Female footballers playing football near a goal.

Annabel Jeffery

Leah Williamson and Beth Mead both missed out on this summer’s FIFA Women’s World Cup due to ACL injuries. Their absence from the competition has seen an outcry for more research into injury in women’s sport. 

Before them, it was Chloe Kelly, Alexia Putellas, Vivianne Miedema. ACL are the dreaded three letters that female football players have come to fear.

It has struck 25 per cent of the top 20 female Ballon d’Or nominees of 2022, and is just as prominent in women at the grassroots level. But it takes two big names and a World Cup with 25-30 top players absent to amplify the issue.

In the men’s game: Alan Shearer, Paul Gascoigne and, more recently, Virgil Van Dijk and Tyrone Mings, have all suffered the same injury. But its prevalence in the women’s game is much more striking. According to the Journal of Arthroscopic and Related Surgery, women are up to 3.5 times more likely to suffer an ACL injury than men. However, other studies have shown that the likelihood of severe ACL injury could be six to eight times higher in women.

If the risk were as high in men’s football, would clubs and football associations be taking more action?

What are ACL Injuries?

The anterior cruciate ligament (ACL) contributes to stability within the knee and helps to keep thigh and shin bones in place. There are three levels of severity in an ACL injury: grade one being a stretch, two being a partial tear and three a complete rupture.

One small ligament torn, 90 minutes in theatre and one year in rehabilitation. And that’s if players are lucky. Pro players may access fully-funded surgery in a matter of weeks. Women in the lower leagues may join an 18-month NHS waiting list. This means that they could be out for two or more seasons.

“Women are expected to adapt to the men’s version of the game and its training techniques. The sport is not tasked to adapt to the women” 

Charlton midfielder Lois Roche has recently recovered from an ACL injury and was somewhat fortunate in her treatment. However, she said she has seen various GoFundMe pages set up by players from lower leagues to be able to afford their surgery and ultimately keep them in the game.

There are some extremely worrying statistics: 45 per cent of those injured will never compete again, and 35 per cent will not meet their previous levels of athleticism. This is a far from ideal situation as the popularity and demand in women’s football grows.

Why is women’s football more impacted by ACL injuries?

ACL injuries are always going to be likely in football. Quick starting and stopping, jumping and landing, sidestepping and dodging all elevate the risk. The increasing demand in pace and strength as the game grows also contributes.

Nevertheless, take an equitable sport such as tennis, and the risk is much lower for female players. According to The Female Body Bible (2023) author Dr Emma Ross, this is because female tennis players have access to the highest quality sports science staff and research. In traditionally male-dominated sports, like women’s football or rugby, these resources are lacking. Women are expected to adapt to the men’s version of the game and its training techniques. The sport is not tasked to adapt to the women.

“Where boys in football may go into an academy from age nine, many girls will not receive formal strength training until they join an academy in their teens”

Surgeon Luke Jones told Sky News: “If you compare sports where males and females start at the same age, have the same training intensity throughout their sporting life, and perform the same movements during that sport, then actually, the rupture rates equalise.”

But where boys in football may be taken into an academy from age nine, many girls will not receive formal strength training until they join an academy in their teens. Even then, training will not be adapted to their differing needs as women.

Dr Ross highlights the necessity of focused, controlled strength training from an early age to ensure vital brain signals can be relied upon to ensure correct movements in the demanding fast-paced match environment. Many players see ACL injuries reoccur due to their brains slipping back into their previous “lazy” form.

The menstrual cycle “myth”?

Several female footballers have noted that they were on their period when they sustained an ACL injury, leading many to question the impact of the menstrual cycle. Yet there is no data to suggest that women sustain more ACL injuries whilst menstruating.

“We don’t have enough evidence to say that the hormones of the menstrual cycle can really, significantly impact your injury risk,” says Dr Ross, “but we do have enough evidence to suggest something is going on.”

She explains that when oestrogen levels are high in the body, this can impact the collagen levels inside the joints. As a result, there is a few millimetres increase of laxity within a joint during ovulation, increasing susceptibility to injury.

Behavioural factors may also play a role. During this time in a woman’s cycle, she will be more inclined to take risks, perhaps translating to a change in movement within a football match. There is also no data to suggest that women are at higher injury risk during the second half of their cycle, when progesterone levels are higher and women tend to feel more tired.

“You can lift a PB on any day of your cycle,” Dr Ross explains. Hormones do not affect a woman’s speed, strength, power aerobic fitness or strength. It is rather hormones influencing behaviours — such as low energy caused by low blood sugar — that can impact performance and, by extension, injury risk.

Psychological impact of ACL injuries in women’s football

External factors have their own role to play in the epidemic of ACL injuries in women’s football.

Currently, there are no major brands making football boots for women. Boots are adapted by size, but not by design. Despite men’s higher body weight and speed, the studs on women’s football boots are the same as men’s. This means that these studs anchor women’s feet more heavily to the pitch, a contributing factor to knee injury.

Pitch surface is another factor. In many grassroots football teams, women will have a later kick-off than men’s teams, having to play on the same, now uneven, surface. Women walk onto the pitch with a list of ACL injury risks already higher than men’s, when these basic adjustments could easily be remedied. “Women are being embraced into the sport largely, but fitting into this man-sized hole,” Dr Ross says.

Many women footballers, regardless of their league or profile, are fearful of injury. How long will it be before this anxiety effects match performance? These avoidable injuries are already depriving teams of the best players they have.

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Featured image courtesy of Jeffrey F Lin on Unsplash. No changes were made to this image. Image license found here.

Second year BA Modern Languages Student at University of Exeter | Features, Opinion and Lifestyle writer for Empoword Journalism, Exeposé and Razz. Strong interest in women's rights, culture and international current affairs.

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