The ACL Epidemic of Women’s Soccer

Beth Mead Tears ACL, Courtesy of The Independent

Fédération Internationale de Football Association (FIFA) announced this week that Arsenal teammates Beth Mead and Vivianne Miedema will work with FIFA to help understand the increasingly alarming occurrence of anterior cruciate ligament (ACL) injuries within women’s soccer. This development comes after the Union of European Football Associations (UEFA) launched its own initiative in December 2023, creating a health expert panel to research the proliferation of ACL injuries in the women’s game.

Such responses are the result of increasing demands from players and coaches for more serious analysis of the cause of ACL injuries and improved prevention both at the grass roots level and across the professional game. It has long been known that women are four-to-six times more at risk for ACL injuries than men, with causes often attributed to wider hip structures which channel greater pressures to the knees. According to the Journal of Orthopedics and Orthopedic Surgery, one in nineteen female soccer players tear an ACL.

This issue was sadly well-illustrated last summer with 25 to 30 players missing from the 2023 Women’s World Cup in Australia and New Zealand due to ACL tears. 

Enough to form a squad of their own, absent players included some of the best in the game: Mead and Leah Williamson (England), Christen Press and Catarina Macario (U.S.), Delphine Cascarino and Marie-Antoinette Katoto (France), and Miedema (Netherlands). In the U.K. domestic game, Women’s Super League’s (WSL) Arsenal were hardest hit last season (2022-23) with four players sidelined by ACL tears.   

So what is causing the increased rate of ACL tears? And why along such gendered lines?     

The trade union for professional footballers, FIFPRO, reported that with the increased matches, travel, and workload, coupled with insufficient rest and support structures, have exacerbated the ACL issue. Such findings are echoed by the frustrations of current Chelsea Manager and future U.S. Women’s National Team Head, Coach Emma Hayes.

“The vast majority [of ACL tears] come within ten days of changes from international breaks to club, or from club competition to international breaks … It’s not as simple as saying that different teams have a different training load or traveling schedule, or recoveries etc. We need to really reflect on what we do,” said Hayes. “If you want to do a piece of research, go back through all those major injuries and how quickly they coincided with big changes, combined with menstrual stuff, training, pitches etc. That’s just my opinion. There’s a lot of work still to do.”

Researchers have begun to explore a range of possible causes for ACL injuries, looking at physiological, biomechanical, and environmental factors, from body types to running mechanics to surface quality.

Sports injury prevention and research has historically focused on the caucasian male, with women typically treated as “smaller men.” Such gender biases have ignored everything that differentiates female from male athletes, some of which may be contributing factors to ACL tears. 

“It’s important we, as a collective, try and get more done for ACLs and research into it. It is way too common in the women’s game. If that ever happened in the men’s game, a lot more would have been done sooner,” said winger Mead, speaking in March 2023. 

As research into the issue begins to increase, a number of possible contributing factors are under discussion. Muscle strength imbalances are more noticeable in women, which may be partially addressed through structured injury prevention warm-ups. Changing hormones during menstrual cycles may be a variable. Chelsea in the Women’s Super League and Washington Spirit in the National Women’s Soccer League have both started tracking data around players’ menstrual cycles. Additionally, the vast majority of female soccer players currently compete in boots designed for men, despite the fact women tend to have narrower heels and a wider toe area. 

Other identified issue areas are more structural. Rapid growth in the women’s game over the past few years has increased the number of matches and “load” on players’ bodies, but has not been accompanied by a corresponding increase in female-specific sports science and access to elite strength and conditioning experts. Such differences are exacerbated at the youth level, at which girls are rarely exposed to high-level training as early as boys and are unable to build up the same strength and endurance levels from an early age.

A number of possible contributing factors to ACL tears are beginning to be identified and further female-specific research is required to address the ACL epidemic among women’s soccer. Encouragingly, the soccer industry is beginning to listen and take action, but much work remains to be done.

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