The injury gap: why women are more likely to tear their ACL
And how you can protect yours
Welcome to the summer edition of the Impact newsletter, dedicated to feminism and football in celebration of the 2023 World Cup. We’ll be covering the highs and lows of the beautiful game on the pitch, and the fights for equality on the sidelines. Today, Professor Katrine Okholm Kryger explains why so many women footballers are suffering excruciating knee injuries — and what we can all do to prevent it.
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By Megan Clement
It’s a poignant dilemma for a football fan. We’re watching the best World Cup ever, but some of the world’s most exciting players aren’t there. If they were, would it be even better? Marie-Antoinette Katoto and Delphine Cascarino of France, Beth Mead and Leah Williamson of England’s Euro-winning side, the Netherlands’ all-time top goal scorer Vivianne Miedema; all have been sidelined with the same injury – a torn ACL.
The ACL, or anterior-cruciate ligament, runs down the middle of the knee, preventing the leg from over-extending. Women football players are three times more likely to rupture this ligament than men. It’s an excruciating injury, as the World Cup has already shown – Haitian defender Jennyfer Limage was taken off the pitch howling in pain when she tore her ACL in the team’s opening match against England.
One person trying to understand why women are so much more likely to suffer this injury is Katrine Okholm Kryger. An associate professor in sports rehabilitation at St Mary’s University, Kryger is a leading expert in injuries in women’s sports. And like many women in football, she has had to create a place for herself in the game where none existed before.
“When I was 10, I told my mum that my biggest dream in the world was to play for the men’s French national team,” she says. “I couldn’t have possibly imagined myself playing football for a women’s team, because we weren’t exposed to it.”
Her words echo those of Brazilian icon Marta — one of the greatest footballers of all time. “When I started, there were no idols in women’s football,” she told a press conference before her last ever international match two weeks ago. “How could there be if you didn’t show women’s football?”
When Kryger studied sports medicine at university, her ambition was still to work in men’s football. When she topped her class, she expected to be given the opportunity other students were offered – the chance to undertake a work placement with a Premier League team. “I was told that the club didn’t want me because I was female. I could choose any other placement I wanted, but not football,” she said.
Undeterred, she eventually wrote a PhD on men’s football boots. She offered to study women’s boots as well, but manufacturers told her there was no market for it. “I’ve gone through the same mill as every other female out there who’s interested in [women’s] football: being told that it’s niche, and it’s not important, and there’s no market,” Kryger says.
The lack of interest in women’s playing experiences, the lack of opportunities and the consistent underestimating of women in football, the vast gender gaps in research; Kryger says all of this contributes to a world in which women are more likely to get injured for months and miss the opportunity to compete on football’s grandest stage. But, “I’m in a very fortunate position now where I can actually do something about it,” she says.
Kryger spoke to the Impact newsletter about the injury gender gap, and how we might be able to close it. This conversation has been edited for length and clarity.
Megan Clement — How much more likely are women to injure their ACL than men?
Katrine Okholm Kryger — ACL injuries are approximately three times higher in women compared to men in football. But in ballet, the incidence rates are the same for men and women. It’s a very interesting comparison because in ballet, men and women train together, they do injury prevention together, and they have the same environment. And the numbers are exactly the same.
Megan Clement — That is so interesting, because in ballet, men and women are doing quite different activities. In football, they’re doing the same thing. And yet in ballet, you have equality in the environment. It gets into the question of why the rates are so much higher in women footballers. What is the evidence that we have?
Katrine Okholm Kryger — I’ve made a list of the risk factors that I’ve seen discussed in the literature, and there’s around 30. The common reasons you see in the media are hormonal cycles, the idea that women are “unstable”. And the other one is that women aren’t built for football because they have wider hips, and therefore the knee angles make it impossible for them to land when they’re jumping and to run properly. We don’t have any evidence that supports these claims in a strong way. Yes, bodies are different, and we can’t deny that. We can’t assume that what works for men will work for women in terms of preventing injuries because muscle mass is different. The size of the anterior cruciate ligament is different because women are smaller, so the ligament is smaller as well. And yes, women do have wider hips, but it doesn’t mean we can’t move. That’s the sex and genetics part of it. It’s interesting, but it’s not that interesting at the same time, because there are very limited things we can do about it. We can’t change the shape of the pelvis, but we can do something about everything around it – the environment.
The biggest factor to minimise risk of injury is injury prevention training. There have been really good studies showing that you can decrease your ACL injury risk by doing certain exercises as a warm-up for training and games; you minimise it by 60%. If the injury rate is three times higher in women compared to men, we’re close to solving the issue just by doing that.
Then there’s the environment. It’s the World Cup right now, so the pitch is optimal. But when we talk about pitches, even in the best leagues in France and England, most of them are not the same quality as what the men play on. It’s the same for amateurs. Every time I talk to an amateur team, they’re like, “The boys always get that pitch, and we have to go all the way round the corner to this really bumpy one.” If you’re playing on a bad surface, you are at a high risk of getting injured.
Women’s football is improving, and we’ve got more games every year, and it’s amazing. We’ve got more tournaments, we’ve got more money invested and players wanting to play again, because they get more money out of it. It’s all very positive. But obviously, that’s an extra load on them. So how do we balance that increase in load every year as the game is improving and making sure they’re not overworked?
Megan Clement — I have never spoken to someone with a PhD in football boots before. How cool is that! So I have to ask you: how much do you think boots are a factor in ACL injuries, and are women players currently wearing the right boots?
Katrine Okholm Kryger — A couple of brands have launched women’s football boots for the World Cup, which is very nice. But I’ve not seen any data on it so I don’t know how much research has gone into it versus how much is marketing. The usual saying in sports technology is “pink it and shrink it”. If you Google “girls’ football boots”, they’ll all be pink football boots, which I’m not sure is what girls actually want.
We need football boots designed for women. The foot shape is different between men and women, and football boots fit really tightly. If it’s not fitted optimally, it will squeeze your foot and it will be uncomfortable and painful. If you run around in it long enough, it might injure you and will definitely create a decrease in performance. The other thing about football boots for women is the studs and the outsole. The different types depend on different surfaces, but it’s defined for what a man needs, nothing has gone into what a woman needs. Women are lighter, we don’t have the same muscle mass, we don’t produce the same force, we have smaller feet compared to men. But the stud length, shape and numbers are not changed. Whether you have a size five foot or a size ten, the stud length and numbers will be exactly the same. So the traction, the interaction with the surface, is higher for a girl than it is for a boy based on the shoe-size difference. Women need less traction – we don’t want to get stuck in the surface because of basic things like ACL injuries.
Megan Clement — How important are factors like physiotherapists and support staff?
Katrine Okholm Kryge — Massively. The professional men’s team will probably have maybe two or three doctors, five physios, several strength and conditioning coaches, and many of them will have a personal trainer outside of that as well. Women’s teams will have way fewer people, often with less experience because they pay less. There are so many factors. Comparing men’s and women’s football is like comparing pears and apples. There’s so many factors we need to address before we start talking about “women are not built for playing football.”
Megan Clement — That’s the oldest excuse in the book, right? We’ve been hearing that one for a hundred years. I am thinking about some of the stories behind this World Cup, where women’s teams are having to crowdfund just to go, like Jamaica. South Africa refused to play a friendly because the pitch was made of grass and clay. Can the campaigns we’re seeing for equal conditions in women’s football be part of the solution?
Katrine Okholm Kryge — We need individuals out there to actually stand up and speak out because that’s how we’ve made changes. Women are behind on the ladder and it’d be nice if it just was a smooth transition from one rung to the next, but history shows that it is about one person or a group of people standing up and speaking out loud, then people can make decisions based on that. It is important to raise people’s awareness when things are not right.
Megan Clement — The Impact World Cup newsletter is all about getting people to embrace football, even if they traditionally felt excluded. What would you say to women, girls and parents of girls who are worried about getting into football because of the risk of this injury?
Katrine Okholm Kryge — The first thing to know is that football is healthy. We call it bio-psycho-socially healthy because it’s good for your body, it’s good for your mind and it’s good for social interaction. So it ticks all the boxes. And ACL injuries are rare. The risk is three times higher than in men, but it’s rare in men, and it’s rare in women. The final thing to say is that you can do something about it. Coaches, parents, whoever’s running an amateur team can find the FIFA 11+ programme. It has pictures of the exercises, it’s designed for you to be able to do if you’re not an expert, and doing those exercises decreases the chance of getting injured. It’s really important that you are strong, so if you don’t like that, then go to the gym and lift heavy things. That’s really good for you if you want to prevent injuries.
Megan Clement — I’ve been a football fan my whole life, but I’ve never played and I’m wondering if it’s too late for me. I’m always looking for opportunities for a 36-year-old woman to learn how to play football for the first time.
Katrine Okholm Kryge —I was recently in Denmark with a group of coaches and we had this group of players come in with an average age of 74. They’ve designed healthy football for the elderly, with men and women playing together. There was this lovely lady who said that she’d gotten her first goal at the age of 72. Football should be healthy, as long as it’s done in the proper way. And if you do your injury prevention and your warm-up, you can play until you’re 80.
Megan Clement — This is a question that I asked everybody I interview. What is it that keeps you going doing the work that you do, in the face of 2qinequality, and despite the challenges?
Katrine Okholm Kryge — It’s seeing that the things that we’ve been wanting to do for a long time are being implemented. We’re being listened to, and people are seeing the issues. Instead of the barriers we used to have, we have allies in men’s football who really fight for women’s football and invest in it, believe in it, do research into it. It’s so motivating being here. It’s not as much of an uphill battle as it was five years ago.
The latest from the World Cup
Round of 16
England vs Nigeria 0(4) – 0(2) 😬
Australia vs Denmark 2-0 🥳
Colombia vs Jamaica 1-0
France vs Morocco 4-0
Spain vs Netherlands 2-1
Japan vs Sweden 2-1
France vs Australia 0(7)-0(6) 🤯
England vs Colombia 2-1 👯
Matches to come
Tuesday August 15th: Spain vs Sweden
Wednesday August 16th: Australia vs England
Sunday August 20th: 🏆 THE FINAL 🏆
Golden Boot 🥅
Miyazawa Hinata 5
Kadidiatou Diani 4
Amanda Ilestedt 4
Alexandra Popp 4
Jill Roord 4