The current crisis in women’s football: the deadly ACL

With an average recovery time of nine months, an ACL (Anterior Cruciate Ligament) injury is the phrase that nobody, especially elite athletes, wants to hear. Leah Williamson, Beth Mead, Vivianna Miedema, Laura Wienroither, Sam Kerr… the list of professional footballers who have torn their ACL is high, and still rising. But why?

According to research[1], women are around three times more likely to tear their ACL than men. The ACL connects the thighbone (femur) to the shinbone (tibia) and is one of the vital ligaments for stabilising the knee joint. It is most commonly torn whilst changing direction or stopping suddenly. As such, football is a likely sport for this injury. Women in particular are more likely to suffer from the injury due to hormonal factors, neuromuscular factors and environmental factors.

Hormonally, women are more likely to suffer an ACL tear midway through the menstrual cycle (the phase where the egg is released) rather than at the start and end of the cycle (before and after the egg is released). The natural production of oestrogen inhibits a substance (collagen) that reduces the load-bearing capacity of the ACL.

It has also been shown that neuromuscular gender differences play a major role, because females appear to be less effective in stiffening their knee. Women are also more quad-dominant than men, causing the thighbone to move more compared to the shinbone. Furthermore, because a woman’s ACL is generally smaller, this again leads to a greater collision of ligaments when the knee extends.

Finally, with the leap in female participation in sport in recent years (with especially notable jumps seen after the Lionesses’ unforgettable triumph on home soil, becoming European Champions for the first time in their history), comes a natural increase in more females suffering from the injury. However, with this push for more at the elite level comes fixture congestion (lots of matches in a short space of time) and less rest breaks than athletes were used to. Additionally, the fact that there are more international breaks every year, compared to men’s football, means that athletes have to stop and start their training more often. Less rest days mean that athletes are constantly playing and this adds up. Even elite athletes need time to rest.

Why this rise in ACL injuries hasn’t been fully researched is clear to answer: it affects women. I think it is fair to say that if this drastic rise in injuries affected the male game, there would be well-known research already. However, our elite female players are left worried about a season-ending and dream-crushing injury. This is representative of society as a whole, especially women’s health. Women have to pay for menstruation products, and there is often little research done around the symptoms and issues suffered by women. For instance, endometriosis affects around one in ten women, making it just as common as diabetes in women, yet research for diabetes far outweighs research for the former, relatively unknown and unspoken about condition.

 For young people, particularly females interested in pursuing elite sport, this is important in order to protect against injury so you can continue participation in physical activity, whether that be at local or international level. After England’s Euro 2022 win, 68,000 more girls began playing football. This shows just how much things are changing, but we do not want young people to be stopped by injury. To prevent future ACL tears, training programmes tailored to the sexes could help reduce the risk by enhancing knee tension and improving balance. For the next generation, a change in research and attitudes to problems primarily faced by women and girls is needed, on and off the pitch.

[1]  Gender disparity in anterior cruciate ligament injuries, 2014, Yool Cho, Sahnghoon Lee, Yong Seuk Lee and Myung Chul Lee