The Tribune

An ACL injury can be a significant setback for anyone who likes to stay active or compete in sports.

Science now shows that it can be an even more common form of injury for women. Eight times more common, in fact.

The ACL, or anterior cruciate ligament, is located inside the knee and provides stability during movements such as cutting, turning, twisting and jumping.

Scientific literature suggests that how tight or loose the ACL is and the risk of injuring it may be increased when a woman is in the ovulatory phase of the menstrual cycle.

Physiotherapist at Healing Hands Therapy, Nassau, Calvin Rolle, says that the relationship of a women’s menstrual cycle to their risk of injury is a relatively new but well accepted scientific discovery.

According to research, hormonal shifts, such as an increase in the hormone relaxin in the lead up to a women’s period, can relax the ACL - which Rolle likened to a “seatbelt” that keeps things safe and in place - and make it more prone to injury. Around two thirds of ACL injuries occur when there has been no physical contact with the injured person.

In mid 2025, concern over a possible link between ACL injury and the menstrual cycle led to FIFA funding a groundbreaking study at Kingston University investigating whether hormonal fluctuations during menstrual cycles could be contributing to an alarming rise in career-threatening knee injuries in women's soccer.

This discovery comes after a historical bias towards male research participants left this an under-explored area for many years. “Most research to date involves pretty much everything being driven by male participants. That means a lot of  the results of these experiments were originally based on men then they try to extrapolate to women. There has been a move to address this, more women getting positions of power in the sport and also being physios,” he said.

The emerging role played by the menstrual cycle and hormonal shifts on an individual's likelihood of getting injured has caused some to suggest that training regimes should take the menstrual cycle into consideration. However, others have argued that while there is an impact on the probability of injury, it does not tend to be consistent across all women in the same phase of their cycle, and therefore the answer is more complex and personalised.

Deanna Brinks, M.D., a physical medicine and rehabilitation and sports medicine physician at the Mayo Clinic Health System, advocates for greater awareness of the factors behind that can increase the chance of injury, saying this can lead to improved training for women that addresses proper technique, muscle strength, balance and biomechanics

According to Brinks, other factors that can contribute to ACL injuries in women include the ACL in women being thinner than in men; the strength of women's quadriceps — the muscles in the front of the thigh — being greater than the strength of their hamstrings — the muscles in the back of the thigh, while the opposite is true in men; and women's wider pelvises creating a greater angle from the hip to the knee, which changes how force travels through the knee.

One resource for helping prevent ACL injuries is the FIFA 11+ Warm-up Program. It was developed by an international group of experts and is available online for free. Divided into three segments, each segment has its own set of exercises with progression levels to add difficulty and variation. The exercises pay special attention to knee strength and position. Although this 20-minute warmup was developed for soccer players, it can be translated to any sport, from basketball to pickleball.

Rolle says that general leg strength and coordination are among the biggest protective factors when it comes to avoiding injury, in particular “having good single leg balance”.

“If you have the ability to coordinate all of your muscles to stand properly on one leg with your knee staying in position, that’s going to help,” said Rolle. .

If the ACL does get torn, surgery may be needed, depending on the severity. In order to reconstruct the ACL, surgery involves using a graft from the patient's patellar, quadriceps or hamstring tendon.

“It is possible to get back to what you were doing after 9-12 months of physiotherapy, but you have to work hard to get stronger. You don’t need to be going to the physio three times a week but you do need  to check in with someone who can steer you in the right direction,” said Rolle.