What’s causing the ACL injury epidemic in women’s football?

ACL (anterior cruciate ligament) injuries are one of the most common and serious in football. Sky Sports estimates that 195 elite athletes have suffered an ACL injury in the past 18 months and nearly half of all ACL reconstructions in the UK are a result of playing football.

Concerningly, female players are up to six times more at risk than males, with almost 30 missing last year’s Women’s World Cup due to ACL injuries.

From the design of football boots to disparities in training facilities, here Allana Edwards and Eleanor Green investigate the potential factors behind the prominence of female ACL injuries and ask — can anything be done to halt this epidemic?

Why are ACL injuries more common in female players?

ACL tears most commonly occur as a result of changing pace or direction or due to repetitive landing and pivoting manoeuvres, rather than contact between two players.

Various studies have been conducted to look into why females are more prone to non-contact ACL injuries, including consultant orthopaedic surgeon Nev Davies’ study, which showed that female players are four-to-six times more at risk of sustaining non-contact ACL injuries than males. Female players are also 25% less likely to make a full recovery and return to the pitch than their male counterparts.

Yet following these findings, we haven’t seen a decrease in the prevalence of ACL injuries in women.

Let’s dig into some potential factors.

Training and recovery facilities

It’s commonly thought that the genetic makeup of the female body plays a key role in injury risk, with females having wider pelvises and completely different biomechanics and hormones.

However, female health specialist Dr Emma Ross — a prominent speaker on this topic — believes there is “no good evidence” for the roles of “body shape, hip width and the menstrual cycle” as contributing factors to injuries, despite being used as arbitrary excuses for why “women aren't designed to play football.”

Fox et al. (2020) also suggested that confining this to biological causes misrepresents the root causes of ACL injuries, which are likely to be strongly influenced by “gendered environmental disparities” — essentially, different experiences in sport and less access to training facilities.

According to Dr Joanne L Parsons’ paper ‘Anterior cruciate ligament injury: towards a gendered environmental approach’, we need to look at gendered discrepancies in pre-sport activities, training, competition, research and rehabilitation environments.

Women already face plenty of barriers to participation in sport. They don’t need the added challenge of unnecessary injuries holding them back. So far, not enough has been done to tackle this issue by those who have the power and influence to make a difference.

Nearly 30 female footballers — enough players for an entire squad — missed last year’s Women’s World Cup due to ACL injuries and at least 13 WSL (Women’s Super League) players are currently undergoing ACL rehabilitation including England captain Leah Williamson.

This has forced prominent players to speak out, including Beth Mead and Vivianne Miedema in their Netflix documentary ‘Step By Step’. This saw Arsenal players talk about their personal experiences of suffering from ACL injuries in the hope of helping the next generation of female footballers.

We spoke with former Canadian international and Champions League player Kylla Sjoman, who shared:

“It has taken so long for attention to be brought to the indisputable cases of ACL injuries in female athletes. My career was cut short due to an ACL injury which I know could have been prevented or at least rehabilitated if I had been afforded access to the appropriate facilities, resources and coaches”.

Football boots

While the majority of WSL players now have boot deals, there are still a number of professional players who don’t. For them, choosing a new pair of boots means browsing the shelves in a high street store.

Until recently, the vast majority of football boots have been designed specifically for men. Given that women’s feet have completely different bone structures to those of their male counterparts, it comes as no surprise that up to 82% of female players in Europe experience discomfort when wearing football boots.

Could boots be the Achilles heel to ACL injuries in females? Dr Emma Ross explores the impact that football boots have on ACL injuries in her book 'The Female Body Bible':

“You make studs and you make the sole to withstand the capacity of the average man and then you put an average women in them and as fast and as quick as they are, they're not as strong or as powerful as men. So those boots are now designed to grip a heavy, strong man into the ground but you've got a lighter woman in them and they're getting anchored to the ground by them”.

Some brands have finally got the message and started to design football boots for women. Nike is leading the way with the Phantom Luna Elite, claiming that this is the most innovative and evidence-driven female boot design to date. The boot has three key aims: eliminate preventable pain points, improve on-pitch performance and reduce the risk of major injuries.

While there is currently no evidence to suggest that the level of support provided by these boots will make a difference when mitigating ACL injuries, new models can certainly measure ACL loads at different points in time.

Scheduling and fixtures

Others point to the explosion in the popularity of women’s football and the consequential growth in the fixture schedule as the cause of so many ACL injuries by increasing the demands on players’ bodies.

The gruelling run of major tournaments in recent years has included a pandemic-delayed Olympics in 2021, a European Championship shifted back by 12 months for the same reason in 2022 and the Women’s World Cup in 2023 — all on top of WSL and Champions League fixtures. It seems that players aren’t going to be able to rest any time soon with the Paris Olympics taking place in 2024 followed by the next European Championships in 2025.

With the likes of Sam Kerr racking up an astonishing 3,411 minutes of action during the 22/23 season across all competitions, it’s unsurprising that players are suffering injuries.

Terms of employment

Injuries like ACL tears can be career ending — and access to the best facilities and care is essential for players to make a return to the physical demands of football at the highest levels.

With ACL injuries usually resulting in at least nine months off the pitch, players have often been prevented from accessing the state-of-the-art medical treatment and rehabilitation services provided by clubs due to their terms of employment.

Female footballers have historically been employed by clubs on far less favourable contractual terms than their male counterparts. Many of the first WSL contracts contained a clause that allowed clubs to terminate players’ employment if they were unable to train or play games for over three months.

Below is an extract taken from a 2018 standard form contract:

“TERMINATION FOR LONG TERM INJURY

38         If a Player is unable through injury or illness to train or play for the Club for a consecutive period of 3 months in the written opinion of an appropriately qualified medical consultant instructed by the Club (the "Medical Consultant"), the Player shall be deemed to have suffered a "Long Term Injury". Each provision set out below shall apply unless the parties agree a more beneficial provision in substitution for the original provision.

39         Where a Player is deemed to have suffered a Long Term Injury, the Club shall be entitled to terminate this Contract by giving 3 months written notice to the Player (the "Notice Period"). The Club may serve notice at any time after the date on which the Player is declared to be suffering a Long Term Injury by the Medical Consultant.”

Thankfully, this has recently changed. The FA and PFA have agreed new benefits pertaining to injury, illness and long-term sickness which came into effect from the start of the 2022 season to mirror those in the men’s game.

Significantly, the period relating to contract termination has increased from three to 12 months. There are also new uplifts to maternity leave and pay. 

Pitch quality

WSL teams are often allocated artificial pitches or academy pitches to both train and play fixtures on. This has been identified as an area of concern for many, including by Braun, Waterlain and Dragoo (2013), who suggest that friction increases when playing on synthetic surfaces, resulting in an increased rate of injury for the lower extremities (like legs, knees, ankles and feet).

In 2019, FIFA announced that both women’s and men’s football are to be played using the same surfaces and field parameters. Natural grass fields were a requirement for the first time at the 2023 Women’s World Cup.

Nevertheless, there is still a disparity between the facilities accessible by men and women. In January 2023, we were still seeing WSL games being called off due to frozen pitches — a problem that is almost non-existent in the Premier League given that it’s compulsory for clubs to have undersoil heating.

Manchester United and Manchester City have recognised this void in facilities and committed significant funds to combat the disparity. Manchester United Women recently moved into a new £7m training facility while Manchester City Women have submitted plans for a £10m purpose-built training facility.

The Government has also recently announced a £30m investment to build approximately 30 new state-of-the-art pitches and accompanying facilities, designed to prioritise women’s teams across England.

Who has a duty of care?

The players have spoken and medical experts are clear — football is depriving female players of fair and equal treatment. Our infrastructure — originally designed and built to support men — is failing the women's game. This problem has been exacerbated by the accelerated growth of women's football.

Sports medicine specialist and former Chelsea club doctor Eva Carneiro is one of few females to have held a senior medical position at a Premier League club. She believes that the lack of funding and gaps in female-specific research and knowledge is negatively impacting female athletes.

She told Sky Sports: “Gender is still an issue in football. You've got limited funding in the women's game and you don't have very experienced medical teams.”

Clubs and governing bodies owe a duty of care to all their athletes. At the very least, this includes employing physiotherapists and medical professionals with specific training and experience with the female anatomy. However, the talent pool for such professionals is limited, with coaches and physiotherapists working predominantly with men. This must change to ensure that our female players receive adequate care and support. From a legal perspective, female footballers are employees and have the right to receive the same standard of care as males.

What is being done to halt the ACL epidemic?

FIFA has already developed training programmes (such as the 11+) that are designed to prevent ACL injuries and have been implemented by clubs and national teams around the world. Yet there is still a drastic need for female-specific programmes to be developed.

In December 2023, UEFA made an announcement that could well be considered a watershed moment for women’s football — the introduction of an expert panel dedicated exclusively to understanding and improving the health and wellbeing of female athletes.

The central focus of this panel is to gain a deeper understanding of ACL injuries among female players. It has been reported that the long-term aim is to publish a UEFA consensus on ACL injury prevention and management by the summer of 2024, plus an up-to-date ACL injury prevention programme. 

Grace Vella — Founder and CEO of Miss Kick — told us that that her “time in football was really positive but I often felt as a girl, we were treated differently. We were treated second best…”

"…the most important thing that needs to be done right now is the research. In the past, sport science and its findings has predominantly been based around the male anatomy and physiology.

It's only more recently, as the women's game has grown, that we have started to consider whether women and girls need specific equipment.

Ultimately, the goal should be to ensure the player on the pitch is as comfortable as possible and to minimise her risk of injury. It'll be interesting to see what findings come out of the data over the coming years…”

Hopefully, 2024 will be a year of positive change for women’s football as we continue to see strides forward in parity with the men’s game.

Talk to us

We work closely with elite sports clubs, national governing bodies, international federations and large sports agencies both throughout the UK and around the world.

If you need advice on the above or want to talk about how the changing landscape of women’s football could affect your club or playing career, our specialist sports sector team is here to help.