It may surprise you to learn that around 25 – 30 players will have missed the 2023 Women’s 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.

What are some of the affecting factors for ACL injuries in females?

1. 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.

2. 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.

3. Muscle 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.

4. Physical 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.

5. 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.

6. 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.

(PureSports Medicine, London - 2023)

If you have any questions on whether physio is the best option for you, or you have any questions about MVMNT in general, feel free to contact via email.

- Jay Towolawi, Specialist Sports Physiotherapist and MVMNT Founder.