Note: ACL injury = anterior cruciate ligament injury = a tear in a ligament in the knee

This is a particularly high-profile and insidious injury in women’s soccer. The Guardian: “Women players are up to eight times more likely to be struck by an ACL injury than men – as many as 37 players are thought to have missed last year’s World Cup because of it.”

Parsons et al 2021, Anterior cruciate ligament injury: towards a gendered environmental approach

  • The anterior cruciate ligament (ACL) injury rate for girls/women has not changed in over 20 years, and they remain 3–6 times more likely to experience injury compared with boys/men.
  • the growing recognition of how sex and gender (a social construct) are ’entangled’ and influence each other
  • The current paradigm for ACL injury displaces bodies from the conditions of our existence, instead focusing heavily on biomechanical explanations, as if our muscles and joints are not impacted by the weight of our life experiences
  • Presport: Exposure to different experiences during infancy and childhood requires and develops differential physical skill sets which could manifest as altered movement patterns in sport later in life
  • Training: participating in resistance training and increasing muscle mass is not seen as socially acceptable or desirable for girls and women […] Because S & C coaches are overwhelmingly men, women are likely to continue to feel that weight rooms are not a place for them. These gendered training dynamics may be a significant contributor to the ACL injury rate disparity between women and men, given the well-documented lower resistance training participation rates among girls and women compared with boys and men, and the importance of that activity for effective ACL injury prevention programmes.
  • many of the assumptions behind these perceived [sex] differences are based on a belief that they are biological and unchangeable, when in fact they are heavily shaped by modifiable gendered factors
  • Competition environment (complicated)
  • Treatment: Could it be that men and women experience rehabilitation differently due to biases in healthcare settings?

den Hollander et al 2024, Match workload and international travel associated with (ACL) injuries in professional women’s football

  • This study aimed to identify differences in the match workload and international travel between injured and noninjured professional women’s footballers.
  • The anterior cruciate ligament injury group made more appearances (p = 0.09, effect size = 0.8, moderate), had more instances of less than 5 days between matches (p = 0.09, effect size = 0.8, moderate) and had less rest time (p = 0.12, effect size = 0.8, moderate) than the control group.
  • This finding is similar to research accumulated over the past decade in men’s football, indicating that fixture congestion is a significant contributing factor to injuries (Carling et al., 2016; Page et al., 2023). The findings also substantiate the beliefs expressed by the team physicians at the 2019 FIFA Women’s World Cup, who identified reduced recovery time between matches as the most important extrinsic noncontact injury risk factor (Saltzman et al., 2023), as well as players’ beliefs, with elite players voicing their concerns over the increase in match fixtures in a season (James et al., 2023).
  • These findings underscore the importance of careful consideration when developing match fixture schedules in elite women’s football, particularly concerning the number of matches scheduled in a short period.

Bruder et al 2023, Let’s talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes

  • Female athletes/women/girls experience a higher risk of anterior cruciate ligament (ACL) injury compared with male athletes/men/boys.
  • Sex/gender is often erroneously treated as binary and used interchangeably. (!)
  • Female athletes/women/girls tend to experience inferior self-report activity and knee-related outcomes after ACL injury than males/men/boys.
  • no meta-analysis found poorer results for males/men/boys
  • Why might female athletes/women/girls experience inferior outcomes after ACL injury?
  • Biological: Limited evidence from small studies suggests knee laxity, and asymmetrical limb behaviour sex/gender disparities exist in ACLdeficient adults. Increased knee instability may partly explain the worse preoperative knee symptoms and activity limitations as found in six out of seven meta-analyses. However, the detected inferior instrumental knee laxity among females/women after ACLR is minimal—and undetected in clinical examination. […] Some studies suggest female athletes/ women have weaker quadriceps strength after ACLR compared with male athletes/men, and lower hamstring activation postlandings, others do not.
  • Sociocultural psychological: Fear of reinjury and lack of knee confidence may prevent female athletes/women/girls from returning to sport at the same rate as their male athletes/men/boys counterparts.
  • Sociocultural rehabilitation: It is unclear if sex/gender differences exist for other preoperative complaints such as joint effusion, lower limb strength and psychological impairments despite reports that knee complaints may vary by age and gender among adults. It is also unclear if inherent biases among therapists and coaches preferentially support male athletes/men/boys to return to preinjury sport after ACL injury compared with female athletes/women/ girls. […] Given that resistance training is often used during evidence-based ACL rehabilitation, we must consider the influence of access to equipment, space and discomfort in a man-dominated space during rehabilitation and its influence on outcomes.
  • Sociocultural social roles: For females/women after ACL injury, reduced physical activity levels are a likely consequence of work, family and unequal household time commitments, unaffected among males/men

Ellison et al 2021, Sexual dimorphisms in anterior cruciate ligament injury: a current concepts review

  • the literature review indicated that female athletes are at significantly higher risk for ACL injuries than are their male counterparts, but the exact reasons for this were not clear
  • It is likely both intrinsic [sex] and extrinsic [gendered] factors contribute to this increased risk, but further study is needed. (those two annotations are Ren’s, not the authors’)
  • further research is needed to determine why there is disparity in surgical rates and what surgical techniques optimize postsurgical outcomes for female patients