Why Are There So Many ACL Injuries In Women’s Football? – Yasin Patel and Caitlin Haberlin-Chambers
Yasin Patel and Caitlin Haberlin-Chambers explore why female footballers are more susceptible to ACL injuries and, and what can be done by clubs and governing bodies to limit the frequency and severity of these injuries.
In the realm of professional athletics, injuries are an inescapable fact, casting a formidable shadow over the careers of many. However, the current landscape reveals an unprecedented and increasing number in anterior cruciate ligament (“ACL”) injuries in female footballers at all levels of the game.
In fact, the 2023 Women’s World Cup saw between 25 to 30 players injured because of tears to their ACLs.
While advancements in sports medicine have transformed the narrative around ACL injuries, turning them from potential career-ending to manageable setbacks, there remain a number of challenges athletes face in their rehabilitation and return to sporting participation demanding commitment, perseverance, and resilience.
Astonishingly, women face a staggeringly higher likelihood of succumbing to ACL injuries compared to their male counterparts. In the Premier League 2022/23 season, only four male footballers ruptured their ACL. Dr Kate Jackson, a renowned sports and exercise medicine specialist, states that “For 20 years we have known there is an increased ACL injury rate in women and girls…There is a nuanced gender issue that needs exploring. We don’t yet fully understand it.”[1]
The glaring discrepancy between the prevalence of ACL injuries in male and female athletes underscores an imperative for urgent and comprehensive research in order to understand and address gender-specific vulnerabilities.
Why are female footballers more susceptible to ACL injuries?
Gender disparities
A 2021 study published by the British Journal of Sports Medicine, has suggested that gender-related factors contributes to the disparity in ACL injuries between men and women .[2] It contends that the current paradigm in ACL injury prevention and management has primarily centred on a sex-based biological perspective, enriching our comprehension of risk factors, injury mechanisms, and prevention and rehabilitation programmes. This study urges change, recommending the integration of gender considerations into the exploration of ACL injuries. By doing so, it advocates for an increased awareness of potential influences beyond the confines of traditional biological elements. The study seeks re-evaluation of the interplay between sex and gender, challenging us to recognize their inextricable ‘entanglement.’
Beyond research, gender disparities in kit have contributed to the rise in ACL injuries. Historically, football kit has been primarily designed with men in mind. Even the length of the studs on a football boot is designed based on men’s movement. Ill-fitting boots and kits can affect a player’s stability and increase the likelihood of injury. Tailored equipment specifically designed for women’s anatomical needs is essential in reducing this risk.[3]
Increased game time
Research commissioned by the players’ union, Fifpro, looked at the workload of 139 players in the leading women’s leagues in Europe, including 58 who were injured at least once during the 2022-23 season. The results found that injured players had enjoyed fewer rest days than non-injured players whatever the medical issue but observed greater differences with those who suffered ACL problems.[4]
According to the report, “elite female footballers who injured their ACL were exposed to a higher number of matches, lower number of rest time and a higher number of rest periods of less than five days between matches than non-injured players” in the 28-day period that preceded the injury. Similarly, players who injured their ACL were “also exposed to a higher travelled distance, a higher travelled time and a higher number of time zones crossed than non-injured players in the 28-day period preceding the ACL injury date”. [5]
A notable correlation seems to be emerging as the popularity of women’s football rises, coinciding with an uptick in ACL injuries among female footballers. The increasing visibility of women’s football is leading to greater participation in both national and international matches. However, this heightened involvement exposes players to a higher risk of ACL injuries due to the elevated frequency of physical demands.
This connection is intricately tied to the gender disparities prevalent in women’s and men’s football. Boys tend to engage in various sports from a younger age, particularly football. Early involvement allows their muscles to develop and adapt to the physical stress associated with the sport. On the other hand, girls participating in football from a young age may not encounter the same level of physical pressure until they play high -level football or turn professional. This contrast in early experiences contributes to the increased vulnerability of female footballers to ACL injuries as compared to their male counterparts.
Menstrual cycle
Research also suggests that anatomical and hormonal differences play a significant role in the elevated risk faced by female athletes in ACL injuries. Athlete testimony further underscores this concern. For example, Jordan Nobbs, who sustained an ACL rupture in November 2018, observed that many women experiencing similar injuries were menstruating at the time. She remarked that the onset of her period on the morning of the match against Everton was “a very high factor” in her injury. [6]
One proposed explanation lies in the effect of oestrogen, which increases during menstruation and may contribute to greater joint laxity. While increased flexibility can be advantageous in certain contexts, it also renders the joint more vulnerable to damage, particularly in high-impact, rotational movements common in football.
A 2002 study published in the Journal of Athletic Training found a disproportionate concentration of ACL injuries during the first two days of the menstrual cycle, correlating with salivary hormone levels measured at those times.[7] More recently, a meta-analysis of seven studies examined the effect of hormonal contraceptives on ACL injury rates. The analysis concluded that oral contraceptives may reduce the likelihood of injury by up to 20%, potentially due to the higher levels of progesterone in most formulations, which are associated with increased joint stability and reduced passive laxity compared with the luteal phase.[8]
This issue has gained institutional recognition. On 29 April 2025, FIFA announced that it would investigate the extent to which hormonal fluctuations associated with the menstrual cycle may be contributing to the rising incidence of career-threatening knee injuries in women’s football.
These findings highlight the complex interplay between hormonal fluctuations and injury risk. They underscore the need for further targeted research and the development of preventative strategies tailored to female athletes. A deeper understanding of the interaction between anatomy and endocrinology is not only essential for advancing scientific knowledge but also for informing policy, medical practice, and sporting regulation aimed at mitigating the prevalence and severity of ACL injuries in women’s sport.
Mitigating the risk
Research
FIFA expert, Dr Georgie Bruinvels has observed, advancing women’s sports science is critical both for the growth of the game and for the protection of female athletes. She explained,
“It’s expensive, doing research on females, full stop. And it’s complicated. So often we just keep doing it on men, because we’ve done that so far and we can just apply it [as if] they’re the same. But we know that females aren’t just males with reproductive organs, and we need to really understand more about female anatomy and physiology to support females better.” [9]
This call for a more nuanced understanding is central to developing effective prevention and treatment strategies for ACL injuries. It requires recognition of both biological and gender-specific factors. Such a shift represents a pivotal step towards a holistic and tailored approach, directly addressing the disproportionate burden of ACL injuries on female athletes.
The urgency of this issue is heightened by the financial realities of the modern women’s game. With wages, prize money, and sponsorship revenue increasing, the financial consequences of career-threatening injuries have never been greater. Establishing a robust and comprehensive policy framework is therefore not only a matter of athlete welfare but also of economic necessity. Such protections provide female footballers with the security that they will not face disproportionate financial vulnerability in the event of an ACL injury. This proactive approach empowers players to focus on their performance, safe in the knowledge that their careers—and livelihoods—are supported by structures responsive to the specific risks they face.
What does this mean legally?
Coaches, trainers, and medical staff hold a significant duty of care to athletes by virtue of their positions of authority and trust. This duty necessitates the exercise of all objectively reasonable care in the given circumstances to prevent injuries to participants. Legislative changes are progressively imposing additional responsibilities on coaches to minimize the occurrence of athlete injuries.
In Watson v British Boxing Board of Control, the Court of Appeal ruled that a sport’s governing body may be obligated to participants if it assumes responsibility for establishing mandatory minimum safety requirements. Athletes have the right to rely on the stated medical expertise of such bodies.[10] It is crucial for governing bodies and football clubs alike to stay abreast of the latest developments. This ensures they are well-informed on measures to prevent injuries and the most effective rehabilitation practices.
It could be argued that the late advancement of research into ACL injuries in women’s football is illustrative of indirect sex discrimination. Under section 19 of the Equality Act 2010, indirect discrimination arises where a provision, criterion or practice (PCP), although neutral on its face, places persons of one sex at a particular disadvantage compared with persons of the other sex, and cannot be objectively justified as a proportionate means of achieving a legitimate aim.
In the present context, the prevailing approach of governing bodies and clubs has historically been to design training programmes, medical policies, and injury-prevention frameworks on the basis of male physiology. This model, while appearing neutral, disproportionately disadvantages female athletes, whose anatomical and hormonal differences have been shown to increase susceptibility to ACL injuries. The failure to account for such differences results in systemic under-protection, leaving female players exposed to higher injury risks and, consequently, greater career disruption.
This constitutes a particular disadvantage under discrimination law: while both male and female players are subject to the same training regimes and medical standards, female players face significantly higher rates of ACL injury precisely because the standards are not adapted to their physiological needs. In July 2023, the Women and Equalities Committee Chair, Caroline Nokes MP, wrote to football boot brands, including Adidas and Nike, over the lack of boots specifically designed for women and girls.[11] The Committee’s intervention was prompted by evidence of a higher rate of ACL knee injuries among female footballers and concerns that football boots, which until recently have been almost exclusively designed for men, are a potential factor in injury risk for women.
Unless governing bodies can demonstrate that reliance on male-centred models is a proportionate means of achieving a legitimate aim – a difficult argument given the availability of emerging research – such practices may fall foul of the prohibition against indirect discrimination. Importantly, the defence of justification requires more than an appeal to cost or administrative convenience. As Dr Bruinvels emphasised, the historic reliance on male-based data has often been rationalised on the grounds that female-focused research is “expensive” and “complicated.” However, cost alone is unlikely to suffice as an objective justification when weighed against the significant health, safety, and career implications for female athletes.
Conclusion
As researchers and scientists venture into this uncharted territory, National Governing Bodies should proactively invest time, effort, and resources to unravel the complexities surrounding ACL injuries among female footballers in comparison to their male counterparts. Unfortunately, the stark reality is that if this problem were affecting male footballers, such investment would likely already be in progress. As the calls for equality in women’s football grow louder, there will be an increasing emphasis on finding solutions to mitigate the risk of ACL injuries and prioritize effective rehabilitation. This concerted effort is essential not only for the well-being of female athletes but also to foster a more equitable landscape in the realm of football.
[1] https://www.skysports.com/football/news/11095/12926431/future-of-football-why-acl-injuries-have-been-on-rise-in-womens-game-and-the-technology-and-solutions-to-fix-it
[2] https://bjsm.bmj.com/content/55/17/984
[3] https://www.miller-insurance.com/news-and-insights/latest-insights/womens-football-is-thriving-but-the-acl-still-looms-large#:~:text=Increased%20game%20time%3A%20As%20women’s,higher%20frequency%20of%20physical%20demands.
[4] https://www.theguardian.com/football/2023/dec/15/fifpro-research-reveals-factors-affecting-acl-injuries-in-womens-game#:~:text=New%20research%20reveals%20factors%20affecting%20ACL%20injuries%20in%20women’s%20football,-Those%20who%20play&text=Elite%20female%20footballers%20who%20suffer,a%20new%20study%20has%20found.
[5] https://www.theguardian.com/football/2023/dec/15/fifpro-research-reveals-factors-affecting-acl-injuries-in-womens-game#:~:text=New%20research%20reveals%20factors%20affecting%20ACL%20injuries%20in%20women’s%20football,-Those%20who%20play&text=Elite%20female%20footballers%20who%20suffer,a%20new%20study%20has%20found.
[6] https://www.bbc.co.uk/sport/football/48333161
[7] The Menstrual Cycle, Sex Hormones, and Anterior Cruciate Ligament Injury <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164356/ >.
[8] The Effect of Menstrual Cycle and Contraceptives on ACL Injuries and Laxity: A Systematic Review and Meta-analysis <https://journals.sagepub.com/doi/10.1177/2325967117718781>
[9] https://www.fifa.com/womens-football/news/health-and-wellbeing-of-female-footballers-in-focus
[10]https://committees.parliament.uk/writtenevidence/23469/html/#:~:text=Watson%20claimed%20that%20the%20British,duty%20by%20not%20providing%20resuscita
[11] https://committees.parliament.uk/committee/328/women-and-equalities-committee/news/196294/committee-chair-writes-to-leading-football-boot-brands-over-lack-of-womenspecific-designs/
