‘It felt like someone had taken a hammer through my knee’: the cruciate ligament injury crisis in women’s football
Ffrom England international Jordan Nobbs’ agonized scream, which echoed in Everton’s home in Southport as she fell to the ground in 2018, to last month’s news that Sam Kerr will be out for the rest of the season after kicking herself injured during a Chelsea training camp in Morocco, knee injuries – particularly to the anterior cruciate ligament (ACL) – dominate the headlines in the world of women’s football.
Female players have their turn eight times more likely suffer from a cruciate ligament injury more often than men – as many as 37 players are said to have missed last year’s World Cup as a result. Now retired 2019 Ballon d’Or winner Megan Rapinoe suffered three ACL injuries during her career; former Chelsea player and England international Claire Rafferty has had two and there are many players currently out of action, including Gabby George and Aoife Mannion. England captain Leah Williamson, who only returned to play last month, said: “It felt like someone had cut both sides of my knee and driven a hammer through the middle of it.”
The increased interest in women’s football has led to an increase in professionalism and also meant an increase in the demands placed on players’ bodies. International players have not had a summer holiday since 2020. Since then, they have had the postponed Tokyo Olympics in 2021, the European Championships in 2022 and the World Cup in 2023. Now for some teams there are the Olympics in Paris this summer, the European Championships in 2025 and then a break in 2026 before the 2027 World Cup.
“Was it one match too many?” said the English Beth Mead in the documentary Step by Step. “When I’ve looked at it, I’ve gone from 2,000 minutes to 4,000 minutes in one season. Which is a steep jump. We want the game to reach that level, but it keeps our bodies at that level to be able to do that.”
The ACL connects the femur in the thigh to the shin bone and is one of the ligaments that stabilizes the knee joint. In sports it is often torn in off-ball incidents, such as spinning or landing on one leg. With a minimum recovery time of around nine months and many players taking at least a year to return to the field, this is one of the worst injuries a player can suffer.
“When you land on one leg, you have one support mechanism,” says Gillian Weir, senior biomechanist with the New York Yankees. and conducted her PhD research on ACL injuries. “It’s like putting a pumpkin on a chopstick: if you wiggle the pumpkin back and forth, the chopstick will break.
“Since 2005, a lot of research has been done into the contribution of the torso – the upper body –,” says Weir. “There are basic studies of motor control that look at how we control the reorientation/redirection of movements when we are just walking and avoiding an object or people, even if we are just walking and stopping. When you are walking down a hallway and someone is coming towards you and you suddenly have to stop or get out of the way, the way you control your trunk is very different than when you know you are going to stop or move. The same thing happens on the field when team athletes run at high speed and react to opponents, their teammates and the ball.”
Weir’s research was conducted in collaboration with the Australian women’s hockey team, which suffered four ACL injuries prior to the 2012 Olympics, and sought to develop a training intervention that was biomechanically informed.
“What I did is come up with each resistance and plyometric training exercise, which involves short, intense bursts of activity, that targets the four key pillars of injury prevention. The first was dynamic torso control – essentially preventing someone from falling over their leg. The second was dynamic knee valgus – that’s what you see when the knee collapses when you watch a replay of an ACL injury. The third was knee flexion: Landing with a right leg inherently puts the ACL at a higher stretch, putting more stress on the ACL and requiring less force to actually tear it. And then the fourth one looked at the strength of the calf muscles, because there has been research showing that if you have higher muscle forces in your calf muscles, that helps stabilize the knee joint, because it puts muscles around one side, top support, and then you have your quads in the other direction.
Weir gave the exercises to former Australian hockey player and two-time Olympic gold medalist Kate Starre, who was the high-performance manager of the Australian women’s hockey team at the time. The players would do four 20-minute sessions per week. Before they started, they went to the University of Western Australia’s Sports Biomechanics Laboratory to test their movements during planned and unplanned side steps (the movement athletes perform to quickly change direction in sport, a task called in addition to single-leg landings, is responsible for up to 60% of ACL injuries, but can be performed safely in a laboratory setting). One test involved a runway and at one point a screen told them to go right, left or straight, in an attempt to recreate random in-game scenarios. That helped them identify players with poor core control or poor knee flexion, and their sessions could be personalized to focus on those weaknesses.
The results of the two-year injury prevention training program were impressive. They saw a reduction in the number of ACL injuries and lower extremity injuries. In fact, there have been zero ACL injuries among the group of 26 players in the last two years.
There is no one reason why players suffer ACL injuries. Biomechanical interventions can help reduce the risk of injury, but it is all suggested that physiological and hormonal changes during menstruation can increase the risk of injury. Football boots designed for the men’s foot are also a problem: most female footballers wear boots that have gone through a so-called “pink it and shrink it” process – they wear boots designed for the men’s foot that have just been made smaller – and are forced to add insoles or cut holes to widen them at the heel. ACL injuries are equally a problem at a grassroots level, with the quality of playing surfaces being a particular concern.
There is also the possibility of a psychological element, as highlighted by Mead: her ACL injury was suffered at the weekend after she found out that the health of her mother, June, who was battling terminal ovarian cancer, had deteriorated. “We think the psychological aspect played a big role for me. I found out that my mother was not doing well,” she says in Step by Step. Her partner, Vivianne Miedema, also suffered an ACL injury the following month after hearing more bad news about Mead’s mother. There is not necessarily a connection, but if your mind is elsewhere, if you are not fully focused on your movements, then it is logical to conclude that the risk of injury may increase.
Perhaps the most significant contributor to the spate of ACL injuries in recent years has been the impact of increased professionalism and the number of games players have to play as a result. Male players play just as many matches, if not more, but their bodies have been conditioned in elite environments with the best strength and conditioning coaching since they were, in some cases, five or six years old. In contrast, for the vast majority of female players, being a professional athlete is a relatively new experience and their bodies are not as well conditioned for its demands. As Williamson put it: “Ultimately, I think the way you look at women’s football now, you can’t increase ticket prices or get bigger crowds in the stadiums because you’ll run out of players to watch. ”
UEFA, European football’s governing body, has announced a new plan to better understand ACL injuries; Meanwhile, the European Club Association has conducted research into the impact of women’s specific football boots. But if these types of initiatives do not also consider planning, team size, mental health and the development of strength and conditioning facilities for clubs and academies, then the sport will always be reactive to the problem rather than proactively addressing its causes to tackle the problems. injury risks.