Female athletes are more likely to suffer ACL injuries. Graphic / Paul Slater
Being on the end of a serious knee injury is among a sportsperson’s worst nightmares, and it happens more to young female athletes than their male counterparts.
Data from the Accident Compensation Corporation (ACC) tracking the rate of anterior cruciate ligament (ACL) reconstruction surgeries from 2009-2019 demonstrated a 120% increase for female athletes aged 15-19, while it was just 36% for males aged 20-24 in the same period. The injury can keep athletes on the sidelines for up to 12 months.
The answer as to why, however, isn’t as clear as what the stats say. Factors spanning from anatomical, hormonal and biomechanical differences to injury prevention and sport-specific training all have a role to play, according to High Performance Sport New Zealand (HPSNZ) performance physiotherapist Helene Barron.
Barron, who is embedded fulltime with Snow Sports New Zealand, said there are several relevant physiological differences between the male and female body. Such examples include the “contrast in control around the hip and knee change during and after puberty for women” as well as how the hamstrings, which protect the ACL, are slower to fire compared with men. Additionally, research has shown hormonal fluctuations impact neuromuscular control throughout the menstrual cycle, according to the ACC, which can increase female athletes’ risk of an ACL tear.
As a result, she highlighted the importance of continued sport science research to truly understand the optimal ways to train to prevent injury for female athletes.
“There’s a heap of research across the board in sports and sports medicine that has been historically based on men and [when] transferred to women, it’s different,” Barron said.
“Looking at the way we move and making sure that sports specific training and injury prevention is really important in that case too.”
At the community level however, where most of these injuries occur according to HPSNZ sport and exercise physician Dan Exeter, training environments can possibly play a role just as much as hormonal and anatomical differences.
Exeter, who is also the medical director for Athletics New Zealand, stressed that in the high-performance environments, equitable pathways for male and female athletes are firmly established. At the community level, where there is a boom in female player participation (and where the majority of ACL injuries occur), however, it can be a different story.
“This is changing, clearly, but we are seeing young female athletes come through training environments that are not perfectly matched to what we see in our male cohort,” Exeter said.
He added that there’s a challenge navigating the “fine line” between creating as many pathways and opportunities for young female athletes as possible whilst having the athletic development and injury prevention to go along with it.
“We are stuck a little bit between a really admirable goal of trying to get more high-level sporting competitions for women and trying to do that as quickly as possible.”
Instilling knowledge at the community level is a big step in the right direction, according to Barron.
She said “coaching the coaches” to have injury prevention measures in place, which can be as simple as an appropriate warm-up, is already making effects on sports that are homing in on female athlete preparation.
“As physios, we might see people once a week, once every couple of weeks [or] once a month but the coaches are seeing them every training.”
“It’s generally that they need to have a range of exercises [balance, strength, agility and plyometric], as well as the really sports-specific drills, and making sure that technique is correct.”
For ACLs specifically, Barron said the difference in prevention training differs from the age and stage of the specific athlete, making it important to tailor “to those athletes in front of you.”
“It might be that there’s more of a focus around biomechanics or landing control in that early stage of puberty when there’s a little bit of dis-co-ordination [and] un-co-ordination that happens as people change the way they move,” she said.
“I think a lot of codes are doing a good job,” Exeter added.
“We’ve got pretty good data around what might work from an injury prevention point of view based on the work that came out of the Fifa Eleven Plus, and that’s been adapted certainly by Netball and the Netball Smart programme.”
The Eleven Plus, which reduces the rate of ACL tears when performed twice a week by almost 50%, according to ACC, is just one example showing the injury prevention “works”, Exeter said, but the issue remains offset.
“Often, it’s not that support isn’t being provided. It’s just that maybe you’re getting the less experienced person or less of the experienced person’s time or all those little incremental differences that potentially add up,” Exeter added.
The core importance of reducing rates for a crippling injury such as an ACL tear ultimately boils down to keeping female athletes in sport. The 15- to 19-year-old age band have a significantly lower rate of returning to previous levels of competition post-injury, Barron said, as well as highlighting the isolating effect being stuck on the sidelines create.
“Sport offers so much in terms of giving younger people confidence, leadership and decision-making, so a dropout in sports actually does cross over into life off the pitch as well,” she said.
“We’re trying to prevent things but also making sure that if people do have injuries, there’s other ways that they’re encouraged to be active and interact with their peers. It’s really hard when all your mates are active and you can’t be.”