Objectives To investigate if sex modifies the association between change in weekly handball volume and knee injury risk in youth handball players. Design Prospective cohort study. Methods 679 players aged 14-18 reported weekly on any new handball-related knee injury and handball volume (training and competition hours) over 31 weeks through the SMS, phone and medical examination system. Weekly handball volume was categorized based on changes relative to the exponentially weighted moving average of handball volume the preceding four weeks: Bram et al. (2021) less than 20% increase or decrease (reference group), Maffulli et al. (2010) 20% and 60% increase and (Whittaker et al., 2015) increase greater than 60%. Players indicated their sex as a part of their baseline survey, identifying as either a female player or male player. Results Female players who increased their weekly handball volume by over 60% had a knee injury risk of 31.2% (95%CI: 21.6-40.8%) the following week compared to female players who increased their handball volume below 20%, which was higher than that in male players whose risk was 10.5% (95%CI: 2.1-18.8%) corresponding to a risk difference of 20.6%-points (95%CI: 6.5-34.6%-points). Seventy-one knee injuries were included in the analyses. Conclusions Female handball players aged 14-18 years were more susceptible to a handball-related knee injury following weeks with large increases in handball volume compared with age-identical males, suggesting a previously unexplored association between sex-related differences in load tolerance and knee injury risk that warrant further investigation. The provided cut points for increases in handball volume should be interpreted and used with caution.
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