The ACL Crisis in Women's Soccer Part 2: Prevention

In the first installment of this series, we explored some of the factors that increase the risk of someone sustaining an ACL injury. In this installment, we’ll look at what the doctors recommend to do to prevent these from occurring in the first place.

During their interviews with Golazo del Gringo, Dr. Holly Silvers-Granelli and Dr. James “Hash” Hashimoto both stressed the importance of training out bad habits, starting early. Dr. Hashimoto focused primarily on two key points during movment. “So for me,” he noted, it’s a focus on “deceleration (and) landing, and then looking at the structure of how things are aligned, and then figuring out from that, where are the deficits? Or where are the predispositions that you can address through activity modification, meaning, movement?” Education is key to addressing these deficits. “I mean, inherently teaching somebody how to move better, so that they're not moving in a way that puts them at greater risk,” is something that can be done to address these risk factors. “If you can do movement education, and teach the right movements that they have to do and strengthen the muscles that they really need to be more dominant, and then you can reduce the risk factors.”

Dr. Silvers-Granelli helped literally write the book on some of these methods that can help train out bad habits. She started her journey back in the late 1990’s, immediately identifying the issue, and got to work on them. “The (United States) U20s women's team at the time, there was about 25% of the girls (who) had sustained an ACL injury.”

She became incredibly invested in this discipline when her brother-in-law, US National Team goalkeeper Tony Meola, tore his ACL in a game at Estadio Azteca against México in 1999. But because the rates were more prevalent in women, she focused more on that than the men’s side of the game. She went on to co-author the Prevent Injury and Enhance Performance (PEP) plan, which was recommended “to reduce the risk of ACL injuries, especially in female athletes younger than 18 years of age” (Journal of Orthopaedic & Sports Physical Therapy) and tried and implemented by UNAM Pumas Femenil in 2018 that concluded by saying “We advise that this program is integrated to women's soccer training.” (National Library of Medicine, National Center for Biotechnology Information)

She then worked on a team that created FIFA’s 11+ Programme (Jacob B. Stirton, MD), a series of simple exercises that take 10-15 minutes to complete as part of a player’s warm-up routine. The results were astounding.

“The first year the study, we had an 88% reduction,” she says. Once those results came back, it sounded like something was off. “I thought, ‘this is a statistical blip. This is too good to be (true)’, to be honest. So we completed a second year and we had a 72% reduction.”

Those results got noticed. “The following year the CDC (Centers for Disease Control) called us and said, ‘Hey, we're really interested in what you're doing. Why don't we bring this to the NCAA?’ “ So she did, and the results were the same. “We had 61 Division One women's universities involved. Again, the same results, a 72% reduction, and 100% reduction in non contact reoccurrences, because we're always worried about the secondary injury.”

There’s also an 11+ for Kids (Essex County Youth Soccer Association), because the earlier kids integrate this training into their regimen, the sooner they can train in good habits that could reduce the likelihood of suffering an ACL injury. But there’s something else she recommends to parents and caregivers who worry about a child’s injury risk: play other sports.

“By playing a (single) sport year round, you're basically creating imbalance, but we have to create some balance to that imbalance. And sometimes that means, just play something else. Swim. Run. Go throw a ball. It could be anything. Tennis. Anything (else) because we want to vary movement patterns. Because we know there's so much risk associated with overuse, repetitive movement, and just volume and the emotional and psychological burnout.”

Overuse is another factor Silvers-Granelli points to as being a huge risk factor that can be lessened. “I had a player in… they were ostensibly supposed to play six matches over the Memorial Day weekend, in a tournament,. I’m like ‘What are we doing?’ It’s just outrageous.” Naturally this sort of schedule wouldn’t be expected of professional athletes, but professional athletes also have grueling schedules as well.

In 2022, in addition to games played in training as well as pre-season and mid-season friendlies, NWSL teams played 22 regular season games and 6 regular season Challenge Cup games, with potentially two Challenge Cup playoff games and potentially three regular season playoff games. The US Women’s National Team also played 18 games, meaning a player could have conceivably played in as many as 45 games from February 17 when the US played the Czech Republic in the SheBelieves Cup to November 13 when they played Germany in a friendly. This also doesn’t take into consideration games in tournaments like the International Champions Cup or The Women’s Cup

This isn’t a problem unique to the United States however. From September 3, 2021 when the 2021-22 Women’s Super League (WSL) season started to September 15, 2022 (the day before the 2022-23 WSL season started), England played 22 national team games, the Women’s Super League played 22 games, the 2021-22 UEFA Champions League had the potential for 13 games, which is a total of 57 games and doesn’t take into account friendlies and other tournaments like the FA Community Shield, FA Cup, Women’s League Cup, etc. Costa Rica also played a potential 57 games, with 36 regular season games including playoffs in the domestic league, four games in the UNCAF Central American Club Championship, 17 games for the national team during calendar year 2022.

It’s also not a problem unique to teams who are going to the World Cup. In calendar year 2022, México played 12 National Team games and Liga MX Femenil played 46 total games including playoffs, totaling a possible 58 games in 52 weeks.

While reducing the amount of games players are expected to play will help, further investment in the game will help as well. Dr. Hashimoto pointed to the evolution of Sports Science as a discipline, and how it has become more widely available. This helps by having individuals who are playing at high levels get specialized information about what their bodies do during certain movements and motions, which can help identify potential areas to work on to prevent injuries.

“When some of these programs were being developed, even the term Sports Science wasn't as prevalent,” Dr. Hashimoto says. “Look at force plate analysis. It allows us to look at how people are attenuating forces, how much force are they attenuating?” In other words, where do the forces from jumping and landing go, and are they going where they should. “I think how we collect that information has gotten better.”

They’ve also become more widely available for use. “Force plates used to be one of the things that unless you were at a high level university that was doing research, force plates were basically out of reach,” because of the prohibitive cost and expense. That’s all changed. “That technology is more entry level now. You can easily find specific clinics, you can find locations, you can find it's more accessible to more people,” he says.

Just as there isn’t one specific cause for the seeming uptick in ACL injuries in women’s soccer, there isn’t one specific cure either. Implementing the 11+ Programme for kids and adults, further advancements and the democratization of Sports Science, equipment made specifically for women, and reducing match congestion will however lessen the frequency of these injuries, which will in turn allow the next World Cup to be played with as many of the best players as possible instead of just those currently not rehabbing an injury.

In the next installment, we’ll explore what clubs are doing to not only prevent ACL injuries but how they help players heal physically and mentally.