Girls and young women are more likely to tear their ACLs. Here’s why — and how to prevent it

The list of loretta young, female person athletes injuring their ACLs has begun to sense “ the like an epidemic,” according to Dr. Marie-Lyne Nault, a pediatric orthopedic surgeon in Montreal — and one that is also more likely to permanently bench them compared to their male counterparts.

The anterior cruciate ligament, or ACL, acts as a stabilizer in the knee joint by preventing the tibia (shin bone) from sliding too far forward from the femur and the knee from rotating too much. A tear may feel like sudden, intense pain and swelling, along with a popping sensation, with a patient usually needing surgery and up to a year of rehab to recover. 

In her clinic, Nault said she's seeing a significant increase in the number of young, female athletes tearing their ACLs, noting that recent studies suggest they are roughly three to six times more likely to do so than young men in sports.

Her experience is backed up by other data as well, some of which suggests potentially even higher increases.

In the past two decades, the number of ACL surgeries doctors in Quebec performed each year on patients under 18 jumped from 98 to 388. And numerous research papers have cited similar spikes to what Nault has seen in her clinic, though figures can vary depending on the sample size, the sport and the country in which the study was conducted.

The reasons why young female athletes are more susceptible to this injury are diverse, with experts pointing to differences in physiology, training and even social factors. 

There’s also evidence that female athletes are less likely to return to sport after an ACL injury compared to men, said Hana Marmura, a postdoctoral research fellow at the University of North Carolina at Chapel Hill's department of exercise and sport science.

“We see that females tend to have higher levels of what we call, like, injury-related fear, which is then also linked to higher rates of reinjury or lower rates of return to sport,” she said.

Researchers have explored the physiological differences that may contribute to ACL tears in female athletes, particularly around differences in muscle distribution.

This demographic may be more likely to have dynamic knee valgus, said Nault, which is when the knee collapses inward during physical activities like pivoting or landing after a jump. She said this may be because women and older girls generally have a wider pelvis than  men — as well as less muscle strength and different muscle activation patterns.

Volleyball, football, basketball and rugby are some of the more common sports in which players tear ACLs. But soccer is — by far — the leader in the cases she sees, Nault said.

“We'll see one girl and she's like the second or third one [on] her team sustaining an ACL injury," the surgeon said.

There are several ways the injury occurs, Nault said, including when an athlete lands with poor technique, pivots direction after their foot is planted or cuts to avoid an opposing player. In fact, it often happens without ever touching another player. 

Younger females often have very strong quad muscles, and if they are stronger than their hamstrings it can pull forward on the shin bone, she said. 

“And if the hamstring is not strong enough to help the ACL to manage that strain, then that's where you can see an increased strain on the ACL ligament.”

Are athletes' injuries connected to their menstrual cycle?

Research also suggests female athletes may have more laxity in their joints, which might also lead to the higher injury rate. 

But while male and female athletes have physical differences, it’s just one factor, according to Jenna Schulz, a physiotherapist at the Alan McGavin Sports Medicine Clinic in Vancouver, and a postdoctoral research fellow at the University of British Columbia. 

“I think that that puzzle is actually much larger than just, OK, well, it's just their hips or their hormones,” said Schulz. €œWe don't have any high-level evidence to support that you need to change your training based off of what phase in your [menstrual] cycle that you're in.”  

Instead, she points a finger at how social issues, particularly some of the documented differences in how girls and boys are treated early on in sports, are a potential factor in the gender disparity in ACL tears.

“Are girls at a young age taught how to fall, the same as boys? Are girls at a young age taught how take contact the same as boys? Are girls at a young age in the gym lifting weights at the same age as boys?” she said. €œThat piece, I think, also plays a large role in potentially why there's a higher risk in girls versus boys and females versus males.”

A meta-analysis published in the Journal of Orthopedic Research shows that preventative exercises, such as strength training, stretching and practising landing from jumps, may reduce the risk of ACL tears in all athletes by 50 per cent, and may reduce non-contact ACL tears in female athletes by 67 per cent. 

“What's very important to understand is that prevention exercise really works,” Nault said.

Female athletes can focus on building core strength, working on landing techniques and doing balance and agility exercises, she said, including those from the FIFA 11+ program that was developed to prevent soccer injury.

Waiting to specialize in a sport can also help prevent injury, Marmura said.

Playing a variety of sports “is almost like you're doing different neuromuscular training programs,” said the sports and exercise researcher, “because you're getting just more exposure to different ways of moving, being strong, being fast — whatever that looks like.”

Journalist

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