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The rise of ACL tears in women’s football with Professor Wilson

August 4, 2023

The world of women’s football has witnessed tremendous growth and recognition in recent years. With increased participation and viewership, the Women’s Football World Cup has become a highly anticipated global event. However, an unfortunate trend has emerged in recent tournaments, with numerous players sidelined due to the same injury: ACL tears. In conversation with Professor Adrian Wilson, we hear insights into the prevalence of ACL injuries in women, their underlying causes, and the cutting-edge strategies that define the future of ACL reconstruction.

Professor Adrian Wilson

Consultant Orthopaedic
Surgeon & founder

The prevalence of ACL tears

The anterior cruciate ligament (ACL) tear is a common and debilitating injury among football players, both male and female. However, recent Women’s World Cups have seen a significant number of players succumbing to ACL tears. This alarming trend raises questions about the factors contributing to these injuries and the measures needed to prevent them.

Understanding the ACL injury

The ACL is one of the crucial ligaments that stabilise the knee joint. It can be torn or ruptured during sudden changes in direction, pivoting, or high-impact collisions. Unfortunately, ACL tears often require extensive rehabilitation and can have long-lasting consequences, impacting the careers and lives of athletes.

"An effective injury prevention programme demonstrates that a simple 15-minute warm-up, focusing on proper landing and hip alignment, can considerably mitigate the incidence of ACL ruptures and re-injuries by 50%."

Can you tell us why women and girls are predisposed to ACL injury and rupture?

The incidence of ACL rupture is notably higher in women than in men, and even more so in girls compared to boys. This heightened risk is attributed to a combination of anatomical disparities and hormonal differences specific to women.

Beginning with anatomical distinctions, the female pelvis has a unique shape, and women’s hip movements are tailored for different functions than those of men. This pelvic structure and hip movement can contribute to unfavorable knee mechanics, predisposing women to this injury. Within the knee joint, there’s the intercondylar notch (the groove in the femur where the ACL sits) where the cruciate ligaments intersect. In women, this notch is narrower, providing less space for the ligaments. Consequently, if the knee shifts out of position, the ACL is more susceptible to damage near the notch’s edge, a phenomenon observed more frequently in women than in men. Additionally, during landing, women often exhibit inward turning of their hips and knees, generating substantial stress on the ACL, thereby increasing the risk of injury.

Hormonal variations, particularly during the menstrual cycle, may impact ligament laxity and neuromuscular control, potentially increasing the risk of ACL injuries in women. Hormonal fluctuations, specifically changes in estrogen and progesterone levels, may affect ligament stiffness and muscular coordination, making the knee joint less stable.

For women, sports demanding quick directional changes and cutting maneuvers, such as netball, football, skiing, and field sports with pivotal movements, pose higher risks due to the distinct anatomical differences in their hip and knee joints, and the hormone-induced ligament suppleness, rendering them more prone to ACL ruptures than men.

Is ACL injury prevention effective?

Among sports, football stands as the most common contributor to ACL injuries, yet netball, largely played by women, has the highest incidence of such injuries. Similarly, handball, prevalent in Scandinavia, has witnessed significant ACL injury rates. A memorable instance involves the Norwegian ladies’ handball team, aged 16 to 25, where every team member had experienced at least one ACL reconstruction, some even undergoing three. In response, Norway introduced a mandated injury prevention programme, now an integral part of Scandinavian school curricula. This programme entails specific warm-up routines that decrease the risk of ACL injuries by up to 50%. Australia’s netball association has implemented a similarly effective injury prevention programme, demonstrating that simple 15-minute warm-ups, focusing on proper landing and hip alignment, can considerably mitigate the incidence of ACL ruptures and re-injuries. 

Does your ACL reconstruction approach differ because of these sex differences?

Women are categorised as high-risk candidates for ACL reconstruction. In cases of lower risk, ACL reconstruction suffices, but higher-risk individuals necessitate an additional procedure—lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction— which I helped pioneer in 2012, which has gained substantial popularity.

Studies, particularly from Lyon, reveal a 50% reduction in re-rupture rates among high-risk patients undergoing LET or ALL procedures. Hence, all high-risk individuals, including children, elite athletes, those with a history of ACL injury, hypermobility, or lax knee joint, require this supplementary intervention. Moreover, secondary restraints within the knee, like the meniscus attachment, can rupture in inconspicuous areas, leading to a “ramp lesion”. Surgeons must identify and repair these lesions, as doing so significantly minimises the likelihood of ACL re-rupture.

The prevalence of ACL tears among women’s football players in recent World Cups highlights the urgent need for effective prevention and treatment strategies. Jorja Healthcare plays a role in addressing this issue by offering athletes and patients access to world-class MRI diagnostics, expert orthopedic care, and the latest regenerative treatments. Through our comprehensive approach, we empower individuals to overcome injuries and resume their sporting careers.