Why are female soccer players more likely to have an ACL rupture?

By Sydney CBD Osteopath Dr Abbey Davidson

It is scary to think that females are up to 8 times more likely to have a non-contact ACL injury than males. What is an ACL rupture? What are the symptoms of an ACL injury? How is an ACL rupture diagnosed? How to prevent ACL ruptures? Why are female athletes more prone to ACL injuries? Below we discuss all your ACL injury questions.

Check out this short video of Physiotherapist Ryan Dorahy demonstrating a strapping technique for ACL injuries:

What is an ACL Rupture?

The Anterior Cruciate Ligament or ACL is one of the 4 major ligaments which stabilize the knee joint. The role of the ACL is the prevent  anterior translation (forward sliding) of the tibia (shin bone) on the femur (thigh bone).

ACL injuries usually occur in sporting context and range from sprains or partial tears to full ruptures. Ruptures usually occur when an awkward twist occurs with a bent knee. Sudden stopping, changes of directions and poor jumping/landing technique are often responsible in a knee injury of this nature. Non-contact ACL injuries make up 78% of injuries to the ACL and this means the injuries occurs with awkward motion at the knee rather than colliding with another athlete.

Signs and symptoms of an ACL tear may include:

Seeing an athlete go down with a potential ACL injury is not a nice feeling. They may report symptoms like:  

  • “Popping” sound deep within knee joint
  • Knee Pain
  • Feeling of instability or ‘giving way’
  • Swelling
  • Loss of knee range of motion
  • Surrounding muscle guarding/spasm

If you or someone you know has a potential ACL rupture it is important to get assessed by a health professional. Your physio, osteo, chiro or GP will be able to give you the assessment you require.

How is an ACL rupture diagnosed:

Diagnosis of an ACL tear will be made by a health professional asking you relevant questions about your injury. They will perform a bunch or orthopedic tests to assess the stability of the knee. For confirmation of a suspected ACL injury your health professional will refer you for an MRI. The MRI will give a clear indication of if the ACL is still intact. It is unusual to damage the ACL alone; there will usually be some form of damage to other structures within the knee including meniscus, MCL and boney bruising.

Getting back to sport after an ACL rupture usually requires surgery and in-depth exercise rehabilitation which can take up to 12 months. Note that after a ACL reconstruction female soccer players are 5x more likely to re-tear their ACL, 2-4x more likely to have another new knee injury and are more likely to quit the sport as a result.

Why are females more likely to rupture their ACL?

Knee is the most common location for injury in elite female soccer players and research has discussed possible reasons for this. Anatomic, hormonal, environmental and biomechanical risk factors could potentially explain why females are so much more likely to rupture and ACL compared to males.

Over the last 20 years there has been a drastic increase in the number of females participating in sport. FIFA has plans to see the number of female players double to 60 million by 2026. With increasing rates of female players participating in sport, naturally, we must also recognize an increase in the number of female ACL injuries we see.

There are structural differences of the knee between male and females. On average the size/width of a female ACL is much smaller than males. This may be responsible for the increased risk of ACL injury. We must recognize in a game play situation females place their bodies through the same load and intensity of male players. Note that rates of ACL ruptures are much higher in game play situations rather than in practice.

The alignment of the lower extremity are slightly different between males and females. Women typically have wider hips therefore increasing the angle the femur (thigh bone) joins the knee. This angle is commonly referred to as the Q angle or quadriceps angle.  It has been suggested that because women have a larger Q Angle than men their ACL is put under increased load in sporting situations.

Female hormones have also been suggested to impact the integrity of the ACL and potentially have a role in why females are more injury prone. When analyzing females who have encounters and ACL injury it has been shown that a majority occurred during the follicular phase of their cycle (between menstruation and ovulation). Hormones present during this phase impact the ACL making it more lax perhaps explaining the significance of having statistically higher ACL injures in females.  A recent study involving 165,000 female athletes showed an interesting relationship between taking the oral contraceptive pill and decreased number of ACL injuries (18% less). Perhaps further supporting the idea that the female hormone cycle plays a role in ACL injuries.

Nutrition is always a special consideration in female athletes. Female athletes are often not eating enough resulting in fatigue, caloric deficits, nutritional deficits and dehydration. Fatigue results in poorer form which can predispose to injury. Nutritional deficits can lead to lack of nutrients available for collagen production (essential for healthy ligaments)  and poor repair for training sessions. It is important to parents, coaches and athletes monitor their diet to ensure they are eating a balanced diet which includes sufficient protein, fiber, vitamin C, Omega 3 and calcium. Nutrition is also an important consideration following an injury as good nutrition is required for best possible recovery.

Analysis shows biomechanics and the technique used by females and males to run, jump and land differs. Females are much more likely to have poor jumping technique; landing with less flexion at their hips and knees . Females are also more likely to put valgus stress (knock knees) through the knee when landing and jumping– which places the ACL under significantly more load. ACL injury prevention programs, like FIFA 11+ aim to address technique and strength short comings to reduce the number of ACL injuries we see in soccer players.

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