The challenge to rehab and medical professionals is to ensure that players returning from ACL surgery do so with the minimal risk of sustaining a further injury (Bien and Dubuque, 2015).
Anterior cruciate ligament (ACL) injuries in women’s football are known to have a significantly higher rate of recurrence than in men's football (Allen et al., 2007; Gans et al., 2018; Prodromos et al, 2007; Walden et al, 2011).
Various authors have reported that the actual re-injury rates have ranged from 1 in 4 to 1 in 17 in ACL rehabilitated patients (Paterno et al, 2010) with a higher incidence reported in the first two years post-injury (Wright et al, 2007).
Reinjury rates are also higher in female athletes younger than 25 years and with smaller primary grafts often less than 8 mm in diameter (Nguyen, 2016).
Even after successful primary reconstruction, Allen et al., (2016) reported that 28% of all female soccer players and 34% of reconstructed players who returned to sport subsequently sustained a second ACL tear.
Yet despite our best efforts, developing a uniform protocol to prevent this is something that has been discussed for years and numerous theories have been presented as a result.
ACL injuries sustained through a specific series of non-contact mechanisms associated with jumping and landing, running or twisting the knee during a change of direction have been shown to form 70% of ACL tears in women’s football (Burnham and Wright, 2017).
So it would follow, therefore, that preventative strategies are needed to focus on (among other areas) balance, co-ordination, and that explosive burst of speed required that often accompanies directional changes.
Authors agree that ACL rupture often results from repetitive biomechanical stresses leading over time to imbalances in the muscles acting on the knee coupled with reduced neuromuscular coordination.
This is thought to lead to a weakness of the ACL itself which then likely becomes the main predisposing risk factor for injury.
But in practice, the challenges of ACL rehabilitation in the real world can often be a far cry from the published literature, not least when players are coming back from injury and supervised rehab can be difficult to arrange and maintain.
Key to minimising the risk of non-contact ACL injury is thought to be by achieved by gradually altering the way the body lands after jumping, and in women's football at least, this is where the main predisposing factors come into play (Yu et al., 2002).
Risk factors are thought to arise from the angles of the hip and knee on landing; particularly if the knee is almost fully extended and in a valgus position.
The mechanics of a stiff knee landing on a planted foot coupled with increased rotation at the hip (which increases the valgus stress) can be magnified by a forceful eccentric quadriceps contraction leading to overload on the ACL; leading to a subsequent tear (Chappell et al., 2002; Myer et al., 2011; Leppanen et al., 2016).
In short, the landing needs to be soft; and although the knees and hips should flex slightly upon making contact with the ground, the knee should also be over the centre of the toes as the foot hits the surface to assist with proper alignment of the lower limb as a whole (Tyler and McHugh, 2001).
The front part of the foot should take the bulk of the landing force and as the hip and knee flex, as described above, the bodyweight then transfers to the rest of the foot.
Sutton and Bullock (2013) agreed that neuromuscular and proprioceptive training actively encourages female players to avoid placing their knees in vulnerable positions on landing.
Developing the reactive coordination of the hip and gluteal muscles is one area essential for reducing the load on the knee in twisting and turning manoeuvres in a similar vein and emphasises the theory described above.
Linking into this is the thought that the effects of fatigue can contribute to injury risk by impairing the muscles of the thigh that provide the dynamic knee joint stability required (Ortiz et al, 2010 De Ste Croix et al., 2015).
Strength-endurance training to help defer the onset of fatigue together with improved body control in jumping and landing could well be the key to minimising the risk of sustaining ACL injuries in the long-term.
As fine as it sounds in theory, though, training the body to biomechanically adapt is not something that can be done overnight.
This requires regular meticulous attention and the best approach is simply to ensure that jumping and landing techniques are included as an integral part of a regular training session.
Clubs nowadays place a huge emphasis on preventative techniques and are managing to schedule these into their sessions, but if for any number of reasons this does not happen, then it falls to players themselves to work on preventative strategies.
Prevention of ACL injuries certainly isn't easy to implement nor its success guaranteed!
And of course, there are so many other risk factors to take into account as well. In addition to biomechanics, we have the ever-present risk of fatigue, and the original risk factors mentioned earlier related to gender differences and the menstrual cycle.
However, with the amount of research that has been done over the years, we should in theory at least be seeing a greater reduction in female ACL tears.
Sugimoto et al (2015) consider that evidence-based medicine should be practised instead of only considered as "just a concept,” and argue that it is time to translate documented evidence of ACL prevention strategies into actual practice.
This is where the terminology becomes open to debate. Can you really 'prevent' injuries or should we be talking about ‘minimising risk factors’ instead?
Over time I’ve come to think that ‘minimising the risk of injury’ is a more accurate and realistic expression and sits better with players rather than promising injuries won’t occur despite our best efforts to avoid them.
It was Bahr and Krosshaug (2010) who stated that a combination of various factors will render an athlete susceptible to injury, but it is the sum of their interaction that prepares the athlete for an injury to occur in a given situation.
So if we are looking at the high number of recurrences of ACL injuries associated with previous surgery; the potential for another injury always needs to be considered as the various stages of rehabilitation unfold.
It's hard to predict when the circumstances may conspire to lead to the situation described above by Bahr and Krosshaug, especially with so many interlinking risk factors for recurrent ACL prevalent at any given time.
Perhaps we need to re-think our criteria for progression in rehabilitation and consider whether players are ready to move on to the next stage or if current achievements need to be consolidated first; even if that means a longer rehabilitation period is required than originally anticipated.
Over the years, perhaps more research has been conducted into ACL injuries than any other orthopaedic problem. This research has varied between the treatment and management of ACL tears in identifying the causes and mechanisms of injuries.
So although the focus on research has increased our subject knowledge, the high rate of ACL injuries – and in particular recurrences of ACL injuries - remains a cause for concern.
As highlighted by Nilstad et al, (2014) we need to put our increased knowledge of risk factors for lower extremity injuries to better use, and in doing so, continue to develop more highly-accurate and targeted strategies to minimise ACL injury rates in female footballers.
Perhaps we need to go a stage further. In addition to developing injury prevention programmes and identifying common risk factors, further studies are required to assess the effectiveness of current rehabilitation strategies in ACL injury management.
More follows on this fascinating and important subject of ACL injuries in women’s football shortly…
Arendt EA (2007). Musculoskeletal injuries of the knee: are females at greater risk? Minnesota Medicine. Vol. 90 (6); 38 – 40.
Arendt E, Dick R (1995). Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. American Journal of Sports Medicine. Vol. 23 (6); 694 - 701
Bien DP, Dubuque TJ (2015). Considerations for late stage ACL rehabilitation and return to sport to limit re-injury risk and maximise athletic performance. The International Journal of Sports Physiotherapy. Vol. 10 (2); 256 – 271.
Burnham JM, Wright V (2017). Update on anterior cruciate ligament rupture and care in the female athlete. Clinics in Sports Medicine. Vol. 36; 703 – 715.
Chappell JD, Yu B, Kirkendall DT, et al. (2002). A comparison of knee kinetics between male and female recreational athletes in stop-jump tasks. American Journal of Sports Medicine. Vol. 30 (2); 261 –267.
De Ste Croix MB, Priestley AM, Lloyd RS, et al. (2015). ACL injury risk in elite female youth soccer: changes in neuromuscular control of the knee following soccer-specific fatigue. Scandinavian Journal of Medicine and Science in Sports. Vol. 25 (5); 531 –538.
Dugan SA (2005). Sports-related knee injuries in female athletes: What gives? American Journal of Physical & Medical Rehabilitation. Vol.84; 122 - 130.
Gans I, Retzky JS, Jones LC (2018). Epidemiology of Recurrent Anterior Cruciate Ligament Injuries in National Collegiate Athletic Association Sports: The Injury Surveillance Program, 2004-2014. Orthopaedic Journal of Sports Medicine. Vol. 6 (6).
Hägglund M, Walden M. (2016). Risk factors for acute knee injury in female youth football. Knee Surgery, Sports Traumatology, Arthroscopy. Vol. 24 (3); 737 – 746.
Hägglund M, Walden M, Ekstrand J (2006). Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. British Journal of Sports Medicine. Vol. 40 (9); 767 – 772.
Herzberg SD, Motu’apuaka ML, Lambert W, Fu R, Brady J, Guise JM (2017). The effect of menstrual cycle and contraceptives on ACL injury and laxity. A systematic review and meta-analysis. The Orthopaedic Journal of Sports Medicine. Vol. (5) 7; 1- 10.
Hewett TE, Myer GD, Ford KR (2006). Anterior cruciate ligament injuries in female athletes : Part 1. Mechanisms and risk factors. American Journal of Sports Medicine. Vol. 34; 299 311.
Hewett TE, Myer GD, Ford,KR, Paterno MV, Quatman CE (2016). Mechanisms, Prediction, and Prevention of ACL Injuries: Cut Risk With Three Sharpened and Validated Tools. Journal of Orthopaedic Research. Nov. 2016; 1843 – 1855.
Junge A, Dvorak J (2004). Soccer Injuries: A review of incidence and prevention. Sports Medicine. Vol. 34; 929 – 938.
Liu-Ambrose T (2003). The anterior cruciate ligament and functional stability of the knee joint. British Columbia Medical Journal. Vol. 45 (10). 495 – 499
Leppanen M, Pasanen K, Kulmala JP, et al. (2016). Knee control and jump-landing technique in young basketball and floorball players. International Journal of Sports Medicine. Vol. 37 (4); 334 – 338.
Logterman SL, Wydra FB, Frank RM (2018). Posterior Cruciate Ligament: Anatomy and Biomechanics. Current Reviews in Musculoskeletal Medicine. Vol. 11; 510 -518
Mufty S, Bollars P, Vanlommel I, Van Crombrugge K, Corten K, Bellemans J (2015). Injuries in male versus female soccer players : Epidemiology of a nationwide study. Acta Orthopaedic Belgium. Vol. 81; 289 – 295.
Myer GD, Brent JL, Ford KR, et al. (2011). Real-time assessment and neuromuscular training feedback techniques to prevent ACL injury in female athletes. Strength & Cond Journal. Vol. 33 (3); 21 – 35.
Nilstad A, Andersen TE, Bahr R, Holme I, Steffan K (2014). Risk Factors for Lower Extremity Injuries in Elite Female Soccer Players. American Journal of Sports Medicine. Vol. 4; 940 – 948.
Ortiz A, Olson S, Entyre B, Trudelle-Jackson EE, Bartlett W, Venegas-Rios, Heidi L (2010). Fatigue effects on knee joint stability during two jump tasks in women. Journal of Strength and Conditioning Research. Vol. 24 (4); 1019 – 1027.
Paterno MV, Rauh MJ, Schmidt LC, Ford KR, Hewett TE (2012). Incidence of contralateral and ipsilateral Anterior Cruciate Ligament (ACL) injury after primary ACL reconstruction and return to sport. Clinical Journal of Sports Medicine. Vol. 22 (2); 116 – 121.
Pfeiffer RP, Shea KG, Roberts D, et al. (2008). Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. Journal of Bone and Joint Surgery of America. Vol. 88 (8); 1769 17–74.
Prior J, Whittaker JL, Scott AW (2019). Adolescent combined hormonal contraceptives and surgical repair of anterior cruciate tears: a risky recommendation based on an unproven causal relationship, (letter). The Physician and Sportsmedicine, Vol. 47 (3); 240 -241, DOI:10.1080/00913847.2019.1629739
Prodromos C, Han Y, Rogowski J, Joyce B, Shi K (2007). A Metaanalysis of the Incidence of Anterior Cruciate Ligament Tears as a Function of Gender, Sport and a Knee InjuryReduction Regimen. Arthroscopy. Vol. 23; 1320 1325.
Renstrom P, Ljunngvist A, Arendt E, Benynnon B, Fukubayashi, Garret W, Georgoulis T, Hewett TE, Johnson R, Krosshaug T, Mandelbaum B, Micheli L, Myklebust, Roos E, Roos H, Schamasch P, Shultz S, Werner S, Wojtys E, Engebretsen L (2008). Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. British Journal of Sports Medicine. Vol. 42; 394 – 412.
Stuelcken MC, Mellifont DB, Gorman AD, Sayers MG (2016). Mechanisms of anterior cruciate ligament injuries in elite women's netball: a systematic video analysis. Journal of Sports Sciences. Vol. 34 (16) 1516 – 1522.
Sugimoto D, Myer GD, Micheli LJ, Hewett TE (2015). ABCs of Evidence-based Anterior Cruciate Ligament Injury Prevention Strategies in Female Athletes. Current Physical Medicine and Rehabilitation Reports. Vol. 3 (1); 43 – 49.
Sutton K, Bullock JM (2013). Anterior Cruciate Ligament Rupture : Differences Between Males and Females. Journal of the American Academy of Orthopaedic Surgery. Vol. 21; 41 50.
Tyler TF, McHugh MP (2001). Neuromuscular rehabilitation of a female Olympic ice hockey player following anterior cruciate ligament reconstruction. Journal of Sports Physical Therapy. Vol. 31 (10); 577 – 587.
Waldén M, Hägglund M, Werner J, Ekstrand J (2011). The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender related perspective. Knee Surgery, Sports Traumatology, Arthroscopy. Vol.19 (1); 3 – 10.
Waldén M, Hägglund M, Magnusson H, Ekstrand J (2011). Anterior cruciate ligament injury in elite football: a prospective three-cohort study., 2011, Knee Surgery, Sports Traumatology, Arthroscopy. Vol. 19 (1); 11 - 19.
Yu, B; Kirkendall DT, Garrett WE (2002). Anterior Cruciate Ligament Injuries in Female Athletes: Anatomy, Physiology, and Motor Control. Sports Medicine and Arthroscopy Review. Vol. 10 (1); 58 – 68.
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