Alex Garver

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

can take include strengthening exercises focusing on quadriceps, hamstring and

abdominal muscles, exercises that correct the biomechanics when landing a jump, and

oral contraceptives that can balance hormones.

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

through non-contact means in all athletes, but “...female athletes sustain

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.

Fig. 1. Normal ACL vs Torn ACL (“ACL Reconstruction Review”)

 The female anatomy seems to play a big role in why women are suffering ACL

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

to strengthen their bodies and protect their knees.

Another contribution to the occurrence of ACL tears in females may have to do

with a female’s menstrual cycle. One study “... used self-reported menstrual history data

to characterize a participant's menstrual status at the time of injury and demonstrated a

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

highest levels of estrogen (“Relationship between Estrogen and ACL Rupture in a

Normal Cycle.”)

Neuromuscular activation patterns may also be a key factor in why females are

more susceptible to an ACL tear. “Gender differences in neuromuscular activation

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

straightened, or locked out, can be dangerous and lead to hyperextension, which is a

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

such a higher rate than their male counterparts.

Fig 3. Correct landing position vs. ACL risk landing position (“Knee Mechanics:

Neutral Alignment (Left) vs Valgus Alignment (Right)”)

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

athletes can take action to protect their knees from damage.

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

simple but effective preventative measure that everyone can do.

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

that all athletes have the means to take.

Fig. 4. Neuromuscular pattern correcting exercises, right vs wrong (“Drop

Landings and Lunge Exercises.”)

A less well-known prevention method includes oral contraceptives to offset the

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

susceptibility of the ACL to injury”(DeFroda). This method of prevention is most effective

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

hormone levels are naturally at the highest.

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

the anterior cruciate ligament.

It is extremely important that we do everything we can to lower the amount of

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

ACL injuries of female athletes compared to their male counterparts.

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