Just 20 minutes into the first half of the Olympique Lyonnais’ UEFA Champions League Final on 21 May 2022, Matilda’s star Ellie Carpenter hit the turf, clutching her knee. Diagnosed with a torn anterior cruciate ligament (ACL), Ellie joined a long list of elite female athletes whose careers were disrupted by this injury.
It’s becoming an all-too-familiar scene in women’s sport. But ACL injuries aren’t exclusive to professionals. They can affect any woman, from a teenage netballer to a weekend footie player. In fact, women are up to 6 times more likely than men to suffer an ACL injury.
Why is it? And, if you’re a woman who loves playing sports, how can you reduce the risk of sustaining an ACL injury?
The science behind the stats
So, why are women at higher risk of an ACL injury? Research has identified several reasons, including:
- Wider hips: Women generally have wider hips than men, which affects the alignment of the knees. This can lead to a condition called “valgus knee,” where the knees angle inward, putting extra stress on the ACL during activities like jumping or changing direction.
- Smaller ACL size: The ACL in women tends to be smaller and thinner, making it more susceptible to injury under stress.
- Landing mechanics: Women often land from jumps with less knee bend and more upright posture, which doesn’t absorb shock as effectively and increases ACL strain.
- Muscle activation: There’s a tendency for women to rely more on the quadriceps (front thigh muscles) rather than the hamstrings (back thigh muscles) during movements. This imbalance can push the shinbone forward, stressing the ACL.
- Muscle coordination: Differences in how muscles coordinate and respond during movement can affect knee stability. Women may have less neuromuscular control, leading to movements that increase ACL injury risk.
- Hormone fluctuations: Changes in hormone levels throughout the menstrual cycle can affect ligament laxity, potentially making the ACL more vulnerable to injury at certain times.
The cost of an ACL injury
ACL injuries aren’t just physically painful – they’re emotionally and financially taxing too. When you’ve trained so hard, it can be devastating to realise that you could miss out on an entire season or more. Understandably, such injuries can have significant psychological impacts.
Helping women recover from an ACL injury
Female athletes need a different ACL recovery plan than their male colleagues – one that’s customised to their particular anatomical and biomechanical needs.
Factors affecting women’s recovery include:
- Smaller hamstring grafts: When reconstructing a torn ACL, surgeons often use a piece of the patient’s hamstring as a graft. Women typically have smaller hamstrings than men, which means the graft is smaller too. This can increase the chance of the ligament re-tearing and may also raise the risk of further injuries to other knee parts, like cartilage or the meniscus.
- Biomechanical challenges: Even after surgery, women may continue to move in ways that put more strain on their knees. These include how they land from jumps or how their muscles support the knee. These movement patterns can slow recovery and increase the chance of reinjury if not corrected through rehab.
- Hormonal and neuromuscular factors: Hormonal fluctuations that contribute to the original injury can also impact healing. Additionally, if there are underlying issues with how muscles fire or stabilise the knee, these need to be addressed during rehab.
- Postural stability and impact absorption: Women may have lower postural stability and different ways of absorbing impact, which puts more pressure on the ACL. Effective rehab must include training to improve balance, coordination, and strength to avoid reinjury.
- Training and rehab differences: Given the lower levels of investment in women’s sport, female athletes may have less access to elite-level rehabilitation facilities and tailored programs.
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Because of these risks, surgeons sometimes recommend additional procedures, like lateral extra-articular tenodesis. This can be done at the same time as an ACL reconstruction and involves using a piece of the iliotibial band to stabilise the knee further and reduce the risk of re-injury.
Prevention is possible
Given a choice, you’d rather avoid an ACL injury. There are some evidence-based strategies to help you strengthen your knee and reduce the risk of injury, including:
- Structured warm-ups and strength training: Programs like Football Australia’s Perform+ and Netball Australia’s KNEE Program incorporate exercises proven to reduce ACL injury risk. These include strength training, balance drills, and proper landing techniques.
- Building muscle around the knee: Strengthening the hamstrings, quadriceps, and gluteal muscles helps support the knee joint and reduce reliance on the ACL. Try resistance training, squats, and lunges.
- Enhancing proprioception: Your body’s ability to sense movement and position can be trained with balance exercises like single-leg stands and wobble board workouts. This can improve reaction time and reduce injury risk during unexpected movements.
- Educating athletes, coaches and parents: When people understand risk factors and are supported with injury prevention programs, outcomes improve significantly. Coaches and parents should champion warm-up routines and monitor technique, especially in young players.
How can I help?
As we celebrate the triumphs of athletes like Ellie Carpenter, we must also learn from their setbacks.
Whether you’re a professional or amateur player, understanding why ACL injuries are more common in women – and how to avoid them – can make all the difference.
I’m an orthopaedic surgeon with subspecialty training in knee injuries and considerable experience in ACL reconstructions and repairs. If you’re concerned about knee pain or injury, please come to see me.
Disclaimer
All information is general and not intended as a substitute for professional advice. Any surgical or invasive procedure carries risks.
References
- Parsons JL, Coen SE, Bekker SAnterior cruciate ligament injury: towards a gendered environmental approachBritish Journal of Sports Medicine 2021;55:984-990. https://bjsm.bmj.com/content/55/17/984, [Accessed 24 April 2025]
- Mancino F, Kayani B, Gabr A, Fontalis A, Plastow R, Haddad FS. Anterior cruciate ligament injuries in female athletes: risk factors and strategies for prevention. Bone Jt Open. 2024 Feb 5;5(2):94-100. doi: 10.1302/2633-1462.52.BJO-2023-0166. PMID: 38310925; PMCID: PMC10838619. https://pmc.ncbi.nlm.nih.gov/articles/PMC10838619/#, [Accessed 24 April 2025]
