With the women’s football World Cup just weeks away, many of the leading sides are losing key players with damaged knees - and it’s an injury that affects female athletes more than men.
Tournament favourites England are without Chelsea forward Fran Kirby and Arsenal teammates Beth Mead and Leah Williamson,with all three recovering from damage to their anterior cruciate ligaments (ACL). Back-to-back World Cup champions the United States are down four players from their 2019 title-winning squad: Mallory Swanson, Tobin Heath, Christen Press and Sam Mewis. Dutch star Vivianne Miedema, Canada’s Janine Beckie and Kiwi Katie Rood are all also some of the big names in the ACL club.
ACL injuries have become so prominent among female athletes, national football governing associations and clubs have called for governing body Fifa to extend international windows to allow players more time to recover during a busy schedule. Players have often returned from international duty and been required to play for their club the next day.
New Zealand Football performance and prevention officer Megan Lee said female footballers could be as much as eight times more likely to sustain an ACL injury compared with men.
The former Football Fern said female “sex characteristics” leave women more susceptible to ACL injuries for anatomical and hormonal reasons.
She said women have a larger “Q angle” between the hip and knee compared to male players, and during puberty the hips widen in female players, creating a larger angle between the hip and the knee.
Lee has recently returned to top-flight football, recovering from ACL surgery in March 2022. She said her injury could have been prevented “had I tracked my menstrual cycle to be aware that I was higher risk [of injury]”.
Football Ferns centurion Annalie Longo has returned to the field just weeks before the Fifa Women's World Cup, following an ACL injury last July. Photo / Photosport
She said she could have considered not playing, or just warming up with the team instead.
“In the menstrual cycle, studies have shown an increased risk of ACL injuries during ovulation,” Lee said. “This typically occurs around day 14 for people with a regular menstrual cycle of 28 days, with day one being the first day of your period. However, this is widely varied for each individual.”
‘Female football teams get lower priority’
Gender (as opposed to sex) is another factor that could make female athletes more likely to suffer knee injuries, according to Lee’s research.
“Gender refers to the characteristics,internal and external, of males and females based on how we socially construct them and how they play a part within our culture.”
She explains the attitudes and actions towards female footballers, based on how we view girls and women.
“Research has shown that modern and historical societal views on gender may still have an impact today on how women are treated as compared to men, and as this relates to sports and sportspeople,” said Lee, who cites as an example that until 1973, women were not allowed to play organised football.
“Typically, male footballers have been afforded increased rates of funding, resources, and scheduling. This comes down to societal views and underlying beliefs of value. This could mean that female football teams get lower priority and funding for strength and conditioning coaches, gym use and availability, field use and availability, travel, physio and medical support, and medical expenses paid for - all of which could impact football performance and injury rate.”
Injured Lioness and Arsenal captain Leah Williamson (centre) cheers on fans. Photo / Getty Images
The baby study, how society perceives gender
To understand the issue of gender bias, Lee cites a study that removes sport from the picture.
The example represents society’s natural biases and varied perspectives of gender impact motor “learning” and “development” from a young age.
“What these researchers did was put a baby in what you would term boy clothes - blue clothes - and a baby in pink clothes.”
However, “it was actually the same baby”, said Lee.
“They got both male and female adults to come in and interact with the baby, and the way the adults interacted with the baby was purely based on what they perceived that baby’s gender to be.
“When the baby was wearing blue-coloured clothes, adults tended to put the baby down on the ground, encourage movement, play with the baby and entice the baby to move around - use their motor skills.
“Whereas when the baby was in pink clothes, the adults came in perceiving that baby as a little girl. So the adults were more likely to pick up the baby, cuddle the baby and not engage or encourage them to move.”
Lee says right from birth, people can have an impact on neuromuscular patterns which are often established, resulting in girls falling behind in fundamental movements.
“It might not relate to elite athletes, but could relate to why girls and young females get injured at higher rates than boys and young males.”
More research needed into women’s sport
“We should be aware of any differences in the way sports teams and organisations treat and value their players, and if that is based on underlying beliefs of gender and sport,” Lee added.
“Recovery” and “strength and conditioning” are ways to combat these types of injuries - ensuring players meet the physical demands of the code.
“Overtraining can also lead to levels of fatigue and low energy availability where we put our body at risk of injury,” Lee said.
She said more research is needed on why elite female footballers are undergoing higher rates of ACL injuries compared with male players.
“Is it sex-based, gender-based, or are there personal circumstances at play?”
Lee is compiling an easy-to-use guide for girls and women footballers that will be published by New Zealand Football later this year.
