Women’s World Cup, ACL injuries and Physiotherapy Strategies

Every four years, the Women’s world cup takes centre stage, capturing the essence of football: the unwavering determination of athletes, the artistry of a well-timed pass, the precision of goal scoring, and the camaraderie’s of teamwork. However, amid the flashing lights of the global event lies a growing concern – the prevalence of Anterior Cruciate Ligament (ACL) injuries. In this blog post, we explore the intersection between football and ACL injuries, delving into the risk factors and physiotherapy driven prevention strategies that can safeguard players, especially youth athlete’s and promote enduring careers in the industry.

The Women’s world cup and ACL injuries

The Women’s World cup is a spectacular celebration that thrusts female athletes into the limelight, showcasing their dedication and extraordinary talents. However beneath the glamour, a troubling trend surfaces: a significant number of players falling victim to ACL injuries. Reports suggest that female football players are six times more likely to suffer from ACL injuries than their male counterparts. Notable cases like England’s captain Leah Williamson, who ruptured her ACL ahead of her World cup debut, Simone Magill who sustained an injury during Ireland’s opening game, and France’s Marie-Antoninette Katoto limping off the field during a group game against Belgium, are stark reminders of the issue at hand.

Exploring the ACL: Anatomy and Mechanism of injury:

Now before we explore the risk factors of this injury we must understand the anatomy of this buzz word, ACL. The ACL or Anterior Cruciate Ligament is found inside the knee joint. This ligament connects the femur to the tibia bone and prevents the anterior shift of tibia and provides rotational stability to the knee. As the name suggestions the ACL travels from the front of the knee (tibial plateau) diagonally through the centre of the knee to the posterior aspect of the femur (femoral shaft).

So how does this ligament get injured?

There are several ways the ACL ligament can become injuries these include:

  • Rapid change in direction
  • Stopping abruptly
  • Deceleration whilst running
  • Landing from a jump incorrectly
  • Direct contact or collision whilst playing sport.

Exploring the complexity of ACL Risk Factors

A recent systematic review has cast a spotlight on the anatomical components that may increase the likelihood of ACL injuries occuring. Among these factors, the width of the intercondylar notch emerged as a potential determinant. A narrower notched, assessed through the notch width index, has been linked to an elevated risk of ACL injuries. The intercondylar notch is situated at the end of the distal femurs, holds vital structures, notably the anterior cruciate ligament. The review demonstrated that for every millimetre decreased in the notch width there was heightened risk, especially when compared to males. Additionally, the study unveiled a trend of heightened posterior or lateral tibial slope among individuals with ACL deficient knees.

Neuromuscular imbalances
The foundation of strength is paramount regardless of gender. However, female athletes may face critical disparities, notably deficiencies in hip external rotators and hip abductor strength. The review exhibited distinct neuromuscular patterns in female athletes which included differences in muscle recruitment sequencing and imbalances between the hamstring and quadriceps group. These patterns can potentially compromise the knee’s stability and in turn contribute to an increase in vulnerability.

Biomechanical factors intertwine with ACL injury risk, notably with landing mechanics. It exhibited in instances where there was an increase in knee valgus during landing, resulted in elevated ground reaction forces, placing additional strain on the ACL. Notably when combined with abduction and anterior tibial translation, these mechanics escalate ACL tension and increased injury risk.

Hormonal and Physiological influences.
There has been potential hypothesis of hormonal and physiological factors with particular focus on the menstrual cycle. Specifically, the pre-ovulatory menstrual phase seems to be associated with heightened susceptibility to injury risk. However, these findings necessitate further exploration and research.

Building strong knees in preparation for female sport.

Now that we understand the multifaceted risk factors associated with ACL injury risk, now let’s shift the spotlight to the realm of injury prevention. We will delve into the measures that can be embraced both at local clubs and on an individual level. Let’s look at the world of building strong knees and explore how clinical guidelines can be put into practice to mitigate the risk of ACL injuries.

Exercise Based Prevention Programs:
Three notable programs 11+, Sportsmetric and Harmoknee – have emerged as cornerstones of injury prevention, especially for the sporting population.

  1. 11+ (Also known as FIFA 11+)
    The program was designed as an injury prevention program in soccer players, it encompasses 15 structured exercises. These exercises span from core stabilization, eccentric lower limb muscles training, proprioceptive training, dynamic stabilization, and plyometric exercise. The review encompassed both female and male athletes, ultimately concluding the integration of this warmup regimen reduced the injury risk of players by 30%.
  1. Sportsmetric
    The Sportmetric program a 6-week program, centres its focus on ACL injury prevention. Carrying out three sessions, the program incorporates dynamic warmups, strength training, flexibility and plyometrics. Athletes jumping mechanics are also observed at the beginning and at the end of the program.
  1. Harmoknee
    Harmoknee, like the above-mentioned programs addresses knee injury prevention through a structured warm up regimen integrated with targeted strengthening exercises. The program’s main objective lies in enhancing knee health and stability.

Collectively, these programs underline the importance of targeted strength enhancement, neuromuscular control, and sport specific biomechanics. Their impact on injury risk mitigation is underscored by an array of key insights from the research:

  • Importance of Prevention programs:
    The Implementation of programs focusing on neuromuscular imbalances, biomechanics and strength deficiencies consistently leads to a reduction in injury risk.
  • Timing is important:
    Incorporating these programs as integral warm up routines for training sessions and games extending beyond 20 minutes has proven to be strategic approach in mitigating injury risks.
  • Programs For all:
    While traditionally program may be designed to target athletes deemed at high risk, the consensus now highlights that all athletes should actively participate in prevention programs.
  • Preventing preseason vulnerabilities:
    Integration of prevention programs as part of preseason better equipped athletes to manage risks throughout the season.
  • Age implementation:
    The guidelines emphasize the universal applicability of the program, with a particular focus on young athletes aged 12 -25 who are engaged in high-risk sports, by embedding preventive measure in the early years, it helps contribute to long term injury resilience.


As the Women’s World cup continues to inspire and unite, let it serve as a catalyst to enhance the performance of our female athletes. By implementing evidence-based prevention strategies, we can pave the way for enduring careers in the industry while minimizing injury risks. Building strong knees through exercise-based, knee injury prevention programs is a pivotal factor in mitigating injury risks. Collaboration with clinical practice guidelines and consulting with physiotherapy ensure that athletes can embark in their sporting journey with confidence and against potential setbacks.



  1. Bisciotti, G. N., Chamari, K., Cena, E., Carimati, G., & Volpi, P. (2016). ACL injury in football: a literature overview of the prevention programs. Muscles, Ligaments and Tendons Journal, 6(4), 473-479. doi:10.11138/mltj/2016.6.4.473
  2. Bizzini, M., & Dvorak, J. (2015). FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide—a narrative review. British Journal of Sports Medicine, 49, 577-579.
  3. Arundale, A. J. H., Bizzini, M., Dix, C., Giordano, A., Kelly, R., Logerstedt, D. S., … Snyder-Mackler, L. (2023). Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. Journal of Orthopaedic & Sports Physical Therapy, 53(1), CPG1-CPG34.
  4. Beynnon, B. D., Johnson, R. J., & Abate, J. A. (2016). The female ACL: Why is it more prone to injury? Journal of Orthopaedics, 13(2), A1-A4. doi:10.1016/S0972-978X(16)00023-4
  5. American Academy of Orthopaedic Surgeons. (n.d.). Anterior Cruciate Ligament (ACL) Injuries. OrthoInfo. Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/anterior-cruciate-ligament-acl-injuries/
  6. Pfeifer, C. E., Beattie, P. F., Sacko, R. S., & Hand, A. (2018). RISK FACTORS ASSOCIATED WITH NON-CONTACT ANTERIOR CRUCIATE LIGAMENT INJURY: A SYSTEMATIC REVIEW. International Journal of Sports Physical Therapy, 13(4), 575-587.