ACL injuries in female athletes: Risk assessment and prevention
There’s no argument that Anterior Cruciate Ligament (ACL) injuries are a significant issue for athletes, physiotherapists, and sports medicine professionals. Female athletes, in particular, face a markedly higher risk, which has far-reaching implications for their long-term health and athletic careers. A focus on prevention of ACL injuries is the most effective and cost-efficient way to reduce the burden of knee injuries in athletic populations. This blog will explore why female athletes are at greater risk of ACL injuries, how to assess their risk factors, and what physiotherapists can do to help prevent these injuries.
If you want to learn more about ACL injury risk and prevention, watch Dr. Matthew Bourne and Dr. Tyler Collings’ excellent Mastering ACL Injury Masterclass.
The problem for females
Females are 4-6 times more likely than males to sustain ACL injuries while participating in the same sport! While males still account for a larger total number of ACL injuries due to higher participation rates in many sports, the incidence rate in females is disproportionately greater. Alarmingly, the highest annual growth rate in ACL injury incidence is observed in girls aged 5–14 years. This is particularly concerning when we think about the long-term consequences of ACL injury; in many cases it can be career-altering, and can also have longer-term implications for participation in life. Approximately two-thirds of people do not return to their sport following an ACL injury and nearly half experience re-injury within 12 months. Additionally, a staggering 50-90% of people develop post-traumatic knee osteoarthritis within 10-15 years. Research is increasingly directed toward understanding why this is such a big issue for female athletes, with the aim of understanding how to implement prevention strategies and reduce the burden of ACL injuries on female sport. While there’s still a lot we don’t know, there are a few things may contribute to this disparity:
- Biological factors: females typically have smaller ACL volumes compared to males, and morphological characteristics such as greater posterior tibial slope and a narrower intercondylar notch which may increase susceptibility to injury
- Environmental and social factors: let’s face it, while things are moving in the right direction, female athletes still often face reduced access to training facilities, fewer opportunities to participate in sport, and limited access to things like quality coaching and medical resources compared to males.
This highlights the need for targeted prevention strategies, with particular emphasis on individualised care for female athletes, to address the biological, environmental and social factors which may contribute to the higher incidence rate.
Assessing risk factors in female athletes
Effective injury prevention begins with understanding and identifying risk factors, quantifying the level of injury risk and determining whether this is acceptable. Risk assessments should include a combination of components such as clinical history, physical examination, and biomechanical analysis. For example, jump and landing mechanics can provide insights into neuromuscular control deficits, while strength testing (e.g., hip abductors, external rotators, and hamstrings) can reveal potential weaknesses, which at the very least, may need to be addressed to enable the female athlete to perform at her best. Dr. Tyler Collings outlines useful field-based injury risk screening tools in the below video taken from his Masterclass:
Injury prevention strategies for female athletes
Prevention programs tailored to female athletes may reduce the incidence of ACL injuries. These programs should target modifiable risk factors through strategies such as:
- Neuromuscular training programs focusing on improving movement patterns such as landing mechanics.
- Strength training: while there is limited evidence linking strength deficits with ACL injury, strengthening the hamstrings, hip abductors, external rotators is beneficial for overall knee stability and performance,
- Proprioceptive training: this can help athletes maintain proper joint alignment and control during high-risk activities such as single-leg landing.
- Education and access: equal access to training facilities, experienced support staff and medical resources is a critical step we can take in reducing the gender gap in ACL injury.
- Additionally, ensuring the appropriate level of support is available for those who have experienced an ACL injury is an important step in mitigating potential long-term effects.
Prevention programs should ideally start early, given the increasing incidence of ACL injuries in younger athletes. There are multiple prevention programs–such as FIFA-11 and “Prep-To-Play” programs–which have been designed to be low-cost and easily implementable across all sporting levels. Additionally, regular screenings and monitoring can help identify athletes at higher risk, allowing for timely intervention. See Tyler describe a great pre-season womens’ football testing battery in the below video taken from his Masterclass:
Wrapping up
As support for female sports continues to move in the right direction, ACL injuries are becoming an increasing challenge. Physiotherapists play a vital role in mitigating these risks through education, assessment, and implementation of evidence-based prevention programs. By understanding and addressing modifiable risk factors, we can empower female athletes to perform at their best while aiming to minimise the risk of injury. While it is integral to understand how to best support athletes who sustain ACL injury, continued focus on prevention strategies is also essential to addressing this growing issue effectively.
If you want an in-depth understanding of ACL injury risk assessment and prevention, watch Dr. Matthew Bourne and Dr. Tyler Collings’ full Masterclass HERE.
Want to become an expert on ACL injury prevention?
Dr Matthew Bourne and Dr Tyler Collings has done a Masterclass lecture series for us!
“Mastering ACL Injury: From Incidence to Injury Prevention”
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