Once the player hears or feels the “pop”, it almost seems inevitable what is to happen next, especially if the pop is in the knee. Some players have recalled feeling the ligament pull away.
Players will then experience intense pain, rapid swelling, and instability. An MRI scan confirms the ACL tear.
Once a player does their ACL, it's just the start of the journey. This rupture almost always requires surgical reconstruction, especially with footballers who wish to return to competitive football.
But it's not as simple as booking the surgery for the next day. Surgeons require some knee movement before surgery to ensure the procedure's success. Therefore, they need to be an element of mobility. This means players undergo prehabilitation, which is crucial. The aim is reduce swelling, restore full knee extension and reactivate the quadriceps muscles. This helps prevent “knee shutdown,” in which the quadriceps temporarily stop functioning.
In women’s football, it is increasingly complex due to anatomical, biomedical, and hormonal factors that increase injury and re-rupture risks. In fact, there has been little research on the impact of a woman’s menstrual cycle and when they have their surgery, and the impact that has on its success, as hormonal peaks may influence tissue response, inflammation and graft healing.
Orthopaedic surgeon Sarah Bolton explained: “Coaches, doctors, and physiotherapists need to understand there is enormous variability, especially in ACL reconstruction, depending on an individual’s cycle.”
Hormonal influences further complicate women’s recovery from ACL injury. Ligament laxity fluctuates throughout the menstrual cycle, which may affect both injury risk and post-surgical healing.
There is limited but emerging evidence that oral contraceptives may help stabilise hormones, though no conclusive findings exist.
The ACL is reconstructed rather than repaired because the ligament has snapped. The surgeon will use a graft taken from the player's own body, typically using a hamstring or patellar tendon graft. For women, graft size can be an issue, potentially affecting long-term stability.
For a complete tear reconstruction, it is standard practice. However, there is growing emphasis on supplementary procedures, such as lateral extra-articular tenodesis (LET) or anterolateral ligament (ALL) reconstruction, to reduce rotational instability and lower the risk of reinjury in women.
The surgery itself is often described as unpleasant. Beth Mead described the surgical process and the early stages of recovery, and the exercises were particularly uncomfortable, involving knee extension.
She also stated that only players who have experienced an ACL injury truly understand the surgery and what follows.
Once the surgery is complete, the most challenging part begins. If there are no complications, some players take up to 18 months to make a full return. recovery. ACL injury recovery, especially after surgery, is long, structured, and demanding. Typically, the last 9-12 months, Sam Kerr required 20 months due to ongoing complications.
The recovery involves intensive physiotherapy, strength rebuilding, neuromuscular retraining, and psychological resilience.
The process is long and starts with focusing on managing pain and swelling, achieving full knee extension, and activating the quadriceps. The next step is mobility, which involves gradual weight-bearing initially using crutches, then transitioning off them. This is why key exercises like heel slides are essential.
Next, it's to rebuild strength in the quadriceps, hamstrings, glutes and hips, which are critical for knee stability in women. This requires a stable knee, no swelling and a full range of motion.
Running resumes between months three and five, beginning with controlled walking and jogging intervals. This is why confidence-building becomes essential, especially in this phase.
After six months, the primary motivation is for the player to be on the pitch reconditioning through the control-chaos continuum. This includes reactive drills such as changing direction, cutting, and pivoting. Psychological readiness is crucial at this stage, as fear of re-injury often peaks.
The last step is registering the whole team for training, which can be overwhelming given the increased workload. Players will then need to pass the return-to-play test to return to matches, which is done gradually, often involving limited minutes at first. Research shows that for every month the return to sport is delayed, the reinjury risk is reduced by 51%, which is why this recovery process is slow and careful.
Beth Mead returned after 11 months out. She described rehab as slow and mentally exhausting, with days where progress feels impossible. She emphasised patience, resilience and the importance of a strong support system. Leah Williamson spoke about the mental challenge that she endured. She described rehab as a “stale place” where hard work does not always produce visible results. She highlighted the emotional difficulty of constantly questioning her body. She explained that while missing major tournaments like the World Cup is tough, the daily grind of rehabilitation is the most draining aspect.
Sam Kerr revealed she struggled with unexplained pain for 10 months due to a graft-related issue not visible on MRI scans. She underwent further surgery to fix the problem and admitted to questioning whether the pain would ever subside. Kerr also spoke about losing her identity for nearly a year and the difficulty of regaining complete physical confidence.
In lower leagues, lack of support remains a significant issue. Emma Samways had to crowdfund her surgery, highlighting disparities in medical care across the women’s game.
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