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Life in Motion

Why Do Female Athletes Suffer More ACL Injuries than Males?

Sports & Exercise

According to the Women’s Sports Foundation, female participation in high school sports has gone up 900% since the 1972 passing of Title IX. But with this exciting increase in participation, female sports players have seen incredibly high numbers of anterior cruciate ligament (ACL) injuries. High school female athletes in the United States suffer 20,000-80,000 ACL injuries per year1. The issue isn’t only that female athletes are prone to these potentially season-ending injuries: the National Institutes of Health reports that female athletes are two to eight times more likely to suffer an ACL injury than their male counterparts. NEBH orthopedic surgeon and sports medicine expert Paul Weitzel, MD, discusses why females are more susceptible to ACL tears and offers advice on preventing these serious knee injuries.

Background on the ACL

The ACL is one of four major ligaments that work to stabilize and support the knee. It prevents the shin bone (tibia) from moving too far forward on the thigh bone (femur), and it limits the rotational movement of the knee.

An ACL injury occurs from overstretching or tearing the ligament, often caused by changing direction quickly, landing incorrectly from a jump, stopping suddenly, or direct contact from a collision. Although many ACL injuries occur in contact sports like basketball and soccer, 70% result from little or no direct contact with another player. The pivoting, jumping and landing, and sharp changes in direction to out-maneuver a player are often the cause of ACL injuries.

Female athletes incur ACL injuries more frequently than males likely because of physical differences and differences in sports techniques.

Physical differences

  • The intercondylar notch, the groove in the femur through which the ACL passes, is naturally smaller in women than in men. Accordingly, the ACL itself is smaller in women, which makes it more prone to injury.
  • Women more commonly have “knock-knee” alignment, meaning that their knees bend inward when they land from jumps. When a knee buckles, it puts a strain on the ACL to maintain the knee’s stability.

Technique differences

  • Women often land flat-footed, instead of on the balls of their feet, after a jump. This improper landing puts pressure on the knee when the calf muscles should be absorbing the force.
  • Women tend to have an imbalanced quadriceps/hamstring ratio. A female athlete is more likely to rely on her quadriceps muscles to decelerate or change speed, putting more pressure on the knee.
  • Women run in a more upright position than men, adding stress to the ACL and resulting in less control over rotation of the knee joint.

Injuries to the ACL

Injuries to the ACL are serious: most ACL injuries result in a partial or complete tear of the ligament and require surgery to repair. After surgery, it can take an athlete six months or more to make a full recovery and return to playing sports. Female athletes, particularly those playing sports like soccer and basketball where rates of ACL injuries are high, should take precautions to avoid injury. Training and conditioning programs can greatly reduce the risk of ACL injuries. Look for conditioning programs that teach athletes to rely on their hamstrings, instead of their quadriceps, when changing speeds.

Coaches should also be aware of the greater risk female players have of incurring an ACL injury. They should include exercises and stretches into their warm-up routines that emphasize sport-specific stretching, strengthening, agility, and jumping training. Proper training in leg and core strength, balance and speed, and landing techniques can all help minimize the risk of ACL injury in female athletes. Injury prevention training will help female athletes enjoy the game and succeed at their sports.

For additional information about preventing ACL injuries, consult a physical therapist or a sports medicine practitioner, who can recommend specific stretches and exercises to strengthen the muscles that will help you avoid injury. If you think you have injured your ACL, contact your doctor immediately.

1“Effect of Neuromuscular Warm-up on Injuries in Female Soccer and Basketball Athletes in Urban Public High Schools,” JAMA Pediatrics, accessed December 23, 2015.

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