Does Sex Matter in Musculoskeletal Physiotherapy?

By Elaine Miller

Think back to what you were taught about anatomy. Visualise what you saw in your textbooks – what do you see? Something like this?

“Think of a person. Most people will think of a man.” — Caroline Criado Perez

Most people (including me) visualise a male body when we think of a human. It’s well established that this causes a bias in healthcare. Treating female bodies as if they are simply smaller versions of the male ‘normal’ means missing the ways that sex impacts musculoskeletal health, pain, injury and recovery.  Add to that the uncomfortable truth that when women access healthcare, our symptoms are too often dismissed or minimised. This is especially true for conditions like pelvic pain, autoimmune disorders and hormonal issues, all of which disproportionately affect women. 

Healthcare training, including physiotherapy, comes with bias built in. Anatomy textbooks and medical illustrations have always shown male bodies as the standard. Female bodies, when included at all, are often limited to reproductive anatomy presented in a box at the side of the page. A study by Cardiff University and the University of Paris Descartes asked medical students to review female anatomical images and give their impressions [1]. Students frequently perceived the female illustrations as sexualised – in contrast to the neutral, clinical portrayal of male bodies.

This approach reinforces the idea that male anatomy is universal, while female anatomy is ‘other’. It shapes what we notice, what we ask, and how we interpret the body in front of us. Physiotherapists have told me that they feel more comfortable assessing male patients and less confident discussing female-specific anatomy – or even knowing which differential diagnosis to consider when assessing a woman’s hip pain in order to exclude the pelvic floor.

In her 2019 book Invisible Women: Exposing Data Bias in a World Designed for Men [2], Caroline Criado Perez described how gender bias in data collection adversely affects women. For example, crash test dummies were, until 2022, modelled on male dimensions – making cars less safe for women. In healthcare, this male-as-default mindset has serious consequences, including in musculoskeletal physiotherapy. For instance, anterior cruciate ligament (ACL) injuries are two to eight times more common in women than in men, particularly in sports involving pivoting and landing.

The convention is that this is due to anatomy, biomechanics and hormonal influences [3,4,5]. The female pelvis is wider than a male’s, so the quadriceps (Q) angle is greater, affecting lower limb alignment and joint loading. Hormonal fluctuations across the menstrual cycle influence ligament laxity, potentially making the ACL more vulnerable to injury.

However, a 2024 study published in the Journal of Orthopaedic Research by Gant et al. [6] examined the assumption that a larger Q-angle significantly contributes to higher ACL injury rates in female athletes. Their analysis of a mixed-sex athletic cohort found no statistically significant correlation between increased Q-angle and ACL injury risk. This challenges the idea that a wider pelvis and Q-angle are the main culprits. Instead, the study suggests that neuromuscular control, hormonal fluctuations and biomechanical patterns might be more significant. Gant et al. call for a shift in focus towards these modifiable factors in both research and injury prevention programmes. And so, we still don’t fully understand why women are more at risk of ACL injuries, or how to optimise their rehabilitation.

Did you know that up to 50% of women over 50 have pelvic organ prolapse, which can contribute to symptoms of low back pain, pelvic heaviness, incontinence and altered biomechanics? [11]  Have you been taught how to screen for this in back pain assessments of middle-aged women? Would you know what advice to give, or where to signpost a woman with symptoms of vaginal prolapse?  If you do not - is that your fault or an example of institutional bias?  

Conditions which only affect women are under-researched, under-diagnosed and under-funded. The charity Wellbeing of Women found that only 2.4% of all public health research funding is allocated to female specific conditions [7]. And it shows - millions of women live with conditions that go unrecognised or untreated simply because they don’t fit the male-centric template of diagnosis and care.

This research gap ripples through clinical practice. There is a collective blind spot in health about issues which only affect women during key life stages, and as a result, female patients experience pain and dysfunction that is misunderstood or dismissed.

Musculoskeletal Syndrome of Menopause

In 2024 Wright et al. described a cluster of symptoms experienced by women which they published in Climacteric [8].  Musculoskeletal Syndrome of Menopause (MSM) includes joint pain, muscle aches, sarcopenia, reduced bone density and conditions like osteoarthritis and tendonitis.  Over 70% of menopausal women report musculoskeletal symptoms, with about 25% describing them as severe.

Oestrogen has a role in maintaining bone and muscle health and its decline during menopause contributes to the development of MSM. These symptoms are often dismissed as normal ageing, rather than recognised as part of a hormonal syndrome affecting women. Wright et al. argue for greater awareness and recommend interventions like resistance training, nutritional support and hormone replacement therapy to improve quality of life and clinical outcomes.

What Can We Do?

Musculoskeletal physiotherapists need a clear understanding of what sex is and why it matters – not just biologically and physiologically, but socially. Women are more likely than men to carry caring responsibilities, and this extends well beyond the early postnatal period. Menopausal women are often navigating their ‘sandwich years’, supporting adult children, young grandchildren and ageing parents, while also holding down jobs. These life pressures can delay help-seeking and make adherence to advice difficult - we need to recognise that what is clinically optimal for this woman’s rehab might not be practically possible. Knowing whether to - and how to - ask about these factors when taking a social history and tailoring rehab to a woman’s needs can improve outcomes.

If sex differences affect half our caseload, they should be in our curriculum. Sex isn’t niche - understanding how hormones, pelvic health, and life stage impact pain, injury and recovery in 51% of the population should be core knowledge.

What does this mean for physiotherapists in a busy clinic? We could start by acknowledging that sex matters in musculoskeletal practice. We need to become comfortable asking female patients about menstrual cycles, pregnancy history, birth injuries, menopause status and pelvic symptoms – and know what to do with that information.  It also means designing services which reduce barriers for women – why don’t we have child-friendly clinics, flexible appointments and trauma-informed approaches as standard? 

There are in-house effects too - physiotherapy is a female-majority profession, and so menopause isn’t only a clinical issue - there are also occupational health, performance and retention issues too. With over a third of UK physiotherapists aged 45 or older, and a workforce which is 77% female, we can estimate that around 20,000 to 25,000 physios are currently perimenopausal or menopausal [9, 10]. As a profession we should be calling for better research, better funding and better training for sex-based issues and recognising that if we want to support, and retain, our senior female colleagues then menopause needs to be on the trade union and HR agenda.  

The Bigger Picture

Of course, women are not a homogenous group. Factors such as race, class, disability, and age compound disparities and barriers faced by many in accessing health care. Sex is just one of the nine protected characteristics under the 2010 Equality Act, but issues that discriminate against women affect over half the population and the majority of our profession. If we want to provide equitable, effective physiotherapy, we need to recognise how sex shapes health experiences, and ensure that this most common of the protected characteristics is reflected in our clinical reasoning and service design.

In order to close the knowledge gap and prepare all physios to meet the needs of all their female patients then these issues need to be embedded in undergraduate curricula and post-qualification CPD.

Effective clinicians understand bodies, listen to voices and honour lived experience. We all know that physiotherapy can be transformative – but only if we see the whole person. If we want to serve half the population effectively, we need to challenge the assumption that male is the default and start thinking outside her collective box.

References

[1] Morgan S, Plaisant O, Lignier B, Moxham BJ. Sexism and anatomy, as discerned in textbooks and as perceived by medical students at Cardiff University and the University of Paris Descartes. J Anat. 2014;224(3):352–65. doi:10.1111/joa.12070

[2] Criado Perez C. Invisible women: Exposing data bias in a world designed for men. London: Chatto & Windus; 2019.

[3] Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors. Am J Sports Med. 2006;34(2):299–311.

[4] Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2006;14(3):159–70.

[5] Herzberg SD, Motu’apuaka ML, Lambert W, Fu R, Brady J, Guise JM. The effect of menstrual cycle and contraceptives on ACL injuries and laxity: a systematic review and meta-analysis. Orthop J Sports Med. 2017;5(7):2325967117718781.

[6] Gant H, Ghimire N, Min K, Musa I, Ashraf M, Lawan A. Impact of the quadriceps angle on health and injury risk in female athletes. Int J Environ Res Public Health. 2024 Nov 22;21(12):1547. doi:10.3390/ijerph21121547.

[7] Wellbeing of Women. Why women’s health research is underfunded [Internet]. London: Wellbeing of Women; 2022 [cited 2025 May 14]. Available from: https://www.wellbeingofwomen.org.uk/news/research-funding-gap 

[8] Wright VJ, Schwartzman JD, Itinoche R, Wittstein J. The musculoskeletal syndrome of menopause. Climacteric. 2024 Oct;27(5):466–72. doi:10.1080/13697137.2024.2380363.

[9] Health and Care Professions Council (HCPC). Diversity data: physiotherapists 2023 [Internet]. London: HCPC; 2023 [cited 2025 May 14]. Available from: https://www.hcpc-uk.org/resources/data/2023/diversity-data-physiotherapists-2023/

[10] Chartered Society of Physiotherapy (CSP). CSP membership data: age profile of members 2021 [Internet]. London: CSP; 2021 [cited 2025 May 14]. Available from: https://www.csp.org.uk/documents/csp-membership-data-2021-age

[11] Vaughan CP, Bradley CS, Burgio KL, Markland AD, Goode PS, Redden DT, et al. Vaginal descent and pelvic floor symptoms in postmenopausal women: a longitudinal study. Obstet Gynecol. 2011;117(4):881–6. doi:10.1097/AOG.0b013e3182114f77