Female Athletes and ACL Injury

We dug out from the latest (and hopefully the last) winter storm to hit the bluegrass region, Daylight Saving Time was last weekend and spring is nearly here – and with it millions of kids will be taking to the soccer pitches, tennis courts and softball / baseball fields nationwide. As with any sport, there is a risk of injury. This is especially true for female athletes and their risk of “non-contact” ACL injury. Did you know that female athletes are at an increased risk of suffering an ACL injury when compared to male athletes in the same sport? Statistics vary depending on the study, but the rates are 2-10 times higher in female athletes!

So why are female athletes more prone to suffering ACL injury?

There are more than 250,000 ACL tears each year in the United States and women are suffering them much more frequently than men. Part of the reason is that since Title IX was enacted female participation in high school sports has increased 10-fold and collegiate participation 5-fold. With the raw number of female athletes increasing, the number of ACL injuries has increased as well. Now I’m by no means saying that women should be at home cleaning and learning to cook instead of lacing up their cleats, but women DO need to address some important factors that predispose them to ACL injury.


There are several reasons for this phenomenon and I’ll try to explain them as plainly as possible.

1) Ligament dominance – An imbalance between the neuromuscular and ligament control of dynamic knee stability (relying heavily on the knee ligaments to control stability of the knee) (1)

2) Quad dominance – imbalance between quadriceps strength and hamstring strength, recruitment, and coordination (1)

3) Leg dominance – an imbalance between the two lower extremities in strength, coordination, and control (1)

4) Core dysfunction dominance – an imbalance between the inertial demands of the trunk and core control and coordination to resist it (lack of core control which can affect lower extremity alignment) (2)

As a side note, rapid growth associated with puberty can affect coordination, balance, strength, and neuromuscular control which also come in to play with the above factors. There are some other factors like Q-Angle and ovulation during the menstrual cycle which have shown a relationship to knee injury as well. Combining these factors which tend to exist concurrently, and the risk for injury is multiplied.

Collateral damage from ACL Injury

In addition to the injury itself, there are many other things to consider when talking about ACL injuries. First, the average cost of an ACL reconstruction is roughly $25,000; not to mention pre-surgery consultations, rehabilitation and medication. Second are the emotional and physical problems. People who suffer ACL injuries tend to gain weight following the injury due to an abrupt decrease in their physical activity. Occasionally athletes can become depressed because their chance of playing college or professional sports may have been affected, which can negatively impact their academic performance. Additionally, those who suffer an ACL injury are at a 50%-100% higher risk to develop knee osteoarthritis later in life.

So with all the associated problems stemming from an ACL injury one would think that we have this trend under control, but we don’t. In fact it’s getting worse. What is interesting is that the frequency of ACL injury is increasing in 10-12 year olds! Why are girls so young tearing their ACL? Unfortunately, many parents and coaches are contributing unknowingly to this trend by encouraging their kids to specialize in one sport at a very young age in hopes that they’ll receive scholarships or maybe even play professionally. This “early specialization” is associated with increased injury risk, shorter athletic careers, and sport “burn out”. Studies actually show that kids who specialize early on have a decreased chance of playing college or professional athletics. A trend I’m particularly frustrated with is that kids today are less physically prepared for athletics. They might be great at soccer or baseball, but they are lousy athletes. THERE’S A DIFFERENCE. They spend too much time sitting at home and at school which has altered them physiologically and they only know how to play one sport which limits their exposure to movements outside their single sport.

Some coaches or trainers have their athletes perform drills that are too advanced for their developed skill set which results in poor performance and sloppy technique. If they learn it incorrectly at this stage, it’s much more difficult to correct it years later! Females add a disproportionate amount of muscle mass to body mass throughout puberty further reducing their strength and coordination. Subsequently, these advanced exercises become even more dangerous because they haven’t “grown in to their bodies yet.” Additionally, many coaches choose exercises which are downright dangerous but the parents and kids think they’re doing something good because they’re “sore”  or “exhausted” after their workout. SORENESS DOES NOT EQUAL QUALITY and college and professional training programs SHOULD NOT BE APPLIED to kids!

Unfortunately, females have the deck stacked against them in terms of risk for non-contact ACL injuries. However with smart exercise programming, attention to detail, and some effort, these risk factors can be mitigated in a matter of  8 weeks or less.

How do I know if my daughter is at risk for an ACL injury?  How can I help her reduce her risk?

The first thing to do is to have your daughter screened for risk factors. After the screening, are able to identify possible factors and provide a game plan to reduce the risk. This may mean some basic exercises for pre-game and pre-practice  warm ups or a more advanced and thorough hands-on training program. (We recommend each athlete follow a year-round training system with us so we can monitor every facet of their lives in order to produce a healthier athlete.) Finally, re-test weeks and months later to determine efficacy. EVERY strength and conditioning program we write is based on keeping (or getting) the athlete healthy WHILE improving their strength, coordination, deceleration, acceleration, agility, etc. Certainly some females are more prone to injury and require an increased focus on correcting their imbalances before advancing, but every program is designed to address these numerous factors.

I am hosting some upcoming seminars for female athletes that will include:

  • ACL Risk Screening
  • Education for parents, coaches, and athletes
  • Corrective exercises to implement on a daily basis to reduce injury risk

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