Why Female Athletes Are at a Higher Risk for a Torn ACL: There are Far More Reasons Than You Think!
by Melinda Burris

An article written by Ella Brockway this past July for The Washington Post highlighted the growing conversations that are being had about the significantly higher likelihood of ACL tears among women athletes and the varied reasons behind this sobering statistic. Early in her article, Brockway points out, “Studies show female athletes are two to eight times as likely as male athletes to tear an ACL, one of the bands of tissue that connect the femur and tibia at the knee.”¹ This is not news to anyone who has been active in female sports over the last twenty-five years.

Brockway mentions research studies conducted as early as the late 1990s that highlighted statistics found across a variety of sports that showed unquestionably that women were at a higher risk of tearing their ACLs, often in non-contact sports that involved jumping and more specifically landing. Research conducted in 2001 by Toth and Cordasco showed the same finding: “Female athletes have a two-to-eightfold higher incidence of ACL injury than their male counterparts. It is estimated that 38,000 women sustain ACL tears per year.”² The study summation also emphasized, “The majority of ACL injuries in female athletes occur through noncontact mechanisms, most often during deceleration activities, such as landing from a jump or cutting.”² The tie to female hurdlers is obvious as hurdling is a sport that requires a variety of skills: running, the ability to accelerate and clear each hurdle in a coordinated manner, and then immediately prepare to clear the next hurdle before all hurdles are cleared and you sprint to the finish line. Whenever a hurdler lands after clearing a hurdle they must do so properly or risk injury. It is no surprise that ACL injuries are prevalent in hurdling. As the statistics show, female hurdlers are at a much higher risk of sustaining ACL injuries than their male counterparts. We know this to be true. But why the large disparity?

Toth and Cordasco observe, “The risk factors for noncontact ACL injuries can be categorized as intrinsic (anatomic and hormonal) and extrinsic (environmental and biomechanical).”² Brockway breaks this down into layman’s terms by explaining that women are built differently biologically and this in part explains why they are more susceptible to this particular injury of the knee. She explains, “In women, the intercondylar notch, the area in the femur where the ACL sits, is narrower; additionally, women’s pelvises are wider, creating a higher angle between the hips and knees that can put greater stress on the quadriceps and the ACL.” Brockway emphasizes that this causes female athletes to have a tendency “to land flat-footed with knees inward on jumps and have more strength in the quads rather than the hamstrings.” In sports that require a lot of movement in short transition times, such as soccer or hurdling, changing direction suddenly or a faulty landing can mean a torn ACL.¹ Brockway underscores her point by remarking that approximately 70% of ACL injuries occur in “noncontact situations.”¹ This means the injury is inflicted due to improper mechanics. So, how can they be prevented?

The Importance of Strength Training to Prevent ACL Injuries

Repeating the same movement correctly creates muscle memory that the brain and body use to sync the correct movement out of habit, greatly reducing the risk of injury. According to Brockway’s research, this type of preventive exercise done as part of a regular training program has been proven to reduce the likelihood of sustaining an ACL tear by as much as 50%.¹ Strength training is often pointed to by coaches, trainers, and physical therapists as key to preventing numerous common sports injuries—including ACL tears. Wesley Wang, a physical therapist specializing in ACL rehab emphasizes the importance of strength training in avoiding injury of any sort noting, “With strength training, if your body’s a little stronger, it can handle a little more stress. If you combine those two, that is a recipe for success, as far as giving yourself the best chance to stay healthy.”¹

External Contributing Factors

There is agreement in the scientific community that in addition to a biological predisposition to ACL tears, there are external factors that make this injury so prevalent among female athletes. Prevention and strength exercises, while important, have not moved the needle on the rate of ACL tear injuries among women participating in non-contact sports that require landing. Research studies in 2021 show the same “two- to eightfold higher incidence of ACL injury”² among female athletes in comparison to their male counterparts noted in the mid-1990s and in 2001.¹

Brockway observes research studies have found “female soccer teams often engage in fewer strength and conditioning sessions than men’s teams. Girls and women participate in strength-building resistance training at less frequent rates than boys and men.”¹ Many proponents of women’s sports have begun to question if traditional societal roles and the association of a certain physical appearance being viewed as the feminine model may explain some of the disparity.¹ There is no doubt the field of women’s sports is growing at an exponential rate. Are societal perceptions and expectations evolving and advancing at the same rate?

Brockway also points out how women’s teams at the most elite levels have had to fight for access to the same professional-grade facilities for training and competition. For instance, she offers the fact that the U.S. Women’s soccer team had to fight “to play all of their games on grass instead of artificial turf, which has been linked to increased injury rates.”¹ Given the proven proclivity of women to sustain ACL tears, one might assume this would have been an uncontested issue. Brockway also raises the problem of female cleats, contending “Researchers have raised concerns about potential injury risks from playing in cleats designed with a male foot in mind.”¹ She also notes that a recent research study concluded that an overwhelming 82% of female soccer players deal with “regular discomfort because of their cleats.”¹ If cleats are improperly designed to fit the female foot and are a source of pain for female soccer players, it is only logical to assume that female hurdlers, sprinters, and any female participating in any sport that requires wearing cleats deal with the same issues.

There is some good news to be found when researching ACL tear injuries. Advances in medicine now offer those who incur a torn ACL the option of ACL reconstruction surgery. The procedure has a high success rate and athletes generally return to the field in 9-12 months.¹ This has changed the trajectory of many sports because as Brockway correctly notes, “A torn ACL was once considered a career-ending injury.”¹ Still, experts emphasize that rehabilitation can be a long road that is physically, mentally, and financially challenging.²

If you are a female hurdler, heed Coach McGill’s advice to do thorough warmups before engaging in exercise so your body is not subjected to stress before it is ready for it. Practice the proper mechanics of hurdling techniques, particularly landing, so that it becomes embedded as muscle memory to make each motion in a safe, ergonomic manner. Make sure you only wear your cleats when required to avoid overwear issues and run on softer surfaces like grass whenever possible to give your feet and body a rest from the pounding of asphalt.

References:

1. Brockway, E. (18 July 2023). Team ACL: The Growing Women’s Soccer Club That No Player Wants to Join.
2. Toth, A.P. & Cordasco, F.A. (2001). Anterior Cruciate Ligament Injuries in the Female Athlete.