Why do many female soccer players suffer anterior cruciate ligament injuries?

Lea Williamson comforts Vivianne Miedema after she sustained an anterior cruciate ligament injury against Lyon
Arsenal striker Vivian Miedema has been ruled out for an “extended period of time” after tearing his anterior cruciate ligament

Nothing else.

When Arsenal striker Vivianne Miedema left the pitch on a stretcher last Thursday night with her hands covering her face, spectators already feared the worst.

Four days later, it was confirmed – she was one of the best players in the world Suffered from an anterior cruciate ligament (ACL) injuryIt is considered one of the worst injuries for a soccer player.

The all-time leading goalscorer in the Women’s Super League joins an ever-expanding list that includes her partner and teammate at Arsenal Beth Mead Who was UEFA Euro 2022 player, and Ballon d’Or winner, Alexia Potellas.

Once again, there are renewed calls from players, fans and managers for more research into why this type of injury is more common in female soccer players than in males.

England striker Chloe Kelly said the “fear” and “negativity” about ACL injuries “need to change”. So what is being done to try to reduce the risk?

There is no proven reason

Research has long suggested that ACL injuries – the most serious type of knee damage – are… more famous in female soccer players, with estimates ranging from two to eight times more than in males.

Recent discussions have focused on whether injury risk is related to sex – female anatomy and hormones, or whether it could be related to sex – which way In which female athletes are raised and managed compared to male athletes.

“I think there is some truth in all of these areas,” she said.

“We have to be really careful when we talk about this in women’s football because there is a tendency in the research and in the media to be like ‘Oh, women are so unstable and fragile, because of their anatomy and their hormonal fluctuations’ but we haven’t proven that this is the cause of these injuries.” .

“Maybe it’s the way we treat women. I’d like to see that change in people’s perceptions of female athletes and women’s football in general.”

What are the main areas of interest?

1. Anatomy/Biomechanics

Physical differences between men and women, such as women in general having wider hips, which increases the angle of the leg at the knee, and the underdeveloped muscles that prevent the knee from turning when landing, have been the subject of research looking at whether this increases risk.

However, Dr. Okholm Krieger says there is no strong evidence from research that this is a major risk factor.

2. Hormones

The cycle of the menstrual cycle has also been suggested as potentially making females more vulnerable at certain times. During the menstrual cycle when estrogen is high, which usually occurs in the second week, it can affect the stability of the joints, making them more flexible and more lax.

However, Dr Okholm Kryger is keen to stress that there is a lack of research to support whether this increases the risk. “There hasn’t been some high-quality research done on the relationship between menstruation and ACL risk,” she said. “It’s very difficult because you either need continuous blood or saliva samples.

“Most of them are done to predict where women will be in the phase, based on when their menstrual cycle starts, most studies don’t actually measure hormonal levels in the body. So they’re all predictive. When you add all the data together, it shows very little difference.”

Dr. Okholm Kryger also noted that guys often report that they’re more susceptible when they’re on their period at the beginning of their cycle, but in reality the risk should be higher during ovulation.

3. Gender disparities

A 2021 study published in the British Journal of Sports Medicineexternal link Suggest looking at the effect of gender – referring to external factors such as access to training, sport science, facilities and rehabilitation.

Soccer players are likely to have a significantly lower training age – the amount of time and exposure a player has to put in structured training, practice and staging – than their male counterparts.

Other gender differences highlighted by Dr. Okholm Kryger include the pitches used in the WSL compared to the English Premier League and the design of football kits such as boots. She pointed out that women move and run in a different way than men, yet the length of the buttons on the shoes are designed around the movement and traction of men, which increases the risk of women sticking shoes to the surface and causing injury.

4. Workload

With the rapid growth of women’s football, the size of matches and the level of intensity are also increasing rapidly, which leads to increased anxiety among managers and players in the game.

“Obviously you can do everything to put players in the best possible condition but with the amount of matches and limited recovery time right now it’s hard to do anything about that,” said Dr. Öckholm Krieger.

Why are ACL injuries so serious?

Northern Ireland striker Simon Magill has been waiting her entire career on July 7, when her country made its first major tournament appearance at Euro 2022.

But 79 minutes into her team’s first match against Norway, the dream came to an end.

“I went to prop my leg out for balance, and as soon as I got my leg out I could literally feel the strap pulling away from my leg, so I immediately knew it wasn’t great.

“It was awful. I was such a mess.”

It helped that Magill, 28, was surrounded by eight fellow internationals who had passed her before.

“They were brilliant in terms of reassuring me. They were all examples for me of having been through it and coming back to it.

“I had no idea what things had to go through. I’d heard of a lot of people who do that [their ACL] But I didn’t actually know what that entailed.”

What makes the injury so difficult, she said, is the longevity, in addition to having to learn the mechanics of walking again.

“I completely forgot about the natural way you would walk. I had to learn that at home, standing in front of a mirror and just focusing on my knee-to-toe exercise, I had no idea!

“I just assumed I would have surgery, be in pain for a week or two, and then it would all come back to me.

“It was the mental side of it all. I kept thinking, It’s not my knee, it doesn’t feel like my knee. Will I ever feel like my knee again?”

Magill’s anterior cruciate ligament injury was not the first at the European Championships, as Spanish star Botelas was disqualified on the eve of the tournament, while French Marie Antoinette Katoto later became the third player to suffer from it.

“Now that I’m starting to think about it, I definitely think there are underlying reasons why it happened,” Magill said. It’s not just an ‘Oh, it’s an integral part of the game and we have to accept it.

“The rate at which it is happening at the moment is actually frightening.”

A graphic showing a photo of Alexia Potellas

What is being done to try to reduce the risk?

Dr Krieger works closely with a number of Women’s Football League teams, as well as the England team, and said clubs know ACL injuries are “the biggest issue in women’s football at the moment because of the recovery time and potential long-term impact on a player’s career.” “.

But while they are desperate to see improvements, knowing how to deal with it is much more difficult.

BBC Sport has been told that a WSL club has recently recruited professionals to do more research on the AFC Champions League as the game is still growing and acclimating to the increasing professionalization.

Dr Andrew Green, Senior Lecturer in Biomechanics at the University of Roehampton, is a staunch advocate of trying to implement injury prevention programs in women’s football clubs.

Before he also became Chief Performance Officer for Crystal Palace Women’s Club, he approached all Championship clubs and some Women’s Basketball League teams about implementing a neuromuscular programme, aimed at targeting their athletes’ weaknesses.

“What they’re designed to do is address the underlying mechanical issues that we know contribute to injury, factors that we know are in the math,” he said.

He gave the example of the hamstrings which he said tend to be a muscle group that is not active in math.

Palace got involved with the idea because two of their players had suffered anterior cruciate ligament injuries the previous year.

Dr Green said: “If we can take a step back and make sure that the athletes are more prepared for the intensity of the game and are used to stopping, starting and changing direction in a controlled environment, then those core capabilities are there and it will help stabilize joints and reduce risk.

“In the women’s game, while the gym facilities and conditioning programs are greatly improving, I still believe in the tournament, access to the gym is very limited for players. Relying on a gym program once a week is not enough.”

The Football Association (FA) has conducted a study into the prevalence of ACL injuries in women’s football in the Football League and Championship over the past four seasons.

Its results, due to be released in full in the new year, showed that there were 0.1 injuries per 1,000 hours – 0.4 ACL injuries per 1,000 game hours and 0.04 ACL injuries per 1,000 training hours – representing 1.3% of the total number of injuries. Hamstring injuries were the most common, at 11%.

The FA, which does not have the equivalent data for men’s football, said in a statement: “Overall injury rates in these leagues have decreased in the past four seasons, but we will continue our work in monitoring injuries and disease, which will continue to provide us with important medical insight into women’s football.” “.

What needs more than needs to be done?

Search, search, search.

Speaking to players, managers, and academics, they all agreed that there is not enough research into the causes of ACL injuries.

Rehan Skinner, Tottenham manager, spoke out earlier this season after seeing her Two of its players are injuredHe said: “Obviously the demands of the game are changing and we need to understand what that entails.

“I still don’t think there is enough research available for us to collectively devise in the women’s game the best possible plan going forward.”

Dr. Okholm Kryger wants more large-scale research. She said: “A lot of data that comes from one club. AFC Champions League rosters happen often but fortunately you don’t have a lot of it in one season. So if you only have data for one club or one national team, that’s just the amount Very limited amount of data you will get.

She is currently in talks about doing more research and hopes to secure the necessary funding.

One doctor, who previously worked at a Women’s Football League club and did not wish to be named, said he wanted to see the entire football community push for equal access to resources for female players – whether that be coaching, sports science or access to facilities. , starting at the academy level.

“The challenge, for the women’s game across the board, is getting the kind of support that the men are getting,” he said. “What you have in the women’s game is that the support staff don’t get paid particularly well, and that means you’re probably not attracting the very best.

“And the resources—at the highest level of the women’s game, will have no fraction of the staff that would have a very ordinary men’s team or a very ordinary men’s academy.”


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