ACL Injuries in Female Soccer Players: Time to Take Action

01 Jul ACL Injuries in Female Soccer Players: Time to Take Action

Originally published by Erica Suter on https://girlssoccernetwork.com/

 

ACL Injuries in Female Soccer Players

Mallory Swanson. Beth Mead. Vivianne Miedema. Janine Beckie. Catarina Macario. Christian Press.

I’ll spare you the rest of the injured list because it’s downright tragic.

In the last 12 months, more than 20 professional women’s soccer players tore their ACL.

This astronomical number has caused an uproar in the soccer community, and rightly so. With doctors, rehab specialists, chiropractors, team managers, sport scientists, dieticians, and performance coaches chiming into the discussion and giving their take on what is to blame.

“It’s the lack of resources!”

“It’s lack of research in female sports!”

“It’s because of female anatomy!”

“It’s knee valgus mechanics!”

So, then what is it? Who do we listen to? Do we reduce the cause of these injuries down to a single factor, and point the blame at one thing? Do we blame lack of resources? Do we blame lack of research? Do we blame females being female?

This isn’t productive and here’s why.

Injury Risk is Multi-Factoral

We can’t point the finger to one single cause. This is narrow minded and not scientific.

Lack of resources, for example, isn’t the only thing we should be blaming. In fact, it should be the last thing we blame. We are talking about the best teams in the world from Arsenal to the U.S. National Team, who have access to a full sport science and performance staff as well as the best GPS, rehab, and recovery technology in the game.

Female soccer players can achieve vibrant health and high performance with minimal resources. All they need is a power block to progressively load over time. All they need is a field to run sprints and be exposed to high speed running. All they need is a solid program in place, done consistently. There isn’t a shortage of free information online, and it’s part of the reason I create such a high volume of content to better educate young girls, coaches, and parents.

We need to stop playing the blame game and do something. You know, empower girls once and for all.

Let’s dive into actionable steps because I’m all for radical action, especially at the individual level.

1. Physical Literacy

Let’s backtrack. Everyone wants to blame everything that is happening now, but how are young female soccer players being brought up in the sport system? With specialization and year-round leagues, camps and showcases at their apex, let’s think for a second: is this good for the health of the player? Or are they being robbed of building a sturdy athletic foundation in their most plastic years of growth?

Physical literacy means having a broad range of athletic skills, such as coordination, balance, stability, rhythm, and spatial awareness. It also means having strength in all muscle groups, not just the ones overused in soccer, such as the hip flexors and quadriceps. You’d be surprised how many kids can’t skip with coordination, or perform a cartwheel. This means they will struggle to express speed, where intermuscular coordination is required.

You'd be surprised how many kids can't skip with coordination, or perform a cartwheel. This means they will struggle to express speed, where intermuscular coordination is required. Click To Tweet

No one has thought to question what is going on at the youth level. No one has considered that overuse injuries manifest in adolescence and beyond when a youth soccer player has childhood void of play and movement variety.

Twitter has been a whacky place for the knee injury debate. One day, a strength coach tweeted, “I’ve been getting a ton of teenage girls with knee injuries, what does  everyone think the cause is?” Hundreds of people chimed in and said similar, ad nauseam causes yet again:

“Biomehanics!”

“Female anatomy!”

“Knee valgus!”

Then, Jeremy Frisch, poked his way into the conversation and dropped the mic: “it’s everything that didn’t happen in their childhood.”

Jason Advedesian PhD, who studies the impact of the brain on ACL injury, confirms this further. If an athlete is slow in their reaction time, knee instability is more likely to occur, and the torque on it increases. What better way than to improve an athlete’s reactivity than to have them grow up with free play and fun small-sided games?

Athletes learn how to become both fast movers and fast thinkers in this environment. Their reaction becomes sharp. No amount of over-coached snap downs and fake “agility” drills that are the furthest thing from agility will help female soccer players in their reactive ability.

No amount of over-coached snap downs and fake agility drills that are the furthest thing from agility will help female soccer players with their reactive ability. Click To Tweet

It’s the spontaneity we need to bring back. Neural pathways fire fast when the protective layer, the myelin sheath, is strong. Myelin becomes durable from play, problem solving, and creative expression, but also, from consuming A LOT of healthy fatty acids in childhood and throughout old age (more on the nutrition disaster in soccer players later in this article). Our young girls don’t need to be abused year-round by leagues, organized games and practices. They aren’t robots. From ages 8-12 is when we need to optimize their motor skill development and expose them to new, fun environments that aren’t their primary sport.

From ages 8-12 is when we need to optimize their motor skill development and expose them to new, fun environments that aren't their primary sport. Click To Tweet

Too many young girls and adolescent girls play for over 8 months out of the year, tallying up more competitive matches than the pros. For the growing and maturing female body, with all of its physical changes during the growth spurt, this becomes a dire situation. It’s a ticking time bomb before this manifests into a greater breakdown in the knee when they grow into adult athletes.

 

More girls need to be built into more well-rounded athletes who have a broad foundation of athletic skills. They need to start young during the most plastic years of physical and cognitive growth.

Primary sport year-round ruins this, and overuse of a few muscle groups leads to bigger deficiencies, imbalances, and injuries later in life. It’s tantamount to wanting to be a scientist and only learning science in childhood and adolescence. Then, as an adult, they lack communication, writing, reading, and creative skills to function in society.

For more information on a long-term athlete development model that looks out for the well-being and overall physical development of the athlete, check out the National Strength and Conditioning Association Position Statement paper HERE.

2. Year-round Strength

The research on the benefits of strength training for female athletes is overwhelming. And sure, there could be more studies on the female population, but we have enough to know that girls can’t go wrong getting strong.

There could be more studies on the female population, but we have enough to know that girls can't go wrong getting strong. Click To Tweet

Anyone who has time to go on Google scholar and sift through the medical journals will see that we actually have enough information on the benefits of strength training for mitigating injury. ACL injuries can be reduced by over 60% if girls strength train consistently (Tim Hewett PhD is a great resource).

My healthiest female soccer players train strength year-round. They refuse to wither away in season, and they understand the importance of maintaining their muscular gains to handle the year-round sport load. When sport load is greater than tissue tolerance, that equals injury. The equation is simple and not rocket science. Muscles need to be able to handle stress. Wearing and tearing them with the just games isn’t getting muscles any stronger. It’s only breaking them down more. Eventually, the tissue needs a new stimulus, namely a loaded stimulus with weights, firing new muscle groups, to adapt, and get strong.

In my 12 years of coaching, my girls have grown to love the gym. ALL female athletes must keep maintaining and building strength. Mind you, we’ve only had 1 ACL injury in 12 years, and it was a contact ACL right after COVID return to play, with all of its chaos and spikes in load. I think we’re onto something and have a darn good track record. We do year-round mobility, recovery, strength, and speed work. We implement periodization and have a plan.

The focus is on building single leg strength, especially eccentric strength to handle braking forces, which is one of the most important and researched physical qualities female athletes need to reduce ACL risk. If you dare make the time to look at the overwhelming literature that has specifically studied females and strength training, you can read here, here, here, here, and HERE. There’s certainly more, but these are a great start.

And for those still blaming the female anatomy factor, a recent 2023 study, with a sample size of over 880 female athletes, concluded that there is no association between frontal plane hip and knee kinematics (knee valgus) for increased ACL injury risk. Hmm.

So this begs the question: are female biomechanics to blame, OR should general strength be top priority so when athletes do get in less than ideal mechanics, they can handle the load better and still fire the right muscle groups that stabilize the knee? After all, sports movements are so spontaneous and done at such high velocities you’d be hard pressed to find  “perfect” knee mechanics.

The argument for strength training remains strong. It has for years.

Proper Strength Training

The only bilateral movements we do are Goblet Squats for the middle school girls as a starting point, and Hex Bar Deadlifts for both middle and high school girls to load up the hamstrings.

Our training menu gravitates solely to single leg strength movements: split squats, RFE split squats, single leg RDLs, and pistol squats because injuries occur on one leg.

We don’t shy away from upper body strength because the body works as one big unit, with upper body impacting lower body technical ability:

We don’t do sit-ups. Ever. That’s not core training. True core training encompasses all muscle groups that make up the lumbo-pelvic hip complex firing together, adductors, abductors, low back and anterior core:

We also do single leg deceleration work to better handle braking forces:

Then, our plyometrics progress to more intense, faster outputs:

We lift heavy, jump far, and jump high.

We don’t do cute little female athlete ACL “injury prevention” programs that only consist of balance drills and mini bands.

We load. We progress. We truly build muscle strength. We stay relentless with this the entire year. We focus on high performance because when we chase performance, injury reduction is a nice byproduct.

We focus on high performance because when we chase performance, injury reduction is a nice byproduct. Click To Tweet

We also sprint year-round because it’s the best hamstring strengthening movement a soccer player can do. Speed work bulletproofs the hamstrings, which is potent for good knee health. Fast athletes are robust athletes. Every speed drill, I tell my girls to be predators.

I guess you can say I’m lucky to be in the private sector because I have more autonomy over my performance programs. My athletes also make the most of the programming. I get 4x a week with them in a 2-3 month off season. I get 1-2x a week with them in season. It’s concerning how under utilized the team performance coach is at some professional clubs (I’ve heard this from people in the highest positions in the premiere league and at the national team levels).

Pro clubs have the resources…they just don’t use them.

You’d be surprised to hear that some college and professional performance coaches work overtime for little pay to be nothing but glorified warm up  and stretching coaches. They’re given a meager 45 minutes a week with their athletes, and not much time in the weight room. Minimal impact is to be had on the injury reduction front. Worse yet, relationships aren’t built, and athlete buy-in with a strength program becomes tough. I repeat: it’s not lack of resources…it’s a lack of performance coach utilization. And for the sake of anonymity, several of my colleagues at this level have confided in me they feel they aren’t used enough by the team coach. Injuries skyrocket as a result.

Why aren’t performance coaches used the best they can be?

Some team coaches and management fear in season strength because they think the loading is too much, so soccer practice replaces weight room training.

Their fears may seem valid, but actually, the opposite is true: when players continue with strength training, they build durable muscle tissue for higher sport loads and increase their ability to recover faster. They can sustain the jam packed game schedule. It’s a big mistake to discontinue strength training because even just a 4 week cessation in a strength program will cause muscle to atrophy.

3. Load Management

We have all the GPS sensors in the world. More ECNL clubs are buying large quantities with the hopes their players strap them on and make use of the data. Unfortunately, most GPS sensors stay buried in the soccer bag, collecting dirt.

At the youth female soccer level, load management is not great, in fact, non-existent. Proper load management is looking at GPS data, and allowing it to drive macro and micro level periodization. A lot of coaches are bootstrapped, however, because how can you periodize and recover, then build athletes up again, when the game schedule is out of control?

Leagues roll from August then to May the following year. But for most, they go until end of June and into July, then practice begins again in July and August, so that gives the majority of girls in the ECNL and GA a meager 2-3 week off season. This is not enough time to rest an athlete, then implement a gradual speed, strength and conditioning program with appropriate build up to workload.

Look. The USL league has good intent. ECNL has good intent. GA has good intent. These are amazing leagues that have increased the opportunity for girls to develop, and serve as platforms to make it to the college and pro level. But my question is: why the heck is no one blaming the packed game schedules, showcases, and tournaments?

When is there a true off-season for these young women to recover, build up tolerance to load, undergo a new stimulus, get in the gym, and get a meaningful adaptation for true speed and strength development? A meager 2-3 week break from soccer in July ain’t it. Then, it’s plowing through from August-July again, keeping in mind that a lot of these girls overlap with their middle and high school soccer teams. You can’t develop true speed if you’re not recovered. Your Central Nervous System will be fried. You can’t build strength sore. Your muscles will have lower outputs. Your biomechanics could be trained “perfectly” but if a joint is constantly loaded and under fatigue doing the soccer actions over and over again, will it be able to hold up?

 

Shifting gears to the men’s game, they struggle with the same, and have just as many injuries, but with hamstring strains. The other day, I had a phone call with a performance coach in the MLS who was just as frustrated about injuries. The men’s game is a total disaster on the hamstring strain front. I totally understood his frustration and he brought up a point that made me think: “Erica, if these players don’t have a true off-season for a few months, then is the strength and speed I’m doing totally pointless?” Too, similar to the women’s game, the men’s performance coaches are highly under utilized, and it’s nonstop soccer training.

Performance training is non-negotiable.

The best adaptations happen when an athlete is recovered. If my girls come to speed sessions sore or sleep deprived, I don’t let them do the workout because it’s useless. Their Central Nervous System can’t be optimized for fast outputs. As a result, I send them home.

My freshest girls break speed records.

4. Nutrition, Recovery, Sleep and the Female Menstrual Cycle

These go hand-in-hand. If one of these is not dialed in, it causes a chain reaction of problems in all body systems – skeletal, endocrine immune, nervous, and cardiovascular.

If a female soccer player isn’t fueled enough, her hormones will be out of balance. If her hormones are out of balance, digestion suffers. If digestion suffers, sleep suffers. When sleep suffers, brain and muscle recovery suffer. When brain and muscle recovery suffer, that equals high injury risk. It’s a dangerous cycle, and most female athletes are painfully malnourished. When they think they’re getting enough protein, they’re shocked when I tell them one egg is not enough. When they think they’re getting enough fatty acids, they’re shocked when I tell them to double their healthy fat intake than what they’re currently eating, they’re floored.

Nutrition is critical. It’s a disgrace how protein and omega 3 fatty acid deficient female athletes are – the two macronutrients required for human survival and hormonal health in women. If people are so concerned about the female factor and the menstrual cycle as far as ACL injury risk, they’d give more tough love when it comes to nutrition.

If people are so concerned about the female factor and the menstrual cycle as far as ACL injury risk, they'd give more tough love when it comes to nutrition. Click To Tweet

Ever heard someone say, “well, they just seemed so healthy! But how did they get sick or injured?” When girls think they’re eating “healthy” and a balanced diet they’re not. Again, most lack an alarming amount of protein and healthy fats. They’re also including side dishes in their meals that are high in lectins (wheat, soy, beans, peanuts, gluten, grains), which ruin the absorption of magnesium, iron, calcium and zinc, some of the most essential minerals females need. 

When designing a meal plan for a female soccer player, they must have these five non-negotiables in every food they choose:

1. Least amount of inflammation (lower sugar and processed foods)
2. Most nutrient dense
3. Highest amount of proteins and fatty acids
4. Most bioavailable (no anti-nutrients like lectins that ruin vitamin and mineral absorption)
5. One they enjoy (if you enjoy eating the same meat every day, then do that! You don’t need to overthink with variety. Plus, you’ll save yourself from decision fatigue)

An example of a food that meats all five of these criteria is steak. It’s anti-inflammatory. It’s packed with iron, zinc, vitamin A, magnesium, folate, vitamin B12, copper, calcium, potassium, selenium. It is high protein, with all essential amino acids. It’s high in long chain omega 3 fatty acids. It’s bioavailable because the body actually absorbs meat’s nutrients. Basically, it’s the most bang-for-buck and you get the nourishment your body and hormones have been craving. Iron is excellent for energy levels specific to the anemic female athlete. Magnesium is amazing for nervous system regulation. Carnitine and creatine deliver a powerful punch in muscle recovery and ability to sustain high outputs. A salad isn’t enough. One egg for breakfast isn’t enough. A yogurt and banana isn’t enough. Double that or three times that protein amount. It’s magical when you have a high quality protein and the right amount at EVERY meal.

Has Sports Nutrition Failed Female Athletes?

The abundance of nutrition resources are crap for female health. It’s an ugly truth that cuts close to the bones.

Sadly, college cafeterias and college weight room “fueling” stations are the opposite of this list. They have high sugar, processed, and inflammatory food options ready to grab. Minimal nutrient density. Low bioavailability. Sure, muscle milk and Gatorade bars are better than nothing, but we are selling our athletes short. Most sports nutrition plans wreak of anti-female hormonal health. Their inflammatory nature can cause estrogen dominance,and low progesterone, which can lead irregular periods, fatigue, poor muscle recovery, soft tissue injury, mood swings, headaches, brain fog, bloating, indigestion, cramps, acne, anxiety, and depression. And when all these happen is when sport performance suffers, and injury risk rises.

The governing bodies, corporations, and Big Food companies that are the stakeholders in college and professional sports  provide a high volume of foods, yet cheapen quality for profit. Nutrient density wanes, bioavailability is poor, and athletes suffer because they aren’t getting the nutrients they need for high performance. It’s permeating into the youth female soccer space, too, and sets our young girls up for sugar addiction, high inflammatory diets, imbalanced hormones, poor muscle recovery, fluctuating energy and mood, autoimmune issues, and mental health issues.

Females need more protein for muscle building and recovery (over 20 grams a meal is a great start). They need fatty acids from whole sources (red meat, chicken, pork, eggs, butter, bacon, salmon, mackerel, tuna) to boost brain function, reduce cortisol levels, balance estrogen and progesterone and testosterone, improve heart health, and improve mental health. It’s amazing what adding an extra few slices of bacon, or having a fatty meat every single day does for the brain, which is made up of over 60% fat.

If the brain is mainly fat, it needs nourishment with fat. Females have feared high fat diets because of the messaging that it makes you fat, but that couldn’t be further from the truth.

If the brain is mainly fat, it needs nourishment with fat. Females have feared high fat diets because of the messaging that it makes you fat, but that couldn't be further from the truth. Click To Tweet

Female hormonal harmony, high performance, and improved mental health is only achieved through a high protein, healthy fatty acid meal plan.

Sleep

Now let’s talk about sleep. It’s crucial for the muscles to repair and recover because of the growth hormone that is produced in the bloodstream during deep sleep. Ever wake up feeling refreshed, clear, and energized for the day? That means you got enough deep sleep that is needed to replenish the body and mind. If a female athlete doesn’t get quality sleep, her cortisol levels rise, and her adrenals suffer. Again, another negative change reaction takes place because of this one mistake. Lack of sleep causes disrupted digestion, brain fog, weakened immune system, and impaired muscle healing.

Stop Blaming Lack of Resources

Be healthy. Do the the big rocks better.

Everything listed above is basic. And anyone can start today.

Play. Strength train. Sprint. Recover. Have off days. Have an off season. Eat enough protein and fatty acids. Nourish the body like a temple. Balance hormones. Take responsibility because no one else will save you. And watch yourself THRIVE.

People can go on blaming the ACL injuries on lack of resources in the women’s game all they want, but they’re focusing on the wrong things. People are trying to go against what the female needs, and that is quality training, plenty of recovery, proper load management, muscle building, nourishment with nutrient dense animal-based foods and fatty acids. All of these support female hormones. My hope is all girls and women can experience how amazing it feels to do all of these things.

No amount of advanced technology, staffing, thousands of dollars will offset a poorly written performance plan. I’ve seen some of the “best” facilities with Nordic boards, GPS sensors, and not even strength train their athletes consistently. I’ve seen the top nutritionists suggesting sugar and refined carbs are good for female soccer players. Sugar and carbs are inflammatory. They destroy hormones, especially that week before the period when inflammation needs to be brought down, sugar and processed carbs are the last thing a girl should be reaching for. Female athletes need proteins and fatty acids to keep inflammation at bay, and to solve PMS symptoms once and for all. And when PMS goes away, they feel at their best for high performance and reduced injury. They have a new vibrant, glow about them and they become downright unstoppable.

The Way Forward

We need to invest in true physical development, and this starts at the grassroots level. Specialization is dumb. Stopping in season strength training is even worse. Poor load management and blasting through the entire year with practices and games is the biggest disaster. Lack of nourishment destroys female athletes. Sugar and processed foods are the worst thing for menstrual cycle health.

This investment doesn’t require billions. You don’t need much money to play a game of tag, and build a variety of motor skills. You don’t need much to get a power block, or set of dumbbells, which is enough to load and get stronger muscles. My best athletes have home gyms with minimal equipment. They have grit, which is the highest cost of all.

I train out of my home gym in a garage with minimal equipment, and we’ve thrived because of everyone’s insatiable desire to become healthier athletes. We discuss nutrition and recovery weekly. I get on the girls about their pathetic food choices. None of this has been expensive. I have all the resources I need. The most expensive thing in all of this is everyone’s commitment and personal responsibility, which many aren’t willing to pay the price.

A field to run sprints is free. Sleep is free. A walk in nature is free. Meat and eggs are cheaper, more nutrient dense, and more satiating than a high sugar $12 acai bowl at an overpriced cafe. You don’t need much to be healthy. Simplicity always prevails.

Maybe you’re not convinced and still want to blame not enough resources in the women’s game, but how productive is blaming and complaining?

True female empowerment is focusing on the controllables.

By implementing a quality performance, load management, recovery, and nutrition program, whether this is at the level of the organization, or better yet, the individual taking responsibility for their own health, this is the way forward for girls soccer players.

For more research, get Erica’s THE STRONG FEMALE ATHLETE book

ABOUT THE AUTHOR

Erica Suter is a former college 3x All-American soccer player from Johns Hopkins University. She is giving back to the game and to female soccer players as a full-time performance coach. She holds a Master of Science in Exercise Science and has been helping girls with speed, agility, strength, and conditioning for over 12 years in the ECNL, GA, and NPL.

Her players have gone on to play college soccer at UNC, University of Maryland, Pittsburgh, Northwestern, West Point, University of South Florida, University of Charleston, MIT, Johns Hopkins, Carnegie Mellon, Rutgers, Towson University, and more.

Follow Erica on Twitter: @fitsoccerqueen

Check out her podcast: The Soccer Queens Podcast