Home » Team of Experts Channel » Increased Risk of ACL Injuries for Female Athletes: Reasons Unclear

Increased Risk of ACL Injuries for Female Athletes: Reasons Unclear

Dr. Steven HorwitzMore women and girls are playing sports than ever before. The spectacular performance of women in the Olympics, along with the increase in the popularity of women's professional sports, have had a profound influence on little girls.

The speed, power, and intensity displayed by female athletes have dramatically increased over the past decade. Such more aggressive style of play has led, predictably, to an increase in musculoskeletal injuries. One of the more common is a sprain or rupture of the anterior cruciate ligament (ACL). 

ACL plays vital role in some sports

The ACL is one of four main ligaments inside the knee, running from the thigh bone (femur) to the shin bone (tibia). It keeps the tibia from sliding forward on the knee and stabilizes the knee when it rotates or twists. Straight-ahead sports like jogging, swimming, and biking place little stress on the ACL. It is those that involve cutting, planting and changing direction, like soccer and basketball, in which the ACL plays a vital role, and where athletes, particularly female, are at greatest risk of ACL injury.

Women suffer more ACL injuries

According to the U.S. Consumer Product Safety Commission, soccer players sustained more than 81,600 knee injuries in 1998, with players suffering an additional 225,800 knee injuries in basketball.

A 1995 article in the American Journal of Sports Medicine found that NCAA women's basketball players were four times more likely to tear their ACLs than their male counterparts. The same study found that women suffered twice as many ACL injuries in NCAA soccer as men. 

In addition to the significant pain and suffering experienced by these female athletes, the financial cost is enormous. One study found that it cost $44 million to reconstruct and rehabilitate the 2,200 ACL injuries suffered by female collegiate athletes each year.

No easy explanation

Some ACL injuries are easy to explain because they occur as a result of a direct blow to the knee from the side or rear which tears the ACL. But most ACL injuries are not the result of contact. Women may be more prone to non-contact ACL injuries because they run and cut sharply in a more erect posture than men, and bend their knees less when landing from a jump.

Why women and girls are more prone to ACL injuries than men and boys defies easy explanation is also likely due to a number of anatomical and hormonal differences between men and women:

  • Narrower intercondylar notch and smaller ACL: Not only does the intercondylar notch (the groove in the femur through which the ACL travels) tend to be smaller in women, but so is the ACL itself, leading it more prone to injury.
  • Wider pelvis: Women typically have a wider pelvis, which makes the thigh bones angle downward more sharply than in men. The greater the so-called "Q" angle, the more pressure is applied to the inside (medial aspect) of the knee, which can cause the ACL to tear.
  • More lax ligaments: Women's ligaments tend to have more "give" (laxity) than men's. Research has also shown that women's muscle tissue is more elastic than males. Excessive joint motion combined with increased flexibility may be a significant contributing factor in the higher rate of torn ACLs among women.
  • Slower reflex time: Research shows that the muscles stabilizing the knee may take a millisecond longer to respond in women than in men. Scientists suspect that this small difference in contraction time also leads to a higher rate of injury.
  • Greater Quadriceps/Hamstring Strength Ratio: Poor hamstring strength may contribute to ACL injuries in both sexes. If the hamstring cannot balance the power of the quadriceps (front thigh muscle), the imbalance can cause significant stress to the ACL, leading to injury.
  • Changes in estrogen levels. One recent study suggests that changes in estrogen levels during a woman's menstrual cycle may affect ACL strength, predisposing women to the higher injury rate.  However, a 2007 article in The British Journal of Sports Medicine concluded that there is "no conclusive evidence directly linking an increase in ACL injury to a predictable time in the menstrual cycle."

Training and conditioning programs reduce ACL injury risk

Several studies demonstrate that the rate of ACL injury among women can be significantly reduced by proper training and conditioning.

According to Dr. Thomas Haverbush, a Michigan orthopedic surgeon, a training program developed at the University of Vermont Medical School designed to prevent ACL injuries in skiers led to a 69% decrease in the number of knee injuries among ski patrol personnel and instructors who received the training compared with those who did not. 

In the same article, Dr. Haverbush reported that a six week training program in Cincinnati in which athletes were trained to rely more on hamstring muscles than quadriceps in order to protect the knee could reduce the ratio of knee ligament injuries in female athletes as compared to men from five times higher to only one or two times higher.

Most recently, a study reported in the American Journal of Sports Medicine suggests that the ACL injury rate for  female athletes, particularly non-contact ACL injuries, can be significantly reduced if the athlete follows a specific exercise program called the Prevent Injury and Enhance Performance (PEP) program before practices and games. 

Designed in 1999 by a team of experts at the non-profit Santa Monica Orthopedic and Sports Medicine Research Foundation, the PEP program consists of a series of 19 warm-up, stretching, strengthening, plyometric, and sport-specific agility exercises that can be completed in less than 30 minutes without any specialized equipment. 

The studies identify four ways to reduce the risk of ACL injury:

  • Proper leg muscle strength training and core training.
  • Proper neuromuscular (balance and speed) training.
  • Proper coaching on jumping and landing and avoiding any straight knee landing.
  • Proper footwear and orthotics if necessary.


Revised August 8, 2011