Why Are ACL Injuries in Women's Football So Common? Causes, Frequency, Treatment Options & Prevention Methods

In the world of women’s football, an injury that frequently strikes down players is an anterior cruciate ligament tear, also known as an ACL tear.

In comparison to male athletes, women athletes tear ACLs at a rate two to eight times more often (Orthop, 2016) with the average findings of most studies falling in a range between four to six times more likely, according to Dr Andrew Green. Similarly, Mancini et al (2021) concluded that 1 in 19 women soccer players tear an ACL.

In this article, we will take a look at the causes, frequency, treatment options, and prevention methods of ACL injuries in women's football to try and understand why this game-changing injury seems to be more prevalent in women’s sports. First, we need to understand what the ACL is, as well as the role that it plays in knee stability. With a focus on female athletes, we will examine the prevalence of ACL injuries in women's football and explore potential factors that may contribute to the frequency with which they occur.

What is an ACL?

It is important to point out that ACL stands for anterior cruciate ligament. This is one of the major ligaments in the knee joint. The ligament is located deep in the knee and plays a vital role in providing stability as well as preventing damage to the shinbone (tibia) and the thighbone (femur). The ACL keeps the knee joint aligned during physical activity allowing you to remain stable whilst rotating. It helps with activities such as running, jumping and sudden changes in direction, all movements that occur frequently in professional sports.

What causes ACL tears to occur?

ACL tears can be caused by a number of different factors. The most common cause of an ACL tear is a sudden twisting or pivoting motion that occurs during sports. An ACL tear is a common injury in sports as it is often caused by poor landing techniques when jumping, collisions with other players, sudden changes in direction or even poor playing surfaces. At one point, an ACL tear was known as a career-ending injury, however, as treatments have developed players can now return to playing at the level they were prior to their injury.

Are ACL injuries common for athletes?

Yes, ACL injuries are relatively common among athletes, particularly those involved in sports that require quick changes in direction, jumping, or pivoting movements. The risk is especially elevated in sports that involve sudden stops or changes in direction, as well as contact sports where collisions may occur. ACL injuries are common in sports such as basketball, American football, skiing, gymnastics, and, of course, football. Some famous athletes that have suffered an ACL injury include Alan Shearer, Virgil Van Dijk, Tom Brady, Klay Thompson, and Rob Gronkowski. 

How common are ACL injuries in football?

ACL injuries are relatively common in both professional and casual football, however, they occur more often among players who are participating in professional, high-intensity, competitive matches where physical exertion is heightened. Football involves a combination of quick movements and turns, all of which place stress on the joints, particularly in the legs. 

How common are ACL injuries in women's football?

Female athletes participating in soccer have been found to have a higher risk of ACL injuries compared to their male counterparts. Speaking to Inside the WSL, female health specialist Dr Emma Ross suggested that female athletes are up to six times more likely to have a non-contact ACL injury than male athletes. This is thought to be due to a number of different factors.

In the video below Sky Sports investigate why ACL injuries are so common in women's football:

90min Football's panel of doctors, athletes and women's football journalists ( from GirlsontheBall) investigate why ACL injuries are so common in women's football in the video below:

Women’s football and ACL injuries

Why are ACL injuries occurring so frequently in women's football?

As mentioned, it is thought that female footballers are up to six times more likely to suffer from an ACL injury than male footballers. The exact reason for this is still up for debate, however, several experts believe factors such as hormones and body physiology can cause the risk of injury to increase in women. This topic is becoming more widely discussed due to the profile of women’s football becoming greater after the England Women’s national team won the European Championships in 2022.  

In the video below Sky Sports asks consultant orthopaedic surgeon, Nev Davies, to explain why the frequency of ACL injury occurrences is increasing in women's football:

Is a female athlete more likely to re-tear an ACL?

Studies have suggested that female athletes may have a slightly higher risk of re-tearing their ACL after undergoing ACL reconstruction surgery compared to male athletes. Female athletes also have a higher rate of ACL grafts failing during treatment, prolonging their return to professional sport. 

Which famous female footballers have had ACL injuries?

Unfortunately, several high-profile female footballers have suffered ACL injuries. Here is a table of women’s footballers that have at some point in their career faced an ACL injury.

 How are the FA trying to reduce the occurrence of ACL injuries in women's football?

Due to the frequency of ACL injuries, it is natural that people want to find ways of reducing the number of injuries in women’s football. The English Football Association, also known as the FA, are conducting studies to try and understand why so many female footballers experience ACL injuries. By better understanding the causes, the FA feel they can find better ways of preventing these injuries. 

Can FIFA research reduce ACL injuries in women's football?

It is not just the FA that is conducting studies into ACL injuries in women’s football. The world governing body of football FIFA are also producing research around female player health and performance. This comes after players, fans, national teams and professional clubs called on FIFA for answers. 

The chief women’s football officer for FIFA Sarai Bareman said that FIFA had been conducting research for 18 months to address the gap in research. She also said, “It’s devastating, particularly to see some of those big names or any player that will miss out on a tournament of this magnitude (the FIFA Women’s World Cup) because of injury, it’s heartbreaking.”

She continued, “FIFA have what we call our female health project. It's actually something that we've been working away on for the last 18 months a little bit behind the scenes but nevertheless, we have had some of the world's best researchers in the field of female health and in particular around the biology and physiology of females.”

The issue of ACL injuries also directly impacts FIFA. Several big-name players including England captain Leah Williamson and her England teammate Beth Mead, who are crucial to the commercial success of women’s FIFA tournaments, will be missing out on the FIFA Women’s World Cup due to ACL injuries. 

Optus Sport's panel, consisting of Sarai Bareman (FIFA Chief Women's Football Officer) and Fatma Samoura (FIFA Secretary General), discuss how the Female Health Project and FIFA research can reduce ACL injuries in women's football in the video below:

Is more research needed into ACL injuries in women's football?

Perhaps controversially, many fans, clubs and players have pointed out that despite the evidence being there to suggest a higher frequency of ACL injuries in women’s football, there is an insufficient amount of research being conducted by governing bodies to help pinpoint a cause. This is, potentially, what kickstarted the FA and FIFA into action. 

Why could ACL injuries be more common in women’s sports?

But why could ACL injuries be more prominent in women’s sports? There are several theories as to why this may be the case, and experts all over the world believe that it can be down to both hormonal and physiological factors. 

Are there any biological differences in the ACLs of men and women?

Yes, there are a number of biological differences between ACLs in men and women. The differences between male and female ACLs may contribute to the risk of injury. A female ACL is narrower and smaller than a male ACL which may affect its strength and load-bearing capacity. This is thought to be a factor in some female ACL injuries. 

Can sex hormones increase the chances of an ACL injury in women?

Perhaps the most discussed theory surrounding ACL injuries in women is that female sex hormones increase the risk of injury. The hormone oestrogen is known to affect the stability of the joints when it is heightened, interfering with collagen which causes them to become looser. Looser joints are less stable and more susceptible to injury. 

How could a woman's menstrual cycle affect the chances of experiencing an ACL injury?

During the menstrual cycle, the hormones inside a woman can fluctuate. The level of the hormone oestrogen is heightened during the menstrual cycle. This, as mentioned, can cause the joints to become looser which makes them more unstable and more prone to injury. 

Could taking period delay medication affect the chances of experiencing an ACL injury as a female athlete?

Period delay medications are a form of medication that helps to delay menstruation. Normally, a woman will start a period within 30 days of her last period. When you use a period delay medication you can extend the duration before a period by up to 17 days. Different types of period delay medications are available, including Norethisterone and Utovlan. 

The effects of taking period delay medication on the risk of ACL injury in female athletes are not well-studied, and there is limited research available on this specific topic. If a female athlete is considering taking period delay medication, it is advisable to consult with a healthcare professional who can provide personalised advice based on the individual's specific circumstances. 

Could taking the contraceptive pill affect the chances of experiencing an ACL injury as a female athlete?

Contraceptive pills are effective forms of medication for preventing pregnancy. There are many different forms of contraceptive pills that work in different ways, however, they typically affect the hormones in the female body. Popular contraceptive pills include Dianette, Yasmin and Cerazette.

The relationship between contraceptive pills and the risk of ACL injuries in female athletes is an area of ongoing research and debate. Some contraceptive pills contain synthetic hormones which can affect the stability and laxity of joints, including the knees. 

Can differences in anatomy/biomechanics increase the chances of an ACL injury in women?

Yes, alongside hormonal factors, experts believe that female anatomy can play a role in the increased risk of ACL injuries. One of the biggest concerns in female football is the difference in the feet of a man and a woman as well as the boots that footballers wear. Football boots are predominantly based around the feet of men, however, a female foot is actually different to a male foot. Female feet can have different arches and heels, which change the way that they move. 

When a female footballer wears football boots, she is usually wearing a product that was originally designed for a man but has since been changed in size for women. This means that the boot does not offer the support needed, increasing the risk of injury when moving. Because of this, many boot manufacturers began producing female-specific boots prior to the FIFA Women’s World Cup 2023. 

Could the size of the femoral notch increase the chances of an ACL injury in both men and women?

The femoral notch is a groove in the femur, the part of the knee where the anterior cruciate ligament (ACL) is located. The size of the femoral notch varies in terms of width and shape. A smaller femoral notch, particularly those that are narrower and shallower, has been linked to an increased risk of ACL injuries. Having a smaller femoral notch will mean that there is less space for the ACL, which can cause increased stress on the ligament during movement. Whilst there is some evidence that femoral notch size can contribute to ACL injuries, it is important to note that it is not the main contributing factor in the majority of cases.

Can neuromuscular differences increase the chances of an ACL injury in women?

Yes, neuromuscular differences have been identified as one of the contributing factors to the increased risk of ACL injuries in women. Some of the neuromuscular differences that have been observed in women include:

• Knee valgus - Knee valgus refers to the inward collapse of the knee. Women often demonstrate greater knee valgus during dynamic movements such as changing direction or landing from a jump.

• Altered landing mechanics - Women can land differently when jumping compared to men. Women may have more extended hips and knees when landing which can increase the forces imposed on joints.

• Decreased muscle strength - Women generally have lower muscle strength than men, particularly in the hips and hamstrings. This can impact the stability of the knee joint.

Can core stability increase the chances of an ACL injury in both men and women?

Yes, poor core stability can increase the chances of a man or woman experiencing an ACL injury. Core stability exercises are often recommended as part of ACL injury prevention programmes. Core stability refers to the strength and control of the muscles in the abdomen, lower back and pelvis. Having poor core stability can negatively impact body control during dynamic movements such as running and jumping. 

How can you prevent an ACL injury?

Could practising good technique prevent an ACL tear in female athletes?

Yes, practising good technique is an essential component of ACL injury prevention in female athletes and athletes in general. Proper technique can help reduce the risk of ACL tears and other knee injuries during sports. Good technique can ensure that you are going to be turning, running, and landing in the safest way possible to prevent ACL injuries. 

Could reducing workload prevent an ACL tear in female athletes?

Reducing workload can potentially contribute to the prevention of ACL tears in female athletes. High workloads and excessive training volume without adequate recovery and rest can increase the risk of ACL injuries and other overuse injuries. In professional sport, it is not easy to simply reduce your workload. This is why it is important to properly recover to not only help your body to rest, but also to prevent injuries from overworking yourself.  

Could eating a balanced diet prevent an ACL tear in female athletes?

While maintaining a balanced diet is important for overall health and performance, it is not directly linked to preventing ACL tears in female athletes. Proper nutrition, however, plays a role in supporting overall musculoskeletal health, injury prevention, and recovery from injuries. A balanced diet provides energy, nutrients and hydration that can help to prevent ACL injuries by improving muscle strength, bone health, weight management and overall health. 

Could developing all muscle groups evenly prevent an ACL tear in female athletes?

Developing all muscle groups evenly, including the muscles around the knee joint, can contribute to reducing the risk of ACL tears in female athletes. Having balanced strength and muscle development throughout the lower extremities can help provide stability and support to the knee joint, reducing the chances of injury. It is important to note that developing upper body strength and not lower body strength can actually increase the risk of ACL injuries. Having a lot of upper body weight on underdeveloped legs can cause stress to the joints, particularly when doing dynamic movements such as running or jumping. 

Could avoiding training when fatigued prevent an ACL tear in female athletes?

Avoiding training when fatigued can potentially contribute to the prevention of ACL tears in female athletes. Fatigue can negatively impact neuromuscular control, coordination, and overall movement quality, increasing the risk of injury, including ACL tears. In professional sport teams have set training regimes that often focus on recovery just as much as other training. 

Could improving strength and flexibility evenly prevent an ACL tear in female athletes?

Improving both strength and flexibility evenly can contribute to reducing the risk of ACL tears in female athletes. Both strength and flexibility play important roles in supporting proper movement mechanics, joint stability, and injury prevention. It is important to strengthen the muscles in the legs and around the knees as this can help to prevent ACL and other injuries. It is important to note however that no matter how strong your leg muscles are, your knee is still susceptible to ACL injuries. 

How do you treat an ACL injury?

The treatment of an ACL injury can vary depending on the severity of the injury, the individual's activity level, and their specific goals. Treatment options for ACL injuries can include both non-surgical and surgical approaches. It's important to note that the decision to pursue surgical or opt for non-surgical treatment depends on various factors, including the individual's age, activity level, associated injuries, and personal preferences. 

Is surgery always needed after an ACL tear?

No, surgery is not always needed after an ACL tear. The decision to surgically repair ACL injuries will depend on the severity of the injury, the age of the person with the injury, and the profession of the person who is injured. Non-surgical treatment will be considered for people who:

• Have low activity levels

• Have partial ACL tears

• Are older and less active

Non-surgical treatment typically involves a rehabilitation programme that focuses on the strengthening of the muscles surrounding the knee. In some cases, the patient will also need to wear bracing on the knee to provide additional support during physical activity. 

Is the healing process for a ruptured ACL the same in male and female athletes?

The healing process for a ruptured ACL is generally similar in both male and female athletes. After an ACL tear, the ligament itself does not heal or regenerate on its own. Instead, the body initiates a healing response that involves forming scar tissue within and around the injured ligament.

The process of scar tissue formation begins shortly after the initial injury, and over time, the scar tissue remodels and strengthens. This scar tissue helps stabilise the knee joint but does not fully replicate the original ACLs strength and properties.

Is the treatment for an ACL tear different for female athletes compared to male athletes?

The treatment for an ACL tear is generally similar for both female and male athletes. The primary goals of treatment are to restore stability and function to the knee joint, reduce symptoms, and facilitate a safe return to sports and activities. It's important to note that treatment decisions are made on an individual basis, taking into account factors such as the severity of the injury, activity level, goals, and the athlete's overall health. Treatment approaches are tailored to each individual, regardless of gender, and may include both surgical and non-surgical options based on the specific circumstances and preferences of the athlete and their team.

Sources

• Sky Sports - Inside the WSL: Why are ACL injuries so common in women's football?

• Johns Hopkins Medicine - ACL Tears in Female Athletes: Q&A with a Sports Medicine Expert

• BBC Sport - ACL injuries: Is women's football doing enough to combat issue?

• PubMed Central - Anterior Cruciate Ligament Injury Risk Factors in Women

• PubMed Central - Sex-Based Differences in ACL Injury Mechanisms

• British Orthopaedic Association - How to tackle the increased rate of ACL injuries in women's football

• The Athletic - ACL injuries in women's football: How can they be prevented?

• British Journal of Sports Medicine - Addressing ACL injuries in women's football: The role of injury prevention programs

• ITV News - Can the FA solve the ACL injuries blighting women's football?

• Optus Sport - FIFA is conducting research to reduce ACL injuries in women's football