July 18, 2023 at 8:43 am EDT
(Washington Post illustration; Sarah Hashemi/The Washington Post) Comment on this storyComment
Jordan Angeli was 20 years old when she tore her cruciate ligament for the first time.
She was in her third year with women’s soccer star Santa Clara and just eight months away from representing the United States at the 2006 U-20 World Cup. During the workout, she felt a shift in her knee. Other players came by and Angeli described how she knew almost immediately a knee shouldn’t feel like this.
“Well boy,” said a teammate, “welcome to the club.”
Angeli made it back onto the field and played professional football in the top American leagues for five years. But she joined the dreaded three-letter club twice more in her career.
Studies show that female athletes are two to eight times more likely to tear a cruciate ligament, one of the bands of tissue that connects the femur and tibia at the knee, than male athletes. Since 2021, at least 87 players from eight of the world’s top women’s soccer leagues have suffered cruciate ligament ruptures. Some of the sport’s biggest stars – like USA attacker Catarina Macario, Dutch star player Vivianne Miedema and England duo Beth Mead and Leah Williamson – will miss the World Cup because of this injury.
This latest wave is not a statistical anomaly, but further evidence of an ongoing problem that has no easy fix. Addressing this issue, many in the sport say, requires a scaled-down approach that starts at the lowest level of football and peels out all layers of a gender issue, from the physiological to the environmental.
At a time of global growth in women’s sport, the ACL crisis hits the heart of a broader challenge. How can the infrastructure of women’s sports not simply replicate the existing infrastructure of men’s sports, but also be optimized for female athletes? Players argue that such resources are not yet available at the top levels of women’s football.
“Players are expected to be professional footballers. There is an increase in games and then an increase in new competitions. But on the other hand, the professional standards to fulfill those professional commitments are simply lacking,” said Alex Culvin, head of women’s football strategy and research at FIFPro, the global players’ union.
“In my opinion, for a multifactorial problem, there must be a multifactorial solution.”
After noticing discrepancies in ACL injury rates between men and women across different sports in the late 1990s, physicians and researchers began looking for patterns.
At first glance, biology offered some insight. In women, the intercondylar notch, the area in the femur where the anterior cruciate ligament sits, is narrower; In addition, women’s pelvis is wider, creating a greater angle between the hip and knee, which can lead to greater stress on the quadriceps and anterior cruciate ligament. Female athletes tend to land flat-footed with their knees in on jumps and have more strength in their quads than their hamstrings. (Some studies suggest that the menstrual cycle, in which estrogen can cause ligaments to become lax, may play a role. However, many experts agree that research in this area is not extensive or robust enough to confirm to draw direct conclusions.)
These circumstances endanger female athletes before they even step onto the field. In high-intensity sports, a sudden change of direction or an improper landing can mean a tear. About 70 percent of cruciate ligament injuries result from non-contact situations.
“The quintessential ACL-destroying cohort is female soccer players,” said Andrew Pearle, director of the Sports Medicine Institute at the Hospital for Special Surgery. “The numbers really are kind of tragic.”
(Video: Sarah Hashemi/The Washington Post)
Many experts agree that neuromuscular training is essential to reducing the risk of an ACL injury. Regular preventive exercise programs have been shown to help reduce the incidence of these injuries by about 50 percent.
For female athletes, these exercises are essential to build muscle memory for efficient movement, from correct landing position to deceleration techniques.
“Exercising at different angles over and over can better prepare your body for the demands of the sport,” said Wesley Wang, a physical therapist from Rockville, Maryland who specializes in ACL rehab. “When your body is a little stronger when it comes to strength training, it can handle a little more stress. Combining the two is a recipe for success because you get the best chance of staying healthy.”
Although biology has provided important insights, experts warn that attributing female cruciate ligament injuries solely to physiological factors can send a dangerous message.
“Basically, the consequence of the ‘hips and hormones’ narrative is that people don’t feel like they can change that,” said Matt Whalan, a physiology and sports science specialist at the Football Association of Australia. “And it becomes like, ‘If you want to play football and you’re a woman, that’s the risk you’re taking.’ ”
Some researchers did not believe that female athletes should settle for such a conclusion.
In a 2021 study published in the British Journal of Sports Medicine, the trio Joanne Parsons, Stephanie Coen and Sheree Bekker found that the rate of anterior cruciate ligament injury in women and girls is not changing despite nearly 20 years of prevention tactics based on biological factors had. It seemed time to think about a new approach.
“The core of our model is that it flips the inside-body view of the individual body to the outside-the-body view of gender exposures over a lifetime,” Coen said. “We can think about how inequalities in the lives of girls and women might cumulatively create different risk conditions.”
Studies have shown that women’s soccer teams often do less strength and conditioning training than men’s teams. Girls and women take part in strength training less frequently than boys and men. Societal expectations and assumptions about femininity and musculature could play a role.
Dawn Scott, head of performance for NWSL team Washington Spirit, said youth football structures have historically failed to develop young girls into serious athletes in the same way that young boys do.
“I come back to the gender bias when it comes to how women are educated at a young age,” she said. “If you’re in an academy system and you get expert coaching every week, you’re likely to get better coaching and mechanics over time. Are we doing our players a disservice by not training them properly?”
These external factors also affect other facets of the sport. Even at the professional level, women’s teams have struggled to access top quality pitches and facilities that men’s teams are given; US women have successfully advocated playing all of their games on grass rather than artificial turf, which has been linked to increased injury rates. Researchers have raised concerns about potential injury risks from playing in cleats designed specifically for male feet. A recent European study found that 82 percent of female soccer players regularly experienced problems related to their soccer shoes.
Researchers are studying how the brain helps prevent knee injuries
Players have also called for leagues and governing bodies to study the impact of fatigue. As leagues grow – England’s Women’s Super League has grown by four teams since 2015, while the NWSL is expected to reach 16 teams by 2026 – women players are playing more games for their club sides than in previous years. FIFPro has studied how congestion in the form of a large number of games in short windows of time can affect a player’s potential to perform at their best.
While it took nearly 70 years for the Men’s World Cup to grow to 32 teams, the Women’s World Cup has grown from 12 teams in 1991 to 32 in 2023 – a rapid growth that has come with an increase in intensity. A FIFA analysis found that women’s players covered more distance at higher speeds at the 2019 World Cup compared to 2015 and encouraged teams to invest in new training programs for women athletes.
“They changed the schedule to emulate the men, but they don’t give the players the same level of resources,” said Janine Beckie, forward for the NWSL and Canada national team’s Portland Thorns, who tore an ACL in March. said Portal in the spring. She added, “If you’re asking a top athlete to play 50 games a season, you have to give them top-notch care.”
In the last three years, more than ever, women players around the world have spoken out about the state of women’s football. Players like England’s Mead, last year’s Ballon d’Or runner-up, and Christen Press, a US national team star who tore his cruciate ligament last year, wondered aloud if more would have been done if men’s football had become one such a wave of injuries would have come.
For many in the sport, the way forward is to strive for a future where the conditions are not only equal to those in men’s football, but are consciously optimized for women.
How does it look? Scott spent two decades transforming the sports science processes of the US and England women’s national teams and finding new ways to empower female athletes through access to information about their health and body, and is now doing the same with the Spirit. In her view, it starts with the integration between medical staff and service staff; investing in world-class facilities and female health professionals; and comprehensive surveillance studies that could open new frontiers of understanding.
Efforts are being made across football to make injury prevention programs accessible. In 2006, FIFA developed 11-Plus, a series of 15 warm-up exercises adapted by teams and federations around the world. The Hospital for Special Surgery has developed an app that condenses essential exercises into seven-minute sessions. However, implementation remains a challenge, particularly at youth level.
In the longer term, collaboration between stakeholders could create frameworks and protocols to be embedded and regulated by clubs and leagues, much like what is done for brain injuries and concussions.
Ideally, the lessons and learnings from creating first class conditions at the highest level of women’s football will flow in and help build a lineup of players equipped to compete at the highest level.
“Can we educate players earlier on injury prevention, strength and running mechanics so that on the way up they actually have more stamina and are better prepared for some of the demands of training and the game? Scott said. “It starts with a small element, but then you start to expand it. It’s just full support all around the player.”
(Video: Sarah Hashemi/The Washington Post)
“An Injury That Will Change Your Life”
Tierna Davidson, a US national team member at the 2019 World Cup and 2021 Olympics, tore a cruciate ligament while training with the Chicago Red Stars in March 2022.
Until the stories circulated, the centre-back was unaware of how many teammates in the sport had suffered the same injury. (Davidson’s fiancée, who also played soccer at Stanford, had torn ACLs twice and was able to offer plenty of advice on freezing and physical therapy.)
“When I thought about it, I thought, ‘Well, I’m certainly not the only one with this experience.’ And so I started to think, ‘Okay, if all of these players can do it then I’m sure I’ll be fine too,'” said Davidson, who returned to the field in March. “I can imagine that if a 13, 14-year-old manages to get back on the field, I can certainly do that.”
A cruciate ligament tear was once considered a career-ending injury. Meanwhile, ACL reconstruction surgery has a high success rate and many players return to the field after nine to twelve months. (Of the 23 members of the US team at this World Cup, at least six have suffered cruciate ligament tears at some point in their careers.)
But the effect is lasting. Female athletes, particularly those at the high school level, are at a higher risk of re-rupturing the cruciate ligament. Those who sustain this injury at a younger age are more likely to develop arthritis in the future. The winding road of rehab and recovery can take a heavy psychological toll.
After retiring from football in 2016 after years of injury, Angeli had the idea to start a community to empower other ACL survivors, from professional athletes to amateur league amateurs. The ACL Club offers a six-month online course with videos, exercises, mindfulness training and more designed to help others on the long journey.
“It’s an injury that so many people are coming back from now, but it’s also an injury that changes your life in one way or another,” Angeli said. “If you exercise, you should know, ‘I could tear my cruciate ligament.’ And not in a fearful way, but in a way that gives you the opportunity to say, “I’m going to do everything in my power to look at the factors in my body and my preparation that can help me be the best athlete I can.”‘ ”
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