination significantly reduce ACL injury risk in young female athletes.

Practical Exercise Examples

Below are five exercises that cover several key qualities related to performance and injury mitigation:

• Side lunge deceleration control

• Front squat

• Side plank hip abduction iso

• 1-2-1 broad jump

• Split stance press + hip hike

Adjusting variables such as volume, intensity, range of motion, and frequency can make exercises like these highly effective across a range of sports and athlete levels.

Adherence, Enjoyment, and the Training Environment

Several factors can impact adherence in young female athletes:

• time

• enjoyment

• coaching expertise

• equipment access

Research suggests that even two 30-minute sessions per week in-season can meaningfully reduce ACL injury risk, provided a more comprehensive program is completed in the off-season (Sugimoto et al. 2016).

Enjoyment and coaching quality are closely linked. Engagement in the gym setting can be a challenge, particularly for younger athletes. Incorporating competition, variability, and game-based elements can improve buy-in and training consistency.

Reaction, Coordination, and Game-Based Training

The following examples can be used to improve reaction time, coordination, and strength:

• Tennis ball reaction game

• Walking lunge with figure 8 pass

These drills can be implemented in pairs, relay formats, or with sport-specific variations. They also expose athletes to a broader range of movement patterns.

This ties closely into long-term athlete development principles, which are outlined further here:
Build the Athlete First: Why Youth Athletes Need Physical Literacy Before Sport Specialization

An additional benefit of implementing games with different constraints and equipment is the development of energy systems and exposure to a wider range of motor patterns. The importance of this is two-fold.

1. Fatigue has been shown to impact landing control and hip-to-ankle force dissipation in female athletes (Mancino et al. 2024). Improving overall capacity can enhance an athlete’s ability to maintain reaction time and landing mechanics over longer periods.

2. Game and exercise constraints can also help offset the repetitive, high-volume actions seen in many sports. This becomes even more relevant in athletes who specialize early in a single sport.

Luo et al. (2025) found that early sport specialization increases injury risk, reduces long-term performance, and negatively impacts psychological outcomes. With a creative and experienced coach, the gym setting can serve as a valuable environment to address these gaps.

That said, even with a well-informed and diligent athlete who engages in strength training and participates in multiple sports, ACL injuries can still occur.

Surgical Route and Graft Selection

When a discussion has been made and surgery is deemed the best option, the next decision is graft selection. The importance of this choice lies in the fact that it is one of the few modifiable factors (Duchman et al. 2017). For the young female athlete, variables such as sex, age, and sporting demands cannot be changed.

The main graft options include:

• Autograft: tissue harvested from the athlete’s own body. Common options include hamstring tendon (HT), bone-patellar tendon-bone (BPTB), and quadriceps tendon (QT)

• Allograft: donor tissue. Options can include tibialis anterior, Achilles tendon, hamstring, or patellar grafts (Duchman et al. 2017)

Pinheiro et al. (2022) conducted a large analysis in female athletes and found that bone-patellar tendon-bone grafts had a lower incidence of graft failure compared to hamstring grafts. This becomes more nuanced when age is considered.

Mancino et al. (2024) reported that BPTB grafts had lower re-rupture rates in females aged 15 to 20 compared to hamstring autografts. However, in athletes aged 21 and older, outcomes between BPTB and hamstring grafts were similar.

Graft revision risk is also an important consideration. Pinheiro et al. (2022) found that revision rates were 1.8 times higher in hamstring grafts compared to BPTB, increasing to 2.8 times in females under 18. This is particularly relevant, as revision surgeries tend to produce poorer outcomes compared to primary ACL reconstruction (Meena et al. 2024).

More recent evidence suggests that quadriceps tendon grafts produce comparable outcomes in terms of knee stability, functional performance, and re-tear risk (Meena et al. 2024).

Previous injury history should also influence graft selection. Lazarides et al. (2018) reported that a history of moderate to severe patellar tendinopathy was associated with increased graft failure when using BPTB grafts.

Similarly, hamstring autografts may contribute to post-surgical return-to-sport challenges (Bouzekraoui Alaoui et al. 2025), including:

• persistent strength deficits compared to the uninvolved side

• reduced maximum effective angle, a proxy for hamstring function and potential injury risk

In athletes with a history of recurrent hamstring strains or existing strength deficits, harvesting a hamstring graft from the involved side should be carefully considered. This may further complicate the already challenging process of restoring hamstring strength and function during rehabilitation.

Additional Surgical Consideration: LET

Another surgical consideration is the lateral extra-articular tenodesis (LET), which may provide additional protection against re-injury. Recent research has identified specific factors where LET can help reduce risk and may be used as an added layer of structural support (Meena et al. 2024).

These factors include:

• increased general knee ligament laxity

• high tibial slope and increased knee hyperextension

• return to high-demand sport

• younger age

These considerations are particularly relevant for the young female athlete. As discussed throughout this article, hormonal influences on ligament laxity, along with structural characteristics such as knee hyperextension, are commonly observed in this population.

Using appropriate graft selection alongside LET where indicated provides an additional layer of structural support and may improve long-term outcomes in higher-risk athletes.

Summary

There is a complex interplay between hormonal, structural, and neuromuscular factors that may increase ACL injury risk in young female athletes. While many aspects of the research still require further clarity, it is clear that both modifiable and non-modifiable factors are at play.

There are several practical approaches that can help mitigate risk while also improving performance. As participation in female sport continues to grow, appropriate exposure to education, training, and support systems is no longer optional. It is essential.

Actionable Takeaways

• Pre-season screening and strength testing, alongside ongoing in-season monitoring, can help identify and manage risk

• Strength and neuromuscular training should be prioritized, including development of landing mechanics and force absorption

• Coaches can use warm-ups and training creatively to expose athletes to a wider range of movement patterns, which can improve engagement and reduce repetitive strain

• Avoiding early sport specialization where possible can support long-term performance and reduce injury risk

• Graft selection should consider individual factors such as age and injury history, with input from both the physio and orthopaedic surgeon

• Discussing additional surgical options, such as LET where appropriate, may improve outcomes in higher-risk athletes

• Education for both athletes and parents is key. Increasing awareness and training age can have a meaningful impact on long-term development and injury mitigation

For athletes or parents looking for more structured support, this is where individualized assessment and programming can make a meaningful difference: Book an Initial Assessment