Women and sports injury: ACL tears may be sex specific, linked to menstruation

More than twice the number of sportswomen tend to suffer ACL tears than men in sports.

One of the most common injuries among sportspersons, no matter what level they play at, is the tearing of the anterior cruciate ligament, commonly known as ACL. ACL tears despite being common are one of the most serious injuries and require surgery and a long time (anything between six months to a year) to heal. According to data available, about 2 million people suffer ACL tears annually and this injury afflicts more women than men — more than twice the number of women tend to suffer ACL tears than men. Tanvie Hans, who played for the north London club Tottenham Hotspurs women’s team, says, “I was just talking to another footballer about how ACL tears are a lot more common among us than men.”

There is even anecdotal evidence for this. Just recall last year’s FIFA men’s World Cup and the UEFA Women’s Euro tournaments. While there were no abstentions from the men’s tournament due to ACL injuries, world’s current No. 1 women’s footballer the Spaniard Alexia Putellas, who plays for Barcelona FC women, suffered an ACL injury during a training session on the eve of the Euros. During the tournament three more women suffered ACL injuries. Shortly afterwards the tournament’s best player and top scorer England’s Beth Mead and her Arsenal teammate have both suffered ACL tears while playing club football. Both are racing against time to recover and be fit for the FIFA Women’s World Cup, which takes place in Australia and New Zealand later this year.

Not only ACL tears are expensive and time consuming to treat, they are also preventable according to new evidence available, say experts. While more research is needed to establish why a disproportionately high number of women suffer this injury compared to men, there is some evidence to show that it is linked to women’s menstrual cycles. “The body of a woman undergoes cyclical biological changes, hence the approach for the physical activities that they undertake needs to be tailor-made for them,” says Dr Amite Pankaj Aggarwal, director and in charge of the sports clinic at Fortis Hospital Shalimar Bagh.

A study published in the Journal of Athletic Training in 2013 found that the incidence of ACL injuries was greater during days 9 to 14 of a 28-day cycle and lower during the post-ovulatory phase, i.e. day 15 through the end of the cycle. The researchers also found that female athletes were at increased risk of ACL injury during the preovulatory phase and that fewer injuries occurred as the cycle progressed. They found that a narrower femoral notch, higher-than-average body mass index, and general joint laxity predicted ACL injury risk among women. Women with higher knee laxity were 2.7 times more likely to suffer ACL injuries than those with lower laxity. There was no such link for men. This study points to the fact that the anatomical risk factors for ACL injury may be sex specific.

The wider hips and narrower knees which are common among women pose their own challenges. “Their muscle mass also significantly differs from that of men. Due to their narrower knees, women suffer more knee injuries than men. They need to ensure a good warm-up and be aware of any pivoting activities as this could injure their ACL,” says Aggarwal.

While there is a growing acceptance both in the professional world and, to some extent, among fitness enthusiasts that one needs to plan their training schedule in tune with their menstrual cycle, period still remains an uncomfortable subject. While, on the one hand, many athletes and fitness enthusiasts have started using apps or diaries to track their cycles, conversations about the period is still difficult. In part, it is also because the link between training load and menstrual cycles is also a very new thing in professional sport, points out Hans, who currently plays in the Karnataka League.

A study published in the Sport in Society journal last September found that more than two-thirds of the football players, coaches and managers interviewed for the study said that education on the menstrual cycle was not at all provided at their clubs and talking about it was still a taboo. “Even Chelsea, one of the richest and most professional football clubs in the world, only started using an app to track its players’ cycles in 2020 and it was one of the first to do so. So, for something like this to become common in India will take time,” she says. Another study published last December in Science and Medicine in Football found that menstrual health support is still perceived as minimal and although players have their menstrual status tracked, they report little understanding as to why or how this information is used.

However, she is quick to credit the new-age coaches in India who are sensitive and readily accommodate requests from women players. “One of the girls was on the first day of her period and she was visibly in discomfort. She asked the coach if she could sit the training session out and the coach simply said yes. They do understand and are sensitive… even the male coaches,” adds Hans.

There are some coaches in India who are already tweaking training load and intensity in tune with women’s cycles. New Delhi-based running coaching facility All In Running not only tracks the cycles of the women who train with them but its founder Nakul Butta says, “Since women experience menstrual cycles on a periodic basis (duration varies person to person), the training plan may vary. Different women experience different symptoms through their menstruation cycles. Some can train on Day 1 while others can't do so for the first 2-3 days of the cycle. Based on the individual and their symptoms, we try to schedule rest days and workout sessions.”

“We also vary the intensity and duration of a session based on the timing of the cycle. Day 7 to Day 14 may include high-intensity workouts whereas Day 21 to Day 28 may be more endurance focused.”

While this is a step in the right direction, as Hans points out, all this is relatively new information and it will take time before people can start acting on it and talking about it. The more we talk, the less taboo it becomes and the fewer ACL tears women suffer. “Overall, the coaching world globally is only beginning to focus on gender-based factors in training and there is massive work to be done in this regard,” says Butta.