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The prevalence of ACL injuries in female athletes and why are they happening?

As a solicitor in the catastrophic injury department at Irwin Mitchell, and a sports enthusiast, I write this article to raise awareness of the concerns regarding the prevalence of ACL injuries in female athletes. 

This issue arises in the wake of the Women's World Cup 2023, which saw 25-30 players (the size of an entire squad) side-lined due to ACL injuries. 

 Sky News refer to this as an “epidemic of ACL injuries” in women footballers. 

Anterior Cruciate Ligament (ACL)

The ACL is a one of the ligaments inside your knee, which joins your thigh bone to the front of your shin bone. The ACL runs through the middle of the knee and its primary job is to keep the knee stable. The ACL is useful for pivotal movements, as well as walking down hills or stairs.

An ACL injury is a partial or complete tear or detachment of the ligament from the bone. For female athletes this often requires surgery and a six to 12 month period before returning to full activity. This is a costly price for a very limited playing career at the highest level.

What are the causes of ACL injuries? 

ACL injuries are commonly associated with sporting injuries, and in particular in football. Although, the majority of ACL injuries occur by non-contact, such as twisting your knee, quickly changing directions when running and walking or stop/start running. 

A sudden force from a twist or landing can cause an ACL tear. Dynamic movement patterns - often seen in sports such as football, basketball, netball and skiing - are all very important factors contributing to ACL injuries.

If you injure your ACL, you may hear a popping sound and feel pain in your knee. It can cause knee instability, difficulties walking and in more serious cases you may lose full range of movement in your knee. 

Are female athletes more prone to ACL injury?

The rapid increase in the number of women participating in sports, means there are more female athletes than ever before. With this huge increase in numbers, typically there would be an increase in reported injuries. However, there is an alarmingly higher rate of ACL injuries in female athletes when compared to male athletes.

Sky News has reported data from ACL Women Football Club which suggests 195 elite players have suffered ACL injuries in the last year. For a professional footballer, ACL injuries can significantly diminish performance and can be career ending. 

The data suggests women are 2.5 to 3.5 times more likely to rupture an ACL than a male athlete. England defender Jess Carter told Sky News: "There's been way too many women's players who have had ACL injuries and not enough research that's been done about it.

"Why are there so many injuries? How can we prevent it? Why are they happening? A question I sometimes ask is: if this was happening to high profile men's players, would more work be going in to try and improve things?"

The big question: why is this happening? 

There is no proven cause and no answer one to this problem.

The BBC spoke with Dr Katrine Okholm Kryger, a senior lecturer in sports medicine at St Mary's University in London who specialises in football. 

She stated recent discussions had focused on whether the injury risk was sex related - the female anatomy and hormones, or whether it could be gender related - the way female athletes are raised and managed compared to male athletes. 

Dr Okholm said: "I think there's some truth in all of these areas,” but expressed caution

"We have to be really careful when we talk about this in women's football because there is a tendency within research and within the media of being like 'oh, women are so unstable, fragile, because of their anatomy, their hormonal fluctuations' but we haven't proven that is the cause of these injuries. Maybe it is the way we're treating women. I'd like to see that changed in people's perceptions of female athletes and women's football in general."

Nature or nurture

The main areas of concern are split into two categories: nature and nurture. 

Nature is the biology, the genes and the way the body is shaped and muscle mass. 

Dr Okholm Kryger pointed out that women move and run in a different way to men and yet the length of studs on boots are designed around male movement and traction", which increases the risk of women getting their boot stuck in the surface and an injury being caused.

It's only in recent years that boots specifically designed for female athletes (via 3D scans) have become available, whereas it has always been the norm for men.

There's also the nurture of the environment that females are in, in particular concerns that female sporting facilities, the quality of medical staff and professionalism around sports is way behind when compared to male sports. A good example of this is football pitches are often prioritised for male sports, with females having to play after when pitches are often ruined.

Issues with reocvery time

The research also explores with the rapid increase in female sports, one of the biggest problems is with the increase in demand, there is often very little recovery time. This problem is compounded when there is an inequality of access to specialists in rehabilitation, resources, coaches, sport sciences and facilities for female athletes.

Even with reconstructive knee surgery and success rehabilitation, it's still possible to re-tear an ACL. This is why ACL injuries are so feared, and none more so, than female athletes.

Supporting athletes following injury

I often represent female clients with a sporting background, who have suffered major orthopaedic trauma. Part of my job is to put in place a team of specialist rehabilitation providers, to ensure optimum recovery and working with them to meet their goals of getting back to playing sports following injury.

Irwin Mitchell’s sports law team works for sporting individuals, clubs, organisations and governing bodies across a range of legal issues from injuries, tax and employment matters to real estate, sponsorship and commercial contracts. More information can be found on our website.