Euro 2022: Why do female footballers get so many ACL injuries?

Sports Saturday 23/July/2022 10:32 AM
By: DW
Euro 2022: Why do female footballers get so many ACL injuries?
Marie-Antoinette Katoto has scored 26 goals in 32 appearances for France

After opening with a 5-1 demolition of Italy, an early lead in their second game against Belgium made for a surging start from France, whose internal wranglings had led some to write them off.

But then, out of nowhere, and off the ball, Marie-Antionette Katoto hit the turf. Minutes later, she hobbled disconsolately off, aided by medical staff. After a goal and assist in the opening game, the prolific Paris Saint-Germain forward's tournament was over.

The French Football Federation (FFF) soon confirmed that their top attacking threat had ruptured her ACL (anterior cruciate ligament), a tough band of tissue that connects the thigh bone to the shin bone at the knee joint, and one of the injuries footballers fear most.

She wasn't the first to suffer that fate at Euro 2022. Spain star Alexia Putellas, the current holder of the women's Ballon d'Or, had torn her ACL in a pretournament training session on July 5. Two days later, Northern Ireland forward Simone Magill added her name to the list, though, unusually for an ACL injury, this one occurred in a tackle.

"I felt a bit of contact through the back and I put my left leg out to try and stabilize and balance but unfortunately the knee kind of buckled inwards and the ACL just ruptured from that," the Aston Villa forward said. "When it happened, I knew my tournament was over."

The ACL gender gap

The usual minimum recovery time for ACL injuries is nine months, but they aren't especially common.

They can happen in any sport, although football and basketball players are at higher risk due to the dynamic changes of direction involved in those sports. But why had there been three high-profile injuries in the Euros in the space of just nine days?

It's complicated. However, according to a July 2021 study, Putellas', Katoto's and Magill's gender meant they were "three to six times" more at risk of suffering such an injury than their male counterparts.

One of the authors of the study was Joanne Parsons, an associate professor at the Department of Physical Therapy at the College of Rehabilitation Sciences at the University of Manitoba in Canada.

She told DW that biological factors including hormones (particularly in puberty when ACL injuries in girls often occur) and other biological and anatomical differences between the sexes (knee, thigh and hip shapes) undoubtedly play their part. However, they are far from the only reason for the disparity. Genetic factors and injury history are also highly relevant, but so are societal factors.

Parsons says scientists were once puzzled by the fact that annual ACL injury rates in the general population have decreased for males and stayed the same for females in recent years. Parsons believes a crucial piece of the puzzle has been ignored.

Inherent vs. acquired risk

"We need to think beyond the biological," she said. "So rather than [just] look at the inherent risk, we need to look at what kind of acquired risk they [women] are getting. What kinds of environments and exposures are they experiencing that may make them higher risk?

"I always default back to a weight-room analogy. There's been a fair bit of research done on girls and women in the weight room. It's a highly gendered environment where girls and women often don't feel welcomed or supported. So if we have an environment that doesn't really support strength training, which is highly relevant and needed for injury prevention, then we've created increased risk to athletes rather than it being an inherent risk."

ACL stops sport for some

Among the other potential reasons for the different rates of injury are: the way in which girls and boys are encouraged to move by their parents or coaches (for example dancing vs. playing football) at a young age; that less visible pathways to professional sports mean that strength and conditioning training is perceived as less useful for young women; that women are offered surgery to resolve the issue less readily than men; and the fact that puberty is a danger point for girls injuring their ACLs, which stops many from carrying on with their sport.

Brooke Patterson was one of those who sustained an ACL injury at a young age, while playing basketball. She had to wait several months for surgery in her native Australia as her health insurance didn't cover the operation, a situation doubtless echoed around the world. She was eventually operated on, but now wonders whether it was even required. Some medical professionals and researchers now suggest rest, strength and conditioning and allowing the muscle to heal may be equally effective in some cases.

Patterson went on to play in the women's Australian Football League (Aussie Rules) before becoming a physio and coach while studying for a PhD at the Sport and Exercise Medicine Research Centre at LaTrobe University, Melbourne.

Coming back stronger after injury

She says that elite athletes, whatever their gender, will likely return to their sport after a minimum of about nine months, often better than ever. That's true of many players at the Euros.

"That's the biggest thing I've learned," Patterson told DW. "Seeing athletes, whether I'm coaching or rehabbing, become better athletically, and their football performance as well. Like most athletes who go through an ACL [injury], we have actually come out the other end a lot fitter and stronger."

Germany star Sara Däbritz told DW before the tournament this was the case for her, after she had an ACL injury in December 2019.

"This injury made me even stronger, mentally, as a person, but, also on the pitch," she said. "It helped me going through all of those challenges during the injury."

But it's often a different story for those who play recreationally, and many women are lost to sport after picking up such a serious injury at an early age.

"A lot of the community athletes don't really do rehab for as long as they should, or as frequently as they should. So if they don't return to sport, they're obviously not at risk of re-injuring, but they are at risk of early-onset arthritis. It's more of those general health things that those community athletes might not know about," Patterson said.

The lack of proper support structures can also have an impact on mental health for athletes, whether recreational or professional. Though it doesn't solve everything, the rapid professionalization of the top women's clubs and national teams may offer the likes of Magill, Katoto and Putellas more help than they would have received 20 years ago, or if they were playing lower down the sporting pyramid.

"I think it's a big reason why a lot of community athletes don't go back to sport — the trauma of the actual injury, it's super painful," Patterson said.