There are many barriers for women participating in elite level sport; most female athletes need to work to supplement their playing income, access to facilities is often arranged to accommodate men’s fixtures, and media coverage remains heavily skewed towards men’s sport. But one problem female athletes may not anticipate is a predisposition for knee injury.
Spraining, tearing or rupturing the ACL (anterior cruciate ligament) is one of the most common knee injuries in sports such as soccer, football, basketball, and netball, where rapid acceleration, deceleration and changes of direction are required.
Dr David Zbrojkiewicz is an orthopaedic surgery resident at QEII Jubilee Hospital and a researcher at Knee Research Australia.
Dr Zbrojkiewicz said women were up to eight times more likely than males to suffer an ACL injury, due to a number of biological factors including narrower leg bone structure and smaller knee ligaments, which can be exacerbated by high demand sports.
The ACL runs diagonally in the middle of the knee. It holds the two lower leg bones in place by preventing the tibia from sliding in front of the femur, as well as keeping the knee stable during rotation.
In a paper published in the Medical Journal of Australia earlier this year, Dr Zbrojkiewicz and his fellow researchers, Christopher Vertullo and Jane Grayson, found that the annual incidence of ACL reconstructions performed in Australia had increased by 43 per cent from 2000 to 2015. This is a statistic that makes Australia’s ACL injury rate the highest in the world.
With the rising popularity of women’s elite sporting competitions in Australia, the injury has become a growing concern for both athletes themselves, and for the coaching and medical staff who work with them.
Roy Morgan research suggests that 548,000 women are playing one of the four leading football codes – AFL, rugby league, rugby union and soccer – an increase of 4.4 per cent since 2013, and an 8.1 per cent increase in the past twelve months.
These numbers buck the trend of an overall decline in participation in sport in Australia; Roy Morgan found that while men are playing less organised sport, women are playing much more than they were five years ago.
The introduction of the Australian Football League Women’s (AFLW) competition in 2017 has led to a boom in female participation in Australian rules football.
According to the AFL Annual Report, there were 463,364 women playing AFL in 2017, which was an increase of 22 per cent from 2016. In the same period, AFL Queensland saw an increase of 16 per cent in female participation, while the number of female teams increased by 39 per cent.
Miranda O’Hara is the head of medical services for the Brisbane Lions AFLW team and director of Restore Function Physiotherapy & Pilates.
Mrs O’Hara said in the AFLW inaugural season in 2017, eight listed players sustained an ACL injury, while nine sustained an ACL injury in the 2018 season.
“There’s a big difference between the number of rounds between the AFLW and AFL; there’s less than one [ACL injury] per club per season in the men’s space, so some clubs might have one and other clubs none,” she said.
“Whereas we are seeing one per round in the women’s space.”
Jonathan Ward is the head of strength and conditioning for the Griffith University Rugby Sevens and the support strength and conditioning coach for the Wallaroos Australian women’s XV Rugby team.
Mr Ward said while ACL injuries were more prevalent in women, the increase in participation was a big reason for the injury’s current prominence.
“Women’s NRL, AFL women’s, that’s being televised, you can’t just say ‘why are we getting more’, you have to look at participation numbers,” he said.
“We’ve just got more girls competing, from high school up to elite.”
Mrs O’Hara said there were a number of biological factors that increased women’s risk of ACL injury, including higher oestregen levels, differences in knee structure and general hypermobility.
But she said there were also modifiable factors that could be addressed through coordinated injury risk reduction programs.
“These programs are designed to alter movement patterns with an emphasis on landing technique, landing body position during change of direction, [and] deceleration techniques while also improving performance measures like speed, strength and agility,” she said
Injury risk reduction programs have been found to reduce the incidence of ACL injury by more than 50 per cent, but there are limitations particular to female athletes.
“Female AFL players are not full time professional athletes so are limited by time restraints with training, working on their craft and injury risk reduction programs,” Mrs O’Hara said.
Dr Zbrojkiewicz agreed and said neuromuscular training, focused on improving jumping, landing and change of direction techniques, significantly reduced the rates of ACL injury.
Mr Ward said taking into account the cost of looking after an ACL injury and the fact that the injury could often stop players from coming back to their sport, prevention was better than a cure.
“What I do is a mixture of resistance training and what we term ‘neuromuscular training’, that is teaching how to jump, teaching how to balance, teaching you how to land,” he said.
“It pretty much teaches your muscles to activate at the right time so that your knee doesn’t roll in, or so you don’t internally rotate, anything will put your ACL at risk, and at the end of the day we don’t want to injure our athletes.”