"It's the worst possible news on the eve of the tournament," said England midfielder Izzy Christiansen to BBC Sport. Spanish football journalist David Menayo called it "a jug of cold water" thrown over his nation.
They were referring to the loss of Alexia Putellas, who suffered a torn ACL on the eve of this the women's Euro 2022 tournament, leaving Spain without their reigning Ballon d'Or winner. The loss of such a superstar was evident, as Spain, a pre-tournament favorite, looked tame in bowing out to England in the quarterfinals.
Just a week later, young France star Marie-Antoinette Katoto suffered a similar fate in the Euro group stage, and a toothless Les Bleus attack fell short in the semifinals to Germany.
Bright young USWNT star Cat Macario, who lit up the Champions League for Lyon en route to winning the title over Putellas's Barcelona, tore her ACL in the early stages of a meaningless Ligue 1 match in early June. Two weeks later, legendary American striker Christen Press tore her ACL during NWSL play with expansion club Angel City FC. Just a month prior, Macario's Lyon teammate Dzsenifer Marozsan suffered the same fate, ruling the German star out of the Champions League final and leaving her sidelined for the Euros.
first Alexia Putellas, then Simone Magill, and now Marie-Antoinette Katoto has done her ACL. the #WEUROS2022 is an enemy of knees. https://t.co/zHu2YLa1Hf
— Samantha Lewis (@battledinosaur) July 15, 2022It doesn't stop there. USWNT defender Tierna Davidson went down in March of 2022 with an ACL injury during a shortened NWSL preseason. The Australian national team lost three players to ACL tears in a year's span, including young superstar Ellie Carpenter, who has already collected a massive 57 caps at just 22 years old, but went down in late May. A similar rising star for the German national team, Giulia Gwinn, suffered the injury in early October of 2021, her second ACL tear at just 23 years old.
As time progresses, the list just continues to grow — NWSL finalists Kansas City Current saw midfield fixture Claire Lavogez fall victim in the 2022 playoff quarterfinals. In the run-up to the 2023 Women's World Cup, stars Beth Mead and Vivianne Miedema both suffered ACL tears that ruled them out of the game's biggest event.
"The amount of ACL injuries in professional women's soccer in the last two years has just been shocking," Christen Press told ESPN in May of 2023. "If this happened on the men's side, we would have immediately seen a reaction of 'how are we going to solve this and figure this out, and make sure that these players are going to be available at the biggest moments of their career?'"
This is not just limited to the top of the game; clubs and college programs across the United States are noticing an increase in serious knee injuries. The Wake Forest women's team, a top ACC Division I program, has suffered six ACL tears in the past year, an increasingly common struggle for NCAA women's soccer coaches to navigate.
ACL tears have always been a danger in both men's and women's football, but as top players across the women's global game began dropping like flies, The Sporting News began asking questions. It turns out, there are scientific reasons to explain the wave of ACL tears that strike women's soccer.
A devastating 6 weeks for ACL injuries; Carpenter, Macario, Press.
That's not forgetting Majri, Davidson & Marozsán.
Sports Medicine has generally been guided by research undertaken on male bodies. As we enter a new phase of women's football, female specfic research is vital.
— Ann Odong 🐨🇺🇬 (@AnnOdong) July 5, 2022Women soccer players more prone to ACL tears than men?
Getty Images
Over recent years it has become mainstream knowledge that women are, quite simply, more prone to serious knee injuries than men.
Slight anatomical differences between men's and women's bodies, largely concerning variations in hip structures, leave women at a higher risk of ACL tears or other serious knee damage. "These are trends that we've seen in the sports medicine world for years now," said Dr. Howard Luks, Chief of Sports Medicine and Arthroscopy at New York Medical College and a 20-year orthopedic sports surgeon with over a thousand ACL surgeries under his belt.
"Women in general are at higher risk. They have various differences compared to male athletic counterparts."
Research published by the Yale School of Medicine shows that women are two to eight times more likely to suffer ACL tears than men. Due to a wider hip structure, the knees of females are angled slightly differently, putting more pressure on the ACL. The differences are incredibly slight, but the effects can be witnessed over long periods of time.
"The ACL sits within a narrow notch on the inside of the knee joint," Dr. Luks noted. "That notch has more narrow confines in females, which can increase the risk of injuries."
While anatomical differences between sexes are a large contributing factor, there's another significant difference from males to females. There's medical evidence to support that women are significantly more prone to injury during their menstrual cycle. Given the private and personal nature of this information, research has not permeated the athletic community.
"Our ligament tissue changes based on the influence of hormones," Dr. Luks explains. "The best example of this is a woman's pelvis expands significantly due to the influence of hormones, but pelvis ligaments are not the only ones to change during the various cycles that occur."
Even with all the above, an individual's sex is not the only contributing factor in the ACL tears that occur with greater frequency in women's sports. Playing multiple sports, especially at a young age, can help.
"We've seen an increase in ACL tears due to single-sports participation," says Dr. Luks, explaining that repeated pressure in the exact same manner without variation over time can increase the risk of injury.
"The same stress on the same limbs in the same joints on the same ligaments month after month without any rest has an impact."
ACL injury prevention in women's sports
In recent years, women's soccer and other women's sports have sought to acknowledge the differences in injury risk, and to take steps to try and develop methods of prevention to counter the potential causes.
FIFA 11+ program
While there's no silver bullet when it comes to injury prevention, there's one program that stands out from the rest. The FIFA 11+ program was cited by multiple interview subjects for this report, and often without any prompting.
The FIFA 11+ program focuses on forcing athletes to build muscle memory for one key part of athletics, particularly soccer, that athletes often overlook: landing. The program is designed to be implemented as a short 10-minute warm-up performed before training and/or matches to positively reinforce proper landing techniques.
"They look at the way women jump and land on a surface, and what happens in their knees and ankles," says Brian Maddox, head athletic trainer for NWSL club North Carolina Courage. "They find that [women] move with more motion in their knees and hips when they land."
Dr. Luks, a proponent of the FIFA 11+ program, pointed to a superstar of the men's game for inspiration. "Watch Ronaldo when he lands on a header in the box. He lands on a flexed knee, the leg is as straight as possible, and when he lands he cushions the blow by going into a single-legged or a double-legged squat. These are all techniques that are taught [in the program] to diminish ACL ruptures.
"It's drilled into their heads," Dr. Luks explains. The idea being that such a simple action becomes healthy muscle memory. "Let's say you break your ankle, I put you in a cast, I take the cast off — your muscles are all atrophied. Half of that weakness is loss of muscle strength, but the other half of it is the lack of neuromuscular connections — your brain is no longer connected to those muscle fibers."
Dr. Luks' hypothetical metaphor is meant to show that building neuromuscular connections can create what we know as "muscle memory."
Wake Forest women's soccer senior defender Lyndon Wood, who serves as president of the school's Student Athlete Advisory Committee and is conducting her own research on ACL injuries in women's sports, said she brought the FIFA 11+ program to the Demon Deacons. It was quickly given approval by longtime head coach Tony da Luz.
"I felt like something needed to be done; anything we can do to keep one more girl on the field longer we should do," she said. "I brought it to [Wake Forest Sports Medicine program director] Dr. [John] Hubbard and Tony, and they were like 'Yeah, let's do it.'"
U.S. Soccer medical staff confirmed to The Sporting News that FIFA 11+ and other similar models are employed in training programs at all national team levels, although they would not dive into specifics of the programs at the different levels.
The FIFA 11+ program, however, still has yet to catch on everywhere. When Dr. Luks, whose three kids all play youth soccer, brought the FIFA 11+ program to the directors of their youth soccer programs and volunteered his time, they didn't jump at the opportunity.
"We went out to the schools assuming they would love it...no. Nobody wanted it. I can't explain it, and I was never given a good reason."
Special training regimens
The topic of a woman's menstrual cycle and how it affects injury risk in athletics is a sensitive one, and as a result, action has been slow in taking shape.
An assistant coach at a NCAA Division I women's lacrosse program in a Power 5 conference confirmed to the Sporting News that their program has just this season begun to track their athletes' cycles with the backing and participation from the players themselves.
With this information, women experiencing their menstrual cycle conduct separate, lower intensity training to minimize the risk of injury. It's not yet a practice that's widely adopted, and the same coach indicated that the women's soccer team at his school has yet to implement this same practice.
That's not surprising, says Maddox, the head trainer with the NWSL's Courage. "To my knowledge, it is not widely done in the U.S. because it can be a sensitive subject for some." Maddox says that he is aware of one top European club that does track their athletes' cycles, although he's not sure if they have yet to offer separate training based on the information.
It was widely covered following their 2019 Women's World Cup victory that U.S. women's national team players tracked their menstrual cycle throughout the four years leading into the tournament, and national team players publicly stated that there were several off-field programs implemented to complement this with regards to sleep and mental health. However, U.S. Soccer did not confirm whether these methods currently impact training intensity and injury prevention practices.
This may be the next step in the evolution of injury prevention in women's soccer if the USWNT's experience and that of other college programs yields positive results.
An assistant coach at another NCAA Division 1 women's lacrosse program confirmed to the Sporting News that their program suffered five ACL tears in the past year, and all five women were on their period at the time they were injured.
Mental health and injuries
In recent years mental health has gained increased attention throughout the athletics community, and its importance in injury prevention and recovery is being recognized as part of that push.
"Taking care of the athlete holistically...mentally and nutritionally, those resources are available to athletes these days when maybe they weren't as dialed in 15 or 20 years ago," says Maddox, who has prior athletic training experience in the NHL and minor league baseball.
"You can't disregard the mental aspect of it, this day and age every professional team across sports has those resources available to the athletes because it's useful."
When asked what she's learned through the recovery process, USWNT defender Tierna Davidson told The Sporting News, "Just to be patient with myself. It feels cheesy and simple, but I think as athletes we are impatient because we want results and we want to be 100 percent as quick as possible.
"But I think that through this process I have learned how to celebrate where I'm at in each stage, and not getting down on the fact that I suck at heading at the moment or I'm not as fast at the moment, or whatever it is."
A long way still to go
While more information is being gathered, some programs across the globe have been slow to implement change due to social and societal boundaries that are still difficult to breach.
"[ACL injury research] became a really hot topic in the late '90s and early 2000s," says Maddox. "That's when a lot of the research was conducted, specifically with regards to why women tear their ACLs more than men."
Maddox explains that strength training is a key part of injury prevention, but that the culture around women's sports doesn't lend itself to nearly the amount of strength training that is prevalent in men's sports.
"The way women are training from the youth on up...the emphasis in men's sports and boys sports is that you're not an athlete unless you lift weights. That culture is slowly hitting women's athletics, but it's behind the men."
When asked what they've learned in recent years regarding ACL tear prevention, the U.S. Soccer Federation didn't share any specific details or data points, except to confirm that it's top of mind with their programs.
"U.S. Soccer continuously builds loading programs for players. We work diligently with their clubs and/or universities in monitoring the players and develop individualized plans based on multiple factors in building out ACL prevention, but also soft tissue injuries as well. This has been a long-standing pillar for U.S. Soccer’s care of its players."
Why have so many women's soccer stars torn their ACLs?
Getty Images
The ability to pinpoint specific causes of injuries is ultimately an inexact science. When it comes to the human body, there are so many factors and variables that can affect an athlete's propensity or resistance to injury.
U.S. women's national team star Alex Morgan, who tore her ACL way back in high school, told The Sporting News during a USWNT press conference in the fall of 2022 that she thinks it's possible a shortened preseason and extended competition at the domestic level in the United States could be to blame for injuries in her part of the world.
"We look at the [NWSL] Challenge Cup, it was a great preseason tournament to have," Morgan said in early September in reference to the kickoff tournament of the U.S. women's professional season. "But having that bonus set for players to win, having it be a little more competitive than I think players were really ready for, having players playing 90 minutes week-in and week-out...is that the best for players in the first five weeks of the preseason? Probably not."
Dr. Luks says a quick ramp-up to competitive matches early in the season potentially increases the risk for injury. He explained how a proper and full preseason is critically important to avoiding injury during the year. Essentially, nerves that direct muscle movements connect to those muscles via "motor end plates" which degrade over time. Preseason, which features a slow increase in repetitive activity, is required to rebuild those connections.
"If you don't have connections to all the muscle fibers, I don't care how many weights you put on the rack, it's irrelevant, you're only exercising a third of the muscle fibers, because the other two-thirds don't have a connection to your brain, so they're not firing," Dr. Luks explains. "So that's such a critical component of a preseason program."
The Chicago Red Stars' Davidson, who suffered her ACL tear in preseason training in March 2022 before the Challenge Cup, was less convinced there was a common link in the rash of injuries that afflicted the stars of the women's game in 2022, but she acknowledged that an accumulation of minutes could potentially be responsible for her injury.
"I definitely think you can point to the volume and load that a lot of international players take through their club and country, so I'm sure that a bit of fatigue has to do with it. Sometimes it could just be coincidence, I don't know everybody else's schedule, but I do think there could have been some overuse of players."
A look at the numbers does support Davidson's suspicions. From January to November of 2021, the 24-year-old played 3,224 minutes across both club and international duty, including 1,780 minutes after the start of August. Add in three February 2022 national team appearances in the SheBelieves Cup, and with the short preseason ramp-up, she suffered her tear in March.
Many of the top international players injured this spring had similarly heavy loads. The chart below illustrate the range of matches and minutes played by some of the stars who suffered the ACL injuries (statistics via FBref.com).
Work load for soccer stars prior to ACL injury
(Note: Players listed below in alphabetical order.)
| Player | Date Range | Games | Minutes |
|---|---|---|---|
| Tierna Davidson | Jan 22, 2021 — Nov 30, 2021 | 41 | 3,224 |
| Giulia Gwynn | Aug 29, 2021 — Oct 2, 2022 | 43 | 3,305 |
| Marie-Antoinette Katoto | Aug 5, 2020 — Jun 25, 2022 | 66 | 5,145 |
| Catarina Macario | Jul 1, 2021 — Jun 1, 2022 | 45 | 3,021 |
| Dzsenifer Marozsan | Jan 15, 2021 — Apr 12, 2022 | 70 | 4,893 |
| Christen Press | Oct 4, 2020 — Jun 11, 2022 | 36 | 2,686 |
| Alexia Putellas | Sep 19, 2020 — Jun 25, 2022 | 36 | 2,846 |
The table above shows 30-year-old Marozsan played close to 5,000 minutes across a 15-month period. So did 24-year-old Katoto, who logged 5,145 minutes over two years. Christen Press's numbers don't quite jump off the page, but what stands out is that she had little activity between mid-July 2021 before the Challenge Cup in March 2022.
The schedule congestion is not unique to these players specifically, but many top players across the globe are juggling busy club and international schedules that are increasing in load as the women's game explodes in popularity.
Alex Morgan, who's been a professional since 2011, ultimately labeled the rash of star knee injuries in 2022 an "unlucky run." But what is clear is that there are more variables that impact a women's soccer player's injury chances than in the case of a male player. And there's more research and information sharing that still can be done to investigate each of those factors.
Was it an unlucky run? We'll find out soon enough in the lead-up to the expanded Women's World Cup with 32 teams in July 2023. Given the names forced to sit out due to injury in the summer of 2022, a similar rash of injuries would not go unnoticed ahead of the biggest tournament in the sport.
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