Why are women football players at greater risk of ACL injuries?

Elite women’s football has witnessed close to 200 ACL injuries in the last 18 months.  (Unsplash/Jeffrey F Lin)
Elite women’s football has witnessed close to 200 ACL injuries in the last 18 months. (Unsplash/Jeffrey F Lin)


Project ACL, a three-year-long research project launched in the UK in April, is an attempt to find the answer

Last Saturday, two past Ballon d’Or winners faced off against each other. No, not Lionel Messi and Cristiano Ronaldo. It was Barcelona’s Alexia Putellas (two-time Ballon winner) and Olympique Lyon’s Ada Hegerberg (the first ever woman to win a Ballon). The two stalwarts locked horns in Bilbao, northern Spain, in the UEFA Women’s Champions League (UWCL) final on Saturday night in front of more than 50,000 supporters in the stands. Both of them came off the bench and tried to influence the game. Ultimately, Barcelona walked away with the trophy with Putellas scoring in stoppage time to seal the 2-0 win.

The win was noteworthy, but that night, the mere presence of these two stars, Putellas and Hegerberg, on the pitch was a reminder of a stark fact — women suffer a lot more ACL injuries than men. Indeed, if you looked closely, you'd find that a commonality that ties the two players together is that they have suffered serious Anterior Cruciate Ligament (ACL) injuries and spent a very long period of time recovering.

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Women are up to six times more likely to suffer ACL injuries than men and about 66% of women’s football injuries occur without physical contact. In the last 18 months, elite women’s football has witnessed close to 200 ACL injuries, including the Chelsea and Australian striker Sam Kerr, England’s Euro winning skipper Leah Williamson and star player Beth Mead. From her years in football, including playing for the London-based Tottenham Hotspurs women’s team, Tanvie Hans says, “ACL tears are a lot more common among us [women] than among men." Yet, to this day, the best sports medicine minds, sports injury specialists and the medical fraternity in the world don’t know why it is so.

In late April, Fifpro (the international players ’union), England’s Professional Footballers ’Association, Nike and Leeds Beckett University came together to launch a three-year long research called Project ACL. The purpose – to address the glaring gap in knowledge and data available on ACL injuries in women footballers.

What causes ACL injuries?

Unlike men’s football where there is plenty of data on everything from gear and nutrition to injuries and training, there is hardly any data about women’s football. This is mainly due to the lack of investment in the women’s game globally. However, in the recent past since women’s sports such as cricket, football and cycling have started growing both in revenue and popularity, there has been some research into why women suffer more ACL injuries than men.

A study published in the Journal of Athletic Training in 2013 established a link between ACL injuries and the menstrual cycle. The researchers found that incidence of ACL injuries was greater during days 9 to 14 of a 28-day cycle and lower during the post-ovulatory phase, i.e. day 15 through the end of the cycle. The researchers also found that female athletes were at increased risk of ACL injury during the preovulatory phase and that fewer injuries occurred as the cycle progressed. They found that a narrower femoral notch, higher-than-average body mass index, and general joint laxity predicted ACL injury risk among women. Women with higher knee laxity were 2.7 times more likely to suffer ACL injuries than those with lower laxity. There was no such link for men.

The European Club Association’s high performance advisory group conducted a study that found a large number of women footballers play the game in poorly fitting shoes, often using shoes designed for men or children. The study noted that“ proper fit is an important feature related to comfort of footwear but also injury risk, fatigue, mobility, performance, and alignment of the lower limb." Only 18% women customise their boots while the majority use specialised insoles and, at times, cut the shoes at the back to widen the heel. For men’s boots the studs size and type (for soft or hard surfaces) are matched to specific playing surfaces to optimise traction but not for women’s boots. This has led to serious injuries, including ACL tears. A common reason for ACL injuries in elite women footballer is increased shoe-surface traction due to which the shoe gets stuck in the ground. A sole that produces too much traction increases the risk of injury.

Coming to Project ACL, not only is there a lot more player awareness but also much more involvement in it. Lucy Bronze, who was on the field for Barcelona at the Champions League final on Saturday, and wrote her dissertation on ACL injuries in women’s sports, told Reuters, “The recovery time is one of the longest in terms of common injuries, and it tends to be if you’ve done your ACL that’s it, you know that you’re missing the next tournament or the Champions League final, the end of the season, whatever it is, for that reason it’s spoken about so much." Dr Stacy Emmonds of Leeds Beckett University, who is also involved in the study, told Sky Sports News that the study will not just improve the research in women’s football but in female athletes overall.

Shrenik Avlani is a writer and editor and the co-author of The Shivfit Way, a book on functional fitness.

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