ACL Tears - Why Do They Occur, Why Do They Happen Most Often to Female Soccer Players, & How to Prevent Them

ACL tears have become very common and prevalent in sports, especially female soccer players. This is due to the movements of the sport, the muscle imbalances of female soccer players, bodily changes through puberty, incorrect footwear, and improper training.

Let’s begin with some background on the knee. In the knee there is the ACL, PCL, MCL, LCL, patellar tendon, meniscus, and quadriceps tendon, but beyond these that connect in the knee, there are several other tendons, bones, and muscles that run through the area of the knee whether the sides or the back. These muscles, while not directly attached to the knee, can cause pain in the area behind the knee due to tightness or muscle strain. Due to all of these anatomical structures in the knee, it's no wonder so many athletes have issues or pain in and around their knees. 

For example:

• The calf muscle begins in the femur where it is attached and runs down behind the knee to the Achilles tendon

• The hamstring originates in the pelvis and crosses the knee joint to attach in the lower leg

  
  

Let’s get into the big question, why do female soccer players have such a high rate of ACL tears and why do athletes in general commonly tear it? First, we will understand why this is a common injury in athletes. While most of the time we hear about ACL tears, the meniscus and MCL frequently are also damaged in those injuries. Less often is an ACL tear caused from trauma, contact, or blunt force, which means this is an issue that can be highly preventable if fixed and trained for early on.

One of the biggest reasons for ACL tears is muscle imbalance. This means that many athletes have some muscles that are more overdeveloped and some muscles that are more underdeveloped or weak. This imbalance causes our bodies to not have the proper counter muscles to balance the force and strength of the active muscle. The two most commonly underdeveloped muscles, especially in female soccer players, is the medial quadricep and the hamstring muscles. Many athletes are lateral quad dominant or overdeveloped due to the nature of sports involving change of direction, pivoting, cutting, and any lateral movements. Because of this, when an athlete has muscle imbalances, it disrupts knee stability and proper biomechanics during activities common in sports like jumping, landing, change of direction, and more.

For example:

• An overdeveloped quad will pull the tibia (shin bone) forward and when the hamstring is underdeveloped, it cannot provide counterbalance and help control this movement, straining the ACL.

• In lateral movements, the lateral quad pushes the lower leg externally, but with a weak medial quad, there is no counterbalance to control the movement and stabilize the knee.

• Weak glutes and hip flexors can lead to improper hip and pelvic stability, affecting the entire chain of motion and can cause the knee to collapse inward during activity, greatly straining the ACL and knee in general. 

Taking all of this into consideration, the reasons that female soccer players are more prone to this injury include bodily changes from puberty worsening the effects of muscle imbalances, improper footwear, and insufficient training. During puberty in girls specifically the bodily changes are very different than boys, increasing risk for many injuries greatly. For this reason, strength and injury prevention is crucial to begin by this time at the latest. Puberty causes hips to widen, leading to a change in weight displacement, which can lead to the lateral quad becoming more overdeveloped, other muscles becoming weaker, and the risk of an ACL tear or other injuries to increase. Additionally, during puberty, ligaments and joints have greater laxity, increasing the risk of ACL tears and ankle sprains. 

To add to the effects of these bodily changes, athletic footwear, especially for women, has been outdated and incorrect until recently, but many athletes are still uninformed. For example, in soccer there are 4 main types of footwear outside of futsal shoes. There are soft ground cleats, firm ground cleats, all ground cleats, and turf cleats. Each of these cleats is meant for a different surface, but there is some overlap.

• Soft Ground (SG) Cleats

  • Long, often metal studs

  • Should be highly avoided unless playing on an extremely muddy, soft real grass surface in a high level, important game

  • Puts an athlete at high risk for an injury, especially an ACL tear, due to its ability to get stuck in the ground in pivoting, cutting, or change of direction motions

• Firm Ground (FG) Cleats

  • Shorter, typically wider blade shaped, plastic studs

  • Meant for real grass pitches that are shorter, more dry grass

  • Cannot be worn on turf, although they are typically safer on real grass, but due to the shape and their grip, there is still risk for injury

• All Ground (AG) Cleats

  • Shorter, conical studs,

  • Provide safer traction as the shape of the stud allows for easier release from the ground

  • Used on short real grass and turf

  • More highly recommended for female athletes and injury risk prevention, but many female athletes continue to wear FG cleats on turf due to their popularity and lack of information on the risks of those cleats.

• Turf cleats

  • These are the safest form of cleats on turf as they have no studs

  • The texture on the bottom can vary providing more or less grip on the surface

  • These cleats will not risk injury from getting stuck in the turf on turns or cuts

  • There is the possibility of slipping from less grip

In addition to the type of cleats, some companies make cleats deigned for the female foot shape and weight displacement, which most “women” cleats from big brands do not. I live in my IDA cleats (code SUMMERM to save 10%) as they are the only women’s cleats I’ve ever been able to comfortable wear because they are actually designed by women for the female foot. These cleats offer a wider toe box, narrower heel, conical studs in specific placements for a woman’s foot, among other specifications that make these unique cleats special for women. They offer AG, turf, and futsal cleats to provide all the options for female athletes. Most cleats for women aren’t really made for women as the brands simply “shrink it and pink it” without taking into consideration how different the male and female foot and body is. Some brands are beginning to expand to a proper women’s cleat but I’ve yet to see any that I would trade for my IDAs. 

Overall, ACL tears are prevalent in athletes due to the movements of the sport, muscle imbalances, improper footwear, bodily changes through puberty for girls, and improper training. Don’t wait to begin your injury prevention training until it’s too late. ACL tears are not an ankle sprain. They require surgery, a 9-12+ month rehab and recovery period and put you at high risk for re-tearing the same ACL or tearing the other one as I’ve seen happen often. This is an injury that can easily be avoided and should be avoided at all costs through proper, early, consistent injury prevention training and proper footwear.