England’s Leah Williamson and Beth Mead will be watching their teammates from home when the Lionesses play Spain in the 2023 FIFA Women’s World Cup final on Sunday.

Williamson and Mead are two of the casualties of the “ACL tear epidemic” that has hit women’s soccer with female athletes being two to eight times more likely to tear their ACL than male athletes, according to Yale Medicine.

The “epidemic” has cost several of the world’s best players a chance at World Cup glory this year, including the Netherlands’ Vivianne Miedema and the U.S.’s Catarina Macario and Christen Press. Haiti’s Jennyfer Limage joined the “ACL tear club” after sustaining the injury in Haiti’s first game of the World Cup.

But the issue extends beyond the World Cup and professional soccer. It’s seen at the collegiate, high school and youth club levels with 1 in 19 female players rupturing their ACL while playing soccer, according to an article in the Journal of Orthopedics and Orthopedic Surgery.

‘An explosion in your knee’

The ACL, or the anterior cruciate ligament, is a band of tissue that connects the femur to the tibia that can be torn from making contact with another player. It can also be torn without contact when making a sudden stop or change in direction while running. These are most concerning because noncontact tears can be reduced.

Portland Thorns forward Michele Vasconcelos, a Sandy native and former BYU Cougar, has torn both her right and left ACLs during her collegiate and professional career. With both injuries, she knew right away that she had torn her ACL.

“It just feels like an explosion in your knee,” Vasconcelos said. “It is pretty painful.”

Vasconcelos is no longer fearful of suffering the injury a third time but she was when she initially returned.

“I think initially there’s just a little bit of apprehensiveness coming back because you don’t want to do it again,” she said. “So I was nervous at first but then I think it goes away within a couple of months.”

How long does it take players to recover from an ACL tear?

After a player tears their ACL, they wait one to two weeks for the swelling to reduce before undergoing reconstruction surgery. The rehab process after surgery could take nine to 14 months depending on how quickly the player develops muscle.

But even if a player is cleared to play and is back on the pitch, they won’t necessarily be back to the player they were before the injury. A study published in the Orthopedic Journal of Sports Medicine earlier this year found that NWSL players coming back from ACL tears saw a decrease in minutes and goals scored in the year after their injury.

Vasconcelos says it took her over a year after her second ACL tear to get back into her usual playing form and “to feel good again.”

“I felt good physically,” she said. “But it just, I don’t know. It’s almost like, not like you lose muscle memory but, you know, kind of those little instincts where you just trust yourself.”

What causes the increased ACL tear risk in women?

There isn’t one correct answer to this question. When asked if menstrual cycles, ill-fitting boots or biology were the biggest factor, Carolyn Billings, BYU’s director of sports medicine, said “all of them.”

“I don’t know (if) we’re quite in an area where we could research and determine which one impacted,” she said. “When someone goes down (and) tears the ACL, I get asked these questions a lot, and unfortunately, we just don’t know. It’s the the moment that the stars aligned and they tear it.”

Billings has noticed a trend between menstrual cycles and ACL tears, but she isn’t comfortable enough to declare it as the cause.

“But I would say (with) a majority of the ACL tears they are on their period, so it has a huge impact on it,” she said. “But what are you gonna do? You have to have it.”

Menstrual cycles are considered a possible factor because females experience a change of estrogen and progesterone when on their period, which causes a laxity in the ligaments and tendons.

Another factor is that female soccer players tend to land on their heels after a jump and aren’t absorbing the landing, putting undue stress on their knee. This factor is where the most prevention can be done to reduce ACL injuries.

How can noncontact ACL tears be prevented?

The key to reducing ACL tears is training, Billings said. Players need to strengthen the external rotators of their hips in addition to their quads and hamstrings. She says it’s important for players to have an overall balance of muscle development.

This kind of training in addition to working on players’ mechanics can reduce the opportunity of tearing the ligament.

Billings believes that the increase in ACL tears she has seen over the last 15 years is because children are specializing in one sport at a young age.

“I have great concern with how early athletes now are specializing in one sport, and I feel that has a huge impact on it,” she said. “When they start only playing soccer, I think they lose some of the motor pattern development (they get) when they play different sports.”

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She recommends that children who are specializing in one sport should spend time in performance centers, where they can develop properly and learn techniques for sprinting, acceleration and deceleration.

“We can do a certain amount of prevention at the high school level and the college level, but you really need to hit them when they’re younger,” she said. “I used to see a lot of ACL tears occur at college. Now they’re all happening when they’re in club and high school level.”

In pursuing their dreams of playing professional, Billings says that children are being trained harder and for more hours than professional and collegiate athletes as they choose to specialize, putting more wear and tear on their bodies.

“That’s a cultural change that’s really hard to beat when everyone wants to become the next great player and get a college scholarship.”

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