Rethinking sex differences in adolescent sports injuries: Distinguishing injury distribution from per-participant risk

Sports-related ankle injuries are often reported to occur more frequently in female adolescents than males, but it remains unclear whether this reflects higher per-participant risk or differences in injury distribution within injured populations. Using 2024 National Electronic Injury Surveillance System data, we analyzed 33,977 sports-related injuries among individuals aged 10–24 years to examine sex differences across developmental stages and to distinguish within-sample injury distribution from participation-adjusted risk. Among adolescents (10–17 years), females had higher adjusted odds that an injury involved the ankle/foot rather than another body region (OR 1.70, 95% CI: 1.58–1.83), whereas this difference was attenuated and non-significant among young adults (18–24 years; OR 1.08, 95% CI: 0.92–1.27). Ankle/foot injuries accounted for a greater proportion of injuries among females in early adolescence (16.4% vs. 8.0%), with convergence by ages 22–24 (12.9% vs. 13.0%). However, participation-normalized analyses indicated comparable ankle injury risk between sexes in early adolescence and lower per-participant risk among females from mid-adolescence onward. These findings demonstrate that widely reported sex differences in ankle injury patterns during adolescence primarily reflect differences in injury distribution within injured samples rather than elevated absolute risk among female athletes. The observed convergence across developmental stages further suggests that these disparities are transient rather than persistent. Distinguishing injury distribution from denominator-based risk is essential for accurate interpretation of sex differences and for designing appropriately targeted prevention strategies.