Female footballers are putting on a stellar show at the FIFA Women’s World Cup. But more must be done to support peak performance and safeguard their health.

In women’s football, whenever a player goes down clutching her knee, the crowd draws breath and commentators speculate about the three-letter injury: ACL rupture. 

At least eight stars from top-ranked sides missed the FIFA Women’s World Cup due to ACL rupture, and it endangered the participation of several others. 

The ACL – or anterior cruciate ligament – runs diagonally through the knee, connecting the tibia and femur, and providing crucial stability to the joint. Known as ‘joining the ACL club,’ the injury is widely considered one of the more severe that athletes can suffer. When the ligament is ruptured, reconstructive surgery is necessary, with at least nine months of rehabilitation before an athlete can return to sport.  

Female footballers are at least twice as likely to sustain an ACL injury as their male counterparts.  

While football fans are fretting over their favourite players’ knee ligaments, the concern around women’s ACL injuries alludes to a greater conversation about the gendered aspects of sports medicine and sports science. We must urgently do more to understand and support the bodies and experiences of women athletes to bring out their best and keep them safe. 

The female factor

As football professionalises and athletes are playing more matches, there is more public interest in their wellbeing and availability. We know that female athletes are more likely to sustain concussion, can take longer to recover from concussion, and perform worse on cognitive testing after head injuries than male athletes but we’re not totally sure why. 

Mary Fowler and Aivi Luik both missed the Matildas’ second group stage game due to concussions sustained in training. Backup goalkeeper Teagan Micah was lucky to even make the World Cup – she recently returned to the game after a six-month recovery journey following debilitating post-concussion syndrome caused by a boot to the head in match play. 

Scientists know that neck strength, the structural makeup of the head and the mechanism of injury all play a role in concussion and think that sex hormones and cell structure of the brain could also contribute to concussion severity and recovery. 

From midfield to motherhood

Gender considerations extend beyond injury – some women in football are choosing to have children before they retire from the sport. Maintaining the healthcare of mothers in football depends on supportive club environments – players’ unions have won maternity leave minimum standards from FIFA, but clubs can do more.  

For example, when German defender Melanie Leupolz became pregnant, Chelsea FC engaged a pelvic floor physiotherapist to ensure her postpartum recovery was as safe as possible.  

Investing in the pre- and post-natal care for athletes is an important part of creating a safe and healthy work culture in women’s sport and can even enhance the performance of the athlete beyond previous levels. 

Australia’s Katrina ‘Mini’ Gorry chose to undergo IVF in 2021, considering the timing of her pregnancy around the four-year World Cup cycle. Her post-pregnancy return to the sport has been remarkable – she is in the form of her career and has started every game this tournament.  

Matildas players and staff have emphasised the importance of acknowledging motherhood in the culture of the team and including players’ children in camp. 

At the 2019 World Cup, the US Women’s National Team pioneered menstrual tracking to inform training and team selection. Since then, menstrual tracking has become common sports science practice for women, including in football.  

Given the newness of this practice, there is a lack of quality evidence about exactly how the menstrual cycle affects performance and injury risk. Women’s menstrual cycles and bodies can be very different – there is no one-size-fits-all approach. 

In Australia’s A-League, minimum medical standards are applicable to both men and women. They include safeguards such as medical testing prior to the commencement of each season and mandates for all clubs to provide certified specialist sports physicians and registered physiotherapists, as well as keep detailed player medical records. 

Given the short-term nature of women’s contracts, however, this care may cease in the off-season. This league also suffers from a lack of analysts and trainers specialising in managing women’s bodies. 

Research not the golden goal

Historically women have been under-represented in sports science. Players’ unions, universities, clubs and associations are only now investing heavily in research on women’s sports performance, especially ACL injuries and concussions, and this will take time and resources. Translating research into practice is also an expensive exercise and women’s sport is chronically under-funded.  

As we seek to include women in sports science, we should be mindful of what we’re asking. Tracking athletes’ data for research requires the collection of sensitive information. Many women in football are still in precarious employment positions and may feel pressured to consent to allow access to medical information and biometric data.  

For these reasons we should be wary of positioning research as the silver bullet in women’s football – it’s an important piece of the puzzle, but not the only piece.  

Athletes are people, not machines – there are many sociocultural factors impacting their health and performance.  The success of pregnancy-friendly teams in enhancing mothers’ performance is a promising example of what can be achieved when women’s bodies and experiences are understood and supported.  

Top image: Sam Kerr lunging for the ball during the Matildas match against Denmark. Photo: Cal Sport Media/ Alamy Stock Photo

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