Football’s struggle to find solution for its ACL epidemic
Despite high-profile cases, no definitive reason for outbreak of knee injuries has been discovered,
The image of injured Beth Mead comforting Vivianne Miedema as she was taken off on a stretcher last month was not only a blow to Arsenal supporters, it prompted groans from fans of women’s football as a whole.
Dozens of top-flight footballers across Europe have been downed by an anterior cruciate ligament tear in the past calendar year – with Mead and Miedema making it five of the 20 nominees for the 2022 Women’s Ballon d’or sidelined with the knee injury that can take nine months to repair.
But Pippa Bennett, the lead doctor of the professional women’s game for the Football Association, says that the number of ACL injuries has actually gone down since it began tracking the data for the top two tiers of women’s football four seasons ago.
“You need a lot of players, over a number of years, to really see the trend,” Bennett says of the FA’S injury audit for the Women’s Super League and Championship. “We’ve been able to show that, actually, over the four seasons there’s been a very small reduction, but it is coming down, which is the best news ever.
“ACLS represent 1.3 per cent of injuries over all the seasons, so really a small percentage, and they are slightly on the decrease. Of course, when you get high-profile events, it’s big news. And we can’t rest on our laurels – as we do know women are more at risk than men.”
Depending on what study is looked at, women can be two-to-six times more likely to suffer an ACL rupture than men, but there remains no clear reason why.
“If I knew the answer, I’d be loaded – but unfortunately I don’t, and I’m not,” says Prof Mark De Ste Croix of the University of Gloucestershire, who has done extensive work on injury risk and prevention in women’s football. “Understanding the complex puzzle of risk factors is incredibly difficult.”
The main factors experts point to are: anatomical differences in men and women, social context and the menstrual cycle.
Dr Georgie Bruinvels, a researcher at University College London and the female athlete lead at bioanalytics company Orreco, is particularly passionate about the potential impact of the menstrual cycle.
“This area is clouded by a couple of different mechanisms through which I think ACL injuries can occur,” she says. “There’s the ligament laxity theory [at certain points in the menstrual cycle], but there’s also fatigue, lack of coordination, lack of sleep – all of those affect you in a different way, which could also predispose you to being injured.
“I feel like we also don’t track cycles well enough. We need to collect data properly. Previously, researchers have said, ‘The injury happened on this day – were they menstruating or not?’ But what about what day in their cycle? Every time an injury happens, it kind of breaks my heart because we’re missing a data point that could help the next generation.”
Looking at elite female athletes’ early sporting lives could also hold the key. Bennett says: “I was England doctor for 14 years, looking after Kelly Smith, Faye White, Fara Williams, and in that age band some were having to go back to some basic movement skills that they just hadn’t acquired as kids because they didn’t have the same access [to sport as boys].”
De Ste Croix also points to disparities in the academy system, saying: “Boys get quality training from 10, 11 or 12 in academy settings. The idea is to try to get that training age established [in the girls’ game], so that by the time they get into the clubs, they’ve had strength and conditioning work from the age of 12 – not suddenly when they’re 22 and in a club. We need more resources further down the pathway.”
Bruinvels believes it is crucial not to simply accept that this injury will always affect women more. “We can’t just step back and say, ‘Oh well, it’s inevitable that most female footballers will have an ACL injury’. Until we’ve got that data, I just don’t believe we can say that.”