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

In the early months of 2023, Leah Williamson was enjoying an incredible run, showcasing her finest football for Arsenal and the England national team while appearing in promotional campaigns ahead of the 2023 Women’s World Cup. However, a devastating torn anterior cruciate ligament (ACL) abruptly halted her momentum.

The 28-year-old was among nearly 30 players who missed the World Cup due to ACL injuries, highlighting a troubling trend as these injuries have caused significant distress within women’s football, affecting both players and teams alike.

While Williamson has successfully made a comeback, now ready to lead England at the European Championship starting Tuesday in Switzerland, the issue of ACL injuries continues to loom large. Notable absentees from the Euros include Spain’s Teresa Abelleira, Switzerland’s Ramona Bachmann, and England’s Ella Morris, all sidelined due to ACL tears.

Wales’ Sophie Ingle has been included in the squad despite her own ACL tear last September, marking her absence from play since then.

“ACL injuries have been part of women’s football since its inception,” remarked Alex Culvin, Head of Strategy and Research for Women’s Football at FIFPRO, the global players’ union, in an interview with Reuters. “It’s crucial that we place emphasis on tackling ACL injuries as they have a comprehensive impact on players’ careers.”

“Not only do players face a recovery period of at least nine months, but during a career that lasts about ten years, they are two to three times more likely to suffer another ACL injury. Additionally, there are significant commercial and career opportunities lost due to these injuries.”

“Look at Leah Williamson; she was a key figure for Nike, and then suddenly she’s off the pitch. While she has returned and is still an exceptional player, think of the commercial and career opportunities she might miss in that split second…”

Studies show that although the rate of ACL injuries in women’s football has not significantly increased over the past two decades, ACL injuries still account for only 2% of time-loss injuries among elite female players, women, however, are up to eight times more prone to these injuries compared to men.

Australian striker Sam Kerr, regarded as one of the leading goal scorers in football, is among over 500 elite female players who have suffered ACL injuries since 2022. She suffered her injury early in 2024 and has yet to return to the field.

While an elite women’s side typically anticipates experiencing one ACL injury each season, Arsenal faced a dire situation when they lost four players, including Williamson, over a six-month period during the 2022-23 season.

Among these was forward Beth Mead, who also missed out on the 2023 World Cup but is back with England for the Euros. She is dedicated to the tournament in memory of her late mother, June, who passed away from cancer shortly after Mead sustained her ACL injury.

Mead has openly discussed her struggles with mental health during her recovery, an already challenging time that was further exacerbated by her mother’s death.

“Due to the injury, I couldn’t play football, which had always been my escape, my happy place,” Mead explained. “There were moments when outsiders thought I was coping well because of my bubbly personality, but it was actually quite dark for me.”

‘A COMPLEX ISSUE’

Culvin, who is also a senior lecturer at Leeds Beckett University, emphasised the need for a broader approach to researching ACL injuries.

“People often seek a quick solution, but ACL injuries are complex and multifactorial,” she noted. “We can’t attribute it solely to workload or the specific mechanics of how women run, land, or jump. It’s essential to consider the multitude of factors involved, so we aim to examine this issue comprehensively.”

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

“There’s a significant disparity between the levels of professionalisation and the expectations placed on players within inadequate environments. A key aspect of our research is examining how environments could be modifiable risk factors,” she stated.

“While non-modifiable risk factors are primarily physiological, we also consider modifiable factors such as the length of the season, travel commitments, and the actual conditions in which players perform, which significantly influences their well-being.”

A FIFA-funded study at Kingston University is exploring whether fluctuations in menstrual cycles might play a role in these career-threatening knee injuries.

While experts do not deem a pandemic-level concern is present in elite women’s football, UEFA’s chief medical officer, Zoran Bahtijarevic, noted rising numbers among youth players, as more girls are attracted to the sport.

A recent report by Nielsen Sports and PepsiCo indicated that participation numbers among girls have surged, particularly across Asia, where figures have jumped by 300%, and Europe has seen a139% increase led by France.

“We might witness an escalation of ACL injuries in less visible areas, coinciding with the surge in participation,” Bahtijarevic warned. “The highest incidence of injuries in women occurs between the ages of 15-16 and 19, often going unnoticed as these athletes are not widely recognised stars.”