Why Female Athletes Are Getting Injured More, And What We Can Do About It

ACL injuries are often discussed as if they’re random or unavoidable. But when you look at the research, patterns emerge. Female athletes experience ACL injuries at significantly higher rates than males.

Depending on the study, this difference is commonly reported as approximately 2–8 times higher risk (Arendt & Dick, 1995; Agel et al., 2005). The important question is not if the risk exists, but why.

The answer is not one factor. It is a combination of anatomy, hormonal influences, neuromuscular control, training history, and how athletes are actually prepared over time.

Anatomy: Structural Considerations

There are certain anatomical differences that may influence how force is managed at the knee.

One commonly discussed factor is the intercondylar notch, the groove at the end of the femur through which the ACL runs. On average, some female athletes present with a narrower notch structure.

A narrower notch may mean there is reduced space for the ACL, which may increase mechanical stress during high-load movements like cutting, landing, and deceleration

However, this is not a direct correlation. Many athletes with narrow notches never experience ACL injuries, and many injuries occur in athletes without this trait.

Other anatomical considerations include:

• Wider pelvis and increased Q-angle, which may influence knee valgus positioning

• Greater general ligament laxity in females on average

These factors don’t create injury on their own, however, they may influence how forces are distributed when the system is under stress.

Hormonal Influences

Hormonal fluctuations across the menstrual cycle (mainly estrogen and relaxin) have been studied for their potential effects on ligament laxity and neuromuscular control.

Some research suggests small changes in joint laxity, stiffness, and movement control during certain phases, and Wojtys et al. (2002) reported that more ACL injuries occurred during the pre-ovulatory/ovulatory phase.

However, later reviews, including Herzberg et al. (2017), show mixed and inconsistent findings, with no clear causal link established.

Bottom line:

Hormones may slightly influence tissue behavior, but they are not the primary driver of injury risk. The dominant factor is an athlete’s ability to control and absorb force (strength, coordination, and mechanics), which determines how those small fluctuations actually matter in sport.

Neuromuscular Control: Huge Emphasis On This Piece!

If there is one consistent factor across ACL injury research, it is movement quality under load.

This is often referred to as neuromuscular control, which simply means how well your brain and muscles communicate to keep your body stable and coordinated during movement, especially when things are fast, reactive, and unpredictable.

It’s what allows an athlete to land, cut, and decelerate without losing joint alignment or control.

Common patterns associated with higher injury risk include:

• Increased knee valgus during landing or cutting

• Stiff, upright landing mechanics (limited hip and knee flexion)

• Poor deceleration control

• Over-reliance on quadriceps dominance instead of posterior chain and hip integration

ACL injuries are rarely about a single bad moment. They are often the result of long-term movement strategies that fail under high-speed, high-force conditions.

In other words:

ACL injuries happen in milliseconds but are built over years of how an athlete learns to absorb and produce force. That’s why early development matters. It’s not about rushing performance; it’s about building movement patterns, strength, and coordination early so the athlete has a bigger capacity to handle sport demands later. The goal is to develop the foundation now, so the system is more resilient when the intensity goes up.

Early Specialization: Repetitive Stress

Another major contributor to rising injury rates is early and intense sport specialization.

Many athletes now:

• Train and compete year-round in a single sport

• Repeatedly expose the same tissues to identical movement patterns

• Develop limited variability in how they move, cut, and land

This reduces the development of general athleticism, especially:

• Multidirectional strength

• Varied landing mechanics

• Broad force absorption skills

The body adapts to what it is exposed to. If exposure is narrow, resilience becomes narrow as well.

Strength Training: Still Underused and Misunderstood

Strength training is one of the most underutilized tools in ACL injury reduction.

Historically, some sport environments were resistant to lifting due to concerns about:

• Reduced speed

• Increased injury risk

• “Bulking up” athletes

While poorly designed programs can create issues, the problem is not strength training itself, it is execution.

When properly programmed, strength training improves:

• Force production

• Joint stability

• Tissue capacity

• Deceleration ability

• Movement efficiency

So instead of thinking:

Strength training is an add-on to help performance.

Think:

Strength training is the foundational system that allows performance to hold up under sport demands.

Injury Reduction is Trainable: What the Research Shows

A large body of research supports neuromuscular and plyometric training as effective ACL injury reduction tools.

Hewett et al. (1999, American Journal of Sports Medicine) found that a neuromuscular training program (including strength, plyometrics, and landing mechanics) significantly reduced ACL injury rates in female athletes.

Sugimoto et al. (2015, British Journal of Sports Medicine) found ACL injury reductions of approximately 50% or more when structured prevention programs were implemented.

These programs consistently include:

• Strength training

• Plyometrics

• Balance and stability work

• Landing and cutting technique instruction

The conclusion:

When athletes are trained to produce and absorb force properly, injury risk decreases significantly.

Practical Application: How We Build Resilient Athletes

Understanding the science is only useful if it changes how we train.

The following prep block can be used at the start of training sessions or performed independently 2–3x per week. No equipment is required.

Foot & Lower Limb Prep: Pogo Hop Series

We start by developing stiffness and reactivity through the foot and ankle. Everything starts with the foot. It is the first point of contact with the ground so it must be resilient.

• Linear pogos – 10 yards

• Lateral pogos – 10 yards

• Single-leg linear pogos – 10 yards each side

• Single-leg lateral pogos – 10 yards each side

Focus:

• Quick ground contact

• Quiet, controlled landings

• Upright posture

• Think: spring, not sink

Single-Leg Control: Hop Series

Now we build control under dynamic, multi-directional load.

On one leg:

• 3 forward hops

• 3 lateral hops (left)

• 3 lateral hops (right)

• 3 backward hops

Each landing should be stuck and controlled before moving into the next rep.

Focus:

• Ankle, knee, and hip working together

• No collapse or wobble on landing

• Full ownership of each position

Ask yourself: Where do you feel fatigue first?

• Foot?

• Lower leg?

• Hip?

If this is extremely difficult, that’s useful feedback, it shows exactly where capacity needs to be developed.

Mobility & Position Control

True mobility isn’t just flexibility. Flexibility is passive range (what you can get into). Mobility is controlled range (what you can own under tension). If we can’t control range, we don’t really have it when sport speed shows up.

These two examples specifically target the ankles, knees, and hips, which are the main joints responsible for absorbing and expressing force during sport. There are many more options, but these are simple, effective starting points.

• 90/90 hip switches (slow and controlled)

• Deep squat hold (stay relaxed, but actively controlled)

The goal is not just to “open up” the body, it’s to train the system to own positions at end range, where athletes are most vulnerable in cutting, landing, and deceleration.

Foundational Strength Holds (No Equipment Needed!)

2–3x per week: hold for up to 60 seconds

• Iso split squat hold

• Sprinter hamstring bridge

• Side plank with top leg lift (iso hold)

• Hip flexor bridge hold

These positions build:

• Single-leg stability

• Posterior chain strength

• Core integration

• Pelvic control

This is long-term tissue capacity work.

Change of Direction: A Trainable Skill!

Cutting and deceleration are skills.

Examples:

• Sprint → controlled deceleration (5–10 yards)

• Lateral shuffle → stick and stop

• Curved runs to expose different force angles

The goal is to teach the body how to:

• Decelerate efficiently

• Use the hips and trunk appropriately

• Avoid overloading the knee in isolation

Final Thoughts

ACL injury risk in female athletes doesn’t come from a single cause, and it isn’t something that is inevitable.

It’s the result of how several factors build on each other over time.

Things like anatomy, physical development, training history, how much sport exposure an athlete has, and the quality of their movement and control. And importantly, it is highly trainable.

When athletes are exposed to:

• Better strength training

• Better landing mechanics

• Better deceleration skill

• Better movement variability

They don’t just become more athletic, they become more resilient in the environments they compete in.

Think of it like a slow-cooker process. Don’t rush adaptation. Build it through smart progressions, proper movement, and consistent exposure over time. The key is doing the foundations intentionally and repeatedly, not skipping ahead to what looks advanced.

That consistency compounds. Over time, it leads to better performance, a lower risk of injury, and a higher likelihood of staying on the field, court, pool, or wherever your sport is played.

References

References

Agel, J., Arendt, E. A., & Bershadsky, B. (2005). Anterior cruciate ligament injury in National Collegiate Athletic Association basketball and soccer: A 13-year review. The American Journal of Sports Medicine, 33(4), 524–530. https://doi.org/10.1177/0363546504269937

Arendt, E., & Dick, R. (1995). Knee injury patterns among men and women in collegiate basketball and soccer. The American Journal of Sports Medicine, 23(6), 694–701. https://doi.org/10.1177/036354659502300611

Hewett, T. E., Lindenfeld, T. N., Riccobene, J. V., & Noyes, F. R. (1999). The effect of neuromuscular training on the incidence of knee injury in female athletes. The American Journal of Sports Medicine, 27(6), 699–706. https://doi.org/10.1177/03635465990270060301

Sugimoto, D., Myer, G. D., Foss, K. D. B., & Hewett, T. E. (2015). Specific exercise effects of preventive neuromuscular training intervention on anterior cruciate ligament injury risk reduction in female athletes: Meta-analysis and subgroup analysis. British Journal of Sports Medicine, 49(5), 282–289. https://doi.org/10.1136/bjsports-2014-093461

Wojtys, E. M., Huston, L. J., Boynton, M. D., Spindler, K. P., & Lindenfeld, T. N. (2002). The effect of the menstrual cycle on anterior cruciate ligament injuries in women as determined by hormone levels. The American Journal of Sports Medicine, 30(2), 182–188. https://doi.org/10.1177/03635465020300020601

Herzberg, S. D., Motu’apuaka, M. L., Lambert, W., Fu, R., Brady, J., & Guise, J. M. (2017). The effect of menstrual cycle and contraceptives on ACL injuries and laxity: A systematic review and meta-analysis. Orthopaedic Journal of Sports Medicine, 5(7). https://doi.org/10.1177/2325967117718781