The cruciate ligament in women's football

Why ACL ruptures are around 2.8 times more common among female players, how they actually happen, and what a coach can act on. Every figure sourced.

Thibaud C. · Fitness coach · Last updated: September 26, 2026

This is the number one subject, by a distance. Anterior cruciate ligament (ACL) ruptures are markedly more frequent among female footballers. A longitudinal study run over six consecutive seasons at the same club records an incidence 2.8 times higher among the women (1.06% against 0.38% among the men) — Ferré-Aniorte et al., 2025. A rupture means six to twelve months out, and sometimes the end of an amateur career.

One detail of that study deserves highlighting, because it shapes your work: the gap between girls and boys only appears from around 14 years old. Before that, the incidences are comparable. So it's between 12 and 15 that prevention makes the most sense.

The good news is that this risk is in no way inevitable: it's one of the rare areas where training has shown a clear effect.

How it happens, concretely

Systematic video analysis now allows the mechanism to be described precisely. Across 127 ruptures filmed in 25 professional women's leagues between 2022 and 2024, the breakdown is as follows: 49% with no contact at all, 41% with indirect contact (a knock elsewhere than the knee, which unbalances the player), and only 10% with direct contact on the knee.

In other words: nine ruptures out of ten don't come from a blow to the knee. They come from a badly controlled landing or plant. The typical scenario repeats itself:

• a sharp deceleration or a jump landing, on one leg;
• the knee collapsing inwards (what's called valgus) while the foot stays planted;
• the trunk off-axis, often because the player is looking elsewhere — at the ball, at an opponent;
• and a load arriving in the first few tens of milliseconds of the contact, before the muscles can even react.

Those same analyses add one directly usable piece of information: around two ruptures out of three happen in the defensive phase, most often while pressing or tackling. That's no accident — those are the situations where the player is running fast, braking in an emergency and has her eyes on the ball rather than on her feet.

Why the risk is higher

There isn't one single cause, but a cluster of factors. Some can't be changed, others can — and that's where your work counts:

• Anatomical factors: a wider pelvis, a more pronounced angle between thigh and shin, and often a thinner ligament. These don't change.
• Different neuromuscular control: on landing, you observe on average knees collapsing further inwards, less flexion at the hip and knee, and less hamstring recruitment relative to the quadriceps. This can be trained.
• A historically poorer training environment: fewer years of physical preparation, less strength work, often less coaching support. This can be trained too, and it's probably the most underestimated factor.
• Hormonal factors, regularly raised (variation in ligament laxity across the cycle). The data exists but remains debated: no reliable practical instruction can be drawn from it today.
• Equipment and facility factors: poor pitches, unsuitable boots, congested fixture lists. They weigh, and they're sometimes negotiable at the club.

What you can genuinely act on

Three levers, in order of demonstrated effectiveness:

• A regular neuromuscular programme — by far the most effective, and the subject of the next module.
• Building load gradually: spikes in training or matches after a break are risk periods. A return spread over three to four weeks beats a sudden one (see the Load management course).
• The quality of the return after injury: the risk of a second rupture is markedly higher after a first one that happened without contact. Return to play isn't decided on the disappearance of pain alone: the criteria must be functional, and they belong to the doctor and the physio, not the coach.