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Jordan Angeli was 20 years old when she tore her ACL for the first time.

She was in her third year at women’s soccer powerhouse Santa Clara, just eight months removed from representing the United States at the 2006 U-20 World Cup. During practice, she felt a shift in her knee. Other players came over, and Angeli described how she knew almost immediately that a knee wasn’t supposed to feel like that.

“Well, kid,” one teammate said, “welcome to the club.”

Angeli would make it back onto the field, playing professional soccer in the top American leagues for five years. But she also would join the dreaded three-letter club twice more in her career.

Studies <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805849/" target=_blank>show</a> female athletes are <a href="https://www.yalemedicine.org/news/sports-injuries-gender" target=_blank>two to eight</a> times as likely as male athletes to tear an ACL, one of the bands of tissue that connect the femur and tibia at the knee. Since 2021, at least 87 players from eight of the world’s top women’s soccer leagues have torn their ACLs. Some of the sport’s biggest stars — such as <a href="https://www.washingtonpost.com/sports/2023/05/23/catarina-macario-acl-injury-uswnt-womens-world-cup/" target=_blank>U.S. attacker Catarina Macario</a>, <a href="https://www.fifa.com/fifaplus/en/tournaments/womens/womensworldcup/australia-new-zealand2023/articles/miedema-ill-definitely-miss-the-world-cup-injury-netherlands" target=_blank>Dutch star Vivianne Miedema</a> and the English duo of <a href="https://www.washingtonpost.com/sports/2023/04/21/leah-williamson-acl-injury-womens-world-cup/" target=_blank>Beth Mead and Leah Williamson</a> — will miss the World Cup because of this injury.

This recent wave is not a statistical anomaly but further proof of an ongoing issue that has no simple solution. Addressing it, many in the sport say, requires a zoomed-out approach that begins at soccer’s lowest levels and peels back all the layers of a gendered problem, from the physiological to the environmental.

In a moment of global growth for women’s sports, the ACL crisis strikes at the heart of a broader challenge. How can the infrastructure of women’s sports not simply replicate what exists for men’s sports but be optimized for female athletes? At the top levels of women’s soccer, players argue, such resources have not yet been provided.

“Players are expected to be professional footballers. There’s an increase in matches, then there’s an increase in new competitions. But on the flip side of that, the professional standards to meet these professional obligations are just not in place,” said Alex Culvin, the head of women’s soccer strategy and research at FIFPro, the global players union.

“For a multi-factorial issue, I think there needs to be a multi-factorial solution.”

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In the late 1990s, after studies <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1322895/?page=1" target=_blank>began to show discrepancies</a> in ACL injury rates between men and women across a range of sports, doctors and researchers searched for patterns.

At first glance, biology offered some insight. In women, the intercondylar notch, the area in the femur where the ACL sits, is narrower; additionally, women’s pelvises are wider, creating a higher angle between the hips and knees that can put greater stress on the quadriceps and the ACL. Female athletes tend to land flat-footed with knees inward on jumps and have more strength in the quads rather than the hamstrings. (Some<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5524267/" target=_blank> studies</a> have suggested that the menstrual cycle, during which estrogen can cause ligaments to become laxer, can play a role. But many experts agree the research on this front is not extensive or solid enough to draw direct conclusions.)

Those circumstances put female athletes at risk before even taking the field. In movement-heavy sports, a sudden change of direction or an improper landing could spell a tear. Roughly <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3625971/" target=_blank>70 percent</a> of ACL injuries result from noncontact situations.

“The quintessential ACL-busting cohort is in female soccer players,” said Andrew Pearle, chief of the Sports Medicine Institute at the Hospital for Special Surgery. “The numbers are really kind of tragic.”

Sarah Hashemi

Many experts agree neuromuscular training is essential to mitigating the risk of ACL injury. Regular preventive exercise programs have been shown to work in reducing the incidence of this injury by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592422/" target=_blank>roughly 50 percent</a>.

For female athletes, these exercises are crucial for creating muscle memory for efficient movement, from proper landing positions to deceleration techniques.

“If we practice over and over again, at different angles, that can better prepare your body for the demands of sport,” Wesley Wang, a physical therapist based in Rockville, Md., who specializes in ACL rehab, said. “With strength training, if your body’s a little stronger, it can handle a little more stress. If you combine those two, that is a recipe for success, as far as giving yourself the best chance to stay healthy.”

While biology has provided important insights, experts caution that attributing female ACL injuries to physiological matters alone can send a dangerous message.

“The consequence of the ‘hips and hormones’ narratives is basically people feel disempowered that they can change that,” said Matt Whalan, a physiology and sports science specialist at the Australian soccer federation. “And it becomes something of, ‘Well, if you want to play football and you’re female, that’s the risk you take.’ ”

Some researchers didn’t believe female athletes should settle for that sort of conclusion.

In <a href="https://bjsm.bmj.com/content/55/17/984.abstract" target=_blank>a 2021 study published in the British Journal of Sports Medicine</a>, the trio of Joanne Parsons, Stephanie Coen and Sheree Bekker found that despite nearly 20 years of prevention tactics based on biological factors, the ACL injury rate for women and girls had not changed. It seemed time to consider a new approach.

“The crux of our model is that it flips the lens from looking inside at the individual body to looking outside the body at gendered exposures across the life course,” Coen said. “We can think about how inequities over girls’ and women’s lives might cumulatively set up different kinds of conditions for risk.”

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Studies have shown that female soccer teams <a href="https://www.tandfonline.com/doi/full/10.1080/24733938.2022.2070267" target=_blank>often engage in fewer strength and conditioning sessions</a> than men’s teams. Girls and women <a href="https://journals.lww.com/acsm-msse/Fulltext/2000/09000/Changes_in_physical_activity_patterns_in_the.13.aspx" target=_blank>participate in strength-building</a> <a href="https://ijbnpa.biomedcentral.com/articles/10.1186/s12966-019-0797-2" target=_blank>resistance training</a> at less frequent rates than boys and men. <a href="https://journals.humankinetics.com/view/journals/wspaj/25/1/article-p50.xml" target=_blank>Societal expectations</a> and assumptions of femininity and muscularity could play a role.

Dawn Scott, head of performance for the NWSL’s Washington Spirit, said youth soccer structures historically have failed to train young girls as serious athletes in the same way as they train young boys.

“I go back to the gender bias of factors of how are females trained at younger ages,” she said.<b> </b>“If you’re in an academy system, and you’ve got expert coaching every single week, you’re probably going to get better coaching and better mechanics as you come through the ages. Are we doing our players a disservice by not training them right?”

Those external factors stretch into other facets of the sport. Even at the professional level, women’s teams have fought for access to top-tier <a href="https://www.nytimes.com/2017/09/21/sports/soccer/uswnt-us-soccer-artificial-turf.html" target="_blank">fields</a> and <a href="https://fivethirtyeight.com/features/us-mens-soccer-but-not-womens-gets-to-play-all-its-games-on-grass/" target="_blank">facilities</a> that male teams receive; the U.S. women <a href="https://www.usatoday.com/story/sports/soccer/2020/12/01/uswnt-turns-focus-back-equal-pay-after-resolving-workplace-claims/3788222001/" target="_blank">successfully pushed</a> to play all of their games on grass instead of artificial turf, which has been linked to increased injury rates. Researchers have raised concerns about <a href="https://inews.co.uk/sport/football/magda-eriksson-men-football-boots-injuries-female-players-change-2437022" target="_blank">potential injury risks from playing in cleats</a> designed with a male foot in mind. <a href="https://www.theguardian.com/football/2023/jun/27/female-players-pain-wearing-football-boots-european-club-association-study" target="_blank">A recent European study</a> found 82 percent of female soccer players suffered regular discomfort because of their cleats.

Researchers are exploring how the brain helps prevent knee injuries

Players also have <a href="https://justwomenssports.com/reads/fifa-uefa-vivianne-miedema-acl-injuries-packed-schedule/" target=_blank>led calls</a> for leagues and governing bodies to examine the influence of fatigue. As leagues expand — England’s Women’s Super League has grown by four teams since 2015, while the NWSL is set to reach 16 teams by 2026 — players are playing more games for their club teams than in previous years. FIFPro has <a href="https://fifpro.org/media/reufmwpu/2021-fifpro-pwm-womens-annual-report-eng.pdf" target=_blank>studied</a> how <a href="https://fifpro.org/media/xcweuugu/pwm_fwwc_report_2023_twopage.pdf" target=_blank>overload</a>, in the form of a high number of games packed into short windows, can affect a player’s potential to reach peak performance.

While the men’s World Cup took nearly 70 years to expand to 32 teams, the women’s event has grown from 12 teams in 1991 to 32 in 2023 — a rapid pace of growth accompanied by an increase in intensity. <a href="https://www.fifa.com/tournaments/womens/womensworldcup/france2019/news/physical-analysis-of-france-2019-shows-increase-in-speed-and-intensity" target=_blank>A FIFA analysis</a> found players covered more distance at faster speeds in the 2019 World Cup compared with 2015 and encouraged teams to invest in new training programs for female athletes.

“You’ve changed the schedule to mimic the men, yet you’re not giving the female players the same level of resources,” Janine Beckie, a striker for the NWSL’s Portland Thorns and the Canadian national team who tore her ACL in March, <a href="https://www.reuters.com/sports/soccer/canadas-beckie-calls-better-funding-research-tackle-injury-crisis-womens-game-2023-04-28/" target="_blank">told Reuters</a> in the spring. She added: “If you’re going to ask an elite athlete to play 50 games a season, you’ve got to provide them top-line care.”

Clive Rose

In the past three years, female players around the world have spoken out more than ever on the state of the women’s game. Players such as <a href="https://www.theguardian.com/football/2022/dec/22/spoty-winner-beth-mead-calls-for-more-research-into-womens-acl-injuries" target=_blank>England’s Mead</a>, last year’s Ballon d’Or runner-up, and <a href="https://www.goal.com/en-us/news/uswnt-christen-press-acl-crisis-women-game-men-side/blt033d307ef1a27773" target=_blank>Christen Press</a>, a U.S. national team star who tore an ACL last year, wondered aloud if more would have been done had such a spate of injuries occurred in men’s soccer.

For many in the sport, the way forward involves striving for a future where conditions are not just equitable to those in the men’s game but intentionally optimized for women.

What does that look like? Scott spent two decades<a href="https://www.goodmorningamerica.com/gma/story/uswnt-period-tracking-win-world-cup-64709450" target="_blank"> transforming the sports science operations</a> of the U.S. and English women’s national teams, pioneering<a href="https://www.theguardian.com/football/2023/jul/02/monumental-change-football-tackles-the-impact-of-periods-on-performance" target="_blank"> new ways</a> to empower female athletes through access to information about their health and bodies, and is now doing the same with the Spirit. In her view, it starts with integration between medical and performance staff; investment in top-tier facilities and female health experts; and comprehensive surveillance studies that could unlock new frontiers of understanding.

Across soccer, pushes have been made to make injury prevention programs accessible. In 2006, FIFA developed the 11-Plus, <a href="https://www.mayouthsoccer.org/coaches/injury-prevention/" target=_blank>a set of 15 warmup exercises</a> that has been adapted by <a href="https://www.footballaustralia.com.au/performance/football-australia-perform" target=_blank>teams and federations</a> around the world; the Hospital for Special Surgery developed an app that condenses <a href="https://www.riipreps.com/" target=_blank>essential exercises into seven-minute sessions</a>. But implementation remains a challenge, particularly at the youth levels.

Down the line, cooperation between stakeholders could produce frameworks and protocols that are embedded and regulated by clubs and leagues, similar to what exists for brain injuries and concussions.

Ideally, the lessons and insights learned from creating top-tier conditions at the highest levels of women’s soccer will flow down, helping to build a pipeline of players who are equipped to compete at the highest level.

“Can we train the players earlier in terms of injury prevention, strength, running mechanics, so that actually, as they come up through the pathway, they’re going to be more durable and more ready for some of the demands of training and match play?” Scott said. “It starts with one little element, but then you start expanding it. It’s just the full support around the player.”

<b>‘An injury that changes your life’</b>

Tierna Davidson, a member of the U.S. national team during the 2019 World Cup and the 2021 <a href="https://www.washingtonpost.com/sports/olympics" target="_blank" class="contextual_link">Olympics</a>, tore an ACL during practice with the Chicago Red Stars in March 2022.

Until the stories started rolling in, the center back hadn’t realized how many fellow players around the sport had experienced the same injury. (Davidson’s fiancée, who also played soccer at Stanford, had torn an ACL twice and had plenty of advice to offer about icing and physical therapy.)

“When I thought about it, I was like, ‘Well, I’m certainly not unique in this experience.’ And so what I started thinking was, ‘Okay, if all these players can get through it, then surely I’ll be fine as well,’ ” said Davidson, who returned to the field in March. “I can imagine if some 13-, 14-year-old is able to get through it and get back out onto the field, surely I can.”

Joe Puetz

A torn ACL was once considered a career-ending injury. Now, ACL reconstruction surgery has <a href="https://medresources.keckmedicine.org/news/acl-reconstruction-still-the-gold-standard" target=_blank>a high success rate</a>, and many players return to the field in nine to 12 months. (Of the 23 members of the U.S. team at this World Cup, at least <a href="https://docs.google.com/spreadsheets/d/1iioycE-aFb95Cgq2xtfL05pPlHB_cZAjwb3ylcMhKzY/edit?usp=sharing" target=_blank>six</a> have torn an ACL at some point in their career.)

But the effects are lasting. Female athletes, especially at the high school level, have <a href="https://link.springer.com/article/10.1007/s40279-020-01404-7" target="_blank">a higher risk of retearing an ACL</a>. Those who suffer this injury at a younger age are <a href="https://www.nytimes.com/2017/11/06/health/arthritis-risk-acl.html" target="_blank">likely to</a> <a href="https://www.nata.org/press-release/050223/preventing-osteoarthritis-after-anterior-cruciate-ligament-injury-" target="_blank">develop arthritis</a> in the future. The winding road of rehab and recovery can take a heavy mental toll.

After retiring from soccer in 2016 following years of injuries, Angeli had the idea to create a community to help empower fellow ACL survivors, from the professional athlete to the rec-league amateur.<a href="https://www.theaclclub.com/" target=_blank> The ACL Club</a> offers a six-month online course that involves videos, exercises, mindfulness training and more, designed to help others through the long journey.

“It is an injury that so many people come back from now, but it is also an injury that changes your life, in one way or another,” Angeli said. “When you play sports, you should know, ‘I could tear my ACL.’ And not in a fearful way, but in a way that empowers you to say, ‘I’m going to do everything in my control to look at the factors in my body and my preparation that can help me be the best athlete I can.’ ”

Northwestern University, B.S. in journalism and international studies

Ella Brockway is a multiplatform editor on the sports desk. 

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Team ACL: The growing women’s soccer club that no player wants to join