Experts call for focus on risk factors to reduce ACL injuries in women's game

Reuters

01-07-2025

MANCHESTER, England, July 1 (Reuters) - Breaking the cycle of anterior cruciate ligament (ACL) injuries in women's football requires a shift in the conversation away from biological differences such as wide hips and hormonal fluctuations during menstruation, according to experts.
Instead, the focus should be on risk factors that can be controlled, they say.
Women's Euro 2025, which kicks off on Wednesday, will be without Swiss striker Ramona Bachmann who will miss the tournament in her home country after tearing her ACL less than three weeks ago, underscoring the devastation the knee injury can cause in the women's game.
While studies show women are up to eight times more susceptible to ACL tears than men, there is scant research on the injury in professional women's football.
"We want to move away from these kind of stereotypical views that women are just more susceptible to it because of the way that their bodies are," Alex Culvin, Head of Strategy and Research for Women's Football at global players' union FIFPRO, told Reuters.
"They can't take the high workload, all of these quite nonsensical, illogical, overly kind of feminized ways of looking at ACL injury.
"We really want to hone in on things that we can affect. We can't change women's physiologies but what we can change and what we can adapt and improve are the conditions in which ACL injuries occur."
Culvin, a lecturer at Leeds Beckett University, is part of Project ACL, a three-year study launched by FIFPRO, the Professional Footballers' Association, Nike and Leeds Beckett with the Women's Super League.
There is interest in expanding the study to other women's leagues around the world.
"Obviously you've got non-modifiable risk factors which are predominantly physiological but you've got modifiable risk factors which count for calendar, number of games, travel and then actual physical environments that players play in, their working environments, and that's what our focus is," said Culvin, who played professionally for Everton and Liverpool.
Culvin is calling for minimum standards across the women's game to eliminate risk factors in the working environment, in areas such as access to physiotherapy and pitch condition.
"We want to gather as much data around these environmental risk factors as possible and start to build out an evidence base that's not been built before on ACL injury," she said.
Dale Forsdyke, a Lecturer in Sports Injury Management at York St. John University in England, said psychological factors had to become part of the conversation around injury.
"We often forget footballers are human and we forget that the life stresses that they're exposed to can be really significant. What does it do to their bodies?" Forsdyke said.
"We know that it alters their stress hormones. We know that it can impair muscle repair from physical load, and it can give them some peripheral narrowing so their attentional focus goes.
"There's obviously a behavioural mechanism with stress -- if I can't deal with these stresses, then that's going to impact my sleep quality and quantity. And we know that sleep (is important) as a recovery strategy."
Forsdyke said while some teams were starting to work with sleep specialists and include testing for the "stress hormone" cortisol as part of player health screening, if they employed a psychologist, it was usually reactionary. They were often consultants, brought in for injured players or when a problem occurred.
Forsdyke spoke about psychological risk factors in injury to more than 500 medical professionals at the ninth UEFA Medical Symposium in Lugano, Switzerland, earlier this year. The symposium's focus for the first time was on women's football.
UEFA's chief medical officer Zoran Bahtijarevic, who hosted the symposium, appealed to coaches at all levels to learn about preventative programmes in order to help reverse the ACL trend in the women's game.
FIFA 11+, a warm-up programme aimed at preventing injuries, is one of the resources available to coaches.
"We need the attention of coaches. We need the attention of parents," Bahtijarevic told Reuters. "Coaches have a great responsibility to educate themselves, to establish healthy habits of preventive exercises which are (unrewarding) because the result might be obvious only in 20 years.
"But we want to make it a continuous effort to educate everybody involved that prevention is possible. It's boring because you have to repeat it two or three times a week, right? It's boring but efficient.
"So my advice is start doing this... prevention starts with you. Every Cristiano Ronaldo was once a grassroots player. Prevention starts there."