As a sports medicine physician frequently treating ACL tears, I’ve seen one concerning pattern: female athletes suffer ACL ruptures 2 to 8 times more often than males in similar sports. This disparity becomes especially pronounced during adolescence, when participation in pivoting and jumping sports peaks. Here’s what research and clinical experience tell us—and how we can intervene.
Why Are Female Athletes More Vulnerable?
Anatomical differences play a major role. Women typically have wider pelvises, greater Q‑angles (the angle at which the femur meets the lower leg), narrower intercondylar notches, and smaller ACL graft dimensions—all of which result in increased valgus stress and predispose the ACL to injury.
Biomechanical and neuromuscular factors add to risk: female athletes often rely more on quadriceps than hamstrings during landing or cutting, tend to land with straighter legs and inward‑collapsing knees, and display poorer trunk control—all of which amplify ACL strain.
Hormonal influences, particularly estrogen and relaxin, may also contribute by increasing ligament laxity and decreasing collagen stiffness—especially during ovulation—though evidence remains mixed. A UEA medical symposium recently reported no consistent link between menstrual phase and ACL injury risk, emphasizing that anatomy and biomechanics remain key drivers.
What Can We Do to Prevent ACL Injuries?
Good news: prevention programs work—especially in adolescent female athletes. Neuromuscular training regimens (emphasizing plyometrics, balance, strength, and landing technique) can reduce ACL injury rates by up to 67‑88%
Programs like FIFA 11+, PEP (Prevent Injury and Enhance Performance), and Knee Control target high‑risk movement faults—such as excessive knee valgus or stiff landing mechanics—and significantly mitigate risk when consistently applied.
Building muscular strength—especially in the hamstrings, glutes, hips, trunk, and quads—is critical. Exercises like Nordic hamstring curls and hip bridges help optimize muscle activation patterns while counteracting quadriceps dominance.
Early implementation matters: introducing ACL prevention strategies during pre‑season and off‑season gives young athletes time to correct patterns and build neuromuscular resilience before fatigue sets in.
Final Thoughts
Female athletes are disproportionately affected by non-contact ACL injuries due to a complex blend of anatomic, hormonal, and neuromuscular factors. However, this gap is not destiny. With evidence-based prevention training, consistent strength and biomechanical work, and attention to individual risk profiles, we can significantly reduce injury rates—and help more female athletes stay active, safe, and healthy over the long term.
Every team physician, coach, and athlete can—and should—integrate these strategies into regular training. The outcomes speak for themselves: stronger bodies, safer movement, and fewer life-altering knee injuries.
References
Griffin LY, Agel J, Albohm MJ, et al. (2000). Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg, 8(3):141–150. https://doi.org/10.5435/00124635-200005000-00001
Hewett TE, Myer GD, Ford KR, et al. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict ACL injury risk in female athletes. Am J Sports Med, 33(4):492–501. https://doi.org/10.1177/0363546504269591
Wojtys EM, Huston LJ, Boynton MD, Spindler KP, Lindenfeld TN. (2002). The effect of the menstrual cycle on anterior cruciate ligament injuries in women as determined by hormone levels. Am J Sports Med, 30(2):182–188. https://doi.org/10.1177/03635465020300020401Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. (1999). The effect of neuromuscular training on the incidence of knee injury in female athletes: A prospective study. Am J Sports Med, 27(6):699–706. https://doi.org/10.1177/03635465990270060301
