ACL Injury Prevention in Female Soccer

[graffam198]

With the World Cup upon us, aside from stories of triumph and tragedy, there is a thread starting to build around injuries. Predominantly ACL injuries in the women's sport. This Study suggests that as many as 1 in 19 female athletes will suffer an ACL injury in their soccer career.

I coach 2 teams and assist on 2 others. Ages range 9 - 12. As many of the olders are now starting to develop, I would like to start implementing a program to keep their legs healthy; give them a better chance at injury prevention if I can. Find what works and tweak as the youngers start to age into their bodies changing.

Some of the theories around why women are more susceptible than men center around biological and physiological differences in women. Wider hips changes the leg angle, USWNT has a theory on menstruation, lower bone density, etc. I know it's shocking to think that something on the internet might not be accurate, (crazy right?!) so I am turning to the collective minds here for thoughts and guidance.

I'm looking for any articles, research, programs, etc. that would be beneficial in the planning of this. As well as anything some of you other coaches are deploying with your female athletes. I.e. Skiing dryland training. Those athletes have a tremendous amount of strain on their knees (and often suffer injury due to catastrophic failure), but also have great success in joint health barring high speed crashes.

I'm a huge fan of running, big thighs save lives kind of guy. But I don't think this is enough. What kind of stretches, strength training (which introduces other risks around form and weight), core work should I be thinking about, researching, deploying?

@DaveRoberts'Shoes if you have any thoughts

 

[cgori]

The PT I used when I injured my knee sends an email newsletter ~monthly to past patients. I saved a bunch of them and searched quickly to see what she had said about this in the past. She made reference to this article that you might find interesting - suggesting that training for injury prevention and improved performance are mostly well-aligned in terms of time spent:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5800728/

From what I can tell (it's a pretty dense/technical publication so you'll want to take a look yourself), multicomponent training is shown as the most effective prevention. Table 2 in the paper shows what is incorporated in the various meta-analyses (strength, plyometrics, agility, etc). Table 3 lists a bunch of different exercises of each type.

 

[wiffleballhero]

I don't have too much to add, except that my 15 yo daughter who is a good -- but not spectacular, let's not go overboard -- player really now has had her high school soccer experience sort of trashed because of a late winter ACL tear from skiing. She's headed into 10th grade. Had she been able to buckle down, she might have had three years starting on the high school varsity but now she'll be lucky to start as a senior since she's missing her 10th grade year and going to be, now, on a bit of a bubble in 11th grade (the incoming senior class is very thin).

I might be more bummed than she is.

ACL and female athletes is a real thing. My anecdata here is that she popped her ACL on almost nothing, literally standing still (got hit by her friend who skied right into her leg).

 

[wade boggs chicken dinner]

literature review here (mentions skiing): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592422/

 

[graffam198]

The PT I used when I injured my knee sends an email newsletter ~monthly to past patients. I saved a bunch of them and searched quickly to see what she had said about this in the past. She made reference to this article that you might find interesting - suggesting that training for injury prevention and improved performance are mostly well-aligned in terms of time spent:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5800728/

From what I can tell (it's a pretty dense/technical publication so you'll want to take a look yourself), multicomponent training is shown as the most effective prevention. Table 2 in the paper shows what is incorporated in the various meta-analyses (strength, plyometrics, agility, etc). Table 3 lists a bunch of different exercises of each type.

Thank you! This is a great starting point.

I don't have too much to add, except that my 15 yo daughter who is a good -- but not spectacular, let's not go overboard -- player really now has had her high school soccer experience sort of trashed because of a late winter ACL tear from skiing. She's headed into 10th grade. Had she been able to buckle down, she might have had three years starting on the high school varsity but now she'll be lucky to start as a senior since she's missing her 10th grade year and going to be, now, on a bit of a bubble in 11th grade (the incoming senior class is very thin).

I might be more bummed than she is.

ACL and female athletes is a real thing. My anecdata here is that she popped her ACL on almost nothing, literally standing still (got hit by her friend who skied right into her leg).

This is horrible. I am so sorry to hear this. One of the papers suggested that 70% of ACL tears are from non-contact injuries. The paper also spoke about ACL tears in female skiers often being due to a slower twitch in Hamstring paired with rigid boots during a fall. This is a terrible injury to sustain while just waiting for a friend.

 

[graffam198]

literature review here (mentions skiing): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592422/

Thank you!

 

[Humphrey]

There are a disproportionate number of ACL injuries in women's basketball vis-a-vis men.

One girl my daughter played with blew one out in the 8th grade, then the summer before her senior year; blew out the other one. I would think especially the second one might have been preventable.

In her case, she was going to sign with a Division 2 program but her skill set at that level was a bit of a stretch. She recommitted to D3, imho a smart move; not a superstar there, plays 24 min a game.

 

[RedOctober3829]

My D-1 WSOC team a couple years ago had a run of ACL's in a fashion that I've never seen before. I believe we had 7 ACL tears. Happened with all different kinds of footwear, on all surfaces, etc. No correlation between any of them. I firmly believe the amount of soccer these girls are playing on turf from the youth level on up is a big reason why.

My recommendation would be if you're playing on turf is to have your players play either in turf shoes or cleats with artificial ground(AG) spike plates. The firm ground(FG or grass) cleats tend to have longer spikes that can get caught in the turf and can cause non-contact injuries a lot more than the TF or AG footwear.

 

[graffam198]

Thanks! Luckily most of our games are on Grass. We run into a couple tournaments a year on Turf. I am for sure going to recommend Turf cleats in addition to the FG cleats they all have. Hate to ask parents to spend more money, but in this case, I think it is appropriate.

 

[luckysox]

There are a disproportionate number of ACL injuries in women's basketball vis-a-vis men.

One girl my daughter played with blew one out in the 8th grade, then the summer before her senior year; blew out the other one. I would think especially the second one might have been preventable.

In her case, she was going to sign with a Division 2 program but her skill set at that level was a bit of a stretch. She recommitted to D3, imho a smart move; not a superstar there, plays 24 min a game.

I’m struggling to understand what this young woman’s skill set and level of superstardom have to do with her injuring her knees. What’s the point of sharing your opinion about her skill set here? How is it relevant to the thread?

Also wondering how you have figured that,
“…especially the second one might have been preventable.” Like, how? Why?

 

[BaseballJones]

There are a disproportionate number of ACL injuries in women's basketball vis-a-vis men.

One girl my daughter played with blew one out in the 8th grade, then the summer before her senior year; blew out the other one. I would think especially the second one might have been preventable.

In her case, she was going to sign with a Division 2 program but her skill set at that level was a bit of a stretch. She recommitted to D3, imho a smart move; not a superstar there, plays 24 min a game.

My daughter (who played college hoops) tore her right ACL in high school (senior year) and her left ACL in college (junior year).

Cost her a potential state championship in HS (they made the semis the year before and were top 5 in the state regardless of class going into the season) and she tore her ACL during a fall scrimmage before the season even started - cost her a state volleyball tournament appearance too as it happened the day before her first round state volleyball game.

I'm no doctor, but I work with college athletes and obviously have this kind of family experience to draw upon. There is definitely something physiological at play here. Hip width, leg angle is a real thing. Clearly causes stress on the knee joint in ways that are more severe on average than men. Nothing can be done about that. But teaching proper running form, wearing proper footwear, making sure playing surfaces are in proper condition - all this stuff matters. A good friend of mine teaches kinesiology and was an Olympic level athlete, and one thing he researched was the grip of new basketball sneakers on freshly finished basketball courts. The grip in those conditions can be too much. I haven't seen his study; just passing along what he shared with me.

So taking good care of playing surfaces - whether indoor or outdoor - is really important.

I was at the Women's Big East basketball tournament many years ago when UConn's Shea Ralph tore her ACL. Sitting in the second row, it happened right in front of me. She took off on a fast break and someone threw her a long pass. She jumped and caught it and landed with both feet, full stop. And immediately crumpled to the ground. I knew instantly that her knee just shredded. No contact, not even a turn or spin. Just a jump and land - though from a dead sprint to a complete stop in an instant. And boom, the knee blows out.

 

[Humphrey]

I’m struggling to understand what this young woman’s skill set and level of superstardom have to do with her injuring her knees. What’s the point of sharing your opinion about her skill set here? How is it relevant to the thread?

Also wondering how you have figured that,
“…especially the second one might have been preventable.” Like, how? Why?

I think Baseball Jones' reply summates the reasons why Injury #2 could have happened.

 

[graffam198]

My daughter (who played college hoops) tore her right ACL in high school (senior year) and her left ACL in college (junior year).

Cost her a potential state championship in HS (they made the semis the year before and were top 5 in the state regardless of class going into the season) and she tore her ACL during a fall scrimmage before the season even started - cost her a state volleyball tournament appearance too as it happened the day before her first round state volleyball game.

I'm no doctor, but I work with college athletes and obviously have this kind of family experience to draw upon. There is definitely something physiological at play here. Hip width, leg angle is a real thing. Clearly causes stress on the knee joint in ways that are more severe on average than men. Nothing can be done about that. But teaching proper running form, wearing proper footwear, making sure playing surfaces are in proper condition - all this stuff matters. A good friend of mine teaches kinesiology and was an Olympic level athlete, and one thing he researched was the grip of new basketball sneakers on freshly finished basketball courts. The grip in those conditions can be too much. I haven't seen his study; just passing along what he shared with me.

So taking good care of playing surfaces - whether indoor or outdoor - is really important.

I was at the Women's Big East basketball tournament many years ago when UConn's Shea Ralph tore her ACL. Sitting in the second row, it happened right in front of me. She took off on a fast break and someone threw her a long pass. She jumped and caught it and landed with both feet, full stop. And immediately crumpled to the ground. I knew instantly that her knee just shredded. No contact, not even a turn or spin. Just a jump and land - though from a dead sprint to a complete stop in an instant. And boom, the knee blows out.

Thanks everyone for this. Just to add some of the info that I have come across in the journals that highlight your observed experience and back it up with science!

Hip Width is huge. As is the general construct of the leg. The angle of attachment paired with a narrower notch at top of knee lead to increased stresses on the ACL. Another hypothesis with measurable differences is how women land vs. men. The observed reaction / utilization of the hamstring is slower in women which causes an over-reliance on the quads to slow an impact. Which in turn increases the stress to the ACL. As explained, women don't "drop" as much on a jump as men due, they tend to stay more stiff legged, (which I see with my own daughter).

Grip is such an amazing pull! One of the more recent articles I was reading has to due w/the coefficient of friction between the sole plate of a soccer boot and the surface. And to your point, there is too much. Especially on parquet / rubber floors as found on futsal courts. Basically my team will never play on those surfaces after reading that literature. (too infrequent to build up "knowledge"). Also, the woman's boot is not designed for the woman's (traditional) fit. Women have narrower heels and wider toes which makes the men's boot a different ratio (wider heel to toe). As such, this causes undue strain on the knee. And soccer boots are kind of the last frontier for gender specific designs.

I am still trying to understand the relationship to core strength and knee stability; not that I dispute it at all, and it's all over the literature, but haven't found the link I would like.

Final thought on this, new and interesting research out of England on menstraul cycle and the "sweet spot" for injury. Basically day 10-16 is where you want to avoid pivoting as much as possible due to elevated hormones. This is a smaller study but showing interesting results.

Really appreciate everything so far; happy to share out any programs/plans I develop for those that are interested. I have an ortho friend (he does ankles) send me what their Knee guy likes, and that is here:

https://www.sportsmedreview.com/wp-content/uploads/2021/01/ACL-Injury-Prevention-Program-SMR.pdf

Which builds off of the work Rutgers started doing with their PEP plan here: https://rucore.libraries.rutgers.edu/rutgers-lib/37895/PDF/1