The REAL problem with ACL injuries in female footballers (Part 1)
Strength & Conditioning Coach - Jaye Edmunds
There has been a lot of talk in the media recently over the epidemic of ACL injuries that have been plaguing the AFLW. Many journalists and ‘experts’ are speaking out stating we need more research to prevent them, while others are blaming football boots and rule changes. While these points may have some credibility, I think many are failing to see the bigger picture in regards to preventing these injuries.
Having rehabbed quite a few female ACL injuries as well as coaching a large amount of junior athletes, I’m starting to get a greater understanding as to how poorly our junior athletes are prepared from a physical standpoint.
The solution I am going to provide below is not a quick fix. In fact it’s probably the opposite, but the most effective from a performance and injury prevention standpoint. The truth is we don’t need more research. We have more than enough. What we need is to start implementing it, and it starts at the grass roots.
Lets begin.
Australia has the highest rate of ACL ruptures in the world (1). This is largely due to the dynamic nature of sports we participate in. But perhaps the biggest concern is the massive increase of ACL injuries within a particular population group.
Females aged between 15-19
With the rise of AFLW we are seeing a rapid influx of adolescent female athletes flooding to the sport. This is great to see. In 2018 alone, female football participation increased by 14.42%. Making up a total of 32% of football participation in the country.
But this doesn't come without its problems. Females are up to 10x more likely to rupture their ACL in comparison to men (2). This is due to a variety of anatomical and hormonal factors as well as the lack of a neuromuscular spurt during puberty. Previous articles on the Aussie Rules Strength Coach page have outlined these in more detail. But essentially these factors listed above are causing abnormal joint mechanics when performing dynamic movement tasks such as cutting and landing. This in turn can leave the knee more susceptible to collapsing inwards and therefore creating greater rotational forces at the knee. This is the main mechanism behind ACL ruptures.
You only need to look as far as the first few seasons of AFLW to notice the extremely high rates of ACL tears.
However it’s not all doom and gloom. The good news is it’s highly preventable with good training!
It’s been shown that a neuromuscular training program can reduce the likelihood of an ACL rupture by as much as 88% in adolescent female footballers (3). Another study showed knee injury rates were 2.6 times higher in high school female athletes who DID NOT participate in a strength training program (4). These decreases in injury rates are due to the increases in joint stability and adaptations that occur in the bones, tendons and ligaments following strength training.
It has also been shown through a meta analysis of meta analyses (yes I said that right) female athletes who performed a neuromuscular training program were 67% less likely to sustain a non contact ACL in comparison to those who did no training (5). These are substantial, clinically significant reductions. You can't really get much stronger evidence than a meta analysis of meta analyses.
So the research is clear, female footballers need proper Strength & Conditioning training!
Yet why are very few doing it?
In my opinion it's the lack of education and resources provided to clubs and coaches. Most coaches at junior levels are volunteers or parents. They do a fantastic job with the football and managing side of things. However they have little to no understanding of how to prepare athletes. Junior athletes are severely underdeveloped from a physical preparation side of things.
Many would be aware that there is a physiotherapist at virtually every sporting club across the country, yet a qualified Strength & Conditioning coach (Exercise Scientist) who also has similar university qualifications of 3-4+ years is nearly unheard of. Perhaps what's even worse is some coaches don’t believe in hiring a S & C coach altogether!
This is not only doing athletes a disservice, but is borderline negligence in my opinion. There is a plethora of research out there stating stronger, more conditioned athletes not only get injured less, but significantly outperform competitors in tasks such as acceleration, top end speed, jumping, changing direction, tackling, as well as repeat effort specific conditioning. All qualities a footballer needs to be successful. Essentially you hit two birds with one stone. Reducing the likelihood of serious injuries like ACL’s but also maximising key athletic qualities mentioned above.
Improving these qualities requires a sound understanding of exercise principles as well as smart programming based around the individuals needs and goals. Not something you can make up on the fly.
Don’t get me wrong, physios do a fantastic job with diagnosing and treating early stage rehab, however there is little emphasis on performance and preventing the injuries from happening in the first place. Australia is very reactive when it comes to injuries at all age groups. We would rather wait for an injury to happen then prevent it from happening in the first place. (This could be an entire blog post in itself.)
As a result, most of these girls enter senior football not knowing how to train properly. The vast majority can’t do a bodyweight squat, or land efficiently from a jump. The problem with this is, their bodies can’t handle the rise in intensity that is associated with senior football. It’s potentially a large reason why the majority of the ACL ruptures in the AFLW are girls in their first year.
Teaching the girls how to absorb forces and control their own body weight is an absolute necessity during their junior years. Teaching them how to accelerate and decelerate quickly & efficiently. Learning how to jump, land, change direction and then build strength around the knee and hip is critical in developing strong robust athletes. But this takes time to engrain. Repetition is the mother of all skill. 8 weeks of good training isn’t going to reverse the previous 8 years of negative motor patterns you’ve been developing. These girls can’t be rushed, but more importantly need time and repetition to master these movement patterns.
Having these clubs hire a qualified professional to implement these programs properly is absolutely crucial. As mike boyle states “ACL prevention is just good training”. Make the investment and watch it pay dividends.
However in saying that, it may be some time before this becomes mainstream in both junior and senior clubs around the country. Although a Strength & Conditioning coach may be mainstream in countries like the United States, this is not the case in Australia.
So the rebuttal now from most coaches would be ‘how do I have time to fit all of this into a training session that may only be 60 minutes long, we still have to do skills etc’ Although true, I strongly believe there is a lot of wasted time at training that could be made up doing more valuable forms of training.
Regardless of coaching or playing experience I want to give all those involved some go to ideas they can implement with their clubs to maximise performance and reduce the likelihood of injuries.
Stay tuned as I will go over how to do this in part 2
Jaye Edmunds is a Strength & Conditioning coach at Woodford Sport Science Consulting. He is currently finishing up his double degree in Secondary Teaching & Exercise Science. Jaye has worked with a variety of both male and female footballers ranging from VFL to junior level football.
He is currently the head Strength & Conditioning coach at the SFNL umpires association.
He can be found on the following social media platforms;
Instagram: @performancecoach_edmunds
Facebook: Jaye Edmunds - Athletic Performance Coach
References
1.Zbrojewicz D, Vertullo C, Grayson J. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000-2015
- Buller LT, Best MJ, Baraga MG, et al. Trends in anterior cruciate ligament reconstruction in the United States. Orthop J Sports Med 2014; 3: 2325967114563664.
- Hägglund M, Atroshi I, Wagner P, and Waldén M. Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT. British Journal of Sports Medicine 47:974-979, 2013.
- Hewett TE, Lindenfeld TN, Riccobene JV, and Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. The American Journal of Sports Medicine 27: 699-706, 1999.
- Webster KE, Hewitt TE. A Meta-analysis of Meta-analyses of Anterior Cruciate Ligament Injury Reduction Training Programs. Journal of orthopaedic research. 2018 Oct;36(10):2696-2708. doi: 10.1002/jor.24043.
