The Crisis of ACL Injuries in Women’s Football

Anterior cruciate ligament (ACL) injuries have been one of the hottest topics in the women’s game, but not for welcome reasons. 

Why are ACL injuries on the rise in the women’s game?

ACL injuries have been causing havoc within the sport and causing top leagues and tournaments to be without some world class players.

ACL is situated within our knees, it is a short, thick and powerful ligament about the length of a little finger which attaches the thigh bone and the shin bone. When this tears or ruptures it causes devastating injury. 

Football injuries are responsible for nearly half of all ACL reconstructions performed in the UK.

While female athletes across the board are more susceptible, a spate in football specific injuries has gathered concerning momentum. Data suggests that over 195 elite players have been added to causality list in the last 18 months. 

In just over 12 months the Women’s Super League lost key players such as Arsenal trio Leah Williamson, Beth Mead and Viv Miedema. Whilst Chelsea have been without striker Sam Kerr since January. 

The problem is being described as an ‘epidemic’ rippling through the women’s game, to illustrate between 25 to 30 players – enough for an entire squad – missed the Women’s World Cup last summer because of ACL tears. 

Female football-focused studies (which are few and far), suggest that women are six times more likely to suffer ACL injuries compared to men and 25% less likely to make a full return to the game. At present at least 12 WSL players are going through recovery, including Man United’s Gabby George and Leicester winger Hannah Cain. 

Is there a cause? 

Dr Katrine Okholm Kryger, a senior lecture in sports medicine at St Mary’s University has published numerous papers and has said that recent discussions have focused on whether injury risk is down to the female anatomy and hormones, or whether it could be related to how female and male athletes are raised and managed. 

“We have to be really careful when we talk about this in women’s football because there is a tendency within research and within the media of being like ‘oh women are so unstable, fragile, because of their anatomy, their hormonal flucutations’ but we have not proven that is the cause of these injuries”.

Body shape, hip width and the menstrual cycle are all commonly suggested as contributing factors for a rise in injuries. Yet there is still a lack of evidence and research of the role that they play, despite all being used as arbitrary excuses for why ‘women aren’t designed to play football’.

What are the main areas of concern?

• Anatomy

There is physical differences between men and women such as women have wider hips compared to men and so as a result of that it increases the leg’s angle into the knee, and under-developed muscles which prevent the knee from turning in have been the subject of research. 

• Hormones 

The role of the menstrual cycle has also been thrown forward a lot as a potential factor for making more female predisposed to injury at certain times of their cycle. The science behind this is that during certain times of the cycle, oestrogen is elevated which can affect the stability of joints, making them looser and laxer. 

Yet, Dr Okholm Kryger rebuttals this argument: “There has been some not very high quality research done on the relationship between the menstrual cycle and the ACL risk,” she said. “It’s very difficult because you need either continuous blood samples or saliva.

“Most of it is done predicting where in the phase women are, based on when their period starts, most studies haven’t actually measured hormonal levels in the body. So it’s all predictions. When you put all the data together it shows very little difference.”

• Gender Disparities 

External factors such as access to training, sports science, facilities and rehabilitation are also potential causes that have been suggested. 

Typically, girls have not been exposed to the same elite level of football training as early as boy and have not built up the same capacity or base level of strength and endurance compared to boy and so increases their vulnerability to injuries. 

Other gender disparities highlighted by Dr Okholm Kryger include the pitches used in the WSL compared to the Premier League and the design of football kit such as boots. 

Women move and run in a different way to men and yet the length of studs on boots are designed around male movement and traction, she pointed out, which increases the risk of women getting their boot stuck in the surface and an injury being caused.

A report coordinated by the European Club Association revealed that 82% of female players surveyed experience high levels of discomfort wearing football boots.

Dr Kryger’s main argument is that football boots, have until very recently, have always been modelled on a white male player. 

Kryger has undertaken a project to highlight the fundamental differences between a female and male foot by using 3D scanning to map size, shape and variations in heel and arch depth. 

Released before the Women’s World Cup, Nike unveiled their Phantom Luna boot, which took two years in the making and features a unique design with female footballers at the heart of it. 

The Phantom Luna has a higher collar than regular boot which provides increased lockdown to reduce rotational traction, as well as a lower cuff to accommodate the female ankle to thereby reduce the risk of ACL injuries. 

The Phantom Luna has a new and innovative circular stud pattern, named the Cyclone 360, which will allow players to move more freely with agility, precision and security on the pitch.

• Workload

As the women’s game continues to grow rapidly, the amount of games and the level of intensity has increased tenfold, which has led to increasing concern amongst managers and players in the game. 

What is being done to help the issue?

ACL injuries are one of the biggest problems in the game at the moment because of the recovery time and the potential long-term impact it can have on a player’s career. 

The FA has conducted a study into the prevalence of ACL injuries in women’s football in the WSL and the Championship over the past four seasons. 

Its results showed that there were 0.1 injuries per 1,000 hours – 0.4 ACL per 1,000 match hours and 0.04 ACL injuries per 1,000 training hours – representing 1.3% of the total number of injuries. Hamstring injuries were the most common at 11%.

The FA, which does not have the equivalent data for men’s football, said in a statement: “The overall injury rates across these leagues have decreased in the past four seasons, however we will continue with our injury and illness surveillance work, which will continue to give us important medical insight into women’s football.”

UEFA have also stepped up in their efforts by announcing in December the introduction of an expert panel on women’s health to seek a deeper understanding of ACL injuries and their frequency amongst female players. 

Next Steps?

Players have spoken. Medical experts have spoken and made it clear what needs to be researched more and developed further. Coaches and managers agree. Football is depriving its female players of fair and proper treatment. The institution and infrastructure which was built and designed for men by men, is ultimately now failing the women’s game. 

With the rapid growth and development of the women’s game, now is the time for the industry to sit up and listen to recommendations and implement change so that women footballers can get back to doing what they love, rather than sitting on the side lines with their torn ACL injuries.