Earlier this year, England striker Beth Mead fronted a YouTube series about her battle with ACL rupture. “Like someone had hit either side of my knee with a hammer,” is how she memorably describes the injury, which happened during a 2022 club game.
Yet, even then, she didn’t want to fear the worst. “Deep down, I didn’t want to think it was this injury,” she recalls. “I thought, ‘Maybe I’ve just tweaked something – but not the dreaded ACL.’”
Footballers dread anterior cruciate ligament tears for a reason. A serious rupture means months out of the game: usually at least nine, but potentially a year or more.
Yet Mead’s injury came against a backdrop of alarm over ACL injuries in the women’s game more widely. “Why are so many female footballers suffering ACL injuries?” goes a typical recent headline. “New report slams sports’ response to women’s ACL injuries,” reads another.
What exactly is going on?
Why have ACLs become such a hot topic?
The debate has been heightened by injuries to several high-profile players. They include Ballon d’Or winner Alexia Putellas, England captain Leah Williamson, Chelsea’s Sam Kerr, and Mead’s Arsenal teammate Vivianne Miedema (who also features in the documentary). But the full list is longer. Nearly 40 female players are thought to have missed last year’s World Cup because of ACL injuries.
Does the data support the concerns?
It seems to. Recent studies have found women are anywhere from two to eight times more likely to suffer ACL injuries than men, and 25% less likely to make a full return to the sport. Across the world, nearly 200 elite female players are thought to have suffered ACL injuries in the past 18 months. Over 60% of those injuries occurred without physical contact.
Why the ACL in particular?
Damaging the anterior cruciate – which protects our knee from over-rotation, among other things – is a risk in all contact sports. But football is particularly prone due to the twisting and pivoting involved. “If you look at the mechanism of injury, the player is normally semi-flexed, fully weight-bearing, with some rotation,” England physio Gary Lewin tells the YouTube film. “And what happens is the knee tends to buckle inwards. That puts stress on the ACL… and it ruptures.”
So what’s causing the trend in women’s football?
The honest answer is nobody is completely sure. There’s an urgent need for more high-quality data (more on that below). But several suggestions have been made:
- Biomechanical: The “Q angle”, a measurement of the angle between the hip joint and the lower leg, is usually larger in women. A greater Q angle can increase the strain on the quadriceps muscle, which in turn may impact the position of the ACL
- Societal: Many of the staples of elite football – from training and strengthening regimes to footwear – have been developed for men, not women. One recent survey reported that 82% of female players experienced high levels of discomfort from their boots
- Hormonal: Although oestrogen promotes endurance, it also increases laxity in the connective tissues. This makes ligaments like the ACL more susceptible to tears, particularly during menstruation, when oestrogen levels rise
Professional footballers are also playing more games than ever before. A sign of the rising popularity of the women’s game, certainly – but an added layer of pressure on joints and muscles as the season wears on too:
“When I’ve looked into it, I’ve gone from 2,000-odd minutes to 4,000-odd minutes in a season – which is a steep jump!” Mead adds. “We want the game to go to that level, but it’s [about] keeping our bodies up to that level to do that as well.”
What can we do about it?
One thing everyone agrees on is that we need more research into exactly when, where, and how these injuries are happening. Once we have that data, we can start to develop the targeted training, equipment and processes that will protect women players and reduce their risk of injury.
Is that ever likely to happen?
Fortunately, yes, it’s happening right now. This month, the professional footballers’ association FIFPRO launched a landmark, three-year study into ACL injuries in women’s football. Project ACL will work with players at Women’s Super League clubs across England, ultimately aiming to develop a code of best practice.
According to FIFPRO, the research will include “real-time tracking of [players’] workload, travel and ‘critical zone’ appearances”, as well as a complete review of all the existing academic studies. “Most of the research to date on ACL injury has focused on single sex-based risk factors like the mechanics of female bodies,” explains Dr Stacey Emmonds of Leeds Beckett University, one of the project leads. “Our research will look at the bigger picture to consider the gendered environmental factors that may influence injury risk in women’s professional football.”
This is great news, and we’ll be keeping a close eye on Project ACL’s findings as they emerge over the next three years. To learn more about the initiative, head over to FIFPRO’s website. The project leaders have also created a YouTube video to explain how the study will work and what they hope to discover.
