What Female Athletes Should Know About ACL Injuries

ACL injuries often result in a “pop” in the knee, followed by a feeling like your knee is about to give out. These injuries are common, affecting roughly 1 in 3,500 people in the U.S. each year, but they’re especially common in young female athletes.

“Young female athletes experience ACL tears up to 8 times more frequently than their male counterparts,” says Elizabeth Matzkin, MD, co-leader of Mass General Brigham Women’s Sports Medicine. “We’ve led research in this area and there may be several factors at play including female anatomy, hormones, and muscle strength. That’s why holistic, multidisciplinary care and prevention training are so critical for these athletes.”

In this article, Dr. Matzkin explains what female athletes need to know about ACL injuries and why a female-focused approach to surgery results in better outcomes. Dr. Matzkin is a women’s sports medicine surgeon at Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital. She’s also the head orthopedic surgeon for the National Women's Soccer League Boston Legacy FC.

How to identify ACL injuries

An ACL injury is a sprain or tear of the anterior cruciate ligament, a strong band of tissue in the knee connecting the thigh bone to the shin bone. Athletes who participate in sports involving sudden stops or pivots—including soccer, basketball, field hockey and downhill skiing—are the most likely to be affected.

ACL sprains or tears typically occur suddenly when an athlete engages in a knee-straining motion while in play. Slowing down or stopping abruptly and switching direction, landing awkwardly from a jump, or pivoting with the foot planted firmly on the ground are common culprits. A direct blow to the knee can also injure the ACL.

Dr. Matzkin and the team at Mass General Brigham Women's Sports Medicine specialize in world-class prevention, treatment, and recovery of women's sports injuries.

“We evaluate ACL injuries and work together with patients to understand their injury history and goals to not only help them recover from injury, but to also help them prevent repeat injuries,” says Dr. Matzkin. The team provides primary and preventive care, mental health and sport psychology for female athletes, care for pregnant athletes, and sports nutrition coaching.

When ACL surgery is necessary

You may be able to manage your ACL tear with physical therapy and rehabilitation alone, but it’s more likely that you’ll need surgery to reconstruct the ACL. Athletes—particularly those in competitive sports—typically require surgery in order to return to their previous level of performance.

Dr. Matzkin explains that surgery involves reconstructing the ACL, either from the patient's own tendons or the tendons of a deceased donor. In both cases, skilled surgical technique is crucial for a successful outcome.

Females have had less successful outcomes after ACL reconstruction in the past compared to males. Female athletes may benefit from advanced surgical techniques and using a robust tendon graft.

"Rather than relying on a smaller tendon graft, we now have graft options and techniques to ensure a larger and stronger graft,” Dr. Matzkin says. "If we can give our female athletes an adequate graft diameter, we've shown that our outcomes in females and males are equivalent."

Dr. Matzkin’s research and surgical technique resulted in improved outcomes for young women athletes based on an in-depth understanding of the challenges and limitations of female anatomy. “Smaller knees translate to smaller notches, tunnel lengths, and graft choices,” says Dr. Matzkin. “Finding larger graft options from the quadriceps or hamstring reduces the likelihood of re-tearing or graft failure.”

For the most successful outcome, patients should work closely with their surgeon to determine the best graft choice based on their sex, age, sport and future athletic pursuits.

"For every patient I see, we talk about graft choices, what their sport is, and what their goals are,” says Dr. Matzkin. “That plays a role in deciding what the best graft option is. Working together, we can ensure patients are getting the individualized treatment they need to return to activities."

ACL rehabilitation can be long, but it's vital

After surgery, there will be 8 to 12 months of individualized rehabilitation. This helps restore mobility and range of motion to the knee and strengthen the supporting proximal muscles to include the quadriceps and hamstring. In fact, a surgery's success is largely determined by a patient's dedication to physical therapy.

Being out of sports and activities after injury and surgery can be difficult for patients, but it takes time for the new ACL to heal and time to regain motion and strength. "One of the hardest things is the mental component of being out of sport for so long," Dr. Matzkin says. “At Mass General Brigham Women’s Sports Medicine, we have sports psychologists that work with elite athletes and can help you in recovery and as you get back to your sport.”

It's important for recovering patients to keep their long-term goals in mind. Successful surgeries paired with dedicated rehabilitation is the best way for an athlete to regain full knee function, and to return to their previous sports or activities.

ACL injury prevention exercises

Not every ACL injury can be prevented. However, regular preemptive neuromuscular training aimed at strengthening the thigh (quadriceps and hamstring), hip and core muscles can reduce an athlete's risk for injury.

"Athletes need to have proper strength, balance, landing form and techniques specific to their sport in order to reduce risk of injury,” says Dr. Matzkin.

The most effective exercises include:

• Plyometrics
• Strengthening
• Stretching
• Balance training

In many cases, you can add ACL injury prevention exercises as part of your warmup–the National Federation of High Schools offers free resources for coaches and trainers. Serious athletes with ambitions to play in college or professionally may benefit from working one-on-one with a professional, Dr. Matzkin says.

Serious athletes with ambitions to play in college or professionally may benefit from working one-on-one with a professional, Dr. Matzkin says. Mass General Brigham Women’s Sports Medicine Program and the Center for Sports Performance and Research offers preventative training for female athletes, including an individual assessment and tailored training plan.

“Building strength and balance, focusing on proper nutrition, and allowing appropriate time for rest and recovery will help you avoid injury and stay in the game,” says Dr. Matzkin.