Mancini SL, Dickin C, Hankemeier DA, Rolston L, Wang H. Risk of Anterior Cruciate
Ligament Injury in Female Soccer Athletes: A Review. J Orthopedics & Orthopedic
Surg. 2021;2(1):13-21
Review Article Open Access
Page 13 of 21
Risk of Anterior Cruciate Ligament Injury in Female Soccer Athletes: A
Review
Sophia L. Mancini
1
, Clark Dickin
1
, Dorice A. Hankemeier
2
, Lindsey Rolston
3
, Henry Wang
1
*
1
Biomechanics Laboratory, Ball State University, Muncie, IN, USA
2
Ball State University, Muncie, IN, USA
3
Henry County Center for Orthopedic Surgery & Sports Medicine, New Castle, IN, USA
Article Info
Article Notes
Received: March 05, 2021
Accepted: April 30, 2021
*Correspondence:
*Dr. Henry Wang, Biomechanics Laboratory, Ball State
University, Muncie, IN, USA; Email: [email protected].
©
2021 Wang H. This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License.
Keywords
Anterior cruciate ligament (ACL)
ACL injury mechanisms
ACL injury risk
Female soccer athletes
Abstract
Soccer is becoming an increasingly popular sport amongst women. Common
movements during play, such as jumping and cung, require rapid acceleraon
and deceleraon of mulple lower-limb joints. The anterior cruciate ligament
(ACL), which contributes to stabilizaon of the knee, is oen injured during
these events. ACL injury typically requires costly surgery, extended me
away from sports, and jeopardizes long-term joint health. Due to sex-specic
factors such as menstruaon and anatomical disadvantages, women are more
suscepble to tearing their ACL. Injury oen occurs in non-contact scenarios
during rapid acceleraon or deceleraon movements. Research has examined
these movements and established several kinemac and kinec mechanisms
as well as muscle acvaon paerns that frequently occur at the me of injury,
however results tend to vary based on populaon. This arcle summarizes
recent and relevant literature of ACL injury mechanisms and highlights the lack
of specic research in the high-risk female soccer athlete populaon. Due to
inconclusive risk factors, injury prevenon programs within this populaon
have been inconsistent. ACL injury risk for female soccer athletes should be
closer examined so that more specic injury risks can be established, and
eecve protecve measures can be taken. Raised awareness of this need may
capture aenon in the research and medical communies and potenally
smulate the development of strategies that limit future ACL injury and thus
the challenges it brings to the high-risk female soccer athlete.
Introduction
The sport of soccer has been played both recreationally and
competitively since the mid-19th century
1
. Over time, female
participation has increased both globally and within the United
States, who register 1.6 million female players, the most in the world
2
.
With this increase, there have also been increases in injuries, one of
the most notable being to the Anterior Cruciate Ligament (ACL)
3
.
Several of soccer’s most common movements such as jumping &
landing, changing directions, and sprinting
4
, put the athlete at risk
due to their high-intensity, explosive nature. During these athletic
movements, it is typical for high forces, high loading rates, and high
power to act both externally and internally to the body, potentially
leading to injury. Although several common musculoskeletal injuries
may occur in women’s soccer, the mechanisms of ACL injury for the
this review is to provide clinicians, sports medicine professionals,
strength & conditioning professionals, etc. with recent and relevant
literature regarding ACL injury risk while highlighting the lack of
The authors hope that a better understanding of the threatening
Mancini SL, Dickin C, Hankemeier DA, Rolston L, Wang H. Risk of Anterior Cruciate
Ligament Injury in Female Soccer Athletes: A Review. J Orthopedics & Orthopedic
Surg. 2021;2(1):13-21
Journal of Orthopedics and Orthopedic Surgery
Page 14 of 21
programs.
Literature Search
information. Very few articles summarize the risks
that the female soccer population faces, however, there
are several injury risk articles related to the general
population of female athlete. Articles were found via Ball
State University’s Library One Search journal database,
allowing access to several relevant journals such as Web
of Science, SPORTDiscus, ScienceDirect, PubMed, etc. All
cruciate ligament OR ACL) surgery”. Article acquisition
began in January 2020. Searches were limited to the past
3-5 years and occasionally extended to 10 years in order
Bibliographies of relevant articles were cross-referenced
to complete the search. During cross-referencing, some
relevant articles older than 10 years were found and cited
from the last 20 years, at most.
History of Females in Soccer
from 1991 to 2015 was assessed and indicated increases
in competitiveness, potentially due to technical and tactical
development across multiple countries
5
. Additionally, the
nations’ support for player development
5
. In addition to the
world cup, as of 2008, FIFA also holds world championship
tournaments for females registered as Under-20 and
Under-17
6
. As of 2019, there were 13.36 million girls and
women participating in organized soccer
2
.
began at Brown University. At its birth, the sport was
about as widespread as fencing
7
, however, in 37 years the
soccer ranked 2
nd
as the most participated in women’s
collegiate sport in 2018-19
7
. Additionally, many females
from all over the world have come to the United States to
participate in soccer as student-athletes. From 2014 to
8
. Unfortunately, as
this growth of the sport continues, injury rate remains
steady
9
.
Common Injuries in Women’s Soccer
The rise in women’s soccer injuries has been very
apparent with the growth of the sport. A 15-year
surveillance study (1988-89 through 2002-03) of injuries in
9
. A study on top-level international players
reported most injuries involving the lower extremity,
also with ankle sprains as the most common diagnosis.
Additionally, sprains or ligament rupture represented
10
. An analysis of high
school sports reported similar results during 1995-1997
thigh/leg related. Additionally, women’s players sustained
a higher proportion of knee surgeries than males, with
1 case of surgery per 5 team-sessions
11
. More recently, a
study done from web-based sports injury surveillance of
to 2013-14) women’s soccer athletes found an increased
injury rate in games compared to practice. Researchers
predicted, based on sample size, that in these time periods
were responsible for the highest rate of injuries in games
12
.
Another study found ACL injury rate per 1000 person-days
to be higher in college female players (0.391) than high
school players (0.131)
13
, however, data was only collected
from 8 colleges and 18 high schools. In general, female
college athletes were found to have the highest risk for
13
.
Ankle injuries are the most common type to occur in
women’s soccer
14
of all in the sport
15
. Hip or groin injuries are also seen often
with 439 injuries occurring between 2004 and 2014, an
incidence of .57 per 1000 athlete exposures
16
. Poor hip
adductor strength as well as poor hip external rotation
strength has been recognized as a predictor of noncontact
ACL injury in competitive athletes
17
. While knee injuries
might not be the most common of the lower limb, they
are the leading cause of sports related surgeries
18,19
and
result in the most lost playing time for athletes
15,20
. Based
14), national estimates of knee injuries in high school and
12
.
Burden of ACL Injury in Female Soccer Players
1 in 19 females playing soccer rupture their ACL
21
,
making it a well-known burden to the population. Over the
Mancini SL, Dickin C, Hankemeier DA, Rolston L, Wang H. Risk of Anterior Cruciate
Ligament Injury in Female Soccer Athletes: A Review. J Orthopedics & Orthopedic
Surg. 2021;2(1):13-21
Journal of Orthopedics and Orthopedic Surgery
Page 15 of 21
done on female varsity
15
and adolescent
22
athletes, which
could potentially exceed $650 million annually
23
. Despite
this, surgery is still seen as a more cost-effective option
than non-operative physical therapy treatment
24
. The
effectiveness of surgical vs. non-operative treatment
regarding post-traumatic osteoarthritis
25
as well as patient
reported knee scores
26
is still lacking. Additionally, female
soccer athletes have increased rates of graft tear and
contralateral ACL tear compared with similar non-soccer
athletes
27
. This could be due to athletes not reaching
baseline joint health or function before returning, and has
led to suggestions of extending the typical return to play
from 9-12 months to 2 years
28
. Although this may be a
safer option, it does not gain back lost time from sport for
athletes.
Developing early-onset osteoarthritis (OA) is a
debilitating long-term consequence of ACL injuries
29
. A
follow up study done 12 years post-ACL injury on women
30
. OA has also been
compared to healthy individuals. Individuals with OA
reported increased incidences of pain, low energy levels,
poor physical mobility, poor sleep, and poor emotional
reactions
31
. The prevalence of this injury and high stakes
that it presents has led researchers to study mechanisms
that may challenge the ACL’s integrity as well as identify
the common factors in females, however, mechanisms
Risk Factors of ACL Injury in Female Soccer Players
It is established in the literature that females tend to
suffer from ACL injuries more frequently than their male
counterparts
4,21,32-35
, facing a 2- to 10-fold increased risk
36
.
as early as pre-pubertal stages in females
37
. This is likely
due not only to external movement factors such as weather,
type and condition of playing surface, and footwear
38
, but
also intrinsic factors that tend to differ between sexes.
Women tend to have a higher body mass index (BMI)
than males, meaning they have more weight distributed
over a given height. A higher-than-normal BMI has been
associated with increased risk of injury due to potentially
39
hormones and the menstrual cycle are also theorized
to affect injury risk
29,40
, with some research showing
increased risks in post-menarche groups
40
provides evidence suggesting that sex hormones cyclically
increase knee laxity, which may predispose the ACL to a
stretched state
41
. Their research also suggests that more
injuries occur immediately following menstruation and
just before ovulation
41
, however more recent literature
does not support this claim. Smith et al. analyzed several
different measurement techniques, ultimately concluding
that more research is needed in this area
29
. Furthermore,
females are reported as predisposed due to anatomical
disadvantages including decreased intercondylar femoral
notch size, increased posterior slope of the tibial plateau,
anterior-posterior knee laxity, and several others
29
.
ACL Injury Mechanisms
A non-contact ACL tear occurs when a person generates
forces or moments at the knee that put the ACL under
excessive loading
42
while the body is not in contact with
any other person or object. A contact ACL tear happens
when the injury occurs due to a collision with another
person or object. The ratio of non-contact to contact ACL
injuries is about 7:3
33
. It has been generally established that
non-contact injuries have increased chances of occurring
during deceleration and acceleration movements
43
. An
in vivo study on strain behavior of the ACL reported that
during rapid deceleration, the ligament elongates due to
increased strain
44
. Literature has demonstrated that the
most effective interventions for decreasing the likelihood
of strain are balance training and change of direction
45
.
Change of direction movements that put the ACL at high
risk of injury include deceleration prior to sidestepping,
and landing from a jump
33
; two very common movements
in soccer. Kinematics, kinetics, and muscle activation
patterns have been analyzed to determine mechanisms that
may strain the ACL and therefore increase risk of injury.
These analyses can then be used to help guide prevention
programs to focus on necessary strength requirements,
however there are discrepancies in the literature regarding
risk factors and success of prevention programs.
Kinematics
Kinematic values are closely studied to help
understand the movements of a body. Motion can occur
in either the frontal, sagittal or transverse plane and is
respectively expressed in terms of adduction or abduction,
Quantitatively, values are expressed for individual
planes, however, in regards to predicting injury it has
been proposed that multiplanar analysis may be the
best option
46-48
. Quatman et al. reviewed 198 studies to
determine if injuries occur solely due to mechanisms of
pointed towards multiplanar conditions being more likely
to cause injuries
49
, however, any movement that exceeds
the normal physiological range of motion in any plane
could potentially damage joint structures
43,49
.
Mancini SL, Dickin C, Hankemeier DA, Rolston L, Wang H. Risk of Anterior Cruciate
Ligament Injury in Female Soccer Athletes: A Review. J Orthopedics & Orthopedic
Surg. 2021;2(1):13-21
Journal of Orthopedics and Orthopedic Surgery
Page 16 of 21
method for analyzing injury risk, it is necessary to
understand the mechanisms that commonly occur within
each plane. Within the frontal plane, contraindications
to the knee joint are described in terms of valgus or
varus stresses induced by excessive outward or inward
angulation of the tibia, respectively. Hewett et al. found
that frontal plane analysis of valgus alignment at both
predictors of injury risk. In their screening of 205 female
soccer, basketball, and volleyball athletes, they found
a common trend of increased knee abduction angles at
both contact points (8.4° greater at initial contact and
7.6° greater at peak contact) in all nine athletes who later
ruptured their ACL
47
. Other studies dispute the effects of
knee abduction on ACL injury
50,51
, as the medial collateral
ligament (MCL) is the primary resistor of valgus moments.
Frontal plane kinematics occurring at the knee
does not always occur independently of other joints.
In landings with lateral trunk motion, increasing hip
adduction is necessary to keep an upright stance, however,
can contribute to increased knee valgus moments
36
.
Additionally, knee valgus does not seem to occur without
coupled contraindications. In 10 video cases where rupture
occurred studied by Koga et al., it was revealed that both
valgus and internal tibia rotation occurred almost exactly
40 milliseconds following initial ground contact
52
. These
two movements taking place at the same time have been
shown to increase strain on the ACL more than either by
itself
53
. Furthermore, Pollard et al. studied the relationship
between frontal and sagittal plane kinematics in 58 female
54
.
have continually been seen as a risk for injury
55-57
. Using
a stochastic biomechanical model, simulated trials with
and without non-contact ACL injury were compared, and
factor for injury. Additionally, in-situ mechanical behavior
angles and most compliant at 90°
58
. Boden et al. conducted
a 2-part comprehensive study in which 89 athletes were
interviewed about the events occurring during their
ACL injury and 27 video recordings of ACL injuries were
reviewed. A majority of participants reported the knee
position being close to full extension at the time of injury,
contact injuries occurred with the knee close to extension
during a deceleration maneuver
33
. Fox et al. found similar
various studies reviewed
46
.
Range of motion in the transverse plane is fairly
49
,
however tibial internal and external rotation are important
risk factors to be aware of. Miyasaka et al. studied 6
cadaveric knees and found that internal tibial rotation
results in higher ACL strain than external tibial rotation
59
.
While Quatman et al. supported this, they also suggested
that external rotation has the potential to damage the
ligament in weight bearing situations
49
, during which
non-weight bearing instances
60
. Conversely, Koga et al.
analyzed video of 10 injury scenarios and found valgus
loading paired with internal rotation is a contributing
factor to ACL injury
52
. Research does not specify whether
internal or external rotation poses a bigger threat to the
Kinetics
Kinetic values, although not observable, provide
information regarding the forces acting on or within
the body. They are vital factors which contribute to the
described as the equal and opposite forces applied to the
body by the ground in weight bearing situations. Average
61
and ACL strain
44,62
. Forces acting
across joint axes. Internal joint moments at the hip, knee,
and ankle work to counter external moments by generating
eccentric muscle actions to absorb kinetic energy during
landing
63
assists in absorbing some of the compressive forces.
more extended knee position
63-65
and may, in part, explain
the risk associated with stiff landings. In 60 centimeter
drop jump landings, females demonstrated more erect
posture at initial contact and the knee was found to be
the primary shock absorber
55
, meaning that the knee joint
al. looked at lower extremity energy absorption in double
leg jump landings. Results suggested that biomechanical
knee energy absorption during initial impact phase (100
ms after ground contact)
66
. In a succeeding study, it
was found that during the initial impact phase, greater
sagittal-plane energy absorption may indicate greater
ACL loading based on increased knee-extension moments
and anterior tibial shear force
67
. Repeatedly landing with
poor mechanics during sport play can place large energy
absorption demands on joints, leaving athletes at a greater
to head the ball while goalies jump to make saves. It is
Mancini SL, Dickin C, Hankemeier DA, Rolston L, Wang H. Risk of Anterior Cruciate
Ligament Injury in Female Soccer Athletes: A Review. J Orthopedics & Orthopedic
Surg. 2021;2(1):13-21
Journal of Orthopedics and Orthopedic Surgery
Page 17 of 21
important for players to adopt proper landing mechanics
in game scenarios to avoid high impact forces.
Translation of the knee joint can occur in all 3 planes
due to forces. The most common translation that occurs
with landing is compression, likely as a direct result
of ground reaction force and indirect result of muscle
of tibial plateau bone bruises
49
. The tibial plateau has been
assessed in vitro, showing that posterior tibial plateau
slopes increased from 8.8° to 13.2° caused an anterior shift
in the resting position of the tibia which was accentuated
under axial loads
68
. Tibial plateau bone bruises have
been assessed both in vitro
48
and via magnetic resonance
imaging (MRI)
69
to associate bone bruise injury patterns
with loading mechanisms that cause non-contact ACL
injuries.
Although compression is common, it alone does not
place stress on the ACL. Anterior tibial translation due to
shear forces occurring at the proximal tibia is a primary
ACL loading mechanism
38,42,64,70
. Sell et al. state that anterior
tibial translation causes more direct loading than any
62
. Cadaver research found
to peak ACL strain, however, the most critical dynamic
loading conditions included combinations of anterior shear
force and knee abduction and internal rotation moments
48
.
Conversely, a summary of several studies concluded that
anterior shear force at the knee, and thus, anterior tibial
translation
64
. Additionally, these authors view valgus
moment as a post-injury event, stating there is no evidence
that it is a primary loading mechanism.
In the sagittal plane, it was found that shear forces
65
. This supports the notion that
67
, anterior
shear forces, and therefore ACL strain
64,71-73
. The increase
seen in knee extensor moments may be associated with
where risk factors may be present.
Muscle Activation
Both non-contractile (passive) and contractile
(dynamic) mechanisms contribute to maintaining the
integrity and stability of the tibiofemoral joint. The
contractile mechanisms in the knee joint bring about
complex relationships between the muscle-tendon
units, particularly the quadriceps and hamstrings
74
. The
quadriceps tend to have the most elevated activity upon
landing
62,75,76
. This is because their eccentric contraction is
n
landing
63
. In doing so, the quadriceps help to absorb impact
forces, however, they also act as an antagonist to the ACL
and consequently increase strain
62
. The hamstrings serve as
antagonists to the quadriceps, so their activation is crucial
to resist anterior tibial translation and thus ACL strain,
providing stability to the knee
77
. The complex relationship
between contractile and passive components of the knee
joint is essential for safe landing and energy absorption.
muscle activation
36,72,75
, most notably excessive quadriceps
in females
62,75,76,78
. It has been suggested that reduced
hamstring activity relative to the quadriceps may contribute
42,49,65,79
and
therefore injury risk. In addition to increased hamstring
contraction preventing valgus stress on the knee, gluteus
maximus and medius muscles contribute by controlling the
hip joint
36
peak knee abduction angles as well as greater peak knee
80
. In the sagittal plane, increasing
hamstring activation has been associated with greater
77,79
and less external rotation
moments
75
. Furthermore, Palmieri-Smith et al. suggested
that a more balanced co-contraction in the frontal plane
could largely contribute to stabilization of the knee. They
observed less activation in the vastus medialis compared
to the vastus lateralis as well as less activation in the
medial hamstrings compared to the lateral hamstrings in
females
81
. This medial to lateral imbalance may explain
why many females lack the ability to resist abduction loads
in the knee joint
75,81
.
During landing, eccentric muscle actions of the lower
extremities absorb the most kinetic energy
66
. Landing
energy absorption to spread-out over all landing phases,
therefore reducing the excessive loading of the tissues. A
a majority of the energy
63
. With a majority of energy
absorption occurring at the ankle joint, this movement
strategy lessens the propagation of reaction forces up the
kinetic chain. This may be linked to ACL injury prevention
65
.
Prevention Programs
training in female athletes
82-84
, however, results of various
studies on ACL prevention programs for soccer players are
inconsistent
64
Additionally, research in women’s soccer
reports low-level evidence that multicomponent exercise-
based programs reduce ACL injuries
85
. Sugimoto et al.
examined critical components of neuromuscular training
and found age of participants, dosage of training, exercise
Mancini SL, Dickin C, Hankemeier DA, Rolston L, Wang H. Risk of Anterior Cruciate
Ligament Injury in Female Soccer Athletes: A Review. J Orthopedics & Orthopedic
Surg. 2021;2(1):13-21
Journal of Orthopedics and Orthopedic Surgery
Page 18 of 21
variations and using verbal feedback to be predictors that
optimize neuromuscular training
86
. Furthermore, they
interpreted that ACL injury risk can be reduced by 17.2-
to prevention programs
86
. In addition to inconsistent
results, cost
87
and compliance
64,88
are major barriers that
keep teams from participating in prevention programs.
coaches found that most coaches are aware of prevention
programs, however, feel they lack training for instructing a
program
87
able to either hire a position to administer training or
pay to train the coaches, leading to cost being the most
highly ranked barrier for non-users
87
. Additionally, the
time consuming and labor-intensive aspects of prevention
programs may limit compliance. Females who participated
with low compliance faced a relative risk 4.9 times higher
than those with high compliance
88
of female athletes revealed that, of the 44 soccer players
in prevention programs
89
.
Some research suggests that targeting high-risk athletes
86,90
.
analysis and found that 108 and 120 female athletes would
need to be trained to prevent one non-contact or overall
ACL injury, respectively, over the course of one season
86
.
They suggest that identifying at-risk athletes may improve
these numbers. A study dividing high-risk and low-risk
techniques may be necessary for high-risk athletes to
decrease ACL injury risk
90
. Furthermore, it has been
suggested that soccer athletes prevention should include
of the game
91
, however not much research has been done
population.
Conclusion
Lower extremity musculoskeletal injuries are a lingering
threat to all female soccer athletes. The unpredictable, fast
frequently lead to unwanted mechanics that tend to
cause injury. Although this population faces several
common injuries, it seems the ACL injury is one of the
most detrimental in terms of need for surgery, return-to-
play time, and long-term joint health. Based on current
knowledge, there is a lack of understanding regarding ACL
developing population.
kinetic, and muscle activation patterns for female soccer
athletes. The contribution of several kinematic and kinetic
mechanisms as well as muscle activation patterns to ACL
prevention programs for female soccer athletes, which
may be able to produce positive results and potentially
boost compliance.
ACL injury risk for female soccer athletes should be
established, and effective protective measures can be taken.
Raised awareness of this need may capture attention in the
research and medical communities, potentially stimulating
research and thus, the development of strategies that limit
future ACL injury and thus the challenges it brings to the
high-risk female soccer athlete.
Acknowledgement
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