The Rising Wave of ACL Injuries in Women's Football: Unveiling Innovative Solutions and Cutting-Edge Technologies

ACL injuries have become a concerning issue in women's sports, causing significant disruptions and preventing top players from participating in important competitions and tournaments. The list of individuals affected is extensive, highlighting the complexity of this problem, which medical experts and specialists in the field have yet to fully comprehend.

Female football players are facing a distressing situation, often referred to as an 'epidemic'.

The statistics reveal a grim reality. Football-related injuries contribute to almost 50% of all ACL reconstructions carried out in the UK. These injuries impose the most significant burden on recovery and are responsible for nearly one-third of the total time lost during gameplay due to injury.

Consultant orthopaedic surgeon Nev Davies expresses concern over the alarming surge in ACL injuries among young individuals in the UK. In comparison to two decades ago, there has been a significant 29-fold rise, with females being four-to-six times more susceptible. Davies admits that the lack of progress in injury prevention in the country is embarrassing, especially when compared to other nations.

Female athletes in various sports generally have a higher risk of injuries, and this trend is particularly evident in football. Concerns are mounting as data reveals that a significant number of elite players, totaling up to 195 individuals, have experienced similar injuries over the past year.

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England captain Leah Williamson ruptured her ACL in Arsenal's defeat at Man Utd in April

This summer, the Women's World Cup has unfortunately seen the absence of a substantial number of players, ranging between 25 and 30, due to ACL tears. It is disappointing to note that England's squad is also affected, as they are missing their captain, Leah Williamson, and their most accomplished goal scorer, Beth Mead.

Dr. Kate Jackson, an esteemed specialist in sports and exercise medicine, sheds light on this issue by emphasizing the increased rate of ACL injuries in women and girls for the past two decades. She further emphasizes the need to explore the nuanced gender aspect of this problem, as our understanding of it is still incomplete.

Is football failing women?

The alarming number of female players whose World Cup dreams have been shattered by ACL ruptures this year is a cause for concern. The list includes some of the most renowned elite international talent.

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The provision for sports injuries is often based on the needs of Caucasian males, ignoring the specific requirements of women. At the domestic level, Arsenal, in the Women's Super League, faced the most significant impact. Jonas Eidevall's team had four players out of action due to ACL tears during the previous season.

Football-focused studies suggest women are six times more likely to suffer ACL injuries compared to men, and 25 per cent less likely to return after recovery.

We must prioritize collective efforts to enhance ACLs and conduct further research on the subject. Its prevalence in the women's game requires immediate action. Had a similar situation occurred in the men's game, substantial progress would have been made earlier. These remarks were made by Beth Mead, an Arsenal winger, in March 2023.

Jackie Whittaker, a faculty member in the Department of Medicine at the University of British Columbia, suggests that organizations such as FIFA or the global players union FIFPRO should finance a study or collaboration similar to the one initiated by the NBA and General Electric in 2015. This research would examine the prevalence of tendon injuries in basketball, aiming to gather insights and implement preventive measures.

"Whittaker expressed that sometimes private industry acknowledges the significance of a particular matter and shares the sentiment of its importance. In relation to football, Whittaker believes that girls voicing their opinions could potentially enhance the possibility of private industry taking action."

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Laura Wienroither was on the pitch for just 18 minutes before suffering a ruptured ACL last season

ACLs continue to puzzle experts, making it challenging to find a definitive solution. Various factors, including physiology, biomechanics, and the environment, contribute to this issue. These factors encompass body types, running and jumping techniques employed by athletes, and the quality of the playing surface, among others.

Until recently, there have been scattered attempts to comprehend the influence of these factors and their correlations. However, perceptions are now shifting, with stakeholders advocating for a comprehensive examination of one of the prominent shortcomings in modern football.

Cause and effect - from far and wide

Research indicates that the impact of gender bias on injury is associated with societal attitudes towards female sports participation. According to Dr. Jackson, there is a need to explore themes such as attitudes towards physically active girls, accessibility, and opportunity.

Furthermore, muscle strength imbalances are more evident in females, which may explain why structured injury prevention warm-ups that incorporate strength and balance have proven to be highly effective in reducing the risk of ACL injury among young girls. Additionally, as females grow older, anatomical differences and hormonal changes during menstrual cycles have been suggested as potential contributing factors.

Women wearing men's football boots may be one of the reasons for discomfort experienced by 82% of female players surveyed in Europe, according to a recent report from the European Club Association. Additionally, the rising popularity of women's football and an increase in the number of matches have resulted in a greater strain on athletes' bodies. However, female-specific sports science, access to top strength and conditioning, and physiotherapy specialists have not kept up with these demands.

Typically,

, girls have not received the same high-quality training as boys at an early stage, which has limited their development of strength and endurance. As a result, they are more susceptible to vulnerability.

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Injured Chelsea forward Fran Kirby believes girls aren't provided with the right tools to learn the 'fundamentals' from a young enough age

England and Chelsea forward Fran Kirby shares the opinion that it is crucial to establish the fundamental skills at a young age. According to her, there is a difference between how boys and girls are introduced to playing sports. Kirby, speaking exclusively to We from her home in London, emphasizes the importance of teaching young girls the basic mechanics of football and athleticism. She notes that while boys start gym work and learn running mechanics at the age of six, grassroots girls often do not have access to such facilities. Kirby believes that teaching girls proper running techniques, agility, and muscle strength is paramount in their development as footballers and athletes. At present, the 30-year-old player is unable to participate in the World Cup due to knee surgery.

'Women are little men'

"The lack of awareness in the UK regarding the significance of injury prevention programmes is disheartening...our country is lagging far behind," asserts Davies, an orthopaedic surgeon, addressing the topic of injury prevention among young individuals as a whole.

His apprehensions are echoed by many.

Sports medicine expert Eva Carneiro, formerly the doctor for Chelsea Football Club, expresses her belief that the limited funding and lack of knowledge in women's sports has a detrimental effect on the development of female athletes. In an exclusive interview with We, Carneiro addresses the persistent gender disparity in football, highlighting the scarcity of financial resources and experienced medical teams. She emphasizes that doctors, given their accountability for every decision, can be costly but should be seen as valuable contributors rather than threats. Carneiro underscores the importance of information sharing, effective governance, and a thorough understanding of medical judgments.

She expressed concern about the insufficient attention given to women-specific health issues, stating, "What's even more distressing is that, as a woman myself and someone who finds this subject incredibly intriguing, we were trained fifteen years ago to think of women as essentially miniature men. We disregarded any factors that make women unique. This issue stems from academia and the way we were taught, which needs to change."

Dr. Emma Ross, a specialist in women's health, expressed her concerns about the lack of research on females in the field of sport and exercise science. In an interview with Inside the WSL, she mentioned that only six percent of studies focus exclusively on females, leading to various misconceptions about the menstrual cycle and its connection to injuries.

Dr. Whittaker, a medical professor at UBC in Vancouver, shares the same worries about the spread of rumors and speculation. She emphasizes the risks associated with misleading messages and specifically targets the potential harm caused by the belief that menstruating girls are more susceptible to tearing their ACL.

"Before we make any claims about the menstrual cycle or hip width being risk factors, we must be certain of their validity."

Regrettably, despite the significant growth of women's game, research in this area has significantly fallen behind. Dr. Jackson asserts that there is a pressing need for "more focused research, in order to gain a genuine comprehension."

Kryger - the agent of change

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Women are far more susceptible to suffering an ACL injury than their male counterparts

Dr. Kat Okholm Kryger, a sports rehabilitation researcher at St Mary's University and medical researcher for FIFA, recently emphasized the slow advancement in technology specifically tailored for top-level female football players. In a series of papers, she sheds light on the pervasive dominance of male-focused research in football and sports medicine. Dr. Kryger shared her observations with Sky News.

Dr. Kryger is a strong advocate for change, firmly believing that the well-being and performance of athletes have suffered for far too long due to the predominant use of footwear and kit designed primarily for men.

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Leah Williamson is missing the opportunity to captain England at a Women's World Cup this summer

In an exclusive interview with We, Dr. Kryger discusses her research on ACL injuries. She states that her findings do not show an increase in the number of injuries per exposure hours. However, she does identify what she calls "club clusters", where two to four ACL injuries occur within a season in a single club. Dr. Kryger finds it challenging to study and explain this trend, but notes that it occurs regularly in both men's and women's games.

Arsenal were one of the unlucky few last season.

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Arsenal striker Vivianne Miedema was ruled out for the season with an ACL tear that required surgery

The number of ACL injuries observed per 1000 hours of match play varies from 0.6 to 2.2. According to Dr. Kryger, several risk factors for ACL injuries in women can be divided into "nature" and "nurture" categories. She emphasizes that there are at least 30 reasons discussed in the available literature.

According to Dr. Kryger, factors like body shape, hip width, and the menstrual cycle are often mentioned as possible contributions to women not playing football. However, there is currently no substantial evidence supporting these claims. They have been used as arbitrary excuses to justify why women should not participate in the sport.

Dr. Kryger also explains that nurture, in terms of environmental factors, plays a significant role. This includes limited access to high-quality pitches, poorly fitting boots, less availability and utilization of gyms for injury prevention, and lower engagement in injury prevention training.

She believes all aspects "could and should be changed" to minimise injury risk in women.

The technology causing a stir

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IDA was launched in an attempt to revolutionise the football boot for female players

IDA: The boot revolution

Consider an aspect in Dr. Kryger's 'nurture' argument: football boots. Historically, footwear has predominantly been designed based on the anatomy of white males.

In an effort to emphasize the inherent distinctions between female and male feet, Dr. Kryger embarked on a project utilizing 3D scanning technology to accurately analyze size, shape, as well as variations in heel and arch depth.

She is not alone. We had an exclusive conversation with Laura Youngson, one of the co-founders of IDA. This company focuses on creating "high-performance and comfortable footwear specifically for female athletes."

Youngson expressed her astonishment at the fact that even "women who excel in their sport" are still using footwear intended for the opposite gender.

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Laura Youngson, co-founder of IDA, is fervently dedicated to transforming the experiences of female players. According to her, the key lies in crafting footwear that encapsulates the essence of female biomechanics. To illustrate this standpoint, consider the realm of running, where women-specific running shoes have been accessible for quite some time.

Our approach is twofold: to enhance performance by offering customized products and to ensure an inclusive experience where girls can feel acknowledged when they enter a shop. Our aim is to revolutionize the way people shop. Youngson highlighted the significance of Dr. Kryger's research in shaping the core values of her company, as well as the scientific foundation that enables us to offer a wider range of top-quality equipment.

The release of Nike's Lunar has had a significant impact on our business as it emphasizes the importance of women's footwear. However, it is important to note that this shoe is inherently gender-neutral, catering to both men and women. Unfortunately, it does not address the underlying issue adequately.

Laura Youngson, co-founder of IDA, stated that their primary emphasis has been on the anatomical differences between men and women's feet. Specifically, women typically have narrower heels and a wider toe area. This discrepancy often leads to discomfort and pain, as many female players have experienced sore little toes due to the discomfort caused by ill-fitting boots.

Data should serve as a foundation. The establishment of the company was motivated in part by Dr. Kryger's research. Many women choose to remain silent about their pain because they receive free footwear from sponsors. However, this does not contribute to the improvement of their physical well-being or performance.

Regarding the anterior cruciate ligament (ACL), we possess knowledge about surfaces and footwear. We are of the opinion that certain adjustments can be implemented to decrease the associated risks. One simple structural change involves customizing boots for different surfaces. Typically, women tend to train and play in the same boots, regardless of the playing surface. The entire system needs to be addressed comprehensively to bring about necessary improvements.

Quantifiable progress is being made in the tech sector, although women's access to such innovation is not yet widespread in the game.

Patrik Olsson, CEO of Spiideo, a video recording and analysis tool, explains, "We automate the process of capturing sports on video, recording the game or training from multiple angles in high resolution."

The women's game could greatly benefit from adequate investment to enhance the data pool. This has the potential to be a game-changer.

Spiideo is utilized for monitoring and categorizing various aspects such as distance, speed, impact frequency, and different types of transitions that could precede injury incidents. Olsson believes that the cumulative effect of these factors will contribute to preventing future injuries.

He elaborates, "In essence, our focus lies in monitoring players, the ball, and activities on the field. Essentially, we're transforming the game into a digital format.

"With the data at hand, numerous additional revelations are expected to emerge. For instance, we can detect when a player is becoming fatigued, suggesting the need for a substitution, or when the game's intensity shifts, calling for a different approach."

"In future we will be able to see up close what is happening from a player's point of view when an injury occurs. Video and data are fundamental to understanding."

A duty of care

Various clubs in the UK and US have taken initiative to address this issue, although progress has been limited. Chelsea and Washington Spirit of the NWSL have recently started collecting data on players' menstrual cycles.

Dawn Scott, the Director and Vice President of Performance, Medical, and Innovation at Washington Spirit, explains that the aim is to alleviate symptoms and enhance individual training efficiency.

Chelsea is focused on decreasing soft tissue injuries by utilizing a custom app to monitor player cycles. Emma Hayes, the manager, emphasized the importance of recognizing the unique experiences women have on a monthly basis. She believes that the lack of proper education regarding reproductive systems in school has led to a need for further understanding and improvement in their performance.

In addition, we sought the opinions of several physiotherapists currently employed at WSL clubs, who shared a similar viewpoint: "while medical services are getting better, the progress is not happening quickly enough." Collectively, they acknowledged the presence of numerous internal and external factors that influence the functionality of an ACL, making it impossible to pinpoint a single cause or individual responsible.

Conclusion and next steps

The consensus was clear: participants expressed a resounding endorsement for the provision of more customized research to assist them in their decision-making processes. This would not only enhance injury prevention strategies but also optimize injury recovery methods.

Players, medical experts, and coaches agree: football is unfairly treating its female players. The existing institution and infrastructure, which historically catered to men, are failing the women's game. But there is hope on the horizon. The industry is beginning to take notice and acknowledge the need for change. Recommendations for improvement are slowly gaining traction in the mainstream.

Karen Carney, chair of an independent review on women's domestic football, has released a set of improvement recommendations, as requested by the government. One notable proposal in the review, which was published a week prior to the beginning of the Women's World Cup, is the implementation of 'minimum standards' in all aspects of the sport. Carney clarified her stance, saying, "I don't want players relying on NHS for injury treatments."

Carney's conversations with both current and former players unveiled a common sentiment of being treated as inferior to their male counterparts in the world of football.

The report proposes the establishment of a FA-funded research unit that will focus on investigating various challenges faced by female footballers, including the previously overlooked issue of ACL injuries, which has never been thoroughly studied in the UK.

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Former Chelsea doctor Carneiro thinks that the women's game can have an "exciting time" ahead. She believes that as more evidence emerges, it will reveal things that will significantly enhance the performance of these women. Carneiro stated that this progress is exciting not only for women's football but also for female athletes in general, especially if they receive medical support for the first time in history.

Undoubtedly, what initially seemed like a discouraging reflection of past shortcomings could potentially turn into signs of progress. Although the path forward may not be completely clear, at least it now exists.

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