Why are we seeing more ACL injuries in footballers than ever before?

Beckham is a four-part Netflix documentary about David Beckham’s life and career. The first episode explores his childhood, signing with Manchester United and beginning a secret romance with a certain Spice Girl.

Reflecting on his childhood in East London, Beckham notes that he would usually come home from school and head into the garden with a football until it got dark. This wasn’t official training – it was simply a kid who loved soccer enjoying active, unstructured play with a ball.

It’s over 20 years since Beckham started playing for England. During that time, there’s been a significant increase in anterior cruciate ligament (ACL) injuries across football codes. This can be a devastating knee injury with a long recovery time.

Major clubs like Arsenal, Aston Villa and Chelsea all had players benched with ACL injuries last season. France entered the 2023 Rugby Union World Cup without star fly-half Romain Ntamack. And about 30 players – 30! – missed the 2023 FIFA Women’s World Cup due to ACL injuries, including England stars Leah Williamson and Beth Mead.

It’s not just adults engaged in elite sports who are sustaining ACL injuries, though. We’re seeing a steep rise in these injuries among under-20s too.

Victorian data shows that the annual rate of ACL injuries in children and adolescents increased by 147% from 2005/6 to 2014/15. In the UK, NHS Hospital Episode Statistics for under-20s show a huge increase in ACL-related surgical procedures over the last two decades. For every ACL reconstruction performed 20 years ago, surgeons are now doing 29 operations.

What is going on?

Factors affecting ACL risk

There are probably several factors contributing to what has been called an ‘epidemic’ of ACL injuries.

Sports specialisation at a young age

As well as kicking a ball around in his garden, a young David Beckham no doubt did plenty of formal soccer training. He made his first debut for Manchester United aged 17.

Childhood was different then, though. He probably didn’t have homework in primary school, certainly didn’t own an iPad and clearly wasn’t overscheduled as he remembers plenty of time for free play.

These days, it’s very different. Kids are more likely to be indoors and on screens apart from bursts of structured activity in swim squads or footie teams. The sporty ones are more likely to specialise in a particular sport at a younger age – defined as intensive training in a single sport at the exclusion of other sports for at least 8 months of the year.

Overscheduling formal activities also cuts out time for free play – when kids might recruit other muscles or movement patterns distinct from the ones they rely on in their chosen sport. Exceeding a 2:1 ratio of organisation to free play and training more hours per week than the child’s age in years have been linked to increased injury risk.

More intense training

There’s very little rest in an athlete’s schedule these days and heavy demands are made on an athlete’s body. One game is quickly followed by another, especially for players with obligations to both a club side and a national team.

The more you’re on the pitch, the greater your risk of injury.

A Swedish study of nearly 3,000 footballers found that players were most at risk of an ACL injury when they:

• Were in the first 30 minutes of a game – this suggests that ACL injuries are not primarily due to fatigue
• Got a new coach
• Moved to a higher division.

Increase in women’s sport

Greater numbers of women and girls are participating in football codes than ever before.

In mid-2023, FIFA reported that 16.6 million women and girls around the world now play football. Those numbers had risen by nearly a quarter compared to just 4 years earlier in 2019.

The AFLW was launched in 2015 and has grown rapidly to become the single biggest employer of professional sportswomen in the country with 420 players on the books.

And the NRLW now boasts 10 teams across two states.

It all sounds wonderful…except for the fact that female athletes are up to 8 times more likely to injure their ACL than their male counterparts.

The staunch pro female commentators out there apparently don’t like it when we blame the increase in women’s ACL injuries on women being…. Women.  I know, it’s complicated!

Better medicine

A 1997 study examined how often ACL ruptures had been overlooked or misdiagnosed.  Seven (13%) of the 54 patients in the study had originally been misdiagnosed with a first-degree sprain rather than an ACL injury. When considering the total number of ACL injuries, the data showed that 30% had been overlooked. Four or 5 years later, those patients had an unstable knee because their original injury had not been appropriately treated at the time.

That’s much less likely to happen with today’s advanced imaging techniques. We’re able to identify and treat ACL injuries in a more timely manner.

Reducing the risk

So, how do we protect the ACL? One of the best ways is to ensure a knee-specific warm-up and conditioning routine.

The study of Swedish footballers noted low rates of participation in knee-specific warm-up routines despite evidence of benefit:

Preventive programs have proven to be effective in reducing the risk of non-contact ACL injuries in football. Given the increased risk during the early part of football games, implementing knee-specific exercises in the pre-game warm up could possibly help to further reduce the number of ACL injuries.

The present study found that 31.4% of the females and only 15.6% of the male players reported that they use a knee-specific warm up program. This clearly indicates that even with the strong evidence of the effectiveness of the preventive programs, implementation and compliance remain a challenge. Continued efforts to promote neuro-muscular preventive programs are vital in reducing the number of ACL injuries in football.

Several organisations are now promoting knee conditioning to reduce the risk of injury, including Power up to Play and Football Australia’s Perform+ program. Cultural change is needed from the grassroots to the elite level to embed knee-protective practices into sports practice.

Written by Orthopaedic Surgeon Dr Ross Radic.

Dr Ross Radic has extended expertise in all aspects of knee and shoulder surgery including:

• ACL reconstruction or repair
• Robotic knee replacement
• Multi-ligament knee reconstruction – complex procedures for patients who have sustained several different knee injuries at once
• Limb realignment

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