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Shaping the Narrative: Why Our Conversations About Female Athletes and ACL Tears Matter

Writer's picture: Micaela Zettel, PT, MScPT, MCISc AHCP SEM, BScHK(hons), Micaela Zettel, PT, MScPT, MCISc AHCP SEM, BScHK(hons),

Something that has really been getting under my skin lately…..

female playing beach volleyball

When information about female athletes and their health is presented in a way that suggests we are fragile and/or are to blame for our injuries/health/mental health. 


NO NO NO. 


I see this happen in a lot of places. I'm going to focus on the ongoing challenge with female athletes and ACL injuries, which deserves all the attention it’s getting, but can we all please do so much better at how and what we communicate! 


Here are two examples of what I mean

  1. The ongoing debate about whether females are at a higher risk of tearing their ACLs because of hormones has NEVER BEEN PROVEN, but is still a message that is pervasive when we talk about ACLs and female athletes. Researchers that have hypothesized that estrogen would increase ligament laxity and therefore cause an increased risk of ACL tears in females, have never proven this theory. Studies that suggest a connection with ligament laxity and ACL injuries, ALSO found greater knee valgus and tibial external rotation during functional activity (1)*. These are BIOMECHANICAL ISSUES, that we can do something about. Instead of pointing a finger at the menstrual cycle (MC) and blaming estrogen for ligament laxity, something that is completely out of our control and a very natural and normal process, why don’t we focus instead on improving motor control, biomechanics, strength and so on? What a different message. One we have control over vs one that seems to have us doomed for injury. 


*It should also be noted that these research studies have been rated as low quality. 


2. A colleague sent me a post about new research on secondary ACL tears following an ACLR in female athletes. The post was by a rehab pro, who is an “expert” in ACL rehab, which they probably are. But the post started with this title: Beware the young, confident ACLR athlete. Then went on to describe the research findings and the moral of their story was that we, practitioners, are looking for “Goldilocks”  when it comes to athlete readiness for return to sport (RTS). Someone who is not too confident, not too petrified, but rather “just right”. And they highlight this is particularly important for young female athletes.


I shake my head. NO NO NO! I have a big problem with this messaging.


  • The title of the research is ”Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction” (2). 

    • First I want to say, it’s awesome research. We need more research on female athletes. 

    • Second, the takeaway of this research was that athletes who met the criteria for RTS earlier AND had higher scores on psychological readiness, were more likely to have a secondary tear of their graft or other knee within 2 years (they were also all hamstring grafts). 


So, it’s not about “goldilocks” at all!!  It’s about using the outcome measures and knowing best practice guidelines for RTS combined with current research, and using this to counsel athletes for RTS. In this case, this research gives us another tool to help identify risk for athletes. Having high psychological readiness is not negative, in fact it’s positive, BUT, it needs to be with an appropriate timeline for return to sport, which is not early. We already know there is an increased risk of re-injury returning to sport before 12 months (3). 

Picture of Micaela shaking her head

All this to say, I can’t get behind this kind of messaging. Sure it’s click bait, but the impact of the message is still not ok for me. If an athlete reads that, or a health pro communicates that to a female athlete, what are they going to think? Maybe they are going to think they can’t be too confident, or too risky because that’s detrimental for them (introducing psychological strain/load/doubt), or maybe they don’t work as hard at rehab because they will need to wait anyways. You see where I’m going. I also think it’s important to understand how female athletes work, not everyone is the same, but many are type A perfectionists (we’ve been conditioned to be this way….). This kind of info would not go well and I don’t believe it would yield the outcome or impact that perhaps was intended. 


Here is what I would have written if I were making a post about this new research: 

“New research findings that help lower the risk of a second ACL tear following ACLR in female athletes”. What a different impact that message has: we, the health pros can better help you, the athlete, with this information. Instead of: you, the athlete, must adjust your mental state or you'll get injured, again. 


I want all of us who work with female athletes to really consider when we find out new information, whether it be about hormones or psychological factors, what are we going to do with that information? How will we use it to help, not hinder athletes?


Say research finds in fact that female athletes are at higher risk of tearing their ACLs in the pre-ovulatory phase, what will we do with that? Would we counsel an athlete to track their cycle and just avoid competing during that time each month? Time of ovulation can vary by a couple of days each month.


NO! What a ridiculous concept.


Imagine you are a pro athlete, “ah sorry, I can’t play that big game because I’m about to ovulate”. I shake my head. But again, the research shows there are biomechanical issues as well, so instead, we could focus the messaging on getting strong and improving these biomechanical issues, helping the athlete to be confident in all phases of the MC.


There’s also a slew of other things that can be improved to help, and many argue these factors have an even bigger impact on injury risk/prevention. These factors are focused on considering the sex-specific environmental differences that can contribute to an increased risk of injury for female athletes including (4): 

  • Limited access to and availability of advanced training facilities (4) 

  • Kits/gear/equipment are designed for males, and used by females, but females have many differences in their anatomy (4) 

  • Quality of playing surfaces/facilities (ie: in soccer, often females play the day after males and the quality of the pitch is poor) (4) 

  • Specific physiotherapy programs and training protocols have yielded great results in reducing the risk of injury (and are needed in school aged athletes) (4)


All this to say that how (and what) we communicate can have a big effect on the impact and meaning of that information and when it comes to female athletes I want the information to be used to empower them, not disempower them.


Knowledge is power, but we need to be mindful of how and what we communicate. I cannot support messaging that implies we, females, are flawed, weak, fragile or to blame. It's just not true.


We can all do better. 


References:

(1) Balachandar, V., Marciniak, J. L., Wall, O., & Balachandar, C. (2017). Effects of the menstrual cycle on lower-limb biomechanics, neuromuscular control, and anterior cruciate ligament injury risk: a systematic review. Muscles, ligaments and tendons journal, 7(1), 136–146. https://doi.org/10.11138/mltj/2017.7.1.136

(2) Zarzycki R, Cummer K, Arhos E, Failla M, Capin JJ, Smith AH, Snyder-Mackler L. Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction. Sports Health. 2024 Jan-Feb;16(1):149-154. doi: 10.1177/19417381231155120. Epub 2023 Mar 19. PMID: 36935576; PMCID: PMC10732117.

(3) Fowler Kennedy Sports Medicine: ACLR Return to Sport Risk for Re-Injury - PDFhttps://www.fowlerkennedy.com/wp-content/uploads/2023/03/ACLR-Return-to-Sport-Risk-of-Re-Injury.pdf

(4) Mancino F, Gabr A, Plastow R, Haddad FS. Anterior cruciate ligament injuries in female athletes. Bone Joint J. 2023 Oct 1;105-B(10):1033-1037. doi: 10.1302/0301-620X.105B10.BJJ-2023-0881.R1. PMID: 37777208.


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