Why Are ACL Injuries More Common in Female Athletes?
Female athletes face a higher risk of ACL injuries than male athletes participating in many of the same sports. But there isn’t one simple explanation as to why. Differences in anatomy, strength, movement mechanics, ligament laxity, hormones, training and sport exposure can all play a role.
James T. Johnson, MD, a board-certified orthopedic surgeon at Panorama Orthopedics & Spine Center, has seen ACL injuries in female athletes at nearly every level of competition. During decades in sports medicine, he’s cared for recreational athletes, collegiate competitors and Olympic champions, including years working with the U.S. Women’s Alpine Ski Team. Today, he serves as head team physician for the University of Denver Women’s Lacrosse team.
Understanding the factors that contribute to ACL injuries in female athletes can help patients, parents and coaches recognize potential risk factors and identify areas where training and prevention may help reduce injury risk.
ACL Tears: Why Female Athletes Face Greater Risk
The anterior cruciate ligament, or ACL, is one of the primary ligaments that helps stabilize the knee. ACL injuries are especially common in sports that involve quick stops, landing, cutting and pivoting, including soccer, basketball and lacrosse.
Research shows that female athletes may be up to eight times more likely to sustain an ACL injury than males, although the level of risk varies by sport and other factors.
Many ACL tears also happen without direct contact. An athlete may plant her foot to change direction, land from a jump or suddenly slow down. These movements can place a combination of forces on the knee that can lead to an ACL tear.
That gives you the specific research-backed number Dr. Johnson’s study provides without really adding any length to the section.
So, Why the Difference?
On average, females tend to have smaller ACL and knee dimensions and greater joint laxity. Differences in strength and the way muscles work together during movement can also affect how the knee handles force.
“There isn’t one single reason female athletes tear their ACL more often. It’s really a combination of anatomy, joint laxity, muscle strength and how the muscles around the hip and knee work together. Some of those factors we can’t change, but others we absolutely can.” — Dr. Johnson
Some female athletes rely more heavily on their quadriceps during rapid movements, with less contribution from the hamstrings. The hamstrings help control forward movement of the shinbone and support the knee during landing, cutting and sudden stops.
How an athlete moves is another piece of the puzzle. Some female athletes land with less bend in the hips and knees or allow their knees to move inward during jumping, landing and cutting.
“One of the biggest opportunities we have is teaching athletes how to move better. Improving hip and hamstring strength and training athletes to land, cut and change direction with better control can reduce the forces going through the ACL—and ultimately help lower their risk of injury.” — Dr. Johnson
These are trends seen across groups of athletes, not rules that apply to every female. Anatomy, strength, movement and sport exposure vary from person to person.
Some Risk Factors You Can’t Change. Others You Can.
When it comes to ACL injuries, some risk factors are simply part of an athlete’s anatomy. Others can be addressed through training. The goal isn’t to suggest that every ACL tear can be avoided. It’s to focus on the areas where training may help lower risks.
- ACL and knee anatomy
- The shape of the femoral notch: the groove in the thigh bone where the ACL sits
- Posterior tibial slope: the natural angle of the top of the shin bone
- Certain aspects of ligamentous laxity: how naturally loose or flexible the ligaments are
- Growth and development: natural changes to the body that happen during puberty and adolescence
- Hip, hamstring, quadriceps and trunk strength
- Landing and cutting technique
- Balance and body control
- Deceleration skills
- Training load and fatigue management
- Consistent injury-prevention training
Can Female Athletes Reduce Their Risk of ACL Injury?
Not every ACL injury can be prevented, but prevention programs can make a difference.
Structured neuromuscular training has been shown to reduce ACL injury risk in female athletes. These programs typically combine strength, balance, agility, jumping and landing exercises, along with practice changing direction safely.
The harder part can be making time for prevention before someone gets hurt.
“The best time to work on ACL prevention is before an athlete ever has an injury. You don’t need hours of extra training—a consistent program that focuses on strength, balance, landing and cutting mechanics can make a meaningful difference.” — Dr. Johnson
These exercises don’t have to be limited to organized team practices. Athletes can also work on them independently or with teammates. For anyone playing a sport with frequent jumping, cutting, pivoting or sudden changes of direction, consistently working on strength and movement mechanics can be a valuable part of training.
A Career Focused on Understanding the Female Athlete
Dr. Johnson has served as a physician for the U.S. Ski Team since 1999, initially spending more than a decade with the U.S. Men’s Alpine Ski Team. After the birth of his third daughter, he became particularly interested in the health and performance of female athletes and transitioned to working with the U.S. Women’s Alpine Ski Team.
“Every female athlete and every knee is a little different, and I think that’s especially important when we’re treating an ACL injury. We need to look beyond just the torn ligament and understand that athlete’s anatomy, knee stability, sport, activity level and risk of another injury.
Those factors can vary considerably from one patient to the next. The goal is to use all of that information to design an ACL treatment plan that is personalized to the individual athlete, rather than taking the same approach to every knee.” — Dr. Johnson
Why an Individualized Approach Matters in ACL Reconstruction
When an ACL injury requires reconstruction, understanding the individual athlete becomes especially important. Female athletes may have anatomical, biomechanical and other risk factors that should be considered when developing a surgical plan.
ACL reconstruction is not necessarily the same operation for every knee. Depending on the athlete’s anatomy, knee stability, injury history and risk of reinjury, a surgeon may consider additional procedures alongside the ACL reconstruction. These are known as concomitant procedures and are performed at the same time as the primary reconstruction when appropriate.
This individualized approach allows the surgeon to address not only the torn ACL, but also other factors that may affect the stability of the knee and the athlete’s risk moving forward.
Understanding the Female Athlete as an Individual
Female athletes share certain ACL injury trends, but that doesn’t mean every athlete has the same risk factors or needs the same treatment.
Some risk factors are outside an athlete’s control. Others, including strength, movement mechanics and consistent prevention training, are areas where athletes can be proactive.
Understanding those differences can help athletes, parents and coaches make more informed decisions about training, injury prevention and when to seek care. And if an ACL injury does happen, the athlete’s anatomy, sport, goals and individual risk factors all matter when deciding what comes next.
“The more we understand about ACL injuries in female athletes, the better we can help them reduce their risk and compete with confidence. And when an injury does occur, treatment should be individualized—taking into account each athlete’s anatomy, her sport, her goals and her specific risk factors.” — Dr. Johnson
If knee pain or an injury is keeping you from the activities you love, schedule an appointment with Dr. James Johnson at Panorama Orthopedics & Spine Center to get the right care for you.
Sources
- Mancino F, Gabr A, Plastow R, Haddad FS. Anterior cruciate ligament injuries in female athletes. The Bone & Joint Journal. 2023;105-B(10):1033-1037. View on PubMed
- Renstrom P, Ljungqvist A, Arendt E, et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. British Journal of Sports Medicine. 2008;42(6):394-412. View article