ACL Injuries in Women's Football


Football is without doubt the most popular sport in the World. It attracts significant funding and is extremely competitive, however many fans cannot miss to note the high number of knee, especially anterior cruciate ligament (ACL), injuries in the women's game.

These injuries have been monitored by clinicians and The Football Association (The FA) for many years now too. The healthcare professionals working in the background, already at Club level, are trying to eradicate these potentially career ending injuries through the youth phases of the game. Substantial injury prevention programmes and injury surveillance is in place consequently.

Nevertheless, currently the England team is missing the likes of Beth Mead and Leah Williamson, whilst Internationally five of some of the best female players in the world are unable to play at the World Cup (e.g Vivianne Miedema of the Netherlands), whilst Spain's Ballon d'Or winning Alexia Putellas only just recovered in time for the competition.

Statistics & studies vary. Many of them suggest that ACL injuries are 2-3 times more likely in women than in men’s footballers, however many research findings estimate this number to be as high as 4-6 times.

Furthermore, those women who successfully recover have a 30% chance of re-rupture of their ACL on the same side or injury to their contra-lateral knee.

Long-term, surgical interventions often contribute to degenerative arthritis of the knees, especially if meniscal (cartilage) damage occurs as well. So, a higher number of women may also face knee replacement surgeries prematurely later in life.

Why is it though? Why are there so many ACL injuries? What factors contribute to these deterring statistics? This short article will discuss just a few of them.

The biomechanics behind an ACL Injury

Women are inevitably built anatomically differently to men.

Their Q angles, the angle formed between the quadriceps muscles and the patellar tendon, are larger and have a narrower intercondylar femoral notch, and therefore a smaller ACL.

Women are also more likely to land or terminate their run with their knees in a more extended position than men and go into a valgus position (with more load going through the innermost aspect of the joint and be prone to a rotational force thereafter). During this rotation, it is more common that the non-dominant knee sustains the unfortunate injury, in preparation for the kick with the contra-lateral, dominant lower limb.

The mechanism of the ACL injury and the 'pop'

The above is important as ACL injuries mostly occur if a player plants her foot, and then a rotational force is also applied to the knee (e.g. if a boot gets stuck in mud or the player slips in adverse weather conditions). Therefore, this kind of ligament injury is often not linked to the heavy contact nature of the sport (such as from tackles). Players often report an audible 'pop' - in essence they hear the rupture occurring.

Women are more often flat-footed

There are also suggestions that women are often more flat-footed and consequently are to have gender specific football boots manufactured for them. The likes of Nike and Adidas are keen to support the elite game with their footwear, however sport shops and retailers are often more reluctant to stock female only boots (as they expect fewer sales in the community).

As the popularity of the women's football game blooms, so does the prospect for more girls to earn a living through their talent. Hopefully the era of new women’s boots is ahead of us.

Natural ligamentous laxity and fluctuation in oestrogen levels

Most ACL injuries of athletes occur during the pre-ovulation phase. It starts at the first day of menstruation and often continues for 10-17 days of the cycle. Unfortunately, higher oestrogen levels are directly linked to increased laxity and weakness of the ligaments. Inevitably, there is an increased risk of injury during the first half of the cycle therefore.

Muscular imbalance in female footballers

It is not exclusively seen in women, but players can be quadriceps dominant which is a term we use clinically when the muscular interplay between the quads and the hamstring muscles are not in balance. Therefore, players often need hamstring strengthening and appropriate stretching programmes to combat this.

Female reflex times, balance, and proprioception

It is thought that women at an elite sports level have longer reflex times and less sturdy balance as well as less refined ability to sense the body's movement in space, during a particular action or movement pattern.

We may find goalkeepers defying all expectations and they belong to the top 1% of society with their reaction saves for example. Inevitably, Mary Earps of England is one of the World's best goalkeeper and deserves all recognition for her exceptional skills.

However, not all hope is lost as experienced clinicians and effective injury prevention programmes are thought to reduce the risk of ACL ruptures by 70%, as well as can minimise the risk of re-injuries to single digits rather - often to the region of 5%, instead of the dreaded near 30%.

Here, at the White House Clinic we welcome athletes, as well as members of the public to support your preventative care and / or recovery. ACL injuries are not exclusive to the game of football, but are seen in rugby, skiing and a wide range of other, everyday scenarios.

Do not let these hinder your long-term fitness and joy of an active lifestyle! Contact us for more information if you would like to discuss your circumstances in a bespoke manner.

Zsóka Balogh

Advanced Physiotherapy Practitioner & First Contact Practitioner Team Lead

Zsóka qualified from Keele University in 2015 with a BSc (Hons) degree in Physiotherapy. She is a fully registered clinician with the HCPC and the CSP.

Zsóka Balogh

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