By Joan Grey
The dreaded Anterior Cruciate Ligament (ACL) injury is a footballer’s nightmare.
It waits in the shadows at training and games to pounce on an awkward twist or rocky landing and claim its next victim.
Female footballers are three to six times more likely to fall victim to the ACL injury than male footballers.
With the FIFA Women’s World Cup approaching in July, the female football cruciate curse is making headlines.
Some of the world’s top women footballers have suffered ACL injuries in recent months, including English star Beth Mead and Netherlands striker Vivienne Miedema, threatening their world cup prospects.
Main photo: England and Arsenal striker Beth Mead is at risk of missing the FIFA Women’s World Cup due to an ACL rupture. She was runner-up to Alexia Putellas in the 2022 Ballon d’Or. Photo credit: Arsenal.com.
What is an ACL injury?
An ACL injury is tearing the anterior cruciate ligaments in the knee. The injury usually occurs during a sudden twisting movement when the footballer stops quickly and changes direction, lands awkwardly from a jump, or collides with another player.
ACL injuries often require surgery, and the player must undergo up to a year of physical therapy before returning to football.
Women are more susceptible to ACL injury; why?
Dr Sophia Nimphius, Professor of Human Performance at Edith Cowan University in Perth, Australia, believes female ACL injury relates more to the player’s environment. Women don’t have the same quality coaching, strength and conditioning, and facilities as men, affecting their skill development and self-efficacy.
“From the day that girls start playing sports, they already have fewer opportunities, fewer hours of practice, lesser quality of the pitch and poorer lighting,” she says, adding that the quality of coaches is often lower with some coaches using women’s teams as “a stepping stone to get to the men’s league.”
The focus of ACL injury risk reduction should not be sex-specific but rather athlete-specific, she says.
“Things like appropriate training, better coaching, better physical environment, better safety and support psychologically and physically.”
Downplaying the female anthropometry theory
It has been widely proposed that female anthropometry — their skeletal structure — makes the female athlete more susceptible to ACL rupture.
Dr Nimphius acknowledges skeletal structural reasons have some merit, but they apply whether you’re a man or a woman.
For example, if you’re designed with a forward tibial slope, it’s easier for your femur to slide over your tibia and put stress on your ACL, causing it to rupture.
“The closest place to look to find out if you have an increased skeletal risk is to ask your mum, dad, sisters, brothers, aunts, uncles if they have had ACL injuries in the past.”
The Q-angle, the angle formed between the upper leg at the hip joint and the lower leg at the knee joint, is wider in females and supposedly makes the ACL more vulnerable.
Dr Nimphius asserts there’s no evidence to support the Q-angle as a risk factor.
“It’s been passed on from the 1980s to the 1990s to the 2000s to the 2010s, quoting old literature.”
Dr Nimphius says to understand the female cruciate curse, we need to look beyond the female anatomy and focus on the football environment.
“It’s so much easier to blame women and girls for being innately susceptible for why they get injured.”
Dr Nimphius offers three tips for football coaches to reduce the risk of ACL injuries.
One: Earn a coaching accreditation
Accreditation courses teach coaches to structure their trainings and optimise players’ performance with a focus on injury prevention. New Zealand Football offers a variety of community coaching accreditation courses through regional federations here.
“Accreditation shows you how to properly train, coach the exercise and what we call periodize which is planning your training so that you have times to work hard and rest,” she says.
Two: Use the FIFA 11+ warm-up before training and games
The FIFA 11+ is an injury prevention programme developed by FIFA that warms up players before a game or training. It has specific strengthening exercises and drills to reduce injury risk for football players.
“If you’re a coach, and strength and conditioning isn’t your area but you want to help your athletes, the FIFA 11+ has a lot of research behind it, and when implemented, it’s highly successful.”
Three: Have a variety of football drills in your training
Training with longer passes can help develop players’ top speed, says Dr Nimphius.
Shorter passes such as 3 V 3 and 5 V 5 mini-games are also beneficial for players. “That smaller concept gives you more start and stop movements. The start-stop and the deceleration work is advantageous because it teaches people how to stop. The skill of stopping is very important for reducing your risk of injuries.”
Part Two: How players can reduce the risks of an ACL injury
Friends of Football writer Joan Grey loves playing and writing about football. She captains the Strathallan College Girls First XI and represents Franklin United in the NRF Women’s Championship.