Abstract
Background:
Women’s lacrosse is an increasingly popular sport. Current rules allow incidental body and stick-to-stick contact, with limited required protective equipment. Injuries to the head, face, and lower extremities are common, especially at higher levels of competition. Differences in injury rates and types based on competition level remain largely unknown.
Purpose:
To systematically review the literature to better understand injury differences between scholastic and collegiate female lacrosse athletes.
Study Design:
Systematic review; Level of evidence, 4.
Methods:
Under PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses), 543 studies were identified in September 2025 in PubMed, Scopus, Google Scholar, and Cochrane Central databases that reported on injuries occurring in female scholastic (youth/high school) and collegiate lacrosse players. Inclusion criteria included studies reporting injury rates per athletic exposure (AE), injury mechanisms, body regions injured, injury diagnosis, and injury setting (practice vs game). Incidence rates for variables of interest were pooled as proportions using inverse-variance weighting and displayed in forest plots, with heterogeneity among studies assessed by the I2 statistic.
Results:
A total of 31 studies were identified and included in our analysis. The overall injury rate was 3.83 (range, 0.11-5.19) per 1000 AEs for collegiate athletes versus 0.72 (range, 0.07-8.69) for scholastic athletes. A significantly higher proportion of injuries occurred in scholastic athletes from direct contact with the ball (15.2% [556/3644] vs 7.9% [211/2668]; P < .001) and stick (18.7% [683/3644] vs 9.4% [116/1233]; P < .001), while collegiate players sustained a greater number of direct player-to-player injuries (15.2% [4508/29,651] vs 13.5% [513/3807]; P = .005) and noncontact injuries (36.9% [10,927/29,651] vs 22.7% [968/4269]; P < .001). Injuries to the head and face (19.4% [914/4718] vs 14.8% [4429/29,991]; P < .001), including concussions (16.8% [583/3470] vs 11.4% [3317/29,101]; P < .001), as well as ankle injuries (23.7% [637/2681] vs 16.2% [4817/29,723]; P < .001), were greater in scholastic athletes, while collegiate players sustained a higher number of knee injuries (18.1% [5381/24,342] vs 14.5% [455/3143]; P < .001) and lower leg injuries (10.6% [3146/29,733] vs 5.3% [127/2388]; P < .001). Injuries occurred more frequently during game competition at both competition levels.
Conclusion:
This review showed that in female lacrosse athletes, overall injuries were greater in collegiate athletes when compared with scholastic athletes, with a significantly greater proportion of player-to-player, noncontact, knee, and lower leg injuries at the collegiate level. Injuries to the head, face, and ankle, along with injuries involving contact with the ball and stick, were more commonly reported among scholastic athletes. Further studies evaluating potential rules and equipment modifications may guide targeted injury prevention strategies to improve athlete safety at the scholastic and collegiate levels.
Women’s lacrosse is a rapidly growing sport, with >500 National Collegiate Athletic Association (NCAA) varsity programs as of 2025, an increase from 344 in 2010. 43 Previous sport modifications have focused on improving player safety as the game has evolved, with play at an increasingly faster pace. In 2005, the use of eye protection was mandated, leading to a substantial reduction in the number of head, face, and eye injuries. 25 Rules and regulations differ for female athletes when compared with males, including the number of players on the field, the size of offensive and defensive field playing zones, as well as variable stick lengths based on position, with more extensive protective equipment required for males. 4
Prior investigations have reported rates of anterior cruciate ligament (ACL) injuries among high school female lacrosse athletes ranging from 0.07 to 0.32 per 1000 athlete-exposures (AEs). 38 When compared with males, female athletes have higher rates of concussion-related injuries, most commonly involving stick-to-head contact. 50 Moreover, higher injury rates and the incidence of more severe injuries, including concussions and ACL tears, have been reported among collegiate female lacrosse athletes as compared with athletes competing at lower levels of competition.30,50 When compared with athletes at the high school and youth (ie, scholastic) levels, collegiate female lacrosse athletes also sustain injuries more frequently in practice and competition settings. 36 While previous studies have separately examined the epidemiology of injuries in youth, high school, and collegiate female lacrosse athletes,6,21,27,36 the incidence and types of injuries among competition levels remain largely unknown.
Based on the increased popularity of lacrosse, a better understanding of injuries unique to the level of competition in female lacrosse athletes is warranted. The purpose of this investigation was to systematically review the current literature to examine differences in injury rates, mechanisms, body locations, injury diagnoses, and setting (game vs practice) in scholastic versus collegiate female lacrosse players. We hypothesized that overall injuries and those involving direct player-to-player contact would be more common in collegiate athletes secondary to increased speed and impact at the collegiate level of play.
Methods
Search Strategy and Eligibility Criteria
A systematic review was conducted according to the 2020 PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-analyses). 35 A literature search identifying studies reporting on injuries in female lacrosse athletes at the youth/high school (scholastic) and collegiate levels was performed on September 25, 2025. Two authors (C.J.F. and D.C.T.) independently conducted a literature review of the following databases from inception to September 2025: PubMed, Scopus, Google Scholar, Cochrane Database for Systematic Review, Cochrane Central Register for Controlled Trials, and Embase. The search was performed with the search terms “female lacrosse,”“women’s lacrosse,”“collegiate,”“National Collegiate Athletic Association,”“high school,”“scholastic,”“injuries,” and “injury rate.”
Inclusion criteria consisted of studies written in English or with English-language translation, reporting on injuries in female lacrosse athletes at the scholastic level (ie, youth and high school)15,24,27 and/or collegiate level, with injury rates per AEs, injury mechanisms, body regions involved, injury diagnosis, and setting (practice vs game). Exclusion criteria consisted of prior meta-analyses or systematic reviews, review articles, editorial commentaries, and studies including athletes not classified as either female scholastic or collegiate lacrosse athletes.
Two authors (C.J.F. and D.C.T.) independently performed title and abstract screening, followed by full-text review to determine if the studies met inclusion/exclusion criteria (Figure 1). The senior author (D.M.K.) was assigned to consult if any disagreements were encountered, of which there were none. References from the included studies were reviewed to ensure that no additional studies meeting the inclusion criteria were overlooked, and no further studies were identified.
PRISMA diagram (Preferred Reporting Items for Systematic Reviews and Meta-analyses).
Data Extraction
For studies meeting criteria for full-text review, the following characteristics were extracted from each article and entered into a Microsoft Excel (version 16.98) spreadsheet: study title, publication year, first author, level of evidence, competition level (scholastic vs collegiate), number of injuries, number of AEs, injury rates per AE, injury setting (practice vs game), injury mechanism (ie, player-to-player contact, contact with stick, contact with ball, noncontact, overuse), specific body regions injured (ie, head/face, knee, lower leg, ankle), and injury diagnoses (ie, sprain/strain, contusion/abrasion/laceration, concussion). The total numbers of injuries across each study were tabulated and stratified according to injury mechanism, body part, and injury diagnosis based on competition level.
Study Quality Assessment
Two independent authors (C.J.F. and D.C.T.) performed a methodological quality assessment using a modified version of the Newcastle-Ottawa Scale (NOS)8,46 to minimize bias. If any disagreements based on a score discrepancy ≥1 point were encountered, a third author (D.M.K.) was consulted, and no such discrepancies occurred. The modified NOS criteria consisted of 7 items: description of female lacrosse athletes (eg, collegiate, scholastic [high school, youth level]), definition of injury, representativeness of the exposed cohort, ascertainment of exposure, whether follow-up was long enough for outcomes to occur, adequacy of follow-up cohorts, and statistical measurement of the association of risk factors. An article was awarded a maximum of 1 star for each item if the risk of bias was low such that the maximum score was 7 stars. Studies were categorized as high risk of bias (≤3 stars), moderate risk (4 or 5 stars), or low risk (≥6 stars).
Data Analysis
Study characteristics were compiled and analyzed in Microsoft Excel. Injury incidence rates were reported as the number of injuries per AE, which were converted to injuries per 1000 AEs for consistency in comparison. Given the similarity in game rules, scholastic athletes were defined as those competing at organized youth and high school levels. Injuries were defined as (1) any conditions occurring directly from lacrosse participation, (2) ones requiring medical attention from an athletic trainer or physician, and (3) those resulting in ≥1 day of time loss from lacrosse team participation. AEs constituted athletic participation in 1 practice or game session,6,21 with exposure to the possibility of athletic injury. Injury rates were calculated and pooled by competition level (scholastic vs collegiate) and setting (practice vs game) and presented as an overall rate with minimum and maximum values. Rates of specific injury mechanisms, body regions affected, and injury diagnoses were presented as categorical variables and pooled as proportions. A comparative analysis of categorical data was performed with chi-square tests, while independent t tests were used to analyze and compare injury rates (injuries per 1000 AEs). The incidence of noncontact and ankle injuries was compiled and pooled as proportions, using a random effects model with inverse-variance weighting. Forest plots, including 95% confidence intervals, were generated in Microsoft Excel. The heterogeneity of the pooled studies was assessed by the I2 statistic.
Results
The initial literature search identified 543 articles (Figure 1). After removal of 178 duplicates, 365 studies underwent title and abstract screening. A total of 61 articles were selected for full-text review, after which 31 were identified as meeting inclusion/exclusion criteria and included for further analysis. Two studies were of level 2 evidence,5,32 28 were of level 3 evidence, ‡ and 1 study was of level 4 evidence. 48 The mean NOS score across the 31 studies was 5.8 (range, 5-6), with 80.6% (n = 25) rated as a low risk of bias and 19.4% (n = 6) as a moderate risk of bias (Appendix Figure A1).
Injury Rates
Injury was consistently defined across all 31 studies as any condition resulting directly from participation in lacrosse during practice or competition. In all but 5 studies,3,5,17,23,48 injury was further defined as any condition requiring the attention of a certified athletic trainer or physician. A total of 15 studies § defined injury as any condition resulting in 1 or more days lost from lacrosse team participation. Two studies17,23 relied on retrospective self-reported survey data completed by athletes to provide further details regarding medical attention and time lost.
Overall rates of injury among scholastic and collegiate female lacrosse athletes were reported across 13 studies ‖ and 12 studies, ¶ respectively (Table 1). The overall injury rate among scholastic athletes was 0.72 (range, 0.07-8.69) per 1000 AEs, while that among collegiate athletes was 3.83 (range, 0.11-5.19) (Table 2). ACL injury rates among scholastic and collegiate athletes were 0.10 (range, 0.07-0.32)5,38-40 and 0.18 (range, 0.09-0.23)1,2,5,20,32,38 per 1000 AEs. Concussion injury rates were 0.34 (range, 0.20-0.55)9,26,27,30,34,45,47 and 0.53 (range, 0.25-1.06)10,11,16,20,27,50 per 1000 AEs among scholastic and collegiate players.
Overview of Clinical Studies and Patients a
ACL, anterior cruciate ligament; AE, athletic exposure; LOE, level of evidence; NR, not reported.
All females.
Injury Rates Among Scholastic and Collegiate Female Lacrosse Athletes a
Bold indicates P < .05. ACL, anterior cruciate ligament; AE, athletic exposure.
Values expressed as percentage (range) unless noted otherwise.
Values expressed as rate per 1000 AEs (range).
Scholastic practice-related injury rates were 1.29 (range, 1.09-5.63)19,22,45,47 per 1000 AEs, while scholastic game-related injury rates were 2.52 (range, 1.48-17.11).19,22,45,47 Collegiate practice- and game-related injury rates were 4.12 (range, 0.33-4.21)6,13,16,21,31,50 and 8.84 (range, 1.31-9.03)6,13,16,21,31,50 per 1000 AEs, respectively (Table 2).
Mechanism of Injury
Mechanisms of injury among scholastic and collegiate female lacrosse athletes were reported across 8 studies3,17,21,36,39,40,45,47 and 5 studies,6,16,21,23,36 respectively (Table 1). Noncontact injuries were the most common mechanism of injury between the groups, with a significantly greater incidence (P < .001) among collegiate as compared with scholastic athletes. The pooled incidence of noncontact injuries among collegiate athletes was 36.8% ± 0.3% (mean ± SE; 10,927/29,651; 95% CI, 36.3%-37.4%; I2 = 98.61%; P < .01) (Figure 2A), while that among scholastic athletes was 22.3% ± 0.6% (968/4269; 95% CI, 21.0%-23.5%; I2 = 96.68%; P < .01) (Figure 2B).
Forest plot of proportions for prevalence of noncontact injuries during a single season of female lacrosse: (A) collegiate and (B) scholastic. Ev, events (total number of noncontact injuries); Tot, total (total number of injuries reported).
The proportion of injuries resulting from contact with the ball3,6,17,21,22,36,45 (15.2% [556/3644] vs 7.9% [211/2668]; P < .001) and stick3,17,21,22,36,45 (18.7% [683/3644] vs 9.4% [116/1233]; P < .001) was significantly higher among scholastic athletes, while player-to-player # contact injuries were greater among collegiate athletes (15.2% [4508/29,651] vs 13.5% [513/3807]; P = .005). Overuse injuries were reported in 20.4% (465/2281) of scholastic athletes22,36,39,45,47 and 19.9% (5781/29,088) of collegiate athletes6,16,21,36 (Table 2).
Injuries Based on Body Location
Injured regions of the body among scholastic and collegiate athletes were reported across 10 studies** and 6 studies,6,16,21,23,27,36 respectively (Table 1). Injuries to the ankle were the most common injury location among scholastic and collegiate athletes, with a significantly greater incidence (P < .001) among scholastic as compared with collegiate athletes. The pooled incidence of ankle injuries among scholastic athletes was 23.7% ± 0.8% (637/2681; 95% CI, 22.1%-25.3%; I2 = 80.89%; P < .01) (Figure 3A), while that among collegiate athletes was 16.2% ± 0.2% (4817/29,723; 95% CI, 15.8%-16.6%; I2 = 94.75%; P < .01) (Figure 3B).
Forest plot of proportions for prevalence of ankle injuries during a single season of female lacrosse: (A) scholastic and (B) collegiate. Ev, events (total number of noncontact injuries); Tot, total (total number of injuries reported).
The proportion of injuries to the head and face †† was greater among scholastic athletes (19.4% [914/4718] vs 14.8% [4429/29,991]; P < .001), while collegiate players sustained a significantly higher percentage of knee injuries ‡‡ (18.1% [5381/24,342] vs 14.5% [455/3143]; P < .001) and lower leg injuries3,6,16,19,21-23,36 (10.6% [3146/29,733] vs 5.3% [127/2388]; P < .001) (Table 2).
Injury Diagnosis
Injury diagnoses among scholastic and collegiate female lacrosse athletes were reported in 6 studies §§ and 3 studies,6,16,21,36 respectively (Table 1). Sprains and strains were the most common injury diagnoses among scholastic (41.1%; 1429/3477) and collegiate (41.5%; 12,075/29,101) female lacrosse athletes. When compared with collegiate athletes, scholastic female lacrosse players sustained a significantly greater proportion of contusion, abrasion, and laceration injuries (19.4% [721/3723] vs 12.1% [3524/29,101]; P < .001), as well as a higher incidence of concussion-related injuries (16.8% [583/3470] vs 11.4% [3317/29,101]; P < .001) (Table 2).
Discussion
The primary findings from this investigation were that collegiate female lacrosse players experienced a greater overall injury rate (3.8 per 1000 AEs) when compared with scholastic athletes (0.7 per 1000 AEs), consistent with our hypothesis that overall injuries would be greater in collegiate athletes. Scholastic athletes reported a significantly higher proportion of equipment-related injuries, including injuries resulting from contact with the ball (15%) or lacrosse stick (19%). Consistent with our hypothesis, collegiate players experienced a higher percentage of direct player-contact (15%) injuries, in addition to a higher percentage of noncontact (37%) injuries. Meanwhile, scholastic athletes experienced a significantly higher proportion of ankle injuries (24%), as well as injuries to the head and face (19%), including concussions (17%). Collegiate athletes sustained a significantly greater proportion of knee (18%) and lower leg (11%) injuries. Game-related injuries occurred more frequently than practice-related injuries at both competition levels.
The higher overall injury rate at the collegiate level is likely a reflection of the increased speed and power of female lacrosse athletes as compared with their scholastic counterparts. Studies comparing NCAA female athletes and high school athletes show that collegiate athletes possess increased lower body power, as measured by vertical jump and 150-yard shuttle run times.37,44 Injury epidemiology studies across several women's open-field sports, including lacrosse, field hockey, and soccer, similarly report higher injury rates among collegiate female athletes as compared with scholastic athletes.14,29,36 In addition to the increased speed and power of collegiate athletes, significant differences in the rules between collegiate and scholastic lacrosse may contribute to a faster pace of play at the college level. Specifically, collegiate lacrosse is played in four 15-minute quarters with a 90-second shot clock, while scholastic games are regulated to two 30-minute halves without a shot clock. 43 While no studies have directly compared game-related metrics between competition levels, women's collegiate lacrosse players cover a mean distance of 4726 m per match, with 12.5% of that distance traveled at higher-intensity speeds (ie, >15 km/h). 12 When compared with other female collegiate sports, such as soccer and basketball, lacrosse athletes cover a shorter overall distance per game but spend a larger proportion of time in high-intensity running, highlighting the faster and more physical environment likely contributing to injury. 12
Collegiate athletes had a higher percentage of player-contact, noncontact, and knee injuries. Previous investigations have similarly reported collegiate athletes to experience greater player-contact injuries owing to the increased strength of the athletes and the overall physicality of the game.3,36 Specifically, at the collegiate level, player-to-player contact is more widely allowed, as fouls are assessed at the discretion of the referee, with players often “playing through” greater levels of contact. 33 Conversely, at the scholastic level, any player-to-player contact is considered a foul, unless it is deemed incidental. 42 With increased speed and strength, open-field cutting and pivoting at faster velocities at the collegiate level account for the majority of noncontact and knee injuries, including ACL tears. Specifically, Beynnon et al 5 reported that collegiate female lacrosse athletes had a first-time noncontact ACL injury rate of 0.106 per 1000 person-days, while high school athletes had an injury rate of 0.07 per 1000 person-days. Meanwhile, scholastic athletes experience a higher proportion of equipment-related injuries. Equipment-related injuries likely occur because of underdeveloped motor skills in younger players, resulting in a less developed skill set in stick and ball handling.17,22,36 As players mature, technical skills (eg, cradling, stick handling) and situational awareness enabling effective body positioning to their competitive advantage are expected to develop. Learning proper body positioning, for offensive and defensive players, can help reduce the risk of incidental injuries and contact that occur in competition and practice. 22
Scholastic athletes experience a greater proportion of ankle injuries, as well as injuries to the head and face, including concussions. Developing athletes with less coordination and lower body strength may be more prone to ankle injuries when compared with those at more experienced levels who are actively engaged in strength and conditioning training under the guidance of a professional staff.41,49 In addition, women's lacrosse players are required to wear only protective goggles without a helmet, leaving their skull and face exposed. While current rules prohibit players from placing their stick in proximity of an opposing player's head (within the player's “sphere”), illegal stick checking remains a common mechanism for head and face injuries, including concussions. 33 Furthermore, age-related differences in coordination, exposure to competition, and playing rules likely all contribute to a greater proportion of stick/ball and concussion injuries experienced by players at the scholastic level. Video analysis has revealed that up to 57% of head injuries in scholastic female lacrosse result from stick contact to the head, with 62% of these incidents being unintentional. 7 Our investigation supports these findings, with a significantly higher proportion of head/face (19% vs 15%) and concussion (17% vs 11%) injuries in scholastic players when compared with collegiate athletes. For this reason, proposals have been suggested to implement helmet use in female lacrosse players, with strong evidence demonstrating a decrease in concussion rates when headgear is worn.9,18 Despite this, as of 2025, Florida is the only state in which the use of headgear in high school lacrosse athletes is mandated.
This investigation is not without its limitations. A single data source was reported in multiple studies. Specifically, 6 of the 31 articles sampled the High School Reporting Information Online, while 13 articles sampled the NCAA Injury Surveillance Program; 2 articles, the National Electronic Injury Surveillance System; and 2 articles, the National Athletic Treatment, Injury, and Outcomes database. Although the potential for overlapping data sets existed across studies, we attempted to control for this by aligning studies according to season (eg, 2004-2014, 2014-2019) and injury types (eg, total injuries per 1000 AEs, ACL injuries per 1000 AEs, concussions per 1000 AEs), thereby ensuring that each data set was relatively unique. Although conditions were consistently incurred during lacrosse team participation, with most requiring medical attention from a physician or athletic trainer, fewer studies specified time-loss criteria, resulting in heterogeneous definitions of “injury” when comparing injury rates between collegiate and scholastic athletes. Detailed information, including specific injury diagnosis (eg, medial vs lateral meniscus, collateral ligaments, osteochondral injury), injury severity, and injury management, was infrequently reported. As studies generally reported epidemiologic data, details relevant to the clinical presentation of each injury, including imaging and operative reports, were not available. Additionally, outcomes were based primarily on injury proportions rather than population-level incidence, thereby limiting inferences about actual injury risk. Furthermore, time lost to injuries was rarely reported across scholastic and collegiate populations, limiting the ability to perform meaningful analyses and determine whether specific injuries resulted in greater time loss based on competition level.
Conclusion
Our review showed that, in female lacrosse athletes, overall injuries were greater in collegiate athletes when compared with scholastic athletes, with a significantly greater proportion of player-to-player, noncontact, knee, and lower leg injuries at the collegiate level. Injuries to the head, face, and ankle, along with injuries involving contact with the ball and stick, were more common among scholastic athletes. Further studies evaluating potential rules and equipment modifications may guide targeted injury prevention strategies to improve athlete safety at the scholastic and collegiate levels.
Footnotes
Appendix
Final revision submitted January 26, 2026; accepted March 7, 2026.
One or more of the authors has declared the following potential conflict of interest or source of funding: R.H.B. has received consulting fees from Syneos and Anika and is chair of the NFL Musculoskeletal Committee. D.M.K. has received grant support from Arthrex, Inc and support for education from Elite Orthopedics and Smith & Nephew.
