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Why Are ACL Injuries More Common In Female Athletes?

Female athletes are five times more likely to sustain a non-contact ACL injury than male athletes.
Six Star Pro Staff
Six Star Pro Staff
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Female athlete with knee injury

Injuries are something that all athletes hope to avoid. Yet, at some point in their careers, sports injuries are something that most athletes will experience. Statistics show that 90% of student athletes report some sort of sports-related injury. 

A study that analyzed injuries among university-level athletes found that “competitive athletes sustained on average more than two injuries each year, with ankle, knee, and shoulder injuries being most frequently reported.” The study also found that acute injuries (the result of a traumatic event) are more common in team sports, while overuse injuries occur more frequently in individual sports. 

Research also shows that women are more prone than men to suffer many of the most common sports-related injuries. For instance, the Anterior Cruciate Ligament (ACL) is injured in 1 of every 3,000 individuals each year. However, female athletes are five times more likely to sustain a non-contact ACL injury than male athletes. 

Understanding Anterior Cruciate Ligament (ACL) Injuries

The anterior cruciate ligament (ACL) is a flexible band of tissue that runs diagonally in the middle of the knee. It’s one of four major ligaments that work to stabilize and support the knee. 

The ACL prevents the tibia (shin bone) from moving too far forward on the femur (thigh bone), and it limits the rotational movement of the knee. The ACL can be injured when changing direction rapidly, stopping suddenly, slowing down while running, landing from a jump incorrectly, or a collision/direct contact. 

While many ACL injuries occur in contact sports such as soccer and basketball, 70% of ACL injuries result from little or no direct contact with another athlete. Instead, these injuries are usually caused due to the pivoting, jumping and landing, and sharp changes in direction to out-maneuver an opposing player. 

Types Of ACL Injuries

ACL injuries are graded on a severity scale.

Grade 1 Sprains: A Grade 1 Sprain means that the ligament has sustained mild damage and has been slightly stretched. However, it’s still able to help keep the knee joint stable. 

Grade 2 Sprains: A Grade 2 Sprain stretches the ligament to the point where it becomes loose, and is often referred to as a partial tear of the ligament. Grade 2 Sprains (partial tears) of the ACL are rare since most ACL injuries are complete or near complete tears

Grade 3 Sprains: A Grade 3 Sprain is commonly referred to as a complete ligament tear. The ligament has been split into two pieces, and the knee is unstable. When the ACL completely tears, the knee won’t be able to support any weight. 

Also, about half of all injuries to the ACL occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments. Depending on the severity of an ACL injury, treatment may include rest and rehabilitation exercises to regain strength and stability, or surgery to replace the torn ligament followed by rehabilitation.

Signs And Symptoms Of An ACL Injury

Signs and symptoms of an ACL injury usually include a loud pop or a popping sensation in the knee, severe pain and an inability to continue physical activity, rapid swelling, loss of full range of motion, and discomfort while walking. 

Why Are ACL Injuries More Common In Female Athletes?

Studies show that female basketball players are 3.5 times more likely to tear their ACL than male basketball players, and female soccer players are 2.8 times more likely to tear their ACL than male soccer players. 

But why do women suffer more ACL injuries than men? While there are a couple of main theories, there is no single or definitive reason why women are more vulnerable to ACL injuries than men.

Theory #1: Physical Differences Between The Bodies Of Men And Women

One common theory is that women are more prone to ACL injuries than men due to basic physical differences between the bodies of men and women. 

Compared to male athletes, the typical female athlete has higher estrogen levels (along with less muscle mass and more body fat), greater flexibility (due to looser ligaments and less powerful muscles), and a wider pelvis (which alters the alignment of the knee and ankle). 

The intercondylar notch, the groove in the femur through which the ACL passes, is also naturally smaller in women than in men. Therefore, the ACL itself is smaller in women, which makes it more prone to injury. 

Women more commonly have an increased valgus angle of their knees (or a ‘knock-knee’ alignment) than men, too. This means that their knees bend inward when they land from jumps. And when a knee buckles, it puts a strain on the ACL to maintain the knee’s stability. 

Female athletes also tend to have a greater likelihood of inadequate calcium and vitamin D intake. And while some studies have indicated the supposed negative effects of estrogen (and other hormones associated with menstruation) on ligament strength, one study determined that “there is no consensus of the scientific community that sex hormones play a role in the increased incidence of ACL injury in female athletes.” 

Theory #2: Technique Differences

Studies show that women typically jump and land with the soles of their feet instead of on the balls of their feet, and run in a more upright position than men. By landing flat-footed, the knee has to absorb more of the shock, while running in a more upright position gives women less control over how the knee rotates, especially during movements. 

Studies also show that women tend to have stronger quadriceps than hamstrings, which can cause a female athlete to rely more on her quadriceps for movement. This can lead to the knee compensating for the lack of hamstring strength by placing additional stress on the ACL

ACL Injury Prevention

While sports injuries are always a possibility, there are certain steps that female athletes can take to minimize risk factors

Practice Good Technique 

To prevent injuries, a study suggested that “physical movement classes should occur very early in life, teaching children to land safely and in control.” 

However, if you weren’t taught proper form as a child, work with your current coach and/or sports therapist to identify improper form so that you can correct it. 

Work To Develop Muscle Groups Evenly

Since women tend to be ‘quad dominant,’ which means that their quadriceps muscles are stronger than their hamstring muscles, female athletes should focus on specific strength training programs that balance the two. 

It’s also important for female athletes to develop good core and hip muscle strength since a study determined that “lack of control contributes to an individual getting into a position that allows for an ACL rupture.” 

Consider Neuromuscular Training Programs

The way that women move can be modified through neuromuscular training programs, which teach athletes’ muscles to better control the stability of their joints. 

So, once female athletes’ muscles are well balanced, they can fine tune their neuromuscular control (or coordination) by taking part in neuromuscular training programs that work on jumping, hopping, pivoting, and other movements that teach athletes how to quickly stabilize their body. 

Studies have also shown that when women perform these neuromuscular training programs, their risk of ACL tears drops down to the risk of men tearing their ACL. 

Create A Balance Between Strength And Flexibility

Since both tight and overstretched muscles are more prone to injury, working on strength and flexibility in moderation is extremely important when it comes to injury prevention. 

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