ACL Injury in Female Athletes: Reanalyzed & Expanded by Richard Parker, M.D., Cleveland Clinic, Cleveland Rockers WNBA Team Physician

by CoachZ on January 21, 2009

Female Athletes and Anterior Cruciate Ligament Injuries

It is no secret that men and women are inherently different creatures. It stands to reason that male and female athletes may face their sports with contrasting regiments, attitudes and styles. However, sports health physicians now realize that female athletes are more susceptible to anterior cruciate ligament (ACL) tears than their male counterparts.

The ACL is the smallest knee ligament and connects the tibia (shin bone) and femur (thigh bone), providing anterior stability to the knee for activities requiring running, jumping, landing, deceleration, twisting, turning, and changing directions quickly on an extended (straight) knee. Injuries to the ACL commonly occur during sports, which require the above activities and knee position. Thus, sports such as basketball, soccer, volleyball, gymnastics, cheerleading and skiing are considered high-risk sports for ACL injuries. Since women are more active in these sports than ever before, it leaves them very vulnerable to ACL injuries.

Injury to the ACL is usually complete and requires surgical intra-articular reconstruction after a few weeks of rehabilitation to regain range of motion and reduce swelling. Different intra-articular reconstruction techniques exist, but share the common denominator of being performed arthroscopically with either part of the patient’s patellar tendon or semitendinosus (hamstring) tendon. During the surgical procedure, associated injuries such as meniscal and/or articular cartilage damage are addressed. After surgery, immediate rehabilitation is initiated with early motion and protected weight bearing. Rehabilitation lasts for four to six months, with return to sport occurring usually around six months postoperatively, but can range from four to 12 months postoperatively.

Gender Differences

According to the National Collegiate Athletic Association (NCAA), female basketball players are four times as likely to suffer from an ACL tear as male basketball players. Several studies are underway to explain the discrepancy between male and female ACL injuries. Numerous theories abound, ranging from differences in anatomy and hormones to differences in running and sports styles. Some authors believe that since the female has a wider pelvis, she is more vulnerable to tearing her ACL. Some authors, on the other hand, believe that a female may not have as strong or as large of an ACL as she should for the sport being played. The female menstrual cycle may play a role according to a recent study out of University of Michigan and Vanderbilt. The authors found that females were more vulnerable to ACL injuries near the time of ovulation (mid-cycle). Those females on oral contraception seemed to have the same incidence of ACL tears as males. Others believe that females run and play sports, particularly basketball and soccer, in a more upright position, with their knees more extended and vulnerable to ACL injury. Unfortunately, many theories exist regarding why females have a higher incidence of ACL injuries than males. Time and more research will improve our chances of delineating fully the reason or reasons why females are more vulnerable to tearing their ACL.


Unfortunately, no one can totally prevent the tearing of the ACL in an athletic individual. Several researchers have suggested that training programs directed toward maximizing hamstring strength greater than quadriceps strength improves knee function and decreases an injury to the ACL. This makes sense since the hamstrings dynamically reduce anterior translation of the tibia on the femur, which is the same static function of the ACL. Other researchers have outlined an entire rehabilitation program geared towards maximizing hamstring strength and participating in sports in a more “flexed-knee” position. By flexing the knee, the female reduces the stress on the ACL. There is no doubt that improving one’s propioception, hamstring strength, and posture will help reduce the incidence of ACL injuries in females.

Richard Parker, M.D., is a Cleveland Clinic Sports Health doctor, and the team physician for the Cleveland Rockers.

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