It may surprise you to learn that around 25 – 30 players will have missed the 2023 world cup because of an ACL injury, and of the 736 players who went to the tournament, around 25% will have ruptured at least one of their ACLs during their career.
Seems high, doesn’t it?
The ACL (anterior cruciate ligament) runs diagonally in the middle of the knee. It provides rotational stability to the knee – a movement which is vital in football, and other change of direction sports.
How does an ACL injury happen? #
With a ligament injury, people often think it is likely to occur with trauma, like a bad tackle, for example, but the truth is that they most commonly happen when a player very quickly slows down or changes direction after planting their foot, and often does not involve contact with another player.
It’s no secret that ACL injuries are both mentally and physically tough. The rehabilitation process is lengthy, and unfortunately many people experience longer term consequences as a result of the injury. For example, having an ACL injury increases the risk of osteo-arthritis in the knee and, unsurprisingly, the risk of suffering another ACL injury.
Currently, only 65% of women return to their preinjury level of sport and statistics show that men are 1.7 times more likely than women to return to their preinjury levels and abilities.
So, I’m sure you’ll agree that it is an injury we need to understand more about and hopefully be more successful in preventing.
The rate of ACL injury is so much higher in women compared to men. Which raises the question…
Why are women more likely to suffer an ACL injury? #
Well firstly, there are a number of different factors, and to understand their relevance the bottom line is, we need more research.
Most of the research that has been conducted on men and assumed to be transferable to women.
Recently there has been a positive move towards understanding what modifiable factors we should be looking at for our female athletes, but it’s clear that we still have a lot to learn.
What are some of the affecting factors for ACL injuries in females? #
The first is the anatomy. #
Aspects such as the angle of the hip with a wider pelvis affects the forces and weight going through the knee. As well as females being generally more mobile, the attachment and make-up of the ligament are different, leaving it more susceptible to injury.
Although a person’s anatomy is a contributing factor, it is unlikely to fully account for the significant difference between ACL injuries in women vs men.
The second is hormones. #
The ligament itself may be more prone to injury during the follicular phase (from the first day of bleeding through to ovulation) of the menstrual cycle, and there is also some evidence to suggest injury rate may be higher in general in the later part of this cycle phase.
However, cycles are very individual and whilst it is useful to track symptoms to optimise training, we do not have enough evidence to say that variations in hormone levels are responsible for an increased risk of ACL injuries in female athletes.
Currently the quality of papers in this area are not good enough to show that there is a link between hormonal variations and risk of ACL rupture, so more research is needed.
The third area is strength. #
Females tend to have reduced strength and power in relation to body mass index compared to men. For example, the differences in hamstring and quadriceps strength, compared to males, can exist as early as 8 years old. Although behaviour patterns are changing, and we’re seeing more females take up strength training, traditionally women have tended to strength train less than men.
This is an important factor and emphasises why injury prevention programs are useful. The mechanics of how we move are also important; both are modifiable factors and can be addressed and improved with the help of a Physiotherapist or Strength & Conditioning Coach.
The fourth is development. #
Girls have typically played less hours of football by the time they reach adulthood which may affect movement efficiency, and in general more girls drop out of sport during the adolescent years than boys.
As popularity for the game has increased, more girls are playing football from a younger age so this potential factor should actually be reducing. But more needs to be done to keep girls strong and in sport.
The fifth is training load. #
The women’s game has developed significantly in recent years, but many have had to balance work with being an elite athlete which would affect their ability to recover due to their additional responsibilities and demands on time. Also, the increase in popularity in the women’s game has resulted in a more crowded fixture list. This increases physical demand and again affects the ability to recover.
Again, more research is needed to understand the effect of training load on risk.
The sixth and final factor is infrastructure. #
The facilities, support staff and medical expertise in the women’s game is not the same as the men’s at an elite level. This disparity exists throughout from grass roots to academies.
Significant improvements need to be made in infrastructure at all levels, to improve injury prevention and treatment.
The next, and very understandable, question that may now be on your mind is…
How can I prevent the likelihood of an ACL injury? #
There are a lot of really good injury prevention programs, which focus on movement control and strength. If you are playing regular sport these should be a part of your training.
The evidence shows us that if you carry out a researched injury prevention program 2 – 3 times per week, with good coaching, you can reduce the chance of ACL injury by 20 – 50%.
To get a personalised strengthening program for you, it’s best to see a trained professional such as a Strength & Conditioning Coach.
So, there you have it, the truth behind why females are more likely to suffer an ACL injury.
The fact is we’ve already come a long way from where we used to be in women’s football and women’s sport in general, but more research is needed. Knowledge and education remain key when applying effective prevention techniques in to training programmes.
Nothing should stop young women and girls picking up and enjoying the sport of football throughout their lives. For even if someone experiences an ACL injury, we are on hand to help you get back to your best and, most importantly, back on the pitch.
Useful resources for injury prevention #
Here are some useful links we think you’ll enjoy watching following our blog:
ACL Reconstructive Surgery: Recovery and Rehabilitation
What factors (if any) can we use to predict the chance of a successful outcome after anterior cruciate ligament (ACL) reconstructive surgery? Over the past two years our Research Team have conducted an extensive study to answer this question.
Multi-directional Fitness and Return to Sport
Since March 2020 we’ve seen many people turn to HIIT workouts and running to maintain their fitness levels. Whilst this is great, if you are planning on returning to sport, there are specific aspects you need to train for before going back at 100%.
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