Why do female footballers get more ACL injuries?
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Fans of women's football don't need a reminder. The 2025 UEFA Women's European Championships get underway in Switzerland at the start of July. The women play on the same pitch as the men, and the same number of players take the field. But there's one alarming difference. Female players are much more likely to injure their ACL, the anterior cruciate ligament.

Tottenham and England midfielder Alan Morris has withdrawn from the Lionesses squad after suffering an ACL injury. Everton women have suffered their second ACL injury of the season. Forward Inmer Gabaro was injured at the weekend, a week after Aurora Ghali suffered the same injury in their season opener. Arsenal women's Victoria Pullover has become the latest player from the club to suffer an ACL injury. It follows the same knee injury to Leah Williamson, Beth Mead, Viviana Miedema and Laura Wienreuter.

The ACL connects the thigh bone to the shin bone, and it's a key ligament that stabilizes the knee joint. For so long, no one has really understood why women get these injuries more often, but now the sport is starting to take the issue more seriously.

The world governing body FIFA is funding research looking into the issue. On today's episode, we're going to hear how hormones and a woman's menstrual cycle may play a role in making these injuries more likely. And we'll speak with a Manchester United player who suffered an ACL tear on the pitch twice. For anybody, getting injured is a difficult period.

You want to play football and be out on the pitch, and whether that's for six weeks, 12 months, however long you're off the pitch, it's always a difficult process. It's not something that you prepare for. I'm William Lee Adams, and this is What in the World from the BBC World Service.

Here to tell us more is BBC journalist Kessua Brown. Kessua, hi. Hi, how are you? Really good. First things first, are you a football fan? I am indeed. I support Arsenal because my dad got me into them when I was very young. Yeah.

And as a fan, you're very much across this. So let's lay out the numbers. Roughly, how many women endure ACL injuries compared to men? So the numbers aren't entirely clear. However, at the Women's World Cup in 2023, between 25 to 30 players were unavailable due to sustaining an ACL injury. That's enough for an entire squad.

Over an 18-month period, Sky Sports estimated that 195 women playing at elite levels suffered from the injury also. And that's just at elite level. Do we know why this is?

Lots of research is being carried out. The Federation of Professional Football Players are looking into this. They've launched a three-year study into ACL prevention. There are also expert panels looking into this and the world governing body, FIFA, is funding research looking into the issue. They've given money to Kingston University in England and

And one of the people working on this specific study, James Breuner, told me some of the reasons why he thinks women experience this injury. Three main key risk factors we see associated with our female athletes. The anatomy that we see in our female athletes having a slightly larger pelvis causes a slightly knocked knee in some of our female athletes. And therefore, we have a larger internal load being transitioned across that knee joint. Therefore, that gives a greater load in daily life, let alone within our sporting context as well.

We also see that the ligaments, the ACL ligaments in our female athletes is ever so slightly thinner than we see in our male athletes. Therefore, it's not quite as strong as we see in our male counterpart athletes and in jumps and landings where we might jump with a female, I think might land with slightly more upright posture, slightly more straighter leg, not cushioning the jump as much as we see in our male counterparts and therefore having an increased load within the knee itself.

And then finally, one of our key risk factors is the hormonal change associated with the menstrual cycle, where we see with hormone changes in the female athlete, we have an increase in the laxity within our ligamental structures, including the ACL, and this laxity can increase its risk of injury. Back to Kessler now. And as the sport grows and women play more,

Are there other factors that impact the likelihood of an injury? For instance, if you're playing more, you're on the pitch more, it seems like you're more likely to endure an injury. Definitely. And that's a really important point. Women footballers are playing at much higher

higher levels than they did in the last three, four years. And I think, you know, women players also have more international breaks, which means that they'll be playing for their club, but then also they'll go and play for their country. And there has been such an increase in international tournaments or international breaks that

in the last couple of years, and this is playing a huge role. Also, you know, if you're an Australian footballer, but you play in the UK and you have to go from the UK to fly back to Australia to play for Australia, that's going to be an issue because of how long it takes you to get from Europe to Australia on one hand. And also just kind of the time difference as well. They're probably going to be a bit tired when they arrive, which can also play a role. What's actually being done to address the likelihood of an injury?

Well, some teams are rotating their players a bit more because that does also make a difference. I mean, there have been instances where some players have played nearly every minute of their domestic league match, every minute of a domestic league match throughout the whole season. And obviously that's a thousand, you know, that's a very high number of minutes.

So that isn't ideal. So I guess if you have more players that you can rotate, that does make a difference. And also there are some teams that already look into how the menstrual cycle affects their players. You know, Chelsea in the UK and the Washington Spirit also.

also kind of began tracking data around their players menstrual cycles so I think there are things that are being done at club level and internationally too. And what about practical steps? Aren't football boots designed for men's feet? When

When it comes to football boots, especially, football boots have been made with a white European foot in mind. And, you know, women tend to have smaller feet. They tend to have a higher arch. And also their hips tend to be a bit wider. So the shoe that has been made for a male might not suit them. Additionally, women...

play on pitches that seem to be a bit in a bit more worse condition than the pitches that men play on, which can also cause injuries. And also just the shape of the ball. The shape of the ball doesn't suit a woman's foot. And that's been a point that people have spoke about quite a lot recently and is garnering a lot of attention is, you know, football boots, the balls and the pitch, because these are conditions that, you know,

perhaps a small tweak could make a huge difference. Kessler, thanks for explaining that. Thank you so much.

One player who's experienced this multiple times is Manchester United's Gabby George. And I'm pleased to say that Gabby is with us now. So, Gabby, you're in a better position than most to explain these injuries as you've had two ACL ruptures in your career. What was it like when you injured yourself? I think for anybody, getting injured is a difficult period.

You want to play football and be out on the pitch and whether that's for six weeks, 12 months, however long you're off the pitch, it's always a difficult process. It's not something that you prepare for. You want to be as fit as you can and be able to play as many games as you can. So yeah, I think for anyone going through injuries, it's difficult no matter the extent of the injury.

The moment it happens, do you really feel it? Is it incredibly painful? For me, it was quite painful, but for others, it might not be as painful. And how long was your rehab process? Both of them were different. I think the first one I was, I had to wait four months for surgery because it's when we went into the global pandemic with COVID. So by the time I then come back, I think it was looking around a year with the four-month process.

And then the second one, it was around 10 and a half months. Oh, and for someone so used to being active, being out there, does that take a mental toll as well as a physical one? Yeah, I think the injuries take a mental toll. I think in terms of activity levels, you're probably training more and longer than you did before because you're

You obviously have a lot of things that you need to recover, it's not just your knee. After surgery you lose quite a lot of muscle in all of your areas, your quads, your hamstrings, glutes, calves, so it's about trying to maintain them as well as building up the knee and everything around that. It was tough to go through and being in the gym and not out on the grass, that's also tough for anyone I think, any footballer or athlete that you speak to, it's not a place that you want to be.

You're someone who has endured. You know, you've suffered and you've come back. Do you have any advice for other female footballers who might have this injury in the future? Yeah, I think I've always said...

all of my interviews that I think if you can the ACL is not about physically coming over it because we're in a position where we're professional footballers we have the resources to be able to physically come over it I think it's all about your mentality and there's going to be days that are dark days and

and days that are good days when you hit your targets where you're allowed to go back out on the field and stuff like that. But I think mentally you've just got to stay in there and go through it. So my advice is to try and enjoy the moment. It's a tough ride, but if you can get over that, then you can get over anything in my eyes. I think for me personally, getting over them two injuries, I don't think there's anything that can...

be as dark as them days. So it's just about enjoying every single moment that I get on the football pitch because you never know when it's going to be your last moment on the football pitch. And we can't wait to see you out there again. Gabby George, Manchester United, thank you so much. Thank you.

As Kessua told us, ACL injuries among high-profile players are encouraging more research into the issue, from academia to business. Major companies are working on football boots more suited to women, and managers are arresting their players more frequently to reduce the risk of injury. We'll see how this plays out at the Euros and after. That's all for today. Thanks for listening to another episode of What in the World from the BBC World Service. I'm William Lee Adams. We'll see you again soon.

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