Women's Sports and the ACL Conundrum
Rates of ACL injuries are rising among high school athletes too. If we want women's sports to continue to grow, we need fix this problem.
Last week, the Union of European Football Associations (UEFA), the governing body for soccer in Europe, announced a new initiative. They’re going study anterior cruciate ligament (ACL) injuries in the women’s game because ACL injuries are a problem and they want to better understand what’s happening. The goal is to produce a consensus statement on ACL injury prevention and management by the summer of 2024 as well as an up-to-date ACL injury prevention program. These protocols will be tailored to women’s soccer.
In their press release, they say, “The initiative is the result of UEFA’s commitment to the health and wellbeing of female athletes, and an ongoing effort to make the game safer for players.”
This is good news. It’s big news.
But it’s also about time.
If UEFA really cared about making the game safer for women, they should have made this investment years ago.
ACL Injuries are a Big Deal
Let me back up for a second.
The ACL is one of the ligaments in your knee. It connects the thigh bone to the shinbone and stabilizes the knee joint. Injuries often happen in sports where there’s a lot of cutting, pivoting, or jumping movements like soccer, basketball, volleyball, and lacrosse. An athlete can get hurt when they jump and land off-balance or when they rotate or pivot around the knee in a weird way when they’re trying to get around an opponent.
Women athletes have a 4 to 6 times higher incidence of ACL injuries compared to men playing the same sports. But what’s even more disturbing it that the number of injuries among high school athletes has risen 26 percent over the last 15 years (2007 to 2022). The rate of injury in girls (32.3 percent) outpaces the rate of injury in boys (14.5 percent).
You might be thinking: Christine, we know why women tear their ACL more than men. It’s because of their wider hips, higher Q-angle (the angle formed between the quad muscle and the patellar tendon), and hormones.
It’s true that there are physiological, anatomical, and biological risk factors and that some of these factors more likely to affect athletes with female bodies. But they aren’t the sole reason why these injuries arise. By focusing solely on characteristics related to the body, we miss the bigger picture—and opportunities to intervene. (I wrote about this at length in my book UP TO SPEED and this is a great paper that rethinks the traditional injury model.)
Regardless of the reason behind a ligament tear, these injuries are devastating. They often require surgery and can take a full year of rehabilitation. It’s a huge burden—physically, psychologically, and financially.
ACL injuries have increased 26% in high school athletes in the last 15 years. This has huge implications for youth and their ability to be physically active, not to mention their long-term athletic development.
Once you hurt your knee, you’re less likely to return to sport or return to same level and you’re more likely to re-injure yourself, either re-tearing the same ligament or tearing the ligament on your other knee. (Raises hand to both these situations!) When these injuries happen when athletes are young, it can affect the trajectory of their physical activity and athletic development.
There are so many ups and downs and setbacks along the way. It’s been 10 weeks since my third ACL reconstruction and let me tell you, it is hard in many ways, but especially mentally and emotionally.
It’s not just about the ACL
While UEFA says that they are committed to the health and wellbeing of players on the women’s side, this intiative also a business decision.
Doctors and researchers have known that girls and women have a higher rate of ACL injuries since the 1990s. They sounded the alarm back then, calling the number of injuries almost epidemic.
Despite education and calls for action, nothing has changed. In the last 30 years, the incidence of these injuries in girls and women hasn’t changed while it’s decreased in men. WHYYYYY.
Yet, the ACL story continues to be portrayed as new news. In the lead up to last summer’s Women’s World Cup, ACL injuries were all over the media because some of the best players—Catarina Macario, Christen Press, Beth Mead, Fran Kirby, Leah Williamson, Vivianne Miedema—would miss the tournament because of ACL injuries. In 2022, more than 50 women across six major professional soccer leagues tore their ACLs.
People were outraged and sounded the alarm again. Still, I wondered what it would actually take for people to pay attention and actually do something about the ACL problem in women’s sports.
When we think about the infrastructure needed to support women’s sports, we think about all the things needed to prop up the game. We think about the leagues and the opportunities to play professionally. We think about media and sponsorship. We think about viewership and attendance.
But what we seem to take for granted are the athletes—that they will always be there. That there will always be an endless pipeline of athletes—healthy athletes. Yet, if we don’t invest in athlete health and wellbeing, we’re missing a key part of the equation.
“It’s harder to build a fan base, attract sponsorship, and negotiate media deals when star players aren’t competing. There’s no women’s sports without both healthy athletes in their prime and future star players in development,” I wrote for The Boston Globe Magazine in July.
It’s a bit of a chicken or the egg scenario. People in charge, the federations and leagues, the sponsors, need to see women’s sports as a good business investment. Then, they will have more incentive to keep players healthy and invest in research and athlete health initiatives. But it’s hard to continue to build interest in women’s sports if athletes keep getting hurt, especially popular players.
Now, there’s a reason for people to pay attention. Deloitte estimates that women’s sports are expected to exceed $1.3 billion in revenue in 2024, 300 percent higher than their 2021 prediction. The spotlight is on women’s sports and people are finally recognizing that women’s sports is a good investment.
So for UEFA to invest in this initiative, I don’t doubt they’re concerned about their players but I also hope that it’s a sign of more investment to come.
How to Reduce ACL Injuries
It’s impossible to rid sports completely of injuries. It’s part of the risk we all take when we play sports and move our bodies. But there are things we can do to decrease the prevalence of injuries like ACL tears.
ACL prevention programs have been shown to decrease ACL injury by 50 percent.
50 percent!
It shocks me that these programs aren’t more commonplace.
Neuromuscular control around the lower body and awareness and control around the knee joint, or the lack thereof, is a major contributing factor to ACL injuries. These program focus on improving neuromuscular control in specific ways and are evidence-based. They don’t take a lot of time and can be incorporated into warm-ups.
I know prevention isn’t sexy but still. We have to tools to make a difference.
So can we finally do something about this?
Thanks for being here. More soon.
Christine
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Your book really helped me understand that there are more layers to this issue than I realized. This is the injury I feared the most when I played volleyball. Maybe all of the years I spent jumping out of trees as a little kid helped protect me.
This is so important and overdue.
Can you recommend a link to the best and basic ACL tear prevention exercises we all should do? (As a runner, I usually don’t worry about this much, but now that I’m skiing, I do.) The link above to the scientific paper is an abstract with a paywall. Thank you for covering this!