Hidden support for the lionesses: a breast/bra intervention

ABSTRACT

Despite health and performance benefits of appropriate breast support in sport, elite women athletes’ knowledge of breasts/bras is poor leading to poor bra choices, breast pain and performance decrements. This multiphase intervention assessed breast/bra issues and preferences, individually prescribed sports bras and evaluated outcomes for the England Senior Women footballers. Breast/bra workshops were delivered to England players; all 36 completed pre-intervention surveys and breast/bra assessments, before being prescribed bras six weeks before European and World Championships (2022, 2023). 24 players completed post-intervention surveys. Pre-intervention outcomes identified poor knowledge, poor bra fit, many bra issues, and cultural sensitivities. Breast pain was prevalent (61%), with 25% reporting clinically significant breast pain. Post-intervention, players reported significant improvements with prescribed sports bras. 91% reported improvements in knowledge and benefiting from the intervention. This successful intervention provided an evidence-base for ongoing breast health initiatives with England Teams, plus roll-out to all levels of women’s football.

KEYWORDS:

• Mastodynia
• skin strain
• bra fitting
• bra prescription

Introduction

Despite health and potential performance benefits associated with wearing appropriate breast support in sport, breast/bra knowledge is known to be poor in elite women’s sport (B. R. Brisbine, J. R. Steele, E. J. Phillips, et al., 2020; Wakefield-Scurr et al., 2022, 2023). Previous research has reported elite athletes experiencing breast pain (B. R. Brisbine, Steele, Phillips, et al., 2020; Wakefield-Scurr et al., 2023), breast injuries Brisbine, B. R., Steele, J. R., Phillips, E., & McGhee, D. E. (2020). and making poor bra choices (B. R. Brisbine, J. R. Steele, E. J. Phillips, et al., 2020; Wakefield-Scurr et al., 2022, 2023). To address these issues, only one previous breast/bra intervention with elite athletes has been identified (Wakefield-Scurr et al., 2022, 2023). It covered multiple sports, assessed sports bra needs, then developed and implemented interventions. Through bra prescription, this intervention improved knowledge, reduced breast pain and offered perceived performance benefits (Wakefield-Scurr et al., 2023). Prior to this only one other athlete breast/bra intervention was identified which focused on junior athletes in Australia (McGhee et al., 2010). This study demonstrated improvements in bra knowledge, fit and support through education and bra assessment. These previous breast/bra interventions covered multiple sports within the same intervention (McGhee et al., 2010; Wakefield-Scurr et al., 2022, 2023). Despite substantial within cohort differences in somatotypes, bra sizes, breast support requirements and bra preferences, both interventions demonstrated positive outcomes, which, it is hypothesized, could be even more beneficial if the intervention were specific to the athletes’ sport.

Until more recently, female athlete health awareness, education and assessment was reasonably limited (Brown et al., 2021; Holtzman & Ackerman, 2021). Understanding the importance of female athlete health interventions at an elite level, in a particular sport such as football, may provide an evidence-base for interventions across all levels of play. Acceptance and promotion of an intervention at an elite level is known to boost engagement at lower levels or even in the general public (Walton et al., 2019). Additionally, providing an appropriate evidence-base on the benefits of female athlete health interventions will hopefully ensure that such interventions are embedded into future practice.

England football reported that the number of women and girls’ football teams across England has more than doubled over the last seven years with almost 1500 new teams registered in 2022 (Veevers, 2024). Football is a highly dynamic activity with the top five footballers in the Women’s European Championships 2022 covering an average of 10 km per match (Union of European Football Associations UEFA, 2023). No data exists on the breast support requirements for football, however, a 10 km run with an average stride length of 1 m, would result in 10,000 breast bounces. The previous breast and bra intervention with elite sportswomen (Wakefield-Scurr et al., 2022, 2023) did not include any footballers, all of which provides a strong rationale for research in this area.

Prior to this intervention, breast/bra education, assessment and bra prescription was not undertaken for the England Senior Women’s Football Team. Furthermore, no previous interventions have been identified that offer breast/bra education, investigate breast/bra issues, and prescribe bras in women’s football. Based on the success of multi-sport breast/bra interventions, this study worked with the England Senior Women’s Football Team prior to the 2022 European Championships and the 2023 World Cup. The first aim of this intervention was to assess breast/bra issues and preferences through surveys and individual assessments. Secondly, to individually prescribe sports bras and thirdly to evaluate the impact of the intervention. Based on previous research it is hypothesized that this intervention will deliver sports bras that are perceived as significantly better than players current sports bras.

Methods

Following institutional ethical approval (SHFEC 2022-023A), 30 minute face to face breast/bra educational workshops covering breast anatomy, sports bras, bra fitting and breast awareness were delivered to the England Senior Women’s Football Team players and management at training camps in 2022 and 2023. At the end of the educational workshops players were giving an explanation of the intervention, 36 players volunteered, provided informed consent, and completed pre-intervention surveys online, assessing breast/bra knowledge, perceived bra size, breast pain, bra issues, bra preferences, and general demographics (described elsewhere, Wakefield-Scurr et al., 2022, 2023).

Thirty-six players then undertook individual, face to face breast/bra assessments with breast health researchers (trained bra fitters; >6 years experience). Assessments took 15 minutes, beginning with confirmation of consent, then demographic details were recorded, including current bra size and style worn for football. Bra fit was assessed in an everyday bra (Marks and Spencer, full cup, unwired) using best fit criteria (McGhee & Steele, 2010), under and over bust measurements were taken (White & Scurr, 2012). Players were introduced to different sports bra styles (2022 intervention: six Nike bras; 2023 intervention: four Nike bras, which were marketed as medium and high support, Figure 1), all with GPS tracker pouch retrofitted to the back. Players bra style preference was discussed and their bra fit assessed in their current bra and their preferred new style. Players were given advice on bra fitting using the best fit criteria. Players were then fitted in alternative styles to demonstrate variations, before final preferences and size were recorded. During assessments discussions were semi-structured around breasts/bras during sport, bra requirements for football and why they opted for their current bra. Players received their prescribed bra (two samples) at least six weeks before the Championships. Players trialled their bras and were able to changes the size or style chosen.

Figure 1. Nike bra options available for the bra prescription in the 2022 intervention, in the 2023 intervention (**) or in both (*).

Between five and nine weeks after both Championships 24 players were invited to complete post-intervention surveys (67% response rate). This survey investigated benefits of the intervention, perceived changes in knowledge or behaviour, and evaluation of their prescribed (new) bra compared to their pre-intervention (old) bra. Data from pre- and post-intervention surveys were matched, anonymized, coded and analysed. Numerical ratings for players old bras were compared to their new bra using one-tail, non-parametric Wilcoxon Pair Samples Tests (α = 0.05) (Figure 2).

Figure 2. Post-intervention median numerical rating (0 to 10) for players old sports bra compared to their newly prescribed sports bra (n = 22). Significant differences *p < 0.05.

Results

None of the players had given birth, breastfed, undergone breast surgery or been diagnosed with breast cancer. Average age was 25.8 years (standard deviation 4.1 years) and mode body mass was 56 to 60 kg. Pre-intervention, 78% of players rated their breast/bra knowledge as average or below average, but following the intervention 91% perceived an improvement in knowledge (Table 1).

Table 1. Responses to the breast/bra survey, pre- (n = 36) and post-intervention (n = 22).

	Pre-intervention	Post-invention
How would you rate your knowledge of breasts/bras (such as bra fit, appropriate support, etc)?	Good = 8, Average = 20, Poor = 8	91% reported improved knowledge
Last professional fitting for a sports bra?	Never = 22, Unknown = 10, >1 year = 4
Mode bra size	32C self-report, 34A measured	XS to M
Have you ever experienced breast pain?	61% (n = 22)
Severity of breast pain (0=no pain, 10=worst possible pain)	0 = 0, 1 = 1, 2 = 4, 3 = 8, 4 = 1, 5 = 4, 6 = 2, 7 = 2, 8 = 0, 9 = 0, 10 = 0
Is your breast pain related to your menstrual cycle?	All except 1 related to cycle
Have you ever undertaken any of the following activities to relieve your breast pain?	8 of 20 breast pain sufferers had done nothing about it. 2 used pain medication
To what extent do you experience breast pain during exercise?	Often = 1, occasionally = 16, never = 4, sometimes = 1
Has your breast pain ever affected your ability to give 100% in training or competition?	n = 1
What type of bra do you wear for training?	100% = sports bra
What type of bra do you wear for competition?	97% = sports bra
What is your preferred style of sports bra?	Compression = 97%, Combination = 3%	Compression = 65%, Combination = 35%
Important features in your sports bra	Comfort = 36, Fit = 30, Support = 24, Material = 12, Breathable = 12, Easy on/off = 10, Shape = 10, Colour = 6, Brand = 5, Lift = 4, Price = 1
Do you have a preference in sports bra strap style/configuration?	Racerback = 34, crossover = 4, adjustable = 2, t-back = 1, straight = 1
Why do you choose to wear a sports bra when training or competing?	Exercise in comfort = 33, reduces breast movement = 25, incorporate smart device = 16, improves performance = 11, reduces breast pain = 7, like the look = 6, matches sportswear = 4, Less embarrassing = 3
Preference for adjustable shoulder straps and band	16% = Yes
Preference for underwire	6% = Yes
Preference for padded/moulded cups	12% = Yes
Preference for wide straps	34% = Yes
Preference for narrow straps	21% = Yes
Preference for padded straps	10% = Yes
Preference for maximum coverage	76% = Yes
How often do you replace your sports bra?	<3 months = 3, <6 months = 12, <1 yr = 3, >1 yr = 11, never = 2, unknown = 5
How often do you wear upper body devices such as heart rate monitors, GPS trackers?	Always = 28, regularly = 6, rarely = 1, never = 1
Do smart devices conflict your sports bra?	11% = Yes
How important do you feel it is to wear a sports bra when you exercise?	Essential = 89%, Very important = 11%	Essential = 83%, V important = 13%, somewhat important = 4%

Pre-intervention, four players (out of 36) reported being professionally fitted for a sports bra. Seven players were unsure of their bra size. For those that reported a bra size the mode was 32 underband (n = 13) and C cup size (n = 8). However, measurements taken during individual breast/bra assessments identified a mode bra size of 34A (Table 1). Thirteen players reported the same underband size to their measured size and three players a similar cup size to their measured size. Only one player reported the same underband and cup size to their measured bra size. The greatest size difference was a player wearing a bra two underband sizes and three cups different to her measured size.

Pre-intervention, 61% of players reported experiencing breast pain, with two players resorting to pain medication, while 40% took no action to resolve symptoms. Only one player felt her breast pain affected her football performance. Mode severity of breast pain was 3 out of 10 (Table 1).

All players reported wearing a sports bra during training and matches, this was predominantly a compression crop top style for all except one player (who wore a combination sports bra). Key features desired in a sports bra were racerback and maximum coverage, with comfort, fit and support the most important characteristics. A high percentage of players did not want adjustability (84%). All except two players experienced some issues with their old sports bras (Table 1).

In the first intervention (2022), only three of the six sports bras available were prescribed; these were all compression style sports bras (Figure 1b, c, e), there was a mixture of medium (52%, n = 15) and high support (48%, n = 14), padded (86%, n = 25) and non-padded (14%, n = 4), adjustable (48%, n = 14) and non-adjustable (52%, n = 15). Sizes ranged from XS to M. Based on these outcomes, the range of sports bras was adjusted for the second intervention (2023) and each sports bra was prescribed. Following both interventions (n = 22), 91% of players reported wearing their prescribed bra at least once a week for training (91%) or matches (59%) (Table 2). Compared to their old bra, significant improvements were reported in their new bra (Figure 2).

Table 2. Responses to the post-intervention survey (n = 22).

	Post-Intervention
How often have you worn your new sports bra?	91% ≥once a week
Have you used your new sports bra for	Training = 20, matches = 13, everyday wear = 1, other activities = 1
If you have stopped using your new sports bra, what are the reasons for this?	Issues with GPS or other smart devices = 3, Prefer another sports bra = 3, Difficult to get on and off = 2, I don’t have enough = 1, Conflict with sponsor = 1, The Velcro comes off quickly = 1, Uncomfortable = 1
Did you benefit from the breast/bra education?	91% = Yes
Did you benefit from the bra fitting sessions?	91% = Yes
Will you do anything different following the breast/bra education and bra fitting sessions?	Replace sports bra more regularly = 14, Wearing different sports bra styles = 8, Get professional bra fittings = 5
Will you continue to use your new sports bra?	86% = Yes

During individual breast/bra assessments most players preferred a compression bra due to feelings of compression and the lower profile, flatter shape it provides. All players reported a dislike of padding due to annoyance with removable pads requiring rearranging, pads folding and making their breasts look larger. Some players, even if an encapsulation or combination bra felt more supportive, reported that they would not wear it because “it would make their boobs look too big”. Players physiques were highly athletic, with a broad back, this meant that some bra styles did not fit appropriately. Some players were reluctant to wear bras with closures or componentry at the back.

This intervention was well received by players; 91% reported benefitting from the education and breast/bra assessments (Table 2). All except two players reported behaviour change following the interventions, with 71% reporting they will replace their sports bra more regularly and 86% reporting they will continue to use their new sports bra after the intervention (Table 2).

Discussion

To our knowledge, this is the first scientific breast/bra intervention in women’s football. Beginning with elite players, the goal was to provide an evidence-base for broader breast health initiatives across all levels of play, as well as ensuring that such interventions are embedded into future practice at an elite level. The first aim of this intervention was to understand the baseline (or current practice) within elite women’s football by assessing breast/bra issues and preferences. Pre-intervention, 78% of players reported their breast/bra knowledge as average or below average, although disappointing, this is similar to that reported by UK adult women (77%) (Burnett et al., 2015), and better than that reported by GB Olympic athletes (83%) (Wakefield-Scurr et al., 2023). The breast/bra education was well received with 91% of players reporting improvements in breast/bra knowledge.

Bra fitting was an issue for this group, with only one player reporting the same underband and cup sizes to their measured size. On average, players were wearing a bra that was half an underband size smaller and one cup size bigger than their measured bra size, with one player wearing a bra that was two underband sizes and three cups different to her measured size. Only four players reported being professionally fitted for a sports bra previously, which highlights the importance of this intervention. Wearing a poorly fitting sports bra compromises the bra function, which could compromise breast health (McGhee et al., 2010).

Sixty-one percent of players reported experiencing breast pain, which is higher than the general population (52%) (Scurr et al., 2014) and that reported in GB Olympic athletes (51%) (Wakefield-Scurr et al., 2022), but similar to Australian elite women athletes (63%) (B. R. Brisbine, Steele, Phillips, et al., 2020). For most symptomatic players, the severity of pain was mild (3 out of 10), however, nine players (25%) reported clinically significant breast pain (>3 out of 10) (Ader & Browne, 1997). This novel finding enabled the medical team to follow up with specific players who may not have been identified otherwise, highlighting one of the health benefits associated with this intervention. This finding also suggests that breast pain is an important consideration for this population and warrants further attention.

The second aim of this intervention was to prescribe sports bras. Interestingly, only three of the six bras available in the first intervention were prescribed and all were compression bras. Semi-structured discussions suggested that football culture and appearance (compression bras giving a flatter profile) affected players bra choice more than the breast health or comfort considerations. This outcome was not reported during similar work with GB Olympic athletes who opted for the most appropriate bra regardless of appearance (Wakefield-Scurr et al., 2022, 2023). This outcome affected the range of bra options made available in the second intervention, resulting in a more appropriate range of bras. Football culture was not considered during the protocol development for this intervention, however, based on the comments from players and a subsequent review of research, this is an area that needs further exploration and acknowledgement (Cleland et al., 2022). These cultural considerations in women’s football may be important in bra choice, given that many supportive bras accentuate breast shape or size. This may also be an important consideration for those making and selling sports bras for football. This outcome should inform product development and future interventions making them more targeted in terms of sports bra choices. Consideration of cultural sensitivities may encourage even more engagement in sports bras, particularly in football which is dominated by masculine values (Cleland et al., 2022).

The difference in players physiques compared to the general population (broader chest and back, smaller cup size, longer body/torso), suggests that some bra ranges may not be appropriate for this group. For example, working with bras sized as small, medium or large was challenging due to the fixed ratio between the cup and underband which often did not work for this group. Sports bras with increased adjustability could help, however, players disliked adjustability. Therefore, a bespoke solution or bras sized in cup and underband would work better in future interventions. Despite this, when compared to their old bra’s players reported significant improvements in the new sports bras, suggesting that the intervention in its’ current form is still highly valuable.

The final aim was to evaluate the impact of this intervention. Ninety-one percent of players reported that they benefitted from education and breast/bra assessments. This intervention demonstrated improvements in knowledge and bra fit for all except one player. As the majority (58%) had not replaced their sports bra within the last six months, this intervention provided a means to do so. When compared to their old bra players reported improvements in the new sports bra across all metrics. All except one player reported some behaviour change, with 64% reporting that they will replace their sports bra more regularly and 86% reporting that they will continue to wear their new sports bra after the intervention.

In conclusion, this was a successful, novel intervention for elite athletes that demonstrated poor bra fit, high prevalence and severity of breast pain, cultural sensitivities around breasts/bras, plus non-standard physiques. Following the intervention, 91% of players reported improvements in breast/bra knowledge, 91% reported benefiting from the intervention and most reported some bra behaviour change. Twenty-five percent of the squads reported clinically significant breast pain, which was followed up by the medical team. This intervention offered a unique reporting mechanism for players who may not have been identified otherwise. New findings provide further opportunities for improvement of this intervention based on football culture and bra sizing considerations. This study provided an evidence-base for ongoing breast health initiative with the England Women’s Football Team and discussions around breast health interventions across all levels of women’s football in England.

Acknowledgements

Nike for providing the prescription bras for this intervention.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the The Football Association Limited.