Anyone who is a fan of the U.S. Women’s Soccer team has noticed the large number of star players who have had serious knee injuries during this World Cup. The most recent potentially career-ending injury was Megan Rapinoe, which required reconstructive knee surgery. The culprit is a torn Anterior Cruciate Ligament, better known as the ACL. According to the American College of Sports Medicine, female soccer players are six times more likely to experience an ACL tear than their male counterparts. Now here is another statistic that will get the attention of “soccer moms” everywhere… according to that same study, approximately 25% of all female soccer players ranging from junior high to high school will suffer an ACL injury at some point.

Why are ACL injuries more common in women? 

It’s all in the anatomy. Women have a smaller ACL, along with natural ligament laxity. In other words, their ACL is smaller and not as tight as those of men. Women also tend to have weaker quadriceps and hamstring muscles therefore leading to weaker extension and flexion of the leg. This leads to a valgus or outer alignment of the knee. This causes greater stress on the knee ligaments during physical activities. Finally, there is what is referred to as the “landing position” of female athletes. Women tend to be flat-footed when they land on the ground from a jumping position. This causes their knee to be in extension, which transfers most of the energy of the impact to the knee. Men, on the other hand, tend to absorb more of the energy of impact by landing with their knees in a flexed position.

What is the treatment for an ACL tear? 

Treatment of a tear of the ACL consists of a surgical reconstruction of the ACL. This is usually done through the application of a graft from the patient’s own patellar ligament or hamstrings. The procedure is performed through minimally invasive surgery using small incisions. So recovery is fairly quick, approximately 2 weeks. This is followed by six weeks of physical therapy while using a knee brace. The vast majority of patients are able to resume their soccer playing at full capacity… the vast majority of the male soccer players that is.

According to the American College of Orthopedic Surgery, female athletes have a thirty percent chance of tearing their ACL again after surgical correction of a previous ACL tear. After intensive video analysis of ACL tears in these players, the main reason for this phenomenon can be attributed to the biomechanics of the foot and knee,i.e. that pesky flat-footed “landing position” women tend to have after jumping with the knee in the extended position. The creation of a rigid flat-foot particularly during defensive plays transfers the stress from the arch of the feet to the knee. 

So can we fix this problem? 

Yes, the factors that put female soccer players at risk for ACL injuries can be modified through prevention at a young age. The Children’s Hospital of Cincinnati developed an ACL injury prevention program called Sportsmetrics. It consists of training female athletes as young as five years old to maintain knee flexion and avoid knee extension during landing in order to decrease the stress on the knee. Along with the rehabilitation, there is also a biomechanical evaluation of the patient’s foot type. If after successfully completing the physical conditioning the patient is still purchasing the ground with a flat-foot, then it is necessary to fit these patients with a custom molded orthotic that corrects the collapsing arch during a forceful landing on the ground. These orthotics are thin and very comfortable and are placed inside the patient’s cleats. They are specifically designed for soccer players. The difference is in the way they are cast, with the foot in a stressed flexion position. This program has decreased ACL injuries in its female participants by seventy percent. 

In our practice, we have implemented a Sportmetrics program targeting school-aged female soccer players. The program is simple, it consists of a biomechanical evaluation of the patient’s lower extremity. Based on our findings a physical rehabilitation program is prescribed, along with a custom orthotic for correction of any contributing foot pathology such as flat feet; if needed.

Additionally, this program can also be used to rehabilitate patients who have previously had an ACL injury. I urge parents to get involved in prevention programs as soon as their daughters begin playing sports, particularly soccer.

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