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It is well known within the athletic community that female athletes sustain non-contact anterior cruciate ligament ruptures at a higher rate than their male counterparts – 2-8 times higher when compared to male athletes in a similar sport in fact. So, the question that we need to ask is: Why is that? And what can we do to help prevent it?

To understand this, first we must look at the mechanisms for injury to the ACL. The ACL is in a vulnerable position when the knee collapsed inward (valgus), has excess internal rotation on the tibia, and when the knee is hyperextended. This means that at risk situations for athletes sustaining a non-contact ACL rupture are deceleration, cutting or changing direction, and landing.

Intrinsic differences between females and males

Next, let’s look at the intrinsic differences between females and males that may contribute to the higher incidences of ACL injury:

Hormonal
There are limited studies surrounding this topic, but the research does suggest that ACL injuries in women occur at a higher rate during the ovulatory (mid-cycle) phase of the menstrual cycle compared to the follicular/luteal phase (late cycle).

Anatomic
Women typically have a greater Q-angle than men, which is the angle between the hip and the knee, and because of this are more likely to have a naturally greater knee valgus – a more vulnerable knee position for ACL rupture.

Neuromuscular
Difference in neuromuscular activation patterns between the sexes seems to be the main variant contributing to increased ACL rupture. Females have been found to be less effective at stiffening their knee, and maximum contraction of the knee musculature significantly decreases anterior tibial translation. As well as this, females take longer to generate maximal hamstring force, and the muscle recruitment order is different for some female athletes.

Core stability
Lack of core control contributes to an individual getting into a position that allows for ACL rupture.

How can we mitigate this risk?

Core and balance training is extremely important to include in your exercise programme. Balance and proprioceptive training will improve your body’s positional awareness and help you to identify when you may be getting into an at-risk position, and core strengthening will help to keep you out of those positions.

Quadriceps and hamstring training – especially during eccentric (lengthening) contraction – will increase the muscular support available for the knee if you do find yourself in a vulnerable position.

Because the knee only has one plane of motion while the hip has several, often it is the strength of the hip muscles that controls the direction of the knee. Therefore, it is important to keep the hip muscles, such as the gluteus medius and the TFL, strong and stable.

One of the biggest things to remember is that everyone’s body is different, regardless of sex or gender. As an athlete, it is important to know any areas of deficiency that may contribute to increased risk of injury. An assessment can be provided by a relevant practitioner such as a physiotherapist, sports chiropractor, exercise physiologist, or a strength and conditioning coach to identify any weaknesses and provide suitable exercise advice as to the direction of your training.