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ACL Injuries Cast a Shadow Over the Women’s World Cup—and Girls Soccer

ACL Injuries Cast a Shadow Over the Women’s World Cup—and Girls Soccer

Star players from several nations are out. Research shows that female athletes, especially at the youth level, are at greater risk of the injury.


By Rachel Bachman, WSJ


July 7, 2023 8:00 am ET



The anterior cruciate ligament is only about 1½ inches long. At the Women’s World Cup that kicks off July 20, however, that tiny strip of knee tissue will cast an ominous shadow over the host nations of Australia and New Zealand.


ACL injuries have knocked the equivalent of a global all-star team out of the World Cup. Gone are high-scoring U.S. midfielder Catarina Macario and 2019 World Cup champion forward Christen Press. The Netherlands will be without star Vivianne Miedema when it faces the U.S. in group stage play on July 26, while France will be missing Marie-Antoinette Katoto. Such injuries have also sidelined three starters from the England squad that won the 2022 European championships: Beth Mead, Fran Kirby and captain Leah Williamson.


It’s difficult to know whether and how much ACL injuries are rising globally in women’s soccer, or whether the current run is an alarming outlier. Such injuries are more common among female athletes, however, and far more common among female soccer players in the U.S., according to research.


Researchers began to see the problem surge more than a decade ago.


“We did a study showing a 300% increase in ACL injuries in adolescents and teenagers,” Dr. Andrew Pearle, Chief of Sports Medicine at New York’s Hospital for Special Surgery, said of a study that ended in 2009. “So this is an incredible epidemic.”


The problem is especially acute at the youth level. ACL injuries are as much as six times more common among female high school soccer players than among male players, Pearle said. A girl who plays soccer year-round has a 16% chance of injuring her ACL during her high school years, he said.


Although the causes for ACL injuries aren’t fully known, they appear to have risen as competitive soccer’s calendar has expanded from the youth ranks all the way to professional leagues. For female players, competition makes a difference: High school girls were more likely than boys to sustain injuries during games versus in practice, according to a 2020 study.


The good news for amateur players is that half or more ACL injuries are preventable with regularly performed exercises called neuromuscular training, Pearle said. The Hospital for Special Surgery and the Aspen Institute recently formed the National ACL Injury Coalition to encourage their adoption.


At soccer’s higher levels, where many players are already doing preventive exercises, the contributing factors for ACL injuries are more complex. A rising number of matches and increased intensity of play have come without a parallel rise in medical and material support, players say. Women’s physiology and a lack of research about it further complicate the picture.


In general, several factors are thought to put female athletes at higher risk of ACL injuries, Pearle said. Female athletes tend to move their knees inward when landing from a jump rather than keeping them in line with their toes. They’re more knee-dominant in their change-of-direction movements rather than engaging the muscles around their knees and hips. Their joints are generally looser than those of male athletes. And women and girls have less muscle mass around the knee to reduce force on the joint.


In recent years, the growing number of matches also has created more opportunities for injury. Teams in England’s Women’s Super League each played four more regular-season games this year than they did five years ago. Teams in the U.S. pro league, the National Women’s Soccer League, each play four more games than in 2019, as the regular season has increased to 28 games including the in-season Challenge Cup tournament. Playoffs can push a team’s total above 30 games.


Add in national team matches, and the number of games in a year for some players climbs to 45 or more.


Meanwhile, the intensity of the women’s game is rising. Players at the 2019 Women’s World Cup in France covered more distance at higher speeds than they did at the 2015 tournament, according to data gathered from the teams.


The number of ACL injuries in elite women’s soccer “just shows that there’s not enough resources in the sport for the women to play the schedule that we’re currently playing,” said Meghan Klingenberg, who plays professionally for the NWSL’s Portland Thorns and was on the 2015 U.S. Women’s World Cup-winning team.


Klingenberg listed the areas where the women’s game often lags behind the men’s: medical staff, physical and massage therapists, access to the best training environments, field surfaces and pay. “All of that adds up,” she said.


The NWSL’s collective-bargaining agreement caps the total number of league matches in a year at 38. This year the league mandated minimum levels of support staff for each team, such as two board-certified and fellowship-trained physicians along with two certified athletic trainers, a physical therapist and an applied sports scientist, a league spokesperson said.


Not every study shows a gender disparity. In England, an ongoing study of the top two women’s pro leagues hasn’t shown a higher rate of ACL injury than in men’s football over a four-year period, although data is still being analyzed for the recently completed season, said a spokesperson for England’s Football Association, which owns and operates the women’s leagues.


U.S. Soccer Federation officials say they customize injury-prevention exercises for players on the U.S. women’s team and work with players’ clubs to monitor their overall workloads. The federation also implements “robust recovery, nutritional and mental health programs as part of our holistic approach along with daily screens to assure we are addressing the whole athlete at all times,” U.S. Soccer’s chief medical officer George Chiampas said.


A growing area of interest is the tracking of hormonal changes among female athletes and mitigation of menstrual-cycle symptoms such as fatigue and cramping that might make players more vulnerable to injury.


Dawn Scott led an effort to do that for the winning U.S. team at the 2019 Women’s World Cup, as the U.S. high-performance coach at the time. Scott is now senior director of performance, medical and innovation for the NWSL’s Washington Spirit. She said there is no consensus in the research, however, that women are more likely to tear their ACL at one point in their cycle or another, but said that more research is needed.


So far it’s lacking. Only 6% of sports science studies have focused exclusively on women, said Christine Yu, a sports science journalist and author of the recent book, “Up to Speed: The Groundbreaking Science of Women Athletes.”


The rise in funding to top women’s clubs is starting to move the needle. The Spirit has 13 full-time staff and three Ph.D students working in its performance, medical and innovation department. FC Barcelona’s technology and research center, Barça Innovation Hub, is in the midst of studying the hormone profiles of 21 women’s first- and second-team players and their potential link to injury risk.


Meanwhile at the youth level, neuromuscular training has been shown to prevent many ACL injuries, Pearle says.


One such routine, called 11+, was developed by FIFA for players 14 and older. One study found a reduction in injuries of up to 50% in female players aged 13—18 when the exercises were performed at least twice a week.


The Sports Medicine Institute of the Hospital for Special Surgery in New York has launched a website called RiipReps—Riip stands for “reduce injuries, improve performance”—with several sample sessions of its own exercises. The effort also includes a free app that coaches and organization leaders can use to coordinate and track the exercises on their teams.


A large majority of ACL injuries come in noncontact events, such as when a soccer player is playing defense, stops off-balance and her knee caves in, Pearle said.


“So these exercises really build the muscle memory for you to do that safely every time,” he said.


Write to Rachel Bachman at Rachel.Bachman@wsj.com

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