In the world of sports, injuries are a struggle that almost every high performance athlete faces at sometime through their career. One of the most common and devastating of them all is the anterior cruciate ligament injury, or the ACL injury.

The ACL, essentially, is a vital knee ligament that connects the thigh bone to the shin bone and is highly prone to sprains and tears which can derail an athlete’s career, sometimes permanently.

Multiple studies conducted in the field of ACL injuries show that female athletes are two to eight times more susceptible to an ACL tear than male athletes. The Indian women’s sporting landscape is no stranger to ACL injuries either.

Back at the 2016 Olympics in Rio De Janeiro, wrestler Vinesh Phogat tore her ACL in the right knee during a quarter-final bout. A top medal prospect for India until then, a weeping Phogat had to be stretchered off the mat. She only returned to the sport after spending more than a year in rehab following a surgery.

Recently, veteran footballer Bala Devi suffered an ACL injury during her stint with Rangers FC in the Scottish Women’s Premier League in September 2021. It was only earlier this year that the 33-year-old forward made her comeback to the field.

Legendary boxer Mary Kom endured the same fate during the trials for the Birmingham Commonwealth Games last year. The 40-year-old underwent a surgery soon after, but is yet to compete in any event since.

But, what causes an ACL injury?

“In sport, ACL injuries most often happen with sudden changes of direction or sudden stopping, causing the sprain or tear,” explained Dr Sheree Bekker in a chat with Scroll.

Bekker, a renowned researcher, was recently honoured by the Canadian Institute of Health Research and the Institute of Musculoskeletal Health and Arthritis for her work on ACL injuries in female athletes.

ACL injuries often take athletes by surprise, which leads to pain, instability and an even longer rehabilitation process.

While the causes and mechanisms of ACL injuries have been extensively studied over the years, Bekker introduces a unique perspective as to why women are more at risk of picking up the injury compared to men.

Traditionally, it has been believed that women are more prone to ACL injuries due to physiological differences such as wider hips and hormonal fluctuations during menstrual cycle. However, Bekker challenges this and argues that these presumptions may actually be obscuring the real reasons for their increased rate of risk.

“We need to move away from the sole focus on women’s hips and hormones as key factors for an ACL injury risk and move towards a gendered environmental approach,” she asserted.

This approach focuses on the impact of the gendered environment in which girls and women grow, train, compete and rehabilitate instead of just the physiological factors.

It takes into account the societal norms and expectations which shape athletes from a young age. From infancy, girls and boys are treated differently and these early influences have long lasting effects, Bekker said.

“For example, from the time that we are born, girls are treated differently from boys,” she said. “Girls are treated as more fragile and encouraged to be more passive [playing indoors]. Boys, on the other hand, are encouraged to be active [rough-and-tumble play outdoors].”

These contrasting experiences shape physical capabilities with boys becoming stronger and arguably less injury-prone over time, while the girls are left more vulnerable to injuries.

Bekker also said that the increased risk of ACL injuries women is also influenced by disparities in access to sports, the quality of training and resources, and overall investment.

“They often train at lesser quality facilities, or are only allowed to use facilities after the men’s teams do,” she said. “Further, girls and women simply are not afforded the same expectations about their physical capabilities than boys and men are. These are all social factors that accumulate over a lifetime, playing into making women more prone to injury.”

While ACL injuries can be career-threatening, there is no one size fits all answer regarding the chances of reoccurrence. It depends on multiple factors, including the athlete’s recovery process, adherence to rehabilitation, and individual circumstances.

Bekker also asserted the need to have a multifaceted approach to reduce the gender gap and prevalence of ACL injuries among women.

“First and foremost, we need to challenge gendered norms and expectations in sport and physical activity,” she added.

This, according to her, can be achieved by incorporating four different methods:

(i) Re-evaluating norms about women’s bodies and physical capabilities, that is, challenging the existing notions about how a woman’s body should be even before they enter a sporting environment. Not restricting young girls only to activities which are traditionally considered girly.

(ii) Eliminating gendered terminology in sporting equipment and exercises. For example, there should be no women’s or men’s barbells, just a 15kg or a 20kg barbell.

(iii) Fouscing on the overall well-being of an athlete rather than just their physical appearance, that is, focusing on the strength gain made by a female athlete rather than focusing on how she has bulked up.

(iv) Working towards equal access to resources and high-quality training facilities by providing female athletes the exact same equipment and facilities men use to train and compete.

The 2023 Fifa Women’s World Cup saw as many as nine players, including England captain Leah Williamson and 2022 European Championship Golden Boot (highest goalscorer award) winner Beth Mead among others miss out due to ACL injuries.

Alexia Putellas, a member of eventual winners Spain, played the World Cup after spending almost nine months out of action due to the same injury.

According to a report in the Economist, around 2 million people suffer from an ACL injury. Furthermore, as much as three-quarters of those who damage their ACL go on to develop arthritis of the knee 15-20 years later in life.

With numbers this alarming, Bekker’s fresh perspective towards ACL injuries in women provides a ray of hope for high performance athletes to reduce the risk of the injury.