ACL Injuries in Women’s Football: A Persistent Challenge for the Game

In early 2023, Leah Williamson was at the pinnacle of her career, excelling in football with both Arsenal and the England team, and starring in advertisements in the lead-up to the 2023 Women’s World Cup. However, a torn anterior cruciate ligament abruptly altered her trajectory.

The 28-year-old was among nearly 30 players sidelined from the World Cup due to ACL injuries. Her experience reflects a broader issue, as many players contend with knee injuries that have sparked an urgent dialogue about ACL tears, which pose significant challenges to both athletes and their teams.

Fortunately, Williamson has made a successful comeback and is poised to captain England at the European Championship commencing on Tuesday in Switzerland. Despite her return, discussions about ACL injuries linger, with players like Spain’s Teresa Abelleira, Switzerland’s Ramona Bachmann, and England’s Ella Morris also missing out on the Euros due to similar injuries.

Wales’ Sophie Ingle has been included in her squad, despite having not played since her own ACL tear last September.

“ACL injuries have been a part of women’s football for as long as the sport has existed,” stated Alex Culvin, Head of Strategy and Research for Women’s Football at global players’ union FIFPRO, in a conversation with Reuters. “It’s crucial that we prioritise ACL injury awareness. It’s a comprehensive issue that affects players’ careers in a myriad of ways.”

“Not only does an injury like this typically result in at least nine months on the sidelines, but over a typical 10-year career, a player is two to three times more likely to sustain another ACL injury. We must also consider the commercial and career opportunities players miss out on because of this injury.

“Take Leah Williamson, for instance; she was the face of Nike but suddenly found herself out of the game. While she has returned and continues to excel, she has inevitably lost out on numerous commercial and career prospects because of that sudden setback…”

Research indicates that there hasn’t been a surge in ACL injuries within women’s football over the past two decades, with ACLs accounting for only 2% of time-loss injuries in elite female football. However, the risk remains notably higher for women, as they are up to eight times more likely to suffer this type of injury compared to men.

Australia and Chelsea striker Sam Kerr, renowned as one of the leading scorers in the sport, is among the more than 500 elite female players who have sustained ACL injuries since 2022. She experienced her injury in early 2024 and has not played since.

While elite women’s teams may typically expect one ACL injury per season, Arsenal faced a significant challenge when they lost four players, including Williamson, throughout a six-month span during the 2022-23 season.

Forward Beth Mead was another casualty, missing the 2023 World Cup but returning with England for the Euros. She is dedicating this tournament to her late mother, June, who passed away from cancer just two months after Mead’s ACL injury.

Mead has openly discussed her mental health struggles, a concern for many players during ACL recovery, which were further compounded by her mother’s death.

“Not being able to play football because of the injury took away my escape, my happy place,” Mead revealed. “There were moments when people assumed I was okay due to my outgoing nature, but those times were incredibly dark.”

‘MULTIPLE FACTORS’

Culvin, who also serves as a senior lecturer at Leeds Beckett University, emphasised the necessity for broader research into ACL injuries.

“There’s a desire for quick solutions, but we must understand that ACL injuries are multifaceted,” she explained. “It’s not solely about workload, or the way women run, land, or jump. There are numerous components at play, making it challenging to pinpoint just one or two factors; we need to approach this from a holistic perspective.”

She is involved in Project ACL, a three-year initiative launched by FIFPRO, the Professional Footballers’ Association, Nike, and Leeds Beckett University, focusing initially on England’s Women’s Super League but with ambitions to extend research to other leagues.

“There’s often a disparity between the level of professionalisation and the expectations placed on players operating in less-than-ideal environments. A significant area of focus for us is exploring how these environments can be modifiable risk factors,” she added.

“Of course, there are non-modifiable risks primarily related to physiology, but we must also consider modifiable factors, including the calendar, number of competitive fixtures, travel, and the physical settings in which players operate.”

A FIFA-sponsored study at Kingston University is examining whether changes in menstrual cycles could play a role in these debilitating knee injuries.

Although experts dismiss the idea of an epidemic in elite football, UEFA’s chief medical officer Zoran Bahtijarevic has noted a concerning rise in injuries among youth players as more girls take to the game.

A recent study conducted by Nielsen Sports and PepsiCo showed a significant increase in participation among girls, especially in Asia, with an astounding 300% rise in China, and Europe, with France leading the way at 150%.

“We may witness a surge of ACL injuries occurring under the radar due to this influx of participation,” Bahtijarevic told Reuters. “The highest injury rates for women are observed between the ages of 15-16 and 19, but these incidents often go unnoticed, as these young athletes aren’t household names.”