Professional Documents
Culture Documents
ENG 1201-509
Prof Strehle
26 April 2020
Why Are ACL Tears More Common in Female Athletes And How Can They be
Prevented?
Any athlete performing at a competitive level is familiar with the devastating and
in most cases season ending injury of a torn anterior cruciate ligament, commonly
referred to as the ACL. However, what may not be as widely known is the startling
statistic regarding the occurrence of these tears in female athletes versus males;
females are up to eight times more likely to suffer a torn ACL than their male
counterparts. Knowing this, female athletes, like myself, want to do everything possible
to lower this statistic. Anterior cruciate ligament tears are more common in female
athletes because of the female anatomy, the hormones produced in females, and the
neuromuscular activations that female athletes commonly possess, for example, landing
jumps with legs straightened. The most effective preventative measures female athletes
abdominal muscles, exercises that correct the biomechanics when landing a jump, and
The ACL is a major stabilizing ligament in the knee as it connects the thigh bone,
femur, to the shin bone, the tibia. It helps prevent hyperextension and excessive rotating
of the knee joint. A healthy ACL is crucial in any physical sport, especially those that
require cutting motions. There are two ways to sustain an ACL tear; contact and non-
contact. Contact ACL tears require a blow to the knee in a way that either hyperextends
the joint or comes from the side pushing the knee inwards. Non-contact injuries have to
do with things like cutting at high speeds, pivoting with the foot firmly planted and
landing a jump in near or full extension. Almost 70% of all ACL tears are sustained
non-contact tears at a rate 5 times higher than males” (“State of the art..”). This statistic
points out that the female athlete is built in a way that makes it much more susceptible
to ligament tears in the knee, and there are many factors that contribute to this.
tears at alarming rates. In females, hips are wider set to help with childbirth. In turn, this
causes the knees to angle inwards, toward the midline of the body (Giugliano and
Solomon). When the knees face inward, this puts pressure on the anterior cruciate
ligament and is just over all not a natural or comfortable state for the knee to be in.
Female athletes with longer legs and wide set hips are in the highest risk group for a
non contact ACL tear. The pressure is already high on the ligaments in the knee with
inward facing kneecaps, so it doesn’t take much for a non contact injury such as landing
a jump awkwardly to end an athletes season and send them into months of grueling
rehabilitation. Although there is no “fix” to the female anatomy to lessen the pressure
put on those ligaments, exercises have been put together to give female athletes a way
with a female’s menstrual cycle. One study “... used self-reported menstrual history data
greater incidence of noncontact ACL injuries among women athletes during the
preovulatory phase” (Beynnon and Shultz). This can be attributed to the hormone
produced during this phase, called estrogen, that has been shown to decrease the
elasticity of certain ligaments in the female body, especially the anterior cruciate
ligament. Ligaments should be elastic and able to stretch to certain limits, so when
excess estrogen is produced during the preovulatory phase of the female menstrual
cycle, ligaments don’t stretch as easily and therefore are more easily torn. This cause
for increase in ACL tears is not as well known as the female anatomy and
neuromuscular activation patterns, however it is just as much at fault in the case of
female athletes being significantly more likely to injure the anterior cruciate ligament.
Fig. 3. Days 8-16 of menstrual cycle have highest number of ACL ruptures due to
Normal Cycle.”)
Neuromuscular activation patterns may also be a key factor in why females are
patterns have been reported to contribute to ACL injury. Compared to males, females
have been found to be less effective in stiffening their knees”(Ireland). Many studies
have shown that “...even well-trained female athletes tend to ‘lock out’ , straighten rather
than bend, their legs- especially when jumping, and tend to land with a flat foot and a
straighter leg than their male counterparts”(Lyle). Landing a jump with the knee
common way the anterior cruciate ligament is torn through non-contact means. Females
have neuromuscular activation patterns that contribute to landing jumps with
straightener legs and “locking out” the knee while landing or pivoting. These are two
huge factors that contribute to female athletes injuring the anterior cruciate ligament at
Fig 3. Correct landing position vs. ACL risk landing position (“Knee Mechanics:
ACL prevention programs seem to be the overall best way for females to lessen
the risk of suffering this knee injury. Constant exercises that stress landing with the
knees bent and facing outwards have shown benefits as does pure strengthening of the
quadriceps, hamstrings and abdominal muscles (McDaniel). It’s recommended for high-
intensity contact sports like soccer, basketball and football that players start ACL
prevention programs as early as possible. For best outcomes they should be done at
least 3 times a week. Another prevention method takes effect by controlling the amount
of estrogen produced during the menstrual cycle; oral contraceptives. Birth control isn’t
a popular or very well known method of ACL tear prevention but multiple studies have
shown it to be very effective. Between these three methods, there is hope that female
A specific way athletes are preventing ACL tears is with intense workouts that
strengthen the muscles that protect the knee along with the abdominal muscles which
are key in maintaining good balance and posture. The quadriceps and hamstring
muscles are the most important muscles to strengthen when it comes to ACL
prevention. “A few exercises that can greatly improve the quad and hamstring muscles
effectiveness in protecting the knee include lunges, leg press, hamstring curls, and wall
sits”(McDaniel). Strengthening the abdominal muscles, the “core”, is also shown to have
significant benefits as it positively affects balance and in turn has significance when
doing actions like landing jumps. It’s no surprise that building muscle can reduce the
risk of ACL injury, just like it reduces the risk of many other common injuries. It’s a
Another specific method of ACL tear prevention that coincides with strength
training is exercises that correct the female biomechanics. Like mentioned earlier, the
female anatomy is a huge reason for the incorrect biomechanics that female athletes
possess, mainly because the knee should always stay in line with the foot. When
landing jumps, it’s common for female’s knees to sink inwards, which is a big contributor
to non-contact ACL tears. By doing exercises that correct those biomechanics, the
knees can be “trained” and strengthen the outer leg muscles to help prevent the knees
from sinking inwards when landing jumps or squatting. Adding these exercises into leg
and core strengthening workouts is a very effective and simple preventative measure
menstrual cycle affecting the preovulatory phase. “We think our study adds to the
literature showing that changes in estrogen and progesterone likely affect the laxity and
in female athletes ages 15-19; this group had a 63 percent reduction in the rate of tear
compared with those who did not take OCPs (DeFroda). Most oral contraceptives
contain a small amount of estrogen and progesterone and they keep the levels of these
hormones much more regular in your body. In growing females, these hormones can be
very irregular and their levels are changing constantly; by regulating the levels of
estrogen and progesterone via oral contraceptives, it can make ACL tears less likely to
occur. This method could be seen as controversial as birth control pills are known to
have less than comfortable side effects. However, multiple studies have proven that
OCPs do a phenomenal job in balancing hormone levels and making female athletes
less likely to have injuries to ligaments during phases of the menstrual cycle where the
Although studies show that oral contraceptives can significantly reduce the risk of
tearing the anterior cruciate ligament, they can also cause many health issues. Some
minor side effects of birth control pills include headaches, nausea, and mood swings.
(“Birth Control Pill FAQ”)Oral contraceptives have also been linked with causing high
blood pressure. A serious side effect of oral contraceptives is an increased risk for
thrombosis, which are blood clots throughout the body that can lead to hospitalization
and even death if not treated quickly. Another serious side effect of birth control that
some studies have shown is a link to increased risk of breast cancer. Both breast
cancer and thrombosis are very rare in link to oral contraceptives, but they are possible.
For these reasons, many scientists do not recommend female athletes be placed on
oral contraceptives strictly for purposes relating to their ability to decrease risk of tearing
ACL tears occurring in younger athletes. Most will choose to have surgery and continue
playing sports, now at a higher risk of retear. So much stress on the knee early in life
can lead to joint issues and the need for knee replacements much earlier than desired.
ACL tears are more common in female athletes because of the female anatomy, the
hormones produced in females, and the neuromuscular activations that female athletes
commonly possess. The most effective preventative measures female athletes can take
include strengthening exercises focusing on the leg and abdominal muscles, exercises
that correct the biomechanics when landing a jump, and oral contraceptives that can
balance hormones. Between intense prevention workout programs and use of oral
contraceptives, there is hope that in the coming years we can see a decrease in the
Bibliography
Phase, and the Risk of Anterior Cruciate Ligament Injury.” Journal of Athletic
March 2020
Choi, Won Rak, et al. “MRI Comparison of Injury Mechanism and Anatomical
PLoS ONE, vol. 14, no. 8, Aug. 2019, pp. 1–11. EBSCOhost,
Patients.” Physician & Sportsmedicine, vol. 47, no. 4, Nov. 2019, pp. 416–420.
“Drop Landings and Lunge Exercises.” Top 5 ACL Injury Prevention Exercises, 19 Oct.
2018, soccergrlprobs.com/blogs/blog/top-5-acl-injury-prevention-exercises/
Giugliano, Danica N., and Jennifer L. Solomon. “ACL Tears in Female Athletes.”
Physical Medicine & Rehabilitation Clinics of North America, vol. 18, no. 3, Jan.
March 2020
“Knee Mechanics: Neutral Alignment (Left) vs Valgus Alignment (Right).” ACL Strong, 6
Lyle, Mark A., et al. “Control of Dynamic Foot-Ground Interactions in Male and
Female Soccer Athletes: Females Exhibit Reduced Dexterity and Higher Limb
Stiffness during Landing.” Journal of Biomechanics, vol. 47, no. 2, Jan. 2014, pp.
2020
McDaniel, Larry W., et al. “Reducing the Risk of ACL Injury in Female Athletes.”
Contemporary Issues in Education Research, vol. 3, no. 3, Mar. 2010, pp. 15–20.
EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=eric&AN=EJ1
“Relationship between Estrogen and ACL Rupture in a Normal Cycle.” Research Gate,
ACL-rupture-in-a-normal-cycle-The-rate-of-anterior_fig2_330399663/ Accessed
19 March 2020
“State of the Art, Comprehensive Orthopedic Care by Our World Renowned