Contact Breast Injuries: Combatting the Silent Injury Crisis Threatening Female Athletes
Historically, Australia and several of our global counterparts have been plagued by antiquated socio-cultural norms, whereby sports have been divided into gendered contexts. This has presented enormous barriers to female participation, particularly in programs that have been considered male-dominated, such as AFL, NRL, soccer and cricket.
Recent years have seen a considerable rise in the popularity of women’s sport, in direct response to a concerted governmental effort (with bi-partisan support) to fund and prioritise women’s sport from the junior level, all the way to the international stage. Participation levels have skyrocketed across grassroots programs, and this has been substantiated with impressive retention of female participants through adulthood sporting pathways. [1]
This financial support has extended to marketing and securing media broadcasting rights allowing young, emerging female athletes to witness the sporting prowess of our top international representatives. In 2023, the Australian Women’s Football Team known fondly as “The Matildas” took the country and the world by storm in the FIFA Women’s World Cup. As Australia co-hosted the historic event, the imagination of young children, especially girls all over the country was captivated, and with each alluring win, engagement with local soccer blossomed. For some impressionable youths, a robust role model like Sam Kerr was the motivation they needed to commit to involvement in team sports for themselves.
With such quick uptake, the scale and standard of female sport has been rising expeditiously. However, with rapid growth we often see the hasty implementation of governing guidelines cloned from the men’s code, failing to address the unique anatomical and physiological differences of women. Many of these policy frameworks disregard injury prevention measures necessary for the longevity of a female athlete’s career and their quality of life beyond retirement.
Central to these policy deficiencies are paramount safety concerns for women, especially pertaining to Contact Breast Injuries (CBIs). A systematic literature review conducted by Bibby et al. in 2024 examined various sports worldwide to identify the prevalence of CBIs, the common mechanisms by which they occur, and the extent to which they effect the performance of female athletes. Their findings unearthed three common mechanisms of CBI prevalent in most of the sporting codes analysed. These were: contact with another player; contact with the playing equipment (i.e. a ball); and contact with the ground. [2]
In 2019, a study conducted by Brisbine et al. studied female athletes from several Australian football codes. 58% of their participants reported having experienced a CBI, and 48% of the participants affected felt that their injury had negative consequences for their performance. CBIs exhibit heterogeneous presentation, which is seen in player impact statements. Many reported that pain interfered with their performance, that they felt less confident after an injury, that fear of further injury, or exacerbation of a current breast injury made them less likely to dive and tackle as they previously would have. [3]
Alarmingly, the same study by Brisbine et al. revealed that coaching and medical staff across the football codes remain almost entirely unaware of the prevalence and impact of CBIs on female athletes. While most staff understood that CBIs would be problematic and would have negative ramifications for player performance, the majority of staff surveyed estimated CBIs to have impacted only 5% of female players or less. [3] This alludes to the concurrent issue that CBIs are significantly under-reported to medical support staff and that, from these low reporting rates, an immense proportion of CBIs go untreated. Hence, the incidence and repercussions of these injuries cannot yet be entirely understood. [4]
The Long-Term Effects of CBIs
While the immediate impacts of a CBI are often deferred by young athletes who tolerate the pain, and persist to maintain high performance, there are several long-term consequences which cannot be ignored.
Bruising to breast tissue can cause fat necrosis, and result in the formation of dense lumps in the breast. Even with screening, these fibrous nodules can be difficult to distinguish from breast cancers and can mean that women require biopsies or other invasive exploratory tests to rule out malignancies. Over a lifetime, breast tissue fluctuates in response to hormonal changes, puberty, pregnancy and menopause. Injuries during these pivotal periods can cause permanent damage to the milk ducts which may affect a women’s ability to breastfeed her children. CBIs in conjunction with hormonal fluctuations can precipitate breast asymmetries and deformities especially in developing youths. Breast implants can rupture from the force of contact causing immense pain and often requiring surgical intervention. [5]
Beyond the cost of medical treatments, these injuries can be a source of immense psychological distress with lost confidence and embarrassment. Many women report feeling uncomfortable turning to male coaches or medical staff for support and treatment in the wake of these injuries, which only exacerbates the propensity for long-term damage.
A Comparison to Other Codes: Cricket
Cricket Australia (as well as the England & Wales Cricket Board) have been proponents of mandated protective equipment for years. Cricket Australia regularly conducts reviews whereby the clothing and equipment regulations are updated, and players who do not comply can face sanctions for breaching Cricket Australia’s Code of Conduct. After the tragic passing of Phillip Hughes in 2014 after being struck in the neck by a cricket ball, Cricket Australia recommended the use of a neck guard as a helmet fixture when facing fast- and medium-pace bowling. In 2023, after several more players had been struck and were forced to take time away from the sport due to concussion management protocols, Cricket Australia mandated the safety equipment and enforced these procedures with penalties. This approach to safety is a leading example of an administration taking all legal and practical steps necessary to ensure the protection of their athletes.
However, in other areas of the game, mandating safety equipment has not been necessary with players taking accountability for their own protection. Since the inception of the sport, the abdominal/testicular guard, affectionately termed ‘the box’, has been universally adopted and pre-dates the implementation of helmets. It has served as vital protection from electric over-arm bowling and has inevitably preserved the reproductive capacity of athletes for over a century. [6] All this has been without the need for intervention from a governing body. However, the same sentiment has not been shared when it comes to avoiding CBIs.
A Comparison to Other Injuries: Concussion
Over time, as new data has emerged and lived experience is brought to our attention, these contact sporting codes have identified the need for safety reform in other areas of the sport. There is no denying that the physical nature of AFL, NRL, and football codes generally results in repeated contact with the head, and often, concussion. Ongoing concussions regardless of rest and treatment can cause irreversible damage to the brain, and have been associated with development of dementia, mental ill-health, and chronic traumatic encephalopathy (CTE). All of these conditions cause a deterioration in an individual’s quality of life. Some can also cause memory loss, pain, and diminishment of one’s basic motor skills like walking, talking and eating.
This is becoming an increasingly litigated issue, with athletes accusing their sporting codes of not taking the proper care and precautions to protect participants from the effects of these brain injuries. Currently, over 160 former Rugby League players are involved in a class action against joint defendants the Rugby Football League and British Amateur Rugby League Association (BARLA). The players allege the governing bodies failed in their duty of care to establish and enforce appropriate diagnostic guidelines to assess, identify and treat concussion injuries. [7] In the NFL, litigation brought by more than 4,500 players asserted that the league’s dismissal of concussion concerns has resulted in CTE symptoms and enduring consequences. This resulted in a USD $765 million settlement, whereby the league would be covering treatment costs for players diagnosed with brain-related illnesses caused by on-field collisions. [8] These concerns are not unique to this case with several similar cases emerging from players of the NFL, AFL and NRL.
However, the AFL has responded to these concerns, taking drastic measures to implement and re-interpret rules to promote player safety and reduce the incidence of concussions. For example, within the Laws of Australian Football 2025 (for AFL and AFLW), several provisions specify intentional or careless contact with the head as a Reportable Offence. This is punishable by suspension depending on the classification of the offence. Such offences are set out in Section 22.2.2 and include either intentionally or carelessly:
“(vi) bumping or making forceful contact to an opponent from front-on when that Player has their head down over the football;
(vii) head-butting or making contact to another person using the head;
(viii) making unreasonable or unnecessary contact to the eye region of another person; [or]
(ix) making unreasonable or unnecessary contact to the face of another person”. [9]
Likewise, the AFL engaged its Chief Health Officer to evaluate the risk of concussion in the game. This resulted in several recommendations which have led to the Concussion Management Protocols. The rule change means that for AFL/W players there is a minimum 12-day return-to-play procedure, to allow for the proper assessment, identification and treatment of suspected concussions. At all lower levels of community football, including state level VFL/W, this is a 21-day period to account for the resource disparity between elite and community levels, and to reflect the necessity of attaining a medical clearance.
In 2021, the State Coroner made several recommendations to reduce the burden of repeated concussions to AFL players. After the death of Richmond player Shane Tuck, and subsequent findings of severe brain trauma from CTE, Judge John Cain made a series of recommendations to the AFL, including limiting the contact training load. This forced acknowledgement and response from the AFL to the Coroner’s report. Leading Counsel Stephen Meade emphasised that the AFL remained committed to the safety of its players and to funding brain health research, and would look to implement the proposed recommendations. [10]
Many of the leading sporting codes around the world failed to effectively intervene to prevent brain injuries until players began to exhibit severe brain injuries. In the breast health space, there is still opportunity for early remediation and adoption of safety protocols. Without intervention the risks of serious breast trauma and maternal health concerns will become increasingly prevalent in the years to come.
Injury Prevention Strategies: Policy Support and Practical Intervention
Reform is absolutely necessary to ensure female athletes are not bearing the ongoing consequences of CBIs in their life beyond sport. Ultimately, all sporting codes with female athletes need to recruit expert sports physiologists with a background in female health to carefully analyse the biomechanics of the game and make specific recommendations for rule implementation to ensure player protection. We are currently familiar with the “high contact” rule in the AFL, whereby contact below the hips or above the shoulders is prohibited and results in a free kick. Similarly, dangerous tackles where a player’s head makes unnecessary contact with the ground result in a free kick to the aggrieved player. Specialist personnel need to consider the biomechanics of tackling and contact in these sports to consider rule changes which deter contact with the breast, either from other players directly or from knock-on contact between the player’s chest and ground.
Moreover, the duty of care pertaining to CBIs should extend beyond the field of play. Sporting codes need to establish a procedure for mandated professional learning on breast injuries for players, coaches and medical personnel. This is vital to reduce the stigma around injury reporting and seeking treatment. Further, a specific assessment protocol for identifying, diagnosing and treating CBIs is necessary to ensure medical staff, equipped with medical knowledge and the foresight of long-term consequences of untreated injuries are able to intervene where a player is unwilling or unable to seek help for themselves.
Importantly, there are emerging products on the market which can protect the breast tissue from copping the full brunt of contact, reducing bruising and preventing lasting damage. Some of these look like inserts into an athlete’s bra, helping to absorb impact and prevent tension on the internal ligaments and skin of the breast, often associated with pain. [11] Others look like hard chest guards or vests worn under clothing to prevent contact with the ball or the ground. However, these can enhance impact if collision with another player occurs and they are not wearing the same protective equipment. [12] Sporting codes globally need to accept their legal responsibility and discharge their duty of care by fortifying their policies. Mandating protective breast equipment alone may not be an appropriate response to preventing CBIs. Funding breast equipment and a thorough analysis of the rules by qualified sports physiologists is crucial to protecting emerging female athletes as women’s sport continues to grow.
References:
[1] Abbey Boyer, The Matildas playing at home in the Women’s World Cup is a unique opportunity to get children – particularly girls – into sport, The University of Melbourne, 2023. https://pursuit.unimelb.edu.au/articles/the-world-cup-is-a-once-in-a-generation-chance-to-inspire-australia-s-kids
[2] Bibby, K, et al., Contact Breast Injuries Among Female Athletes: A Systematic Review, 2024, National Library of Medicine, National Centre for Biotechnology Information, 1;54(7), 1921-1930. https://pmc.ncbi.nlm.nih.gov/articles/PMC11258151/
[3] Brisbine, B. R., Steele, J. R., Phillips, E., & McGhee, D. E. (2019). Breast injuries reported by female contact football players based on football code, player position and competition level. Science and Medicine in Football, 4(2), 148–155. https://doi.org/10.1080/24733938.2019.1682184
[4] Brisbine, Brooke R (2020). Breast pain and breast injuries experienced by female athletes. University of Wollongong. Thesis. https://hdl.handle.net/10779/uow.27667215.v1
[5] McGhee, D, E., Changes to breast structure and function across a woman's lifespan: Implications for managing and modelling female breast injuries, Clinical Biomechanics, 2023, 107, 106031. 10.1016/j.clinbiomech.2023.106031
[6] Burnton, S., When will cricket have the balls not to call it the ‘groin region’?, The Guardian, 2016. https://www.theguardian.com/sport/2016/apr/13/cricket-box-groin-the-spin
[7] Dan Roan, Nearly two thirds of players in lawsuit ‘show CTE symptoms,’ BBC Sport, 2025. https://www.bbc.com/sport/rugby-league/articles/cg5d9546zzeo
[8] Klawans, J., The NFL’s concussion settlement has seemingly failed its players, The Week, 2024. https://theweek.com/sports/nfl-concussion-settlement
[9] Australian Football League, Laws of Australian Football 2025. https://resources.afl.com.au/afl/document/2025/03/21/19a8bff6-8f49-45b9-b686-83a64db02fe0/LEGAL_2025_150532_Laws-of-the-Game_Booklet_Digital_FA.pdf
[10] Australian Football League, AFL responds to State Coroner recommendations after Shane Tuck inquest, March 25, 2024. https://www.afl.com.au/news/1094784/afl-responds-to-state-coroner-recommendations
[11] Betts, S., Dr Thornton, C., Medical Statement on the Importance of Breast Protection, Boob Protect, 2024. https://boobprotect.us/pages/why-boob-protect
[12] Fempro Armous, Australian Armour Company, Empowering Women with Superior Protection. https://femproarmour.com/product-category/individual-body-protectors/women-individual-armour/