Women and girls account for nearly one-third of the 1.6 million Australian Rules Football players nationally, with the number of clubs with women’s or girl’s teams doubling from 2016 to 2018. 

With the rise of the AFLW, ACL injuries are also in the spotlight. In fact, it’s proposed that women are 2-5 times more likely to injure their ACL while playing sport. 

Our last blog post about ACL injuries in women’s football was two years ago, so how has our knowledge changed since then? What new research has come out? And what should you be doing to prevent ACL injuries in yourself and any athletes you care for or coach?

Firstly, some background. 

The Anterior Cruciate Ligament (ACL) sits deep within the knee joint and helps to prevent anterior translation of the tibia on the femur – it stops your shin bone coming too far forward on your thigh bone. It is supported in this role by the hamstring muscles which are on the back of your thigh.  

ACL injuries are unfortunately all too common. Most people who play sport will know at least one person who has injured theirs or may have injured it themselves. In women’s football, it’s becoming increasingly common.    

There are many proposed reasons as to why women are more susceptible to ACL injuries including: 

• Later transition to football: many women were not able to play football while growing up and have therefore transitioned from other sports with different physical requirements. Reduced sport-specific motor skill development acquired through deliberate practice during the development years may make them more susceptible to injury as their bodies have not yet adapted to the demands on the sport. This is expected to decrease as more women and girls grow up playing football.  
• A wider Q angle: The Q angle is the angle of the hip to the knee, and because women often have wider hips this often means they have a greater Q angle which may place their ACLs at increased risk of injury. 
• Hormonal impacts: There is emerging research coming out which suggests that knee ligament laxity and risk of ACL injury may be increased during the ovulatory phase of the menstrual cycle due to the increase/ fluctuation in hormones such as progesterone. There is also evidence suggesting that hormonal contraceptives may have a positive impact on this, although more research is required.
• Decreased funding: When compared to men, female footballers often receive less time, money and resources to ensure adequate training, nutrition, facilities, and access to support staff. This can leave them more susceptible to injury.  

What can we do about it? 

While the biological differences between men and women are non-modifiable (i.e., they cannot be changed), there are many modifiable differences that can be. There is evidence that addressing differences in experience, skill and training can contribute to minimising differences between men and women in ACL injury rates and risk factors.  

For female football players, injury prevention programmes incorporating multiple exercise-based components can reduce overall injury rates by 27% and ACL injury rates specifically by 45%. 

Prevention of ACL injuries in female football 

The three most common ways the ACL is injured in football are all non-contact: 

–deceleration 

-change of direction 

–jumping/ landing.  

The warmup for football training and games should therefore involve all three of these. The ‘Prep to play’ protocol has been developed specifically for female footballers and is a very valuable resource for coaches, trainers and players to utilise. 

Jumping/ landing techniques should be practiced at training as well. It is important that when you land you absorb the force through your hips and not only through your knees and ankles. Knees should stay stacked directly over middle toes, not come in or out. The more this is practiced outside of game play situations, the more natural it will become and the better you will land in a game. 

Strength training is also particularly important for all athletes and should be undertaken 2-3 times per week. For ACL injury prevention, there should be a particular focus on core and lower limb work and adding in an element of instability to the workouts will enable the body to adapt to the unpredictable nature of football. For example, this may involve multi-joint exercises which incorporate single leg work or the use of bands to add more dynamic resistance. A lack of trunk control has been linked to an increase risk of ACL injury in females, so this is not to be missed. 

For example: 

Single leg Romanian Dead Lift (RDL) 

• Stand on one leg with a weight in your opposite hand to the leg that is on the ground
• Have your knee and hip slightly bent
• Hinge from the hips so you reach towards the ground
• Keep hips level and hinge again so you are back standing straight
• You should feel this in your hamstring muscle group 

Side plank with single arm resistance band row 

• Lie on side facing resistance band tied to pole at elbow height 
• Hold a side plank while pulling on the band and squeezing shoulder blade back 
• You should feel this around your core and upper back/ shoulders

Bulgarian Split Squats 

• Stand in a lunge position with your back foot elevated onto a bench/ box 
• Lunge down so that your back knee goes towards the floor
• Keep your front knee directly over your middle toes- do not let it come in or out 

It is unlikely that ACL injuries will ever be completely prevented, however by following the above tips you will significantly reduce your risk. If you are unsure where to start when it comes to strength training for female footballers or want more information on what you should be doing to prevent an ACL injury, book in to see one of our physiotherapists.  

References 

Crossley, K., Patterson, B., Culvenor, A., Bruder, A., Mosler, A., & Mentiplay, B. (2020). Making football safer for women: a systematic review and meta-analysis of injury prevention programmes in 11 773 female football (soccer) players. British Journal Of Sports Medicine, 54(18), 1089-1098. doi: 10.1136/bjsports-2019-101587 

Fox, A., Bonacci, J., Hoffmann, S., Nimphius, S., & Saunders, N. (2020). Anterior cruciate ligament injuries in Australian football: should women and girls be playing? You’re asking the wrong question. BMJ Open Sport & Exercise Medicine, 6(1), e000778. doi: 10.1136/bmjsem-2020-000778 

Herzberg, S., Motu’apuaka, M., Lambert, W., Fu, R., Brady, J., & Guise, J. (2017). The Effect of Menstrual Cycle and Contraceptives on ACL Injuries and Laxity: A Systematic Review and Meta-analysis. Orthopaedic Journal Of Sports Medicine, 5(7), 232596711771878. doi: 10.1177/2325967117718781 

Lim, B.-O., An, K.-O., Cho, E.-O., Lim, S.-T., & Cho, J.-H. (2020). Differences in anterior cruciate ligament injury risk factors between female dancers and female soccer players during single- and double-leg landing. Science & Sports. doi:10.1016/j.scispo.2020.02.005  

Montalvo, A., Schneider, D., Silva, P., Yut, L., Webster, K., & Riley, M. et al. (2018). ‘What’s my risk of sustaining an ACL injury while playing football (soccer)?’ A systematic review with meta-analysis. British Journal Of Sports Medicine, 53(21), 1333-1340. doi: 10.1136/bjsports-2016-097261 

Prep-to-Play Warm-Up | Coach.afl. (2021). Retrieved 9 February 2021, from https://coach.afl/prep-play-warm