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There are so many reasons that girls/women injure their ACL at a higher rate than boys/men, even if UEFA suggests otherwise. Girls are not exposed to the same elite level of training as early as boys and, therefore, have not built up the base level of strength and endurance, which leaves them vulnerable to injury. Clubs can accommodate this with strength and fitness training sessions to create discipline. This muscle strength imbalance in females is probably a reason for the structured injury, which is easily prevented with warm-ups, strength and balance. It will not eliminate all chances of the injury but would significantly reduce it.
Though some are quick to say it's girls' periods and hormones during the menstrual cycle, this is not the leading theory and is just a minor factor. There is “no good evidence” to suggest “body shape, hip width and menstrual cycle” are contributing factors to why women are not designed to play football.
With all sports, the equipment is needed to partake in the sport. In football, it's the boots. 82% of pro female footballers say uncomfortable boots affect their performance. This issue is due to the lack of resources women footballers get and the limited availability of boots for female feet. Therefore, they are wearing men's shoes.
Women's feet, like all body biomechanics, are different from men's; therefore, their shoes should not be identical and should be made for the client's structure. This has improved; however, companies are saying these shoes are more expensive to make and do not sell, meaning those girls at the lower levels do not have the access and resources they should, with companies using money as they fall back on their lack of diversity.
Boot manufacturers told MPs they were investing in women-only and gender-neutral products. Still, retailers were sometimes reluctant to stock them, and there was lower consumer demand and awareness of the products. Conservative MP Caroline Nokes, who chairs the women and equalities committee, said it was disappointing that no retailers responded to the committee's inquiry. Ms Noke added: "Football brands are making welcome progress on supporting the needs of female football players, but this needs to be better reflected on the High Street and online.”
Dr Kat Okholm Kryger, a sports rehabilitation researcher at St Mary's University said to sports gazette: "If you take the ACL, we know surfaces and boots, and we believe there are adjustments that can be made to reduce the risk factor. Structural changes are as simple as having boots tailored to different surfaces.”
In its response, Puma said sourced on BBC: "One hypothesis might be that women have grown up with the notion that the best way to challenge male domination in football (and all spheres of life) is to challenge it head-on and refuse to be seen as any less capable than men, or different to men."One way this may have manifested is that female players wanted to play and be treated precisely as male players are, with the exact footwear and colourways."
This is incredibly sexist, and the comparison of the genders needs to stop. Just because a girl likes football does not mean she wants to be Harry Kane. She wants to be Leah Williamson. Women have had the challenge of the male-dominated industry; otherwise, they would not be allowed in.
The committee also raised the issue that several boots designed for women can cost over £200 more and asked what the barriers are to producing more affordable boots for women and girls.
Nike responded by offering two styles across the Phantom Luna boot, giving consumers options to choose from. They make it sound like two choices are loads, whereas the men have many options.
The Women and Equalities Committee said: "A health issue of similar magnitude affecting elite male footballers would have received a faster, more thorough, and better-coordinated response," the report added. "While female footballers in the UK have enjoyed great success at club and national level, they have done so wearing ill-fitting footwear. "Few football boots designed for women are available, and those that exist are rarely stocked or promoted by the UK's leading high street sports retailers."The sports science sector's response to the ACL issue has been disparate and slow," the WEC said. Its report calls for better female-specific clothing, footwear and equipment.
Those differences in physiological and biomechanical aspects should not give brands a free pass. This is an investment in a growing market with the rewards looking positive in the future. These women are not afraid to call you out for it; ask Mary Earps when she criticised Nike for refusing to sell her goalkeeper shirt.
Football is responsible for nearly half of all ACL reconstructions in the UK, yet it's the sport with the most money and supposed support.
Consultant orthopaedic surgeon Nev Davies spoke to Sky Sport of the psychological load among young people in the UK, where there's been a 29-fold increase from two decades ago showing females to be 4-6 times at risk, that cannot all be about our periods, plus there 25% less likely to make a total return to the game. However, we have seen in the top teams of Chelsea, Arsenal and Manchester City that they are a minority where their club has the full backing and the resources to help them recover grassroots, and lower teams do not have that luxury.
The Raising the Bar report completed by ex-England footballer Karen Carney spreads awareness of the lack of research on support for female athletes, with only 6% of sports exercise and science research involving only women. With ACL ruptures being far more common in female footballers than males, the lack of research is reflective of that, leading to a limited understanding of reducing ACL injuries. The report says that this situation needs to be addressed urgently. It is unacceptable that players are exposed to this additional level of risk relating to their physical health. Football should ensure athletes have the best pitch products and conditions to perform. Without addressing this, the highest possible level will undermine the credibility and quality of the sports in the future. This impacts not just the welfare of the players and pitch success but also profiles players who are out with injuries, which risks dampening attendance and broadcast interest and has a knock-on impact on commercial revenue. Additionally, seeing elite players consistently sidelined without improving the situation risks putting off future players.
Some clubs are taking action independently, with Chelsea Women's FC targeting reducing soft tissue injuries using a bespoke app to track player cycles. Ex-Chelsea manager Emma Hayes said on the Chelsea FC website : “The starting point is that we are women and go through something very different to men every month. "We have to have a better understanding of that because our education failed us at school: we didn't get taught about our reproductive systems. It comes from wanting to know more about ourselves and understanding how we can improve our performance."
One hope is that this research centred around female athletes will boost understanding of female biomechanics. As spoken above, there's little research on this matter.
While the response and action have been few between many organisations, the Department of Culture, Media and Sport (DoCMS) and the Department of Education have set up a task force to increase research and Develop a strategy to address the inequalities in women’s health and physiology. Though what will happen as a response to this research is unknown, everyone knows the problems. Will anything be done, or will anyone be held to a better standard?
When I emailed clubs, brands and football agencies, I was given either a no we will not respond, or nothing, and when I emailed the DCMS MP, I was just given a link to the Karen Carney Report.
Orthopaedic surgeon Davies said to Sky Sport about injury prevention: “There is a considerable knowledge gap in the UK about the importance of injury prevention programmes... it's embarrassing how far behind we are.”
I was able to get a response from UEFA. However, when I asked the question about why women are rupturing their ACLs more, they changed the questions.
UEFA said: “Any individual performing physical activity risks sustaining an injury - this is also the case for ACL injuries in both men’s and women’s football.”
When I asked Fifpro, the union for players, their response to what UEFA have said surrounding why women are more likely to rupture their ACL compared to men in response, they said: “We understand the cause of ACL injuries to be multifactorial and therefore, we cannot provide a binary answer about why they occur, but we believe it is important that there is a focus on holistic and environmental risk factors as well as physiological. It’s important to note that men’s teams have far fewer resources than women’s teams; this can be true even for some women players representing the same club as men. It is important that women players can also benefit from access to high-performance facilities and expertise.”
But the real issue is the lack of discrepancy. The numbers do not lie that women are more likely to do the ACL, and it's not just about our periods.
Players have spoken out about game congestion and the impact on injury.
UEFA said: “We have conducted injury surveillance studies on elite women’s football since 2018. Before this, multiple studies were conducted in leagues across Europe and the US. These studies analyse the number of injuries (including ACL injuries) per 1000 hours of football (match play and training). All these studies show that the number of ACL injuries for 1000 hours of football has not increased. We see around 0.7 injuries per team per season, as seen in early studies from 2000. Therefore, we have no increase in ACL injuries in women’s football per playing hour, and hence, there is no evidence to suggest that match congestion is a risk factor for ACL injuries.”
Fifpros response to UEFA research suggesting that ACL injuries have not increased over the years firstly started with praising them for their completing such research but responded: “What we do know is that ACL injuries can have a devastating effect on women players’ careers, sidelining them for on average nine months, and increasing the risk of recurrence. (In comparison, male players typically miss seven months after an ACL injury). Research shows that in a squad of 25 players throughout four seasons, three women players suffer ACL injuries on average, compared to two male players.”
Associate Professor of Medicine at the University of British Columbia, Jackie Whittaker who has been involved in the research process and believes organisations like FIFA or global players union FIFPRO need to fund a study, said to Sky Sport: “I think girls speaking out might increase the likelihood of that happening".
FIFPRO has recently reported that increased workload, travel and insufficient rest have all contributed to higher injury rates more broadly. It makes sense, but acknowledgement and admission can only be considered phase one.
This juxtaposes what UEFA said: we need transparency instead of working against each other to work together; that is the only way to resolve the problem.
It’s all good looking at the statistics, but remember, each number is a person. More games mean more opportunities to injure themselves, and less recovery between games increases long-term damage. There have been more games in recent years, which can be reflected in how many ACL injuries; you could make an entire squad for the World Cup in 2023 of all ACL-injured players who missed the World Cup.
I was then linked to UEFA studies, which I will put at the bottom of this piece.
When I asked UEFA what they would do to prevent or advise clubs on surrounding ACL injuries, they said: “Injury prevention and management are critical considerations for our unit. As ACL injuries are severe injuries that lead to players commonly missing 9-12 months due to surgery and rehabilitation, we care about educating coaches, players and medical staff on injury prevention strategies and supporting medical staff with rehabilitation guidelines to ensure optimal evidence-based practice. We, therefore, have multiple initiatives ongoing in this regard:
1) Our UEFA Club Injury study assesses injury trends yearly to ensure that we are proactive if we see changes in injury trends across elite men’s and women’s footballers in Europe.
2) We have recently surveyed more than 2,000 players, coaches, parents/guardians, etc, on their knowledge, attitudes towards and behaviours around ACL injuries and injury prevention.
The above (2) has steered us towards the following actions
3) Two consensus statements in the process of development on (i) ACL injury prevention and (ii) ACL injury management. These are to help guide medical staff and coaches towards the best evidence-based practice using a summary of clear statements based on research and expertise
4) A 2024-25 EU ERASMUS+ Grant performed in collaboration with four nations (universities and national associations) called PREVENT. This project aims to produce and share knowledge on preventing ACL injuries in football. We have excellent evidence today showing that if a football team adheres to an injury prevention basic and easily implementable protocol (e.g., FIFA 11+, PERFORM+, etc.), you can decrease the number of injuries (ACL injuries included) by 50%. Therefore, this project is essential to help implement injury prevention programmes in football - both for men, women, children, teenagers and adults.”
With all this “action” by UEFA, my question is, why has there been an increase in women’s ACL in all levels of professional support? Is it just because it's become more published and known to the public? Is this program used, and does it genuinely work?
I see players dropping on their knees on the pitch. It can be about protocol, playing conditions, game congestion, equipment, and conditioning. Many factors increase the chances. I commend UEFA for spreading knowledge of ACL injuries, but the next step must be taken. Having pitch requirements at an elite level and financially supporting teams to reach that high standard with payments or rewards.
UEFA said about plans: “We are delighted that you reached out to cover this topic as the main source of information about a ’so-called ACL pandemic in women’s football’ predominantly stems from media news sources and not from data. We want to inform the public about the available data and make news articles data-driven.”
Fifpro has described its hopes around this injury for the future: “Our objective is to work with clubs in women’s football to bring together evidence-based conclusions about how to avoid ACL injuries. Of course, we recognise that eradicating them will not be possible. We also want to contribute towards reaching gender parity in football research: currently, only 8% of all sports science research is focused on women. Our project will last three years, and we will make any relevant findings publicly available during that period.
Other than the plans and projects they have in place, it does not seem UEFA has any plans they would share with me. Compared to Fifpro, which has the ACL summit and its three-year plan, I appreciate the specifics they were able to give in hopes of holding them accountable for such information.
I believe a lot of the information in the media comes from players who have experienced or seen with their own eyes the impact of ACL injuries and medical professionals specialising in these types of injuries.
Chelsea have had four players with ACL injuries since January, though they have done their investment in tissue recovery. The same happened to Arsenal a few seasons ago. These are elite clubs with the financial backing to make an impact.
Forward Fran Kirby said: "It's important to get the fundamentals young - there is a difference in how we [boys and girls] are brought up playing. The boys are doing gym work and learning basic running mechanics at six," she continued. "When I was coaching at Reading, the grassroots girls couldn't even access a gym. The most important thing is teaching young girls the basics of being a footballer and a sportsperson."
It is not just the physical impact on the players but also the mental result of long-term injuries that take them away from what they love.
The project ACL launched surrounding players from the WSL on the ACL's reflection, insight and recovery. Rachel Corsie and Lucy Staniforth, who experienced returning from an ACL injury, and Lucy Bronze, who completed a university dissertation on ACL injuries in women’s football, also had six knee surgeries in their career.
Project ACL is a collaboration between FIFPRO, Nike, and Leeds Beckett University dedicated to accelerating research after calls from players concerning the number of ACL injuries in women's football. The stats do not show that women are two to six times more likely to occur than men; about ⅔ of ACL injuries in women’s football when there is no physical contact. Yet, there is little understanding about reducing these injuries.
"The stakeholders must come to the players and work with them to extricate that golden information that will help change women's football and sports."
Over the next three years, Project ACL’s partners will work proactively with clubs and players in the WSL to better understand their current working environment, identify best practices and provide solutions to support the reduction of ACL injuries.
The project will review existing academic research related to professional women’s football, ACL injuries, and existing injury reduction programs. It will also survey all 12 WSL clubs to better understand their resources and facility access and identify best practices. Project ACL will also provide real-time tracking of the workload, travel and ‘critical zone’ appearances of WSL players through the FIFPRO Player Workload Monitoring tool.
So, it has come in strides with the hope of bridging the divide in research surrounding women in sports. One can only hope that companies and organisations will keep their promises and be held accountable for reaching their targets.
Research given by UEFA
UEFA Study
- Hallén, A., Tomás, R., Ekstrand, J., Bengtsson, H., Van den Steen, E., Hägglund, M., & Waldén, M. (2024). UEFA Women's Elite Club Injury Study: a prospective study on 1527 injuries over four consecutive seasons, 2018/2019 to 2021/2022, reveals thigh muscle injuries to be the most common and ACL injuries most burdensome. British journal of sports medicine, 58(3), 128–135.
Other studies
- Tegnander, A., Olsen, O. E., Moholdt, T. T., Engebretsen, L. & Bahr, R. Injuries in Norwegian female elite soccer: a prospective one-season cohort study. Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA 16, 194–198 (2008).
- Waldén, M., Hägglund, M., Magnusson, H. & Ekstrand, J. Anterior cruciate ligament injury in elite football: a prospective three-cohort study. Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA 19, 11–19 (2011).
- Faude, O., Junge, A., Kindermann, W. & Dvorak, J. Risk factors for injuries in elite female soccer players. Br. J. Sports Med. 40, 785–790 (2006).
- Hartmut, G., Becker, A., Walther, M. & Hess, H. Injuries in Women’s Soccer: A 1-Year All Players Prospective Field Study of the Women’s Bundesliga (German Premier League). Clin. J. Sport Med. 20, 264 (2010).
- Hägglund, M., Waldén, M. & Ekstrand, J. Injuries among male and female elite football players. Scandal. J. Med. Sci. Sports 19, 819–827 (2009).
- Horan, D. et al. Injuries in elite-level women’s football—a two-year prospective study in the Irish Women’s National League. Scandal. J. Med. Sci. Sports 32, 177–190 (2022).
- Giza, E., Mithöfer, K., Farrell, L., Zarins, B. & Gill, T. Injuries in women’s professional soccer. Br. J. Sports Med. 39, 212–216 (2005).
Resources used
https://www.topdoctors.co.uk/medical-articles/acl-injuries-in-women-an-expert-s-case-study?amp=1
https://www.bbc.co.uk/news/uk-politics-66433243
https://www.bbc.co.uk/newsround/66040144
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