The sound is the same in every language. A dry, dull crack, barely audible in the stands but devastating on the pitch. Then the collapse, the hand clutching the knee and a grimace of pain that women’s football has learned to dread more than any opponent. Alexia Putellas, Mapi León, Caroline Weir, Beth Mead, Vivianne Miedema, Marie-Antoinette Katoto… The list of elite players who have gone under the knife to reconstruct their anterior cruciate ligament (ACL) reads like the dream eleven of the Ballon d’Or over recent years.
This is not bad luck or coincidence. ACL rupture has become the great silent epidemic of women’s football — a systemic problem that affects women three to six times more often than men. For years, the standard response has been to shrug and file it under “biological risk”. Yet sports science and physiotherapy are beginning to point to a more uncomfortable truth: the industry continues to treat female footballers with the same standards, tools and fixture schedules designed by and for men.
Anatomy is not the only destiny
Traditional medical explanations have focused on intrinsic biological factors in women. It is undeniable that physical differences exist which predispose female players to this injury:
- The pelvis and the Q-angle: Because women’s hips are proportionally wider, the femur descends at a greater angle towards the knee. This increases the Q-angle and promotes knee valgus — an inward collapse of the knee — which is the critical position where the ligament experiences greatest stress during pivoting and deceleration.
- The intercondylar notch: The groove in the femur through which the ACL passes is narrower in women, which can cause the ligament to rub mechanically against the bone during abrupt movements.
- The hormonal factor: The menstrual cycle affects tissue laxity. During the ovulatory phase, the oestrogen peak reduces the stiffness of tendons and ligaments, making them more elastic and therefore more vulnerable to sudden loads.
However, confining the conversation to female biology alone is both incomplete and disheartening. It implies that the only way to stop a woman rupturing her cruciate is to stop playing football. Extrinsic factors — those over which the industry does have influence — are what truly explain why the gap remains so wide.
Men’s boots for women’s feet
One of the most widely cited external factors in recent years is sports equipment. Historically, football boots have been designed around the male foot, with women’s sizes produced simply by scaling the same last down for that market.
Women have proportionally narrower heels than men and a different arch shape. When playing in boots designed to a male last, the foot tends to slide inside the shoe, reducing stability. But the greater danger lies in the sole and the studs.
Men’s boots are designed to generate traction for a greater body weight and physical power. When a female footballer — with a lower average body mass — uses those same studs on firm natural or artificial turf, the boot tends to become excessively anchored to the ground. In a rapid pivot, the foot stays planted while the femur rotates, transferring the full torsional force directly to the knee. The result is the dreaded ACL failure.
A study by the European Club Association (ECA) found that 80% of elite female players suffer regular discomfort from their boots. The industry’s response has been slow but is beginning to materialise: Nike launched the Phantom Luna with the Cyclone 360 stud system — a circular, shorter-stud configuration designed specifically to reduce ground grip in women and lower torsional stress on the knee. Adidas, Puma and New Balance have all redesigned their lasts from scratch using data from female feet. In 2024, the UK Parliament’s Women and Equalities Committee summoned the major brands to answer formally for their role in the ACL epidemic. The fact that a national parliament had to call in football boot manufacturers as part of the problem says much about how long the industry looked the other way.
Pitches, irrigation and the absence of specialist prevention
The condition of playing surfaces in Liga F and other competitions also plays a crucial role. In men’s football, pitch irrigation before kick-off and at half-time is standard protocol at any top-flight stadium. In many women’s football stadiums, however, irrigation remains inadequate or non-existent due to insufficient infrastructure. A dry pitch is a dangerous one.
Compounding this is the approach to physical preparation. For decades, injury prevention programmes have been copied from men’s football manuals. The musculature supporting the knee in women requires a different approach: strengthening the hamstrings — which act as a brake on the ligament — is vital to offset quadriceps dominance, which is particularly common in female movement patterns. Without specialist fitness coaches and rehabilitation staff embedded in the day-to-day routine of every club — not just the three or four at the top — prevention remains an aspiration.
The fixture list paradox
With the growth of international competitions — the Champions League, European Championships, World Cups and the Nations League — elite female players now face schedules as demanding as those of their male counterparts. They do so, however, with one critical difference: women’s squads are considerably smaller.
The lack of squad depth forces the best players to accumulate competitive minutes with barely any rest. Neuromuscular fatigue is the ultimate trigger for the majority of non-contact ruptures: when an exhausted muscle fails to stabilise the joint in a split second, the ligament absorbs the entire load. And the ligament gives way.
The way forward
Addressing the ACL epidemic requires treating women’s football as a discipline with its own specific needs — not as an appendage of the men’s game. That means:
- Applying prevention programmes that already exist: The FIFA 11+, designed specifically for women’s football, reduces ACL injuries by 50 to 70% in teams that implement it consistently. The problem is not that no solution exists — it is that very few clubs actually use it.
- Investment in gender-sensitive medical research: Properly studying the real influence of the hormonal cycle on performance and fatigue.
- Mandatory sport-specific equipment: Requiring suppliers to provide footwear designed scientifically for female foot morphology.
- Better training and playing infrastructure: Guaranteeing well-irrigated, modern-standard pitches.
- Complete medical teams: Regulating a minimum number of fitness coaches and physiotherapists per squad in Liga F.
A female footballer’s knee does not give way because she is a woman. It gives way because the sport she competes in was designed for men, and the industry has yet to accept the cost of adapting it.
Biomechanical studies and reports on ACL incidence in women’s football based on publications by UEFA and the British Journal of Sports Medicine. Footwear data and female-specific boot design via Sky Sports and the UK Parliament Women and Equalities Committee. FIFA 11+ effectiveness data via Journal of ISAKOS.
