From Cognitive Load to Biomechanical Breakdown: Why ACL Prevention in Female Athletes Is Failing: Multidimensional Risk Pathways for ACL Injury in Female Football Players
Subject Areas : Exercise Physiology and Performance
1 - Department of Physiotherapy, Faculty of Health Sciences, University of Pecs, Pecs, Hungary
Keywords: Biomechanics, ACL, Prevention, Female, Cognitive ,
Abstract :
An anterior cruciate ligament (ACL) injury is now seen as a key issue in women's soccer, with non-contact tears almost twice as common compared to men. Recent studies reject the idea of one simple cause labeled 'female weakness,' pointing instead to combined factors like game frequency, body motion patterns, and uneven access to care. Risk rises sharply in teenage years, when bone growth can exceed muscle coordination development. From a movement perspective, female athletes show clear flaws - like less knee bend or greater inward knee stress - notably during sudden directional shifts under mental pressure, not during rehearsed actions. Although warm-up routines work well, they don’t always help in practice because many coaches lack proper training or fail to stick with them. Also, decisions about returning to play usually depend on the Limb Symmetry Index (LSI) - a measure that’s unreliable since it may hide weaknesses on both sides and let risky players through. On top of that, women tend to feel less mentally prepared than men after surgery, even if physical tests say otherwise. In reality, frequent ACL injuries among female soccer players stem from poor movement control under unpredictable conditions, gaps in applying research, and weak assessment tools - not just fixed biology. Fixing this means adding brain-training exercises during drills, using strict performance benchmarks instead of ratios, along with consistent mental health support across recovery.
Andreyo, E., Unverzagt, C., Dos’Santos, T., & Dawes, J. J. (2024). Clinical utility of qualitative change of direction movement assessment in ACL injury risk evaluation. International Journal of Sports Physical Therapy, 19(10), 1263–1278. https://doi.org/10.26603/001c.123483
Arundale, A. J. H., Dix, C., & Dix, S. (2025). Barriers to implementation of injury prevention programs in female youth soccer: A sociological perspective. Journal of Science and Medicine in Sport, 28(2), 145–152.
Bloch, H., Krutsch, W., Klein, C., Achenbach, L., & Reinsberger, C. (2025). ACL injuries in professional football (soccer): Women face higher risk, later surgical care and longer time loss compared to men. Knee Surgery, Sports Traumatology, Arthroscopy. Advance online publication. https://doi.org/10.1007/s00167-025-08045-1
Bolling, C., Delfino Barboza, S., & van Mechelen, W. (2024). Letting go of the "control freak" approach in sports injury prevention: A call for a more systemic perspective. British Journal of Sports Medicine, 58(2), 63–64.
Crossley, K. M., Patterson, B. E., Culvenor, A. G., et al. (2024). Making football safer for women: A consensus statement from the 2023 International Summit. British Journal of Sports Medicine, 58(10), 525–536.
Di Paolo, S., Zaffagnini, S., & Della Villa, F. (2024). Visual analysis of anterior cruciate ligament injury situations in professional female soccer players: A systematic video analysis. Orthopaedic Journal of Sports Medicine, 12(3), 23259671231221350.
Donskov, N., Löfgren, H., & Hagglund, M. (2025). Barriers and facilitators to the implementation of injury prevention programs in women’s elite football: A qualitative study of coaches’ perspectives. Scandinavian Journal of Medicine & Science in Sports, 35(1), e14502.
Gokeler, A., Benjaminse, A., & Hewett, T. E. (2024). Neurocognitive errors and non-contact ACL injury: A framework for diagnosis and training. Sports Medicine, 54(4), 831–842.
Hägglund, M., Waldén, M., & Ekstrand, J. (2024). Injury rates in elite European women’s football: A 10-year longitudinal study. British Journal of Sports Medicine, 58(11), 602–609.
Hamrin Senorski, R., Simonsson, R., Sundberg, A., Piussi, R., Högberg, J., Thomeé, R., Samuelsson, K., & Della Villa, F. (2025). Questioning the rules of engagement: A critical analysis of the use of limb symmetry index for safe return to sport after anterior cruciate ligament reconstruction. British Journal of Sports Medicine, 59(6), 376–384. https://doi.org/10.1136/bjsports-2024-108079
King, E., Richter, C., & Franklyn-Miller, A. (2024). Whole-body biomechanical differences between planned and unplanned change of direction tasks in elite female athletes. Journal of Biomechanics, 162, 111894.
Kotsifaki, A., Whiteley, R., & Hansen, C. (2024). Dual-task testing for ACL return to sport: Normative values and discrimination between injured and healthy athletes in professional football. Journal of Science and Medicine in Sport, 27(2), 112–119.
Lucarno, S., Zazulak, B., & Hewett, T. E. (2024). The adolescent growth spurt and neuromuscular control: Implications for ACL injury risk in young female athletes. American Journal of Sports Medicine, 52(5), 1340–1352.
McCall, A., Pruna, R., & Dupont, G. (2024). The gap between science and reality in injury prevention: A survey of 50 elite women’s football clubs. Science and Medicine in Football, 8(2), 145–153.
Monthuley, G., Okholm Kryger, K., & Verhagen, E. (2025). ACL injury prevention in European women’s football: Exploring knowledge, attitudes and practices in a cross-sectional study. BMJ Open Sport & Exercise Medicine, 11(3), e002558. https://doi.org/10.1136/bmjsem-2025-002558
Obradovic, A., Pastor-Morales, E., Santías, A. M., & colleagues. (2024). Males have higher psychological readiness to return to sports than females after anterior cruciate ligament reconstruction: A systematic review and meta-analysis. BMJ Open Sport & Exercise Medicine, 10(4), e001996. https://doi.org/10.1136/bmjsem-2023-001996
Okholm Kryger, K., et al. (2024). Ten consensus points on football boots for women: The evidence gap and the need for gender-specific technology. Footwear Science, 16(1), 1–10.
Parsons, J. L., Coen, S. E., & Bekker, S. (2024). The gendered environment of ACL injury in women’s sport: A systems thinking approach. British Journal of Sports Medicine, 58(8), 415–420.
Piussi, R., Beischer, S., & Thomeé, R. (2024). Psychological impairments and lower physical activity levels in female athletes 5 years after ACL reconstruction. Physical Therapy in Sport, 65, 45–52.
Webster, K. E., & Feller, J. A. (2024). Psychological readiness to return to sport: A state-of-the-art review. Journal of Orthopaedic & Sports Physical Therapy, 54(6), 320–330.
Wong, W. Z., Tee, Y. K., Ahmad, M. A., Mohd Jamali, M. N. Z., Azmi, N. A., & Mesbah, N. (2025). Knowledge, attitudes, and implementation challenges of preventive rehabilitation programs among Malaysian collegiate football players: A cross-sectional analysis. IIUM Medical Journal Malaysia, 24(3), 92–101. https://doi.org/10.31436/imjm.v24i03.2751