In recent years, anterior cruciate ligament (ACL) injuries have become a prominent topic in women’s football due to their high frequency and significant impact. High profile players such as Sam Kerr, Michelle Agyemang and Alexia Putellas have all suffered ACL ruptures, resulting in their season ending prematurely. While ACL injuries can occur in any sport, and to both male and female athletes, research suggests that female footballers are up to eight times more likely to sustain an ACL injury (1).
This growing awareness has drawn attention to gaps in research and clinical practice, prompting further investigation into why ACL injuries are more prevalent in women’s football.
What is the Anterior Cruciate Ligament?
The anterior cruciate ligament (ACL) is a strong band of connective tissue which provides stability to the knee. It connects the femur (thigh bone) to the tibia (shin bone) and helps control forward movement and rotation of the tibia particularly during pivoting and landing actions (2). Most ACL injuries are sustained without any contact and often happen during a sudden change of direction, pivot on a planted foot or landing awkwardly from a jump. These movements are fundamental to any sport which makes preparation and prevention so important.
Why are ACL injuries more common in women’s football?
The increased frequency of ACL injuries in women’s football has been attributed to a combination of different factors. These include anatomical, hormonal, biomechanical and environmental factors.
- Anatomical
Anatomical factors include physical and structural differences between a male and female body. On average, women have an increased quadriceps angle (Q-angle) which is the angle formed between the anterior superior iliac spine (ASIS) and the midpoint of the patella. A higher Q-angle alters the knee’s biomechanics and may increase valgus forces at the knee when landing or changing direction (3). Studies have also suggested a narrower femoral notch, which is common in women compared to men, can place the ACL under greater strain (4).
- Biomechanical
Biomechanical factors relate to the physical forces and mechanics which affect
movement. Within ACL injury, a common muscular imbalance is seen between the quadriceps and hamstrings. The hamstrings act as a stabiliser to the ACL whilst the quadriceps can increase strain on it. If the hamstrings strength is insufficient, or the quadriceps are overly dominant, the ACL can be placed under greater loads during sudden movements potentially leading to a rupture (5). Fatigue also can further compromise movement quality – as neuromuscular control decreases, the body’s ability to coordinate and maintain joint stability during dynamic movements also decreases.
- Hormonal influences
Hormonal fluctuations throughout the menstrual cycle may influence neuromuscular control and ligament laxity, therefore increasing the risk of sustaining an ACL injury. Oestrogen, a hormone which is released during the follicular phase, has been linked to decreasing collagen synthesis and increasing ligament laxity (6) and so increasing the risk of ACL injury. Further studies have gone on to show that when oestrogen levels were at their peak, so was ACL laxity (7). However, it is important to note that hormonal factors alone are not the sole reason for an ACL injury.
- Environmental
Environmental factors occur externally to the athlete such as terrain and access to programmes. Research has highlighted that women footballers have limited availability to advanced training facilities and often find themselves playing in poor conditions. Football kit is also primarily made for a male player and so does not take into account the demands and needs of the female body (8). A study which focused on ACL injuries within Australian Football identified the reduced access women have to medical/athletic development staff and the limited youth experience as potential drivers for the difference in ACL injury rates amongst males and females (9).
Can ACL injuries be prevented?
It is important to understand that injuries cannot be completely prevented, however it is key to highlight that if the above factors are taken into account, there is potential to reduce ACL injuries sustained within the women’s game. This includes: highlighting and addressing imbalances as well as injury prevention programmes which have shown to reduce injury rates by 53% (10). Injury prevention programmes such as the FIFA 11+ protocol have been designed to prepare the body for the physical demands of football to reduce the frequency of non-contact injuries. The protocol replicates specific football movements and includes:
- Plyometrics
- Agility
- Eccentric control
- Lower limb strengthening
In a study comparing an intervention group that followed the protocol with a control group that did not, no ACL injuries were recorded in the intervention group, whereas two ACL injuries occurred in the control group (11). This shows the importance of consistently following an effective, well-designed injury prevention programme.
Final thoughts
ACL injuries sustained within women’s football remains a significant challenge and will not be a quick fix. It is important to note that female footballers are not ‘fragile’, rather the high rate reflects a history of inequalities in access to appropriate medical support, training and prevention programmes. As women’s football continues to grow, so does the opportunity to introduce injury prevention in youth football, educate young athletes on strength training and research further risk factors. Physiotherapy plays a vital role in ACL injuries especially rehabbing an ACL rupture; however this should not overlook the ability to educate and prevent prior to this. Objective testing to highlight strength asymmetries, appropriate tailored strength training and evidence-based injury prevention programmes can reduce the risk of ACL injury in women’s footballers. Addressing injuries with a prevention-focused mindset, rather than a reactive one, will support long-term development.
Blog By: Jess Simmons (Musculoskeletal Physiotherapist at Crouch Physio).
References
- Mancino, F. et al. (2024) ‘Anterior cruciate ligament injuries in female athletes: Risk factors and strategies for prevention’, Bone & Joint Open, 5(2), pp. 94–100. doi:10.1302/2633-1462.52.bjo-2023-0166.
- Marieswaran, M. et al. (2018) ‘A review on biomechanics of anterior cruciate ligament and materials for Reconstruction’, Applied Bionics and Biomechanics, 2018, pp. 1–14. doi:10.1155/2018/4657824.
- Gant, H. et al. (2024) ‘Impact of the quadriceps angle on health and injury risk in female athletes’, International Journal of Environmental Research and Public Health, 21(12), p. 1547. doi:10.3390/ijerph21121547.
- Wratten, C.J.E., Tetsworth, K. and Hohmann, E. (2015) ‘Three-dimensional femoral notch volume in anterior cruciate ligament–deficient versus anterior cruciate ligament–intact patients: A matched case-control study with inter-gender comparison’, Arthroscopy: The Journal of Arthroscopic & Related Surgery, 31(6), pp. 1117–1122. doi:10.1016/j.arthro.2014.12.014.
- Pappas, E. et al. (2016) ‘Biomechanical deficit profiles associated with ACL injury risk in female athletes’, Medicine & Science in Sports & Exercise, 48(1), pp. 107–113. doi:10.1249/mss.0000000000000750.
- Saber, B., Bridger, D. and K. Agrawal, D. (2024) ‘A critical analysis of the factors contributing to anterior cruciate ligament injuries in female athletes’, Journal of Orthopaedics and Sports Medicine, 6(4). doi:10.26502/josm.511500163.
- Legerlotz, K. and Nobis, T. (2022) ‘Insights in the effect of fluctuating female hormones on injury risk—challenge and chance’, Frontiers in Physiology, 13. doi:10.3389/fphys.2022.827726.
- Mancino, F. et al. (2023) ‘Anterior cruciate ligament injuries in female athletes’, The Bone & Joint Journal, 105-B(10), pp. 1033–1037. doi:10.1302/0301-620x.105b10.bjj-2023-0881.r1.
- Fox, A. et al. (2020) ‘Anterior cruciate ligament injuries in Australian football: Should women and girls be playing? you’re asking the wrong question’, BMJ Open Sport & Exercise Medicine, 6(1). doi:10.1136/bmjsem-2020-000778.
- Huang, Y.-L. et al. (2019) ‘A majority of anterior cruciate ligament injuries can be prevented by injury prevention programs: A systematic review of randomized controlled trials and cluster–randomized controlled trials with meta-analysis’, The American Journal of Sports Medicine, 48(6), pp. 1505–1515. doi:10.1177/0363546519870175.
Barbato, C. et al. (2026) ‘Prevention of anterior cruciate ligament injuries in female soccer: Effectiveness and adherence to the FIFA 11+ protocol’, Journal of Human Sport and Exercise, 21(1), pp. 338–348. doi:10.55860/xm1gsn52.
