Inside The WSL: Why are ACL injuries so common in women’s football?

Female footballers are up to six times more likely to suffer an ACL injury than their male counterparts, and Inside the WSL spoke to players, physios and doctors to try to find out why.

Unfortunately, it’s not uncommon for a women’s club to announce that a player will be sidelined due to a torn ACL. West Ham’s Jessica Ziu, Aston Villa’s Chantelle Boye-Hlorkah and Tottenham duo Kyah Simon and Ellie Brazil are just some of the players to be ruled out this season alone.

The issue was also highlighted during the European Championships in the summer. Ballon d’Or winner Alexia Putellas missed the tournament after rupturing her ACL days before Spain’s opener. Simone Magill also suffered the same injury in Northern Ireland’s tournament opener against Norway, just days after signing for Aston Villa.

France striker Marie-Antoinette Katoto also limped off in their second group game against Belgium, having also ruptured her ACL. She had been one of the favorites to win the Euro 2022 Golden Boot.

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Frenchwoman Marie-Antoinette Katoto injured her ACL during Euro 2022

You could keep rattling off the names of female players who have gone through the long process of ACL rehabilitation, but so far very little scientific research has been done on why women are more likely to suffer the injury than men.

There are theories such as menstrual cycles playing a key role, although there has not yet been enough research to support this.

Talk to Inside the WSLWomen’s health specialist, Dr Emma Ross, explained: “We know that female athletes are up to six times more likely to have a non-contact ACL injury than their male counterparts.

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“We published a paper about a year ago that showed that in sport and exercise science research, only about 6% of studies are done exclusively on women – meaning they study what happens in the female body – then we don’t. There is not a lot of research on female athletes.

“But what we know about the menstrual cycle and injury is that hormonal changes during the cycle can impact the physiology and biomechanics of the body.

“For example, when estrogen is high in the menstrual cycle, and that happens around the second week, it can affect joint stability. This can interfere with the collagen in our joints and create looser, looser joints. The loose joint is therefore less stable and more prone to injury.

Dr. Emma Ross is a women's health expert and shared her thoughts with Inside the WSL
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Dr Emma Ross is a specialist in women’s health and has given her opinion on ACL injuries in female footballers

“So we have some information about loose joints, but what we don’t have is the last step to knowing if it really increases the risk of injury in female athletes.”

Arsenal Women’s physiotherapist Gary Lewin also agrees that menstrual cycles can play a part in increasing ACL injuries.

He said: “Generally I would say there is a connection. What is this connection, we have not found out definitively as far as I know. There are certain assumptions and different phases of a menstrual cycle lead to different levels of fatigue, coordination, which could lead to loss of potency.

“It could be related to the cause of their crusader’s breakup. But women’s sport needs more research in general because so much of the research is based on men’s sport.

“Another thing that I have discovered in my short time in women’s football is that there is what is called an osteochondral defect, where the bone is involved and there is a degeneration of the bone.

Arsenal physio Gary Lewin also offered his thoughts to Inside the WSL
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Arsenal physio Gary Lewin also offered his thoughts to Inside the WSL

“For me, there is a factor in women’s football where this happens more regularly than we realize. Again, this is an area I’d like to investigate that may be related to cruciate injuries.”

One WSL player who has suffered two ACL injuries in recent years is Manchester United defender Aoife Mannion. Shortly after joining Manchester City, she suffered a serious ACL injury in October 2019. Coupled with Covid postponements, Mannion spent 458 days away from the pitch and made just 11 appearances for City.

She left the club at the end of her contract to move to the other side of Manchester last summer. But after a strong start under Marc Skinner, she ruptured her ACL again in March 2022. She is closing in on a comeback eight months later.

“The first time I did it was an out of body experience,” she said. Inside the WSL. “I knew something had happened, I would be saved from some of the pain some people feel, but I definitely heard it go.

Aofie Mannion spoke to Inside the WSL
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Aofie Mannion spoke to Inside the WSL about her two ACL injuries in as many years

“I had one where it was a very simple ACL and the previous one was very complex. In terms of contributing factors, we may have talked about menstrual cycles. It’s hard as a footballer to start thinking that way in terms of ‘does my body at certain times of the month make me more susceptible to an ACL injury’.

“All I’m doing is giving myself the best chance of not starting over and getting back to full fitness. I’m aware of the research, I like to look at things and hear the experiences of people, people who are passionate about ACL rehabilitation and stuff like that.

“I guess I’m a bit of a geek in this category. Right now I’m rehabilitating an ACL so I like to hear the research.”

Mannion has been open about both her ACL injuries and the rehabilitation process, often posting on social media to give updates on her progress.

When asked why, she explained: “The motivation is slightly selfish because I know that when I share, kind-hearted people cheer me on and why wouldn’t you.

“I would encourage everyone to do some of that, to share what they’re doing because people who are on the same page and get it will send encouragement and you have to take all the encouragement that you can get.

“I think one of the reasons people don’t share their rehab is they think either fate is tempting to be hurt again or there will be a setback and they will look idiots. I think if you’re going to get hurt, you’re going to get hurt, so why not share the good times along the way.”

This all leads to the big question – what can be done to help prevent so many female footballers from suffering ACL injuries?

Dr Ross gave his opinion saying: “We need to start measuring hormones because they change over the course of a month and we think that could impact things like joint stability and injury risk.

“It comes at a cost, and it’s a pretty complicated method of research, because you have to track athletes and get them to track hormones, track their symptoms, and track their cycle.

“You also have to wait for them to be injured. The big challenge with injury research is that it is mostly done retrospectively, because we don’t know who is going to get hurt when and why.

“There are a lot of myths about the menstrual cycle and injuries. In fact, when we talk to athletes and footballers, they often say they get nervous if they have their period and they play a game because they think they might get hurt, especially if they have already been injured.

England's Chloe Kelly celebrates scoring her side's second goal in the UEFA Women's Euro 2022 Final at Wembley Stadium, London. Picture date: Sunday July 31, 2022.
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Man City striker and Euro 2022 winner Chloe Kelly is one of the WSL players to have already been sidelined with an ACL injury.

“It’s an anxiety that they will carry into their performance and unfortunately we don’t have strong enough evidence to say ‘yes, there is a specific time in your cycle when you are more likely to be injured’, but we have plenty of headlines suggesting it. Players will read this and start to worry.

“At the moment the best we can do is get players to follow their cycles and if they feel like their hamstrings are tighter or their back is flared up at some point in their cycles, they are best advised to work with their physios and coach to do something about it.

“When people find approaches that have really been helpful to them as a female athlete working with their female body, sharing that with other female athletes who may not have access to this information is extremely helpful.

“We have to consider that everyone is unique and the same approach may not work the same for someone else, but sharing best practices and successful rehabilitation is really important so that we can improve the everyone’s understanding of what might work when it comes to wounds and injuries. resilience in footballers.”

Watch the full feature on Inside the WSL from 6.30pm Thursday on Sky Sports Football.

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