The plague that is ACL injuries in women’s football

Nicole Powell
1

With an increase in games played, ACL injuries have been on a rapid increase lately in both men’s and women’s football. However, the situation in the women’s game is of high concern.

On the 27th of January, Manchester City announced that Jill Roord – Manchester City women’s record signing – is out for the rest of the season after rupturing her ACL.

This news came a day after Eintracht Frankfurt announced that Tanja Pawollek had torn her ACL during their UEFA Women’s Champions League game against FC Barcelona Femení. And just three weeks ago, Chelsea had confirmed that Sam Kerr had torn her ACL during their warm weather training camp in Morocco.

Roord is the latest edition to this ever-growing list. But why is it that ACL injuries are more common in women’s football? Before we get to that, let’s start by understanding ACL injuries.

What is an ACL injury?

An ACL injury occurs when the anterior cruciate ligament (ACL), one of the key ligaments in the knee joint, is damaged or torn. This ligament is essential for providing stability to the knee, especially during activities that involve sudden stops, changes in direction, or pivoting movements.

These injuries frequently happen in sports like (American) football, basketball, and skiing, where there is a risk of sudden stops or changes in direction. ACL injuries can result from various mechanisms including contact and non-contact injuries.

ACL injuries can range from mild sprains to complete tears. The severity of the injury depends on factors such as the force of the impact: the angle of the stress on the knee, and individual factors like muscle strength and flexibility.

In cases of complete tears or significant instability, surgical intervention, typically involving ACL reconstruction, may be recommended to restore knee stability and function.

Rehabilitation and post-surgery recovery are critical components of managing ACL injuries, aiming to have the players return to regular activities, including sports while minimizing the risk of future injuries.

What exactly is happening in the women’s game?

The surge in ACL injuries has struck women’s football with alarming frequency. Big players like Chelsea’s Sam Kerr and City’s Jill Roord are one of the 12 Women’s Super League athletes now on the road to recovery.

The recent blow to Chelsea’s prolific striker, Sam Kerr, shows the severity of ACL injuries. Kerr’s unfortunate injury, sustained during a training camp in Morocco, has ruled her out of the Women’s Super League season, the UEFA Women’s Champions League campaign, and the Matildas’ Olympic qualifying playoffs.

The timeline for her recovery remains uncertain, with the upcoming Paris tournament merely seven months away, making a timely return challenging. She may never play under Emma Hayes again.

ACL recovery is a process demanding a minimum of six months. Previous cases, including Australia and Lyon’s Ellie Carpenter’s nine-month journey, prove the complexities of rehabilitation. Rushing a return heightens the risk of re-injury, creating a delicate balance between short-term convenience and long-term well-being.

How bad are the numbers?

Football-focused research, which remains scarce, indicates that women footballers are six times more likely to experience ACL injuries compared to their male counterparts, and they are 25% less likely to achieve full recovery.

The incidence of ACL injuries per 1000 match playing hours varies between 0.6 and 2.2. In the past 18 months, there has been an addition of more than 195 elite players to the list.

Findings from the UEFA Women’s Elite Club Injury Study, a comprehensive report covering 1,527 injuries across four consecutive seasons from 2018 to 2022, unveiled that 64% of ACL injuries were sustained without direct contact.

On the domestic front, WSL clubs, particularly Arsenal, suffered the most from ACL injuries last season. Arsenal, based in North London, had a total of four players sidelined due to ACL tears. Key players for Arsenal, namely Beth Mead, Vivianne Miedema, and England captain Leah Williamson, have only recently returned from ACL recovery.

But it is starting to look like as soon as one recovers, another falls victim.

Presently, 12 WSL players, including Sam Kerr, are in the process of recovery. Ironically, Mia Fishel, brought in by Chelsea in the summer from Lyon as Kerr’s understudy, is undergoing her own recovery journey from an ACL tear sustained in June 2022.

The ACL injury crisis is so severe that it affected football’s biggest event. Between 25 and 30 players, equivalent to a full squad, missed the Women’s World Cup last summer due to ACL tears. Among the notable absentees were Leah Williamson, Beth Mead (England), Janine Beckie (Canada), Delphine Cascarino, Marie-Antoinette Katoto (France), Vivianne Miedema (Netherlands), Christen Press, and Catarina Macario (United States).

What is the reason for the high numbers?

As the “plague” of ACL injuries continues to unfold, it raises critical questions about the unique challenges female footballers face.

Contrary to what many may think, women footballers are just as skilled and athletic, so it does not come down to that. The key lies in the support provided by those in influential positions within the sport, ensuring that these dedicated female athletes, who just like any other athletes give their all, get the backing they need.

The problem appears to be that there is this big need to make the women’s game very similar to the men’s game. Matching schedules, and a matching number of competitions, however, resources in the women’s game are still very limited. There is no balance unlike in the men’s game where intensity and resource allocation are given equal attention.

For a long time, football has been considered a ‘man’s game.’ So even when it comes to football-related research, the focus has mainly always been on men. But as we have seen in this article, research has been done and continues to be done. The problem is not nearly enough resources and time have been put into the women’s game to implement solutions to the findings.

In the men’s game, high levels of training are implemented from the start of the player’s career. Young boys in football academies are raised and brought up in a tailored manner that will ensure they will be ready to play at an elite level as professionals in the future. That is not the same for young girls.

In the words of England and Chelsea forward Fran Kirby to Sky Sports:

“It’s important to get the basic fundamentals really young – there is a difference when it comes to how we [boys and girls] are brought up playing.

The boys are doing gym work and learning basic running mechanics at the age of six. When I was coaching at Reading the grassroots girls couldn’t even access a gym. The most important thing is teaching young girls the basic mechanics of being a footballer and being a sportsperson.”

There is limited funding for the women’s game, and naturally, that affects the quality of development and rehabilitation methods.

With most football research being tailored to the biology of men, it creates a unique problem in women’s football. Women and men have different bodies, so naturally, prevention, treatment and rehabilitation methods may vary.

Speaking to Inside the WSL last season, female health specialist Dr Emma Ross had this to say:

“We published a paper over a year ago which showed that, in sport and exercise science research, only six per cent of studies are done exclusively on females. There are a lot of myths out there about menstrual cycle and injury.”

Football has been designed ‘for men, by men.’ Football boots, for example, are designed for men to wear. It was only last year that Nike launched its new Phantom Luna boot, which they described as the “most innovative and researched women’s led boot” in the company’s history. They were released just in time for the 2023 World Cup.

More needs to be done

Various factors contribute to the alarming rate of ACL injuries among female footballers. Muscle imbalances, inadequate access to top-quality pitches and training equipment, ill-fitting boots, and less engagement with injury prevention training are among the reasons.

It is very important to note that a lot of this is due to the lack of resources, gender bias, and a historical disregard for women’s specific needs in football.

Amid the crisis, voices within the women’s game, including former players, sports medicine specialists, and researchers, are demanding urgent action. Proposals for improved medical provision, tailored research units, and the development of female-specific equipment – all matching up to the match schedules – will help to address the root causes and reduce the risk of ACL injuries.

The issue of ACL injuries in women’s football demands a comprehensive and coordinated response from those who call the big shots. Just as it is a priority to protect male footballers, it is time for the well-being of female footballers to be prioritized. This will ensure the sport’s long-term success.

The growth of the women’s game has been amazing, but unless more is allocated to ensuring the well-being of these players, the sport risks compromising its athletes’ health and potential, casting a shadow over the remarkable progress of women’s football, and undermining the long-term success of women’s football.

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  1. 1. Cleats increase risk of tearing ones ACL… Proven and documented in scientific journals of note (over 30 authors), but kept from the public. It is a lie of omission!

    2. Cleats increase risk of concussion….. Proven by Newton 3rd law for every action there is an equal and opposite reaction. Would you rather get tackled wearing roller skates or cleats? Hits are greater with cleats therefore increasing the risk of head trauma/concussions. We bounce off each other wearing roller skates where cleats we DRIVE thru the player.

    3. Proven research shows we tear our knees more on artificial turf than natural grass, but we still run our children out there (high school and college football) on the artificial turf experiment. Small example of proof by Jason L. Dragoo ⁎ , Hillary J. Braun, Alex H.S. Harris Department of Orthopaedic Surgery, Stanford University. Or; Galvin J. Loughran, BS*,Christian T. Vulpis, BSJordan P. Murphy, MS, David A. Weiner, MD, Steven J. Svoboda, MD, Richard Y. Hinton, MD, MPH, PT, Dave P. Milzman, MD. Investigation performed at Georgetown University School of Medicine.

    Our children are the guinea pigs in this experiment. Are parents made aware of this danger and sign a release?

    Yes; football is dangerous. Some dangers are inherent; and like cleats some dangers are capable of being negated!

    NOW THAT YOU AND YOUR ORGANIZATION KNOWS WHAT ARE YOU GOING TO DO TO PROTECT OUR CHILDREN IN YOUTH SPORTS? Call me and I will help you.

    The following is a tiny sample of proof.I have much much more! If you do not have a science background you may not understand all the wording. Call me with your questions and I will be gracious. Dr. Sheldon Wernow (904-537-9210).

    I can prove (by DIRECT EVIDENCE) that the NFL, NFL Players Assoc., Nike, and Under Amour are all aware that cleats are dangerous but keep it hidden from the public.

    A small sample of scientific proof…..

    · 2010, the American Journal of Sports Medicine

    Footwear Traction and Lower Extremity Joint Loading

    John W. Wannop, Jay T. Worobets, PhD, and Darren J. Stefanyshyn, PhD

    From the University of Calgary, Human Performance Lab, Faculty of Kinesiology,Calgary Alberta, Canada

    Conclusion: Increased shoe traction significantly increased ankle and knee joint moments during a V-cut. These changes could have an effect on ankle and knee joint injury.

    Clinical Relevance: Shoes with decreased traction could be used in sports to reduce the joint moments in the knee and ankle and potentially reduce injury…..

    Look at the Army of highly respected Doctors and centers of higher education in the next journal article that agree; cleats increase the risk of tearing your ACL. CLEATS REMOVE THE KNEE SAVING ABILITY TO SLIDE AND THEREFORE THE KNEE TEARS BECAUSE THE FOOT IS NAILED TO THE GROUND BY CLEATS. Rarely see a gurney go out on the ice in ice hockey.

    · A consensus group comprising doctors, surgeons, physiotherapists and certified athletic trainers met in Hunt Valley, Maryland in 1999 to discuss the “epidemic” of ACL injuries. The risk factors were examined independently in order to determine the primary factors involved. The same group of researchers met again in Atlanta, Georgia in January 2005 to re‐evaluate the identified risk factors:

    Letha Y. Griffin,*†1 MD, PhD, Marjorie J. Albohm,2 MS, ATC, Elizabeth A. Arendt,†3 MD,

    Roald Bahr,†4 MD, PhD, Bruce D. Beynnon,†5 PhD, Marlene DeMaio,†6 CAPT, MC, USN,

    Randall W. Dick,7 MSc, Lars Engebretsen,4 MD, PhD, William E. Garrett, Jr,†8 MD, PhD, Jo A.

    Hannafin,†9 MD, PhD, Tim E. Hewett,10 PhD, Laura J. Huston,†11 MSc, Mary Lloyd Ireland,12MD,Robert J. Johnson,5 MD, Scott Lephart,13 PhD, ATC, Bert R. Mandelbaum,14 MD,

    Barton J. Mann,†15 PhD, Paul H. Marks,16 MD, Stephen W. Marshall,†17 PhD,Grethe Myklebust,4 PhD, Frank R. Noyes,18 MD, Christopher Powers,†19 PhD, Clarence

    Shields, Jr,20 MD, Sandra J. Shultz,†21 PhD, ATC, Holly Silvers,22 MPT, James Slauterbeck,†5MD,

    Dean C. Taylor,23 MD, Carol C. Teitz,†24 MD, Edward M. Wojtys,†25 MD, and Bing Yu,†26 PhD

    From the 1Peachtree Orthopaedic Clinic, Atlanta, Georgia, 2OrthoIndy, Indianapolis, Indiana, 3

    Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, 4

    OsloSports Trauma Research Center, University of Sport and Physical Education, Oslo, Norway,

    5Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont,

    6Department of Orthopaedics, Bone and Joint/Sports Medicine Institute, Naval Medical Center,

    Portsmouth, Virginia, 7NCAA, National Collegiate Athletic Association, Indianapolis, Indiana, 8

    Department of Orthopaedics, Duke University Medical Center, Durham, North Carolina,

    9Hospital for Special Surgery, New York, New York, 10Cincinnati Children’s Hospital Medical

    Center, Cincinnati, Ohio, 11Vanderbilt Orthopaedic Institute Medical Center East, Nashville,

    Tennessee, 12Kentucky Sports Medicine Clinic, Lexington, Kentucky, 13Neuromuscular Research

    Laboratory, UPMC Center for Sports Medicine, Pittsburgh, Pennsylvania, 14Santa Monica

    Orthopaedic and Sports Medicine Group, Santa Monica, California, 15American Orthopaedic

    Society for Sports Medicine, Rosemont, Illinois, 16University of Toronto, Ontario, Canada, 17Department of Epidemiology, School of Public Health, University of North Carolina–Chapel Hill,Chapel Hill, North Carolina, 18Cincinnati Sportsmedicine Research & Education Foundation,

    Cincinnati, Ohio, 19Department of Biokinesiology & Physical Therapy, University of Southern

    California, Los Angeles, California, 20Kerlan-Jobe Orthopaedic Clinic, Westchester, Los Angeles,

    California, 21Department of Exercise and Sport Science, University of North Carolina,

    Greensboro, North Carolina, 22Santa Monica Orthopaedic and Sports Medicine Research

    Foundation, Santa Monica, California, 23TRIA Orthopaedic Center, Minneapolis,

    Minnesota, 24U of W Sports Medicine Clinic, University of Washington, Seattle, Washington, 25MedSport, University of Michigan, Ann Arbor, Michigan, 26Division of Physical Therapy,

    University of North Carolina–Chapel Hill, Chapel Hill, North Carolina

    “foot fixation”, which occurs when excessive resistance to rotation or “rotational traction” prevents the shoe from moving freely during twists, pivots and cuts. Foot fixation leads to the development of high forces in the knee during rotational movements and is believed to be a factor in the aetiology of knee injury

    · The effect of playing surface on the incidence of ACL injuries in National Collegiate Athletic Association American Football Jason L. Dragoo ⁎ , Hillary J. Braun, Alex H.S. Harris Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA,

    2010 Journal of Sports Medicine

    Results: The rate of ACL injury on artificial surfaces is 1.39 times higher than the injury rate on grass surfaces. Non-contact injuries occurred more frequently on artificial turf surfaces (44.29%) than on natural grass (36.12%).

    Conclusions: NCAA football players experience a greater number of ACL injuries when playing on artificial surfaces.

    · Incidence of Knee Injuries on Artificial Turf Versus Natural Grass in National Collegiate Athletic Association American Football: 2004-2005 Through 2013-2014 Seasons

    American Orthopaedic Society for Sports Medicine

    First published online April 17, 2019

    Galvin J. Loughran, BS*,Christian T. Vulpis, BSJordan P. Murphy, MS, David A. Weiner, MD, Steven J. Svoboda, MD, Richard Y. Hinton, MD, MPH, PT, Dave P. Milzman, MD

    Investigation performed at Georgetown University School of Medicine, Washington, DC, USA

    Conclusion: NCAA divisions (II and III) also showed higher rates of ACL injuries during competitions on artificial turf versus natural grass.

    My question is what ever happened to using mice and animals in experiments, now we are using human beings to experiment with artificial turf and this experiment has caused more injury to these human guinea pigs. Do they need to be told they are Guinea pigs and sign a waiver or has the world changed or are they just a bunch of dumb …….

    · Lambson et al (1999) studied the relationship between the rotational resistance of shoes and the incidence of anterior cruciate ligament tears among 3119 high school football players. Shoes with cleats were associated with a significantly higher injury rate, compared with other shoe types.

    The Journal of the American Academy of Orthopaedic Surgeons

    · Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies

    Letha Y. Griffin, MD, PhD, Julie Agel, MA, ATC, Marjorie J. Albohm, MS, ATC, Elizabeth A. Arendt, MD, Randall W. Dick, MS, William E. Garrett, MD, PhD, James G. Garrick, MD, Timothy E. Hewett, PhD, Laura Huston, MS, Mary Lloyd Ireland, MD, Robert J. Johnson, MD, W. Benjamin Kibler, MD, Scott Lephart, PhD, ATC, Jack L. Lewis, PhD, Thomas N. Lindenfeld, MD, Bert R. Mandelbaum, MD, Patricia Marchak, ATC, Carol C. Teitz, MD, and Edward M. Wojtys, MD

    Higher levels of friction between the shoe and the surface are generally associated with better performance but a higher injury risk.

    Again, much more Journal proof which I will share in the future. I do not want to bore you.

    But the most important published Ph.D. is the one I will call Dr. Cleats for now. He is a renowned expert on cleats at a prestigious University and is the scientist whom the NFL would consult about the dangers of cleats. In one of the journal articles under conflicts of interest it states Dr. Cleats is a spokesman for the NFL, so the NFL knows cleats are dangerous. His works speak to the fact cleats increase the risk of ACL tears. Dr. Cleats introduced me to Nike and Under Amour, so they know cleats are dangerous and I will share this under my section alternatives to cleats. Again, Dr. Cleats works show cleats increase the risk of tearing one’s ACL and a fact the NFL knows, Nike knows and Under Amour knows!

    Do players and their agents know cleats add risk to a dangerous game?

    Daunte Fowler Jacksonville Jaguars rookie Dante Fowler Jr., the No. 3 overall pick in the 2015 NFL draft, tore his ACL on Friday when he went down less than an hour into the first day of rookie minicamp, the team announced. Fowler is expected to miss the entire 2015 season. The defensive end’s left knee buckled during an 11-on-11 drill. He dropped to the ground, grabbed his leg as he rolled from side to side, and eventually got helped off the field. Offensive tackle Watts Dantzler, who was engaged with Fowler when the DE went down, said he didn’t know what happened to cause the injury. “I really honestly have no idea,” Dantzler said. “I was just kicking, got a punch on his shoulder, and he just went down. I don’t really know exactly what happened. I feel terrible about it.” Fowler has not yet signed his rookie contract. “My weight shifted one way, my foot got caught in the dirt,” said Fowler…. Not a signed contract and lacing up cleats!!! Not a word of CLEAT! And the cleats performed like they should nailing him to the supporting surface, taking away his natural ability to slide!

    Do football experts know the dangers of cleats?

    Odell Beckham Jr. The non-contact knee injury that cost Odell Beckham Jr. more than half of Sunday’s Super Bowl of 2022 win over the Cincinnati Bengals is believed to be a torn ACL, NFL Network Insider Ian Rapaport reported Monday. Such an injury would mark Beckham’s second ACL tear to the same left knee, Go to YouTube and hear the play call of a NON CONTACT ACL tear and the announcers not one word of Cleats!!

    Does the NFL Players Association know cleats increase the risk of tearing the ACL?

    Yes… Sean Sansiveri is their executive who introduced me to Dr. Cleats.

    Is there an alternative to cleats? Answer: 1. the Swivel Cleat shoe, 2. the Retractable Cleat, 3. the Basketball shoe.

    Remember, football is entertainment. I love football, but admit it has become more than entertainment! Are NFL, College, and High School players still entitled to be made aware of the risks like we do in open heart surgery, cancer drugs, and insulin? We are talking about full disclosure!

    But talking about alternatives to cleats does tell how long the NFL has kept the dangers of cleats a secret and what they have done about it……Answer: they have known since 1960’s and have slow walked this for over 60 years keeping their lie of omission from the public. And I am not talking cure, I am talking FULL DISCLOSURE so a player or parents can make his own decision to take the risk and lace up cleats!

    o Swivel Cleat Shoe -Bruce M. Cameron, Otho Davis The swivel football shoe: A controlled study: Fixation of the foot through rigid cleating is a primary factor in the production of football knee and ankle injuries. The swivel shoe principle developed in 1962 was moved forward with Hanley’s cleat- less heal. Then a 360 degree turntable was added to the forefoot. Over 350 different designs were made over 6 years. It was successfully tested in 1969. Many respected authors quote this research which states the swivel cleat worked. No one knows why it was not adapted? US3816945A – Swivel cleat shoe – Google Patents. Slow walk new design of cleats knowing in the early 1960’s cleats are dangerous and keeping the dangers of cleats a secret. Google 1920’s cleats and they have hardly changed; tell me something that has not changed in 100 years. King Henry the 8th haberdashers invented cleats and they have not changed much since, for the sake of safety.

    o Retractable Cleat:

    This is a long story of which I am the inventor. It is in the beta form. The engineers say “it shows proof of concept.” It pivots to one side and works with vector math. It has a set screw which one can dial in the amount of pressure it would take to pivot (retract). Dr. Cleats (most important point ironically spokesman for the NFL whose published works say cleats are dangerous) introduced me to Under Armor and then Nike. Both companies know cleats are dangerous! A lie of omission.

    o Court (Basketball) Shoe:

    SHOE-SURFACE TRACTION OF CONVENTIONAL AND IN-FILLED SYNTHETIC TURF FOOTBALL SURFACES

    Martyn Shorten1 , Bret Hudson1, 2 and Jennifer Himmelsbach1 1BioMechanica LLC, Portland, Oregon, USA. 2 University of California, Davis, California, USA

    Each of the six shoe types demonstrated adequate slip resistance on dry, in-filled surfaces so an athlete’s shoe selection could be based on minimizing resistance to rotation……………the uncleated basketball shoe (A) produced the lowest average peak moment resisting rotation (19 N m) and the lowest average traction coefficient (0.82).

    Let’s compare popular trillion dollar collision industries; Automobile verses NFL when it comes to Performance vs. Safety. The Auto Industry (Ralph Nader Unsafe at any speed 1960’s) opted for Safety…seat belts, air bags, crumple zones. Are you lawyers going to let your/our children and grandchildren tear their knees wearing dangerous (Performance) cleats or do something about it?

    Everyone knows the game of football is dangerous…… You got your leg bitten off at the beach because the red flag was not put out when sharks were sighted. Should one be told of this increase risk (sharks in the water) to an activity we know is dangerous like swimming in the ocean? Should one be told of the increased risks of cleats tearing the ACL? Lie of omission! Should you be told the floor at Macy’s was mopped wet? You know floors are dangerous….

    Although I am mainly talking about ACL tears we should also consider cleats being involved in concussions/CTE. Why did the attorney’s in the helmet lawsuit not include cleat manufacturers in their lawsuit as cleats have a fair effect on the brain (Newton’s 3rd law of physics) while being tackled? We DRIVE thru the opponent while tackling. Did those attorneys commit malpractice or was it a lie of omission that stopped them?

    What are the long term damages of an ACL tear? Answer: Premature Osteoarthritis.

    The Long-term Consequence of Anterior Cruciate Ligament and Meniscus Injuries: Osteoarthritis – L. Stefan Lohmander, P. Martin Englund, Ludvig L. Dahl, Ewa M. Roos, 2007

    The Long-term Consequence of Anterior Cruciate Ligament and Meniscus Injuries: Osteoarthritis

    At 10 to 20 years after the diagnosis, on average, 50% of those with a diagnosed anterior cruciate ligament or meniscus tear have osteoarthritis with associated pain and functional impairment: the young patient with an old knee.

    Thank you for reading,

    Dr. Sheldon Wernow

    904-537-9210

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