FIFPro to launch groundbreaking 'Project ACL' to address knee injury epidemic in women's football

Sam Kerr gives the thumbs up after going under the knife to repair her anterior cruciate ligament. (Instagram: @samanthakerr20)

This weekend, as Melbourne City take on Sydney FC in the 2023-24 A-League Women (ALW) grand final, three players will be watching and cheering their team-mates on from the sidelines.

City forward Holly McNamara, and Sydney defenders Natalie Tobin and Kirsty Fenton, have all suffered an ACL injury this season, keeping them out of action for anywhere between six months and a year.

They join six other footballers from multiple ALW clubs in the stands as the season draws to a close, bringing the league’s total ACL injury list to nine.

Like many other professional women’s leagues around the world, Australia’s top competition has been significantly affected by what players have anecdotally described as an “epidemic” of ACL injuries.

Women athletes are two to six times more likely than men to sustain an ACL injury while training or playing their sport: a number that has not improved despite the rapid professionalisation of women’s football in recent years.

With more and more high-profile women footballers such as Sam Kerr, Beth Mead, Vivianne Miedema, Marie-Antoinette Katoto, Leah Williamson, Janine Beckie, Delphine Cascarino, and dozens more internationals forced to miss major tournaments in the last two years due to ACL tears — all while losing valuable income along the way — the calls for action have grown louder.

FIFPro, the global players’ union, has finally heeded this call.

Today, the union launched a groundbreaking new program titled “Project ACL” that aims to address the many intersecting factors that put women footballers at higher risk of tearing their ACLs.

The three-year study will review existing research into ACL injuries in women athletes, conduct assessments of the resources and structures provided by participating Women’s Super League (WSL) clubs in England, and deploy their own digital tool that tracks the playing workload, travel time, and high-intensity match minutes of WSL players in real-time, generating more comprehensive and nuanced data around the circumstances in which women footballers are most at risk.

While research continues to blossom around ACL injuries in women’s sport, what makes FIFPro’s program revolutionary is combining the academic work — which has mostly focused on internal biological and physiological factors in amateur athletes — with a broader assessment of the external environments that players play, train, recover, and travel in.

As with all sport, resources differ from club to club, with those women’s teams that are backed by bigger, wealthier men’s clubs likely having access to better resources such as qualified staff, gyms, recovery centres and programs, nutrition, and private or business-class travel compared with teams that are less supported.

However, there is simply not enough existing research on these environmental factors to determine which ones are the most significant, and which can be modified by clubs, coaches, and staff in ways that will prevent future injury.

“This research has never been done before,” said Dr. Alex Culvin, FIFPro’s Head of Strategy and Research for Women’s Football.

“It’s a stakeholder-collaborative project, which also hasn’t been done before: we have four big stakeholders [FIFPro, England’s player’s union, Leeds-Beckett University, and Nike] coming together to better understand ACL injuries, as well as the environments and conditions in which they occur.

“This project is a response to the players rightly calling for more research: it’s around centralising the needs of players and their voice, but also moving away from the singular or binary understandings of ACL injuries.

“[Instead of] pointing simply to ‘workload’ or ‘female physiology’, one of the primary objectives of this project is to understand the holistic risk factors, the environmental risk factors, and that fundamentally comes down to the conditions in which players play.”

By partnering with WSL clubs, who will allow FIFPro’s researchers into their facilities to assess things like equipment and facility access, squad sizes, staff-to-player ratios, budgets, programs, playing schedules, and performance data, the union hopes to produce a more holistic understanding of why ACL injuries occur, when and where they are most likely to happen, and how they can be prevented in future.

Not only does more, better, and more comprehensive research into ACL injuries give players and coaches more confidence and certainty in their careers, but it also makes commercial sense, with the growing economy of women’s football resting on the performances of some of the most at-risk players due to their participation in multiple overlapping competitions and increasing demands on their bodies and minds.

This perhaps explains the involvement of Nike, one of football’s biggest financial stakeholders, which will provide funding and support to FIFPro during the three-year project.

Continuing to build this body of research is crucial, according to Dr. Stacy Emmonds, a researcher at Leeds-Beckett who will be leading the study, because the research that currently exists — and which clubs, competitions, and federations use to make decisions — is still too small in scale and too narrow in focus.

“Around six per cent of [sports science and medical] literature is focused on the female athlete, and there have been various calls across recent years to improve that,” she said.

“We also know that, due to this, some of the studies that have been done on women athletes lack power: they’re very small samples, they’re what we call ‘low quality’ evidence based on some of the methodologies, etc.

“We know there are potentially some contributing factors regarding female physiology, but we know there are a lot more things that can be influenced from the environmental factors that female athletes find themselves in, in terms of access to certain facilities and expertise.

“A lot of the language at the moment suggests that some of these risk factors are just inherent to females, and almost suggests we just need to accept that, when we know that they can actually be influenced.

“There’s some good research out there looking at neuromuscular training programs that may be completed prior to training, but the effectiveness of those has not been explored with professional female athletes; they’ve been in amateur or they’ve been in youth athletes.

“So there really is a need for a broad range of research in this space, and we feel one of those key areas is the focus of this project: the environmental factors that contribute to injury risk and reduction in the women’s game.”

The quantitative data collected from these club assessments will then be complemented by qualitative data in the form of anonymous interviews of players — both those who have injured their ACLs and those who have not — to understand their daily workplace environments, how they feel about the support they receive, the amount of games they play, their training load, and how it all ties together in an overall feeling of risk of injury.

While the pilot program will focus exclusively on the WSL at first, FIFPro aims to produce a best-practice report that can be shared among clubs, players, and associations worldwide, with the results and recommendations of the study to be made available to the entire game, with other player unions invited to build upon the existing research by adding their own context-specific data around things like climate, playing surfaces, travel times, season length, etc.

Then, once that body of research is in place, it is hoped that various women’s leagues around the world will use the data in order to advocate for minimum standards across multiple aspects of their playing and training environments, with clubs potentially held accountable or liable if minimum standards of care and support are not met if they are so negotiated within something like a collective bargaining agreement.

For the Project ACL leaders, ‘success’ of this three-year study comes in many forms.

First, they aim to change the narrative around ACL injuries so that a player’s multiple environmental factors are always considered as part of the conversation, therefore providing more common knowledge and expectation that these factors can and will be addressed behind the scenes.

Second is laying out a blueprint for collaborative research between various footballing stakeholders in the pursuit of shared solutions that lead to the betterment of the game, with clubs and unions (which are usually at odds with each other) working together towards a common goal.

Finally, and perhaps most importantly, FIFPro hopes this project will further demonstrate the importance of positioning players at the centre of structural changes and decisions that, at the end of the day, affect them most of all.

So while McNamara, Tobin, and Fenton will have to watch their teams either lift or lose a trophy this weekend, this ambitious research project could mean that, in just a few years time, the players who come after them may no longer be at such a high risk of suffering the same fate.