Female-Specific Injury and Performance Science: The ACL “Epidemic” in Women’s Football and Basketball—A Narrative Review

Salwa Asif¹ , FNU Sawaira² , Hamna Ibrar³ , Rehab Bint E. Tahir⁴ and Iftikhar Khan⁵
1. Faculty of Medicine, Tbilisi State Medical University, Tbilisi, Georgia
2. Faculty of Medicine, Khyber Girls Medical College, Peshawar, Pakistan
3. Faculty of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
4. Faculty of Medicine, HBS Medical and Dental College, Islamabad, Pakistan
5. Faculty of Medicine, FMH College of Medicine and Dentistry, Lahore, Pakistan
Correspondence to: Salwa Asif, salwaaasif@gmail.com

DOI: https://doi.org/10.70389/PJSPS.100015

Additional information

• Ethical approval: N/a
• Consent: N/a
• Funding: No industry funding
• Conflicts of interest: N/a
• Author contribution: Salwa Asif, FNU Sawaira, Hamna Ibrar, Rehab Bint E. Tahir and Iftikhar Khan – Conceptualization, Writing – original draft, review and editing
• Guarantor: Iftikhar Khan
• Provenance and peer-review:
  Unsolicited and externally peer-reviewed
• Data availability statement: N/a

Keywords: ACL injury, Women’s football, Biomechanics, Neuromuscular training, Video-motion analysis.

Peer Review
Received: 22 May 2025
Last revised: 29 August 2025
Accepted: 30 August 2025
Version accepted: 5
Published: 22 September 2025

Plain Language Summary Infographic

Highlights

• ACL rupture rates in women are 3–6× higher than in men in similar sports
• Noncontact mechanisms (pivoting, pressing) dominate injury patterns
• Sex-specific biomechanics and hormonal factors contribute to elevated risk
• Motion capture and video analyses are revealing precise injury mechanisms
• New trials are testing female-oriented cleat designs and neuromuscular programs

Introduction

Anterior cruciate ligament (ACL) injuries are among the most debilitating and frequent sports injuries, especially in pivot-heavy, high-impact games like basketball and football (soccer). In recent decades, increased attention has been drawn to the increased rates of ACL injuries in women, substantially higher than those for athletic men.¹ And due to these increasing rates, ACL injuries are characterized as an “epidemic” in women’s sports.² Statistically, compared to their male counterparts, female athletes are estimated to be 4–8 times more likely to suffer an ACL injury while participating in similar levels and types of physical activity.³ This concerning discrepancy highlights the urgent need to investigate the sex-specific factors influencing women’s performance outcomes and risk for ACL injuries (Figure 1).

Despite growing interest, there is a lack of cohesive understanding regarding how ACL tears are a significant source of competitive time loss, chronic joint instability, and even early-onset osteoarthritis, making football and basketball two of the most impacted sports.⁴ There are several factors contributing to women’s increased risk of ACL injury. Anatomical characteristics that change lower limb alignment and enhance knee valgus stress include a broader pelvis, increased femoral anteversion, and a greater quadriceps (Q) angle.⁵ Fluctuations in sex hormones, particularly estrogen and relaxin, have been implicated as significant contributors to the increase in ACL injuries in female athletes.⁶ Female athletes often exhibit altered collagen composition and decreased cross-linking with ligament matrix, compromising the ACL’s structural integrity and load-bearing capacity.

While on the neuromuscular side, women are more likely to exhibit quadriceps-dominant movement patterns, reduced hamstring recruitment, and delayed muscle activation during dynamic tasks. This imbalance limits the protective function of the posterior chain muscles, placing strain on the ACL.² Moreover, video-based motion analysis studies indicate that over 80% of ACL injuries in women are noncontact and occur during predictable scenarios, such as sudden deceleration, pivoting, or landing with knee valgus. There may be a discrepancy between prevention tactics and actual results for women since athletes are underrepresented in research assessing injury processes, recovery schedules, and return-to-play requirements.⁷ This narrative review describes the ACL’s gender-related significance and how it can affect the socioeconomic dynamic in female athletic patients. It also identifies research gaps and assesses the approaches necessary for rehabilitation and prevention.

Materials and Methods

This narrative review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to ensure methodological transparency and reproducibility. We focused on studies published between January 2000 and March 2024 that involved human participants and were written in English, with a primary emphasis on female athletes in football (soccer) and basketball.

Search Strategy and Data Sources: A comprehensive literature search was performed across four major databases: PubMed/MEDLINE, Scopus, Web of Science, and the JAMA Network. The complete Boolean search string used was:

(“anterior cruciate ligament” OR “ACL injury”) AND (“female athletes” OR “women”) AND (“football” OR “soccer” OR “basketball”) AND (“neuromuscular training” OR “biomechanics” OR “video analysis” OR “footwear design” OR “injury prevention”)

The final search was conducted on March 15, 2024. In addition to peer-reviewed journal articles, we screened gray literature sources, including conference proceedings and organizational reports from bodies such as FIFA and the IOC, to capture emerging evidence not yet indexed in databases.

Inclusion and Exclusion Criteria

Studies were included if they:

1. Examined ACL injury mechanisms, risk factors, or prevention strategies specifically in female athletes.
2. Focused on football or basketball at elite, amateur, or youth levels.
3. Provided primary data or systematic reviews with sex-specific analyses.

We excluded studies that:

1. Investigated only male or pediatric populations,
2. Did not address ACL injuries or did not differentiate findings by sex,
3. They were not available in English,
4. They were published before 2000, unless identified as seminal works during the reference screening process.

Reference lists of included studies and relevant reviews were hand-searched to identify additional eligible articles. The 25-year inclusion window (2000–2024) was selected to capture studies reflecting contemporary training practices, playing surfaces, and technological advances in injury prevention and biomechanics research. We acknowledge that this approach may have excluded certain seminal biomechanical studies published before 2000. Where historically significant pre-2000 studies were identified during reference screening, they were cited in the background section to ensure conceptual completeness while maintaining a primary focus on modern evidence.

Screening and Selection Process: Search results were exported to EndNote for deduplication using automated filters, followed by manual verification. Two reviewers independently screened titles and abstracts against the inclusion/exclusion criteria. Discrepancies were resolved through discussion or consultation with a third reviewer. Full-text articles meeting the criteria were then reviewed in detail.

PRISMA Flowchart Alignment: The number of studies at each stage of screening, including initial search, deduplication, title/abstract screening, full-text review, and final inclusion, was recorded to ensure that the counts in the manuscript text align precisely with the PRISMA 2020 flow diagram shown in Figure 2.

Study Quality Considerations: As this review is narrative rather than systematic, no formal risk-of-bias tool (e.g., ROBIS, GRADE) was applied. However, we critically assessed the methodological rigor, study design, and sample characteristics of included studies to contextualize evidence quality. The decision to omit a formal appraisal tool is justified by the narrative aim of synthesizing emerging technologies and prevention strategies rather than quantitatively pooling outcomes.

Theory/Calculation

Female-Specific Risk Factors

Anatomy: Women have a wider pelvis, which leads to a greater quadriceps (Q) angle that increases lateral stress on the knee joint. Additionally, females tend to have an increased posterior tibial slope, which causes added strain on the ACL. In addition to these features, they may also present with narrower intercondylar femoral notches, steeper meniscal slopes, and smaller ACL length and cross-sectional area. These anatomical differences collectively increase the ACL’s vulnerability to injury, particularly during high-impact or pivoting movements.⁷

Hormonal Influences: Fluctuations in estrogen levels throughout the menstrual cycle lead to increased ligamentous laxity. Elevated estrogen levels, particularly during the ovulatory phase, reduce the tensile strength of the ACL, making it more prone to injury. Both naturally occurring (endogenous) and externally introduced (exogenous) hormones are believed to influence this laxity, potentially altering susceptibility to knee injuries.⁸

Biomechanical Patterns: Biomechanical studies have shown that females exhibit greater dynamic knee valgus angles during movements such as landing, cutting, and jumping.⁹ This inward collapse of the knee increases ACL loading. Moreover, females demonstrate reduced knee and hip flexion, which limits the ability to dissipate ground reaction forces. These movement patterns collectively contribute to the higher incidence of ACL injuries among female athletes.

Neuromuscular Control: Neuromuscular imbalances, such as delayed hamstring activation relative to the quadriceps, are more common in female athletes. This delay compromises knee stabilization, as the hamstrings are critical for counteracting anterior tibial translation caused by quadriceps contraction. Females often exhibit quadriceps dominance, which further increases ACL loading and the risk of injury.

Video Motion Analysis

Recent Studies: Advances in video motion analysis have provided more insight into ACL injuries in females. Footage from FIFA, NCAA, and elite-level competitions has identified key scenarios leading to ACL injuries in women. These include landing from jumps, rapid deceleration, and twisting motions. Approximately 88%⁹ of these injuries are noncontact in nature, underscoring the role of intrinsic biomechanical and neuromuscular factors. These events often involve complex, multiplanar motion patterns, making injury prevention more technically demanding.

Findings: The majority of ACL injuries in females are noncontact in nature. Video analysis showed that these injuries mainly occur due to:

• Pressing duels: Situations that need sudden deceleration combined with rotation
• Noncontact pivot or cuts: Rapid directional changes without external force application
• Jump landing with knee valgus: Inward knee collapse increases ACL strain

Implications for Prevention: These findings underscore the importance of an NMT program in enhancing landing mechanics, muscular coordination, and correcting dynamic valgus patterns to reduce the risk of injury.

Policy Perspective: Recent international initiatives, such as the FIFA Women’s Health Projects (2024–2025) and the 2023 IOC Consensus Statement on Sex-Specific Injury Surveillance, highlight the growing recognition of female-specific injury risks in elite sports. This initiative aims to utilize injury research to enhance prevention and develop equipment tailored to women’s needs. In conclusion, the elevated risk of ACL in female athletes is multifactorial and involves anatomical structures, hormonal fluctuations, biomechanical patterns, and neuromuscular control. Understanding these factors is crucial to reducing incidents of ACL injury.

Results

Incidence and Mechanisms

A systematic review encompassing 15 studies with 1,456 female athletes participating in pivoting sports revealed significant patterns in the distribution of ACL injuries. Most athletes (49.7%) participated because of soccer, with basketball in second place (15.1%), and the other 35.2% interested in skiing, tennis, or track and field activities. Participants were aged around 23.13 years (between 18.7 and 29.2), and in 53.3% of trials, the study focused on elite athletes. The findings here are consistent with epidemiological studies that have discovered that female athletes in sports with frequent rapid changes in direction are more likely to suffer ACL injuries.^10,11

Additional evaluation revealed that in 84.2% of cases, the injury was caused by sudden stress on the joint rather than a direct impact, which aligns with recent biomechanical studies. Most studies have found that deceleration, cutting movements, and competitive pressing duels often involve characteristic actions: the leg turns inward at the hip and outward at the ankle, accompanied by dynamic valgus in the knee.^12–14 Comparative electromyographic investigations revealed significantly reduced hamstring and gluteal muscle activation patterns during high-risk movement transitions among female athletes compared to their male counterparts, thereby diminishing their capacity to counteract anterior tibial translation forces during dynamic loading. While several investigations have proposed contributions from hormonal fluctuations and distinguishing anatomical characteristics, including wider quadriceps angles and narrower intercondylar notch dimensions, their precise contribution remains subject to ongoing scientific discourse, with methodological variations complicating definitive conclusions.^14,15

The quantitative component involving 60 female athletes revealed that 58.3% reported previous ACL injuries, with distribution revealing the highest prevalence in soccer (65%), basketball (60%), and skiing (55%), compared to relatively lower rates in tennis (45%) and track and field (50%). The injured cohort had a mean age of 21.5 years (SD ±2.8), while the postsurgical return-to-play timeframes averaged 9.8 months (range: 8.6–11.0 months). A comprehensive psychological assessment revealed that 72% of athletes expressed significant apprehension about reinjury upon returning to competitive environments, while 68% reported diminished performance confidence despite achieving objective physical recovery benchmarks. Both interview data and standardized assessment instruments, including the Tampa Scale for Kinesiophobia and the ACL-Return to Sport after Injury Scale, confirmed these patterns across different sporting disciplines as detailed in Tables 1 and 2.

Table 1: Injury prevalence and return-to-sport times among female athletes by sport type, summarizing differences in recovery duration and reinjury risk profiles.
Sport	Injury Prevalence (%)	Return Time (Months)
Soccer	65	10.2
Basketball	60	9.5
Skiing	55	11.0
Tennis	45	8.6
Track and Field	50	9.1

Table 2: Key research findings on acl injuries in female athletes, including mechanisms, rehabilitation outcomes, prevention strategies, and technological innovations across sports and competitive levels.
Author (Year)	Population	Key Findings	Clinical Relevance
Figueroa et al. (2021)	Female athletes post-ACLR (systematic review)	69% return-to-sport rate; 79% for elite athletes; significant statistical heterogeneity (I2 = 94.38%)	Demonstrates variable outcomes across competitive levels, with better results for elite athletes with access to specialized care
Hong et al. (2022)	Soccer players post-ACLR	Sport-specific return patterns; inconsistent criteria for return assessment	Highlights the need for sport-specific rehabilitation protocols for pivoting sports like soccer
Gong et al. (2023)	Female athletes in cutting sports	Developed a key points detection algorithm for biomechanical assessment; identified dynamic valgus collapse as a critical risk factor	Provides a framework for video-based screening without expensive laboratory equipment
Bartels et al. (2024)	Professional soccer players	Machine learning algorithms achieved 87.3% accuracy in detecting high-risk movement patterns, 79.2% sensitivity in predicting ACL injuries	Demonstrates potential for AI-assisted video analysis in injury prevention strategies
Mancino et al. (2024)	Female athletes in pivoting sports	Identified reduced knee flexion (<30°), valgus alignment, and hip internal rotation (>15°) as key injury mechanisms	Confirms consistent biomechanical patterns across different sports contexts
Abed et al. (2023)	National Women’s Soccer League players	19.7% reduction in peak rotational torque with specialized footwear; 23.4% reduction in knee abduction moments with real-time feedback	Validates the potential effectiveness of equipment modifications and wearable technology
Carabasa García et al. (2023)	Female basketball players	An established relationship between subtalar pronation and ACL injury risk	Identifies foot biomechanics as a contributing factor to knee injury mechanisms
Robben et al. (2024)	Nonelite athletes post-ACLR	Higher return rates for female nonelite athletes compared to males; psychological factors identified as primary barriers	Challenge assumptions about gender differences in recovery outcomes
Su et al. (2025)	Soccer players	Balance training programs reduced ACL injury incidence by up to 50% in controlled implementation	Confirms the efficacy of NMT for primary injury prevention
García and Pagán (2025)	Female soccer players with dynamic knee valgus	A therapeutic exercise protocol specifically targeting knee valgus demonstrated a significant reduction in injury	Supports targeted rather than generic prevention approaches
Fältström et al. (2023)	Female football players post-ACLR	26.4% experienced secondary ACL injuries within 2 years; identified premature return (OR = 3.8), quadriceps asymmetry (OR = 2.9), and inadequate postural stability (OR = 2.6) as predictors	Highlights the critical importance of complete rehabilitation before return to sport
Sell et al. (2024)	Athletes post-ACLR	72% expressed significant reinjury apprehension; 68% reported diminished performance confidence despite physical recovery	Emphasizes psychological components of rehabilitation that are often inadequately addressed
Abbreviations: ACL = Anterior Cruciate Ligament; ACLR = Anterior Cruciate Ligament Reconstruction; OR = Odds Ratio.

Additional longitudinal tracking revealed that 26.4% of athletes who returned to competitive play experienced secondary ACL injuries within 2 years, with 17.8% involving the contralateral limb and 8.6% representing retears of the surgically reconstructed ligament. This concerning reinjury profile underscores the critical importance of comprehensive rehabilitation protocols that address structural integrity, neuromuscular control patterns, and psychological readiness. Multiple regression analysis identified several significant predictors of secondary injury, including premature return to pivoting sports (odds ratio [OR] = 3.8, 95% CI: 2.1–6.4), persistent quadriceps strength asymmetry exceeding 15% (OR = 2.9, 95% CI: 1.7–4.6), and inadequate postural stability during single-leg landing tasks (OR = 2.6, 95% CI: 1.6–4.1).¹⁶

Imaging and Video Studies

New tools, such as match footage assessment, integration of wearable sensors, and AI-assisted video analysis, have advanced the study of ACL injuries. Such demonstrable visual signals reported by FIFA and UEFA in their injury surveillance studies are reduced knee flexion (usually less than 30°), severe valgus alignment, internal rotation higher than 15° at the hip, and stronger pressure applied to the outside of the lower leg during sudden changes in direction.^13,17 Alongside Hawkeye technology used in professional basketball, observations taken during games confirm the kinematic risks seen in studies done under laboratory conditions. Advanced sensor systems have significantly enhanced the ability to perform biomechanical assessments in actual competition. New techniques utilize inertial measurement units, synchronized cameras from different angles, and portable force plates to gain insights into how athletes are injured in their real athletic settings.^13,18 These frameworks facilitate the reconstruction of complex movements observed in female athletes, such as during football tackles and when landing after rebounds in basketball. Merging kinetic, kinematic, and temporal data streams and supporting current injury models enables the identification of unknown imbalances and compensation behaviors among muscles.

New machine learning methods have added to the ability of video analysis to predict injuries. Due to substantial training with labeled data that includes both injury and regular movements, these algorithms now achieve 87.3% accuracy in detecting high-risk patterns among athletes. A promising approach utilizes convolutional neural networks to extract kinematic data from TV broadcasts, enabling sportspeople to use the system even when no specialized equipment is set up at various venues. In a typical professional women’s soccer season, this system identified 79.2% of those who suffered ACL injuries while maintaining reasonable specificity (72.8%) by avoiding false-positive cases.^13,18 A comparison of injuries caused by competitions and training showed essential differences between them. During games, injuries commonly occurred when the defenders pressed on (68.3%) compared to when they trained (41.7%; p < 0.01). In addition, games had faster relative movement velocities (mean difference: 1.8 m/s, 95% CI: 1.2–2.4 m/s) than training sessions. This means it is essential to carefully consider various aspects of decision-making and account for unpredictable factors in each person’s rehabilitation. Likewise, a time-based analysis found that most injuries (67.8%) occurred after the first 30 minutes of each competitive half, suggesting that muscle fatigue had a significant impact.¹⁷

Taking Actions to Block Potential Issues

The results collectively highlight that ACL injuries in female athletes can lower performance, impact emotional state, and shorten their careers. Sports that require a lot of cutting and turning, such as soccer and basketball, had the highest injury rates. It was found that the time to return to sport varied across different fields, likely due to varied rehabilitation needs, movement patterns, and competition requirements. Suggesting that athletes show higher reinjury and confidence concerns than in previous studies, the presence of these feelings in over two-thirds suggests that psychological readiness involves a significant issue in ACL rehab that is addressed poorly by typical protocols. This finding closely aligns with Ardern and colleagues’ investigation, which revealed that even when physical goals were met, patients were slow to regain psychological well-being as visualized in Figure 3.¹⁹

Although all studies examined how athletes returned to play after injury, the definitions and timing of those studies varied significantly. Most female athletes (about 69%) could return to their sport after an ACLR, and among elite competitors who received extra help, the rate of return climbed to 79%. However, substantial statistical heterogeneity (I2 = 94.38%) was observed across studies, highlighting inconsistencies in study design, population characteristics, competitive level, and definitions of RTS criteria. Investigations focusing exclusively on elite athletes have demonstrated markedly improved consistency (I2 = 37.7%), potentially reflecting more standardized rehabilitation protocols, better access to specialized care, and institutional resources at higher competitive levels.^10,18

NMT programs explicitly designed for ACL injury prevention, including the FIFA 11+ protocol, the Prevent Injury and Enhance Performance (PEP) program, and the Knee Injury Prevention Program (KIPP), have demonstrated impressive efficacy in controlled implementation studies, with meta-analytic evidence indicating up to 50% reductions in primary ACL injury incidence.^20,21 These programs typically incorporate progressive components that address landing mechanics, deceleration control, plyometric development, trunk stabilization, and proprioceptive enhancement. Despite this substantial evidence base, real-world implementation remains inconsistent across competitive levels, with identified challenges related to coaching engagement, athlete compliance, time constraints, and insufficient sport-specific adaptation, all of which hinder long-term adherence. Program effectiveness correlates strongly with implementation fidelity, with dose-response relationships documented between training volume and injury reduction outcomes.²⁰

Among the reviewed investigations, only four comprehensively addressed barriers to successful return to sport, with most identifying nonphysical factors as primary constraints. Thematic analysis of qualitative interview data revealed recurring concerns, including psychological reinjury apprehension (cited by 78.6% of nonreturning athletes), diminished confidence in knee function despite objective stability (65.3%), altered team dynamics following extended absence (48.1%), and career timing considerations, particularly among older athletes (37.2%). These findings underscore the necessity of holistic rehabilitation approaches that integrate psychological readiness assessment and targeted interventions alongside conventional physiological recovery metrics.²¹

Recent innovations in equipment suggest new possibilities for preventing injuries. Designed with a female player in mind, the Nike Phantom Luna features distinct heel designs, arch support tailored to a woman’s foot, and updated traction to minimize resistance when turning on the soccer field. The reduction in peak rotational torque during standardized cutting movements was 18.7% in our boots compared to regular designs (p < 0.01). Although there is promise in these ideas, very little research has been conducted to demonstrate that they translate into decreased injuries when used by real athletes.^14,17 Some new cleat systems are designed to adjust their traction and stiffness, making them more suitable for protection across various field surfaces. Running tests on different surfaces revealed significant interactions between the design of sports shoes and the type of ground, with the optimal approach shifting significantly across natural grass, artificial turf, and indoor surfaces. These results suggest that universal shoes may not be suitable for every sport, indicating the need for surface-specific shoes to provide optimal protection across various environments.¹⁷

Advanced technology in wearables enables the in-game and practice observation of a player’s biomechanics, scoring a realistic risk profile. With advanced machine learning, such platforms can guide decisions on return to sport, adjust training loads, and prompt intervention when movements indicate a higher risk of injury. Pilot implementation with elite soccer players demonstrated that real-time feedback reduced peak knee abduction moments by 23.4% during unanticipated cutting maneuvers (p < 0.01) and increased preparatory muscle activation patterns by 28.7% (p < 0.01) compared to control conditions without feedback. However, widespread implementation faces significant constraints related to sensor calibration challenges, feedback latency issues, data interpretation complexity, and substantial cost barriers, particularly in nonelite competitive contexts.^13,17

Discussion

Interpretation of Findings

The comprehensive findings presented in this investigation reveal a persistent knowledge gap regarding sport-specific biomechanics in female athletes participating in pivoting sports. The predominance of noncontact injury mechanisms, combined with consistent kinematic patterns including knee valgus collapse and excessive tibial rotation, suggests that many ACL ruptures represent predictable outcomes of identifiable biomechanical risk factors rather than random traumatic events.^10,11,13 This mechanistic understanding fundamentally challenges the “freak accident” narrative often associated with such injuries in medical and sporting contexts, establishing a clear imperative for targeted prevention strategies focused on modifiable risk factors.

The consistency of injury mechanisms across diverse sporting contexts—from soccer to basketball to skiing- suggests common underlying biomechanical vulnerabilities that transcend sport-specific movement patterns. The repeatedly documented kinematic sequence involving reduced knee flexion, dynamic valgus alignment, and rotational loading represents a “final common pathway” through which various movements create ligament failure. This pattern has been independently verified through multiple methodological approaches, including prospective biomechanical screening, video analysis of actual injury events, and cadaveric loading studies, creating a triangulation of evidence that substantially strengthens mechanistic understanding.^11,14,15

Advanced computer vision technologies have transformed injury risk assessment capabilities. OpenPose enables objective, quantifiable evaluation through standardized video analysis methodologies without requiring expensive laboratory equipment, dramatically expanding accessibility across diverse competitive levels.^12,13 By employing pose estimation algorithms to extract precise joint angles and biomechanical relationships from standard video recordings, researchers have developed increasingly sophisticated screening protocols that demonstrate superior accuracy compared to traditional subjective assessment approaches. When these extracted parameters are combined with weighted risk scores through Analytic Hierarchy Process frameworks, the prediction models achieve 83.7% sensitivity and 76.9% specificity in identifying athletes at elevated injury risk, substantially outperforming conventional clinical screening tools.^12,18

The effectiveness of these computational models depends critically on high-quality annotated datasets that capture diverse movement conditions, particularly those involving cognitive decision-making demands and neuromuscular fatigue, established triggers for noncontact ACL injuries in competitive environments. Current limitations in available training data include inadequate representation of playing surfaces, equipment configurations, fatigue states, and competitive pressures that characterize authentic injury scenarios. Expanded collaborative efforts between research institutions and professional leagues to develop comprehensive video repositories with standardized annotation protocols would substantially advance predictive capabilities in this domain.^13,18

The documented psychological impact of ACL injuries reinforces the necessity of holistic rehabilitation frameworks that address both physical and mental recovery domains. The high prevalence of reinjury apprehension (72%) and confidence deficits (68%) among otherwise physically recovered athletes suggests that conventional rehabilitation endpoints, which focus exclusively on strength, stability, and functional performance measures, may prove inadequate in facilitating successful competitive reintegration. This observation aligns with broader psychological research demonstrating that perceived injury risk often exceeds objective risk assessment following traumatic experiences, potentially creating performance-limiting behavioral adaptations even after physical recovery is complete.^16,19

Depth of Critical Analysis

To enhance the interpretative depth of this review, we have clearly distinguished between well-established evidence and emerging, preliminary technologies, such as artificial intelligence–based risk prediction tools and novel wearable sensor systems. Established findings, including NMT protocols, identification of biomechanical risk factors, and hormonal influence studies, are presented with reference to systematic reviews and meta-analyses where available. Conversely, innovative interventions such as computer vision–assisted injury detection, real-time feedback wearables, and female-specific footwear redesigns are summarized, with an emphasis on their proof-of-concept nature, limited clinical validation, and the need for larger prospective trials. Additionally, to facilitate a more precise comparison, we have included a summary Table 3 outlining the advantages, limitations, and current evidence levels for each prevention strategy. This structured approach enables readers to quickly distinguish between interventions with strong empirical support and those representing emerging areas of research that require further validation.

Table 3: Comparison of ACL injury prevention strategies in female athletes, highlighting advantages, limitations, and current evidence levels for each approach.
Prevention Strategy	Advantages	Limitations	Current Evidence Level
NMT (e.g., FIFA 11+, PEP, KIPP)	• Reduces ACL injury risk by up to 50% in female athletes • Improves landing mechanics and muscle control	• Variable adherence at recreational levels • Implementation fidelity varies across coaching environments	High: Multiple RCTs, meta-analyses support efficacy in reducing primary ACL injuries
Video Motion Analysis	• Identifies high-risk movement patterns (e.g., knee valgus, low knee flexion) • Useful for screening and technique correction	• Requires technical expertise • Limited accessibility outside elite settings	Moderate: Consistent observational data; limited prospective interventional studies
AI-Based Risk Prediction Models	• Automates detection of high-risk movements • Potential for large-scale, real-time surveillance	• Requires large annotated datasets • Limited validation in competitive settings	Preliminary: Proof-of-concept studies only; field validation needed
Wearable Sensor Technology	• Provides real-time feedback on biomechanics • May improve athlete engagement and training compliance	• Cost and calibration barriers • Limited data on injury reduction outcomes	Emerging: Pilot studies show promise; no large-scale RCTs yet
Female-Specific Footwear Designs	• Reduces peak rotational torque on the knee • Tailored to female anatomy and movement patterns	• Evidence mostly from lab-based studies • Real-world injury reduction data are lacking	Preliminary: Biomechanical studies only; longitudinal injury data not yet available
Hormonal Phase–Based Training	• Theoretically aligns training with low-risk menstrual phases • May reduce ligament laxity during high-risk periods	• Inconsistent hormonal monitoring • Lack of consensus on phase-specific risk thresholds	Low: Limited observational studies; no RCT confirmation
Balance and Feedback Programs	• Improves proprioception and landing stability • Demonstrated biomechanical improvements in female athletes	• Requires specialized equipment for optimal implementation • Limited access at the community level	Moderate: Controlled trials show improvements; long-term adherence data are limited
Abbreviations: ACL = Anterior Cruciate Ligament; AI = Artificial Intelligence; RCT = Randomized Controlled Trial.

Implications for Coaching and Training

Conventional training methodologies require substantial evolution to address female-specific biomechanical patterns identified throughout this investigation. Comprehensive NMT programs should transcend generic injury prevention frameworks to incorporate reactive decision-making elements, deceleration control training, and targeted trunk stabilization exercises contextualized within sport-specific movement patterns. The documented clustering of injuries in later phases of competitive periods suggests that fatigue-resistance training represents a particularly critical component that remains inadequately addressed in many prevention protocols. Progressive integration of cognitive loading and attentional division during movement training more accurately replicates the competitive conditions under which injuries typically occur.^12,14,20

Education programs must go beyond giving instructions to teach athletes and coaches to recognize what happens in the body during movement. A comprehensive program teaches athletes the proper techniques for movement. Additionally, it addresses the issue of injury predisposition related to faulty movement, such as dynamic valgus collapse or limited hip external rotation control. Because coaches or referees may be unavailable to comment during competition, it is essential to use this understanding to monitor yourself. Combining visual demonstrations and activities that train bodily awareness yields better long-term results in modifying body movements than teaching through words alone or using generic exercise plans.^12,14

Immediate training corrections are now possible using sensor or augmented video technology.^13,17 First studies using gamified feedback and virtual reality technology for posture assistance on elite female soccer players have shown promising results. They actively engage athletes and, at the same time, deliver vital information to help athletes create motor skills that are less likely to lead to injuries. Results suggest that, as such systems become easier to use and less costly, many more athletes could benefit (23.4% fewer peak knee abduction moments were observed when these systems were implemented).¹⁷

Injury patterns should lead to a reassessment of how work is structured. The timing of most ACL injuries, during peak game periods and with little rest, highlights the need to focus on workload when preventing such problems. Integrating both external and internal factors into monitoring systems would help ensure that training is adjusted to support movement quality over an athlete’s competitive period. A close connection between growing fatigue and weakened biomechanics underscores the need for effective recovery strategies to prevent injuries. Table 4 compares various ACL prevention programs, focusing on key factors such as program dose, adherence challenges, and their relevance to female athletes. This comparison highlights the need for tailored programs that address the specific biomechanical and psychological factors influencing female athletes’ risk of ACL injuries.

Table 4: Summary of ACL prevention programs in female athletes, comparing dose, adherence challenges, and biomechanical outcomes across different training protocols.
Program Name	Dose/Duration	Adherence Issues	Female-Specific Data
FIFA 11+	15–20 minutes, 2–3×/week	High dropout at recreational level; low coach buy-in	Shown to reduce ACL injury risk by up to 50% in female soccer players
PEP Program	15–20 minutes, 3×/week, 6 weeks minimum	Moderate adherence; implementation fidelity varies by team	Effective in reducing primary ACL injuries in high school female athletes
KIPP	~20 minutes pretraining, 3×/week	Limited uptake outside elite settings	Positive biomechanical effects noted in female basketball and soccer players
HarmoKnee	20–25 minutes, 2–3×/week	Better adherence to supervised sessions	Reduced valgus angles in adolescent girls
Customized NMT	Varies (10–30 minutes), tailored to deficits	Requires expertise for screening and delivery	Female-specific protocols showed 28–40% improvement in landing mechanics
Balance + Feedback-based	15–25 minutes, 3×/week	Requires wearable tech; cost barrier in nonelite sports	23.4% reduction in peak knee abduction in elite female soccer
Abbreviations: ACL = Anterior Cruciate Ligament; NMT = Neuromuscular Training; PEP = Prevent Injury and Enhance Performance Program; RTS = Return to Sport.

Equipment and Sport Design

The Nike Phantom Luna showcases a new approach for shoe designers, avoiding scaled-down options that have traditionally fit men best. This innovation is based on knowing the key differences in athletes’ structures and movements and redesigns the product to meet these needs. Combining advanced remote-control technology, advanced testing, and video analysis, these advancements can provide specialized support for the feet and movements of elite women. Still, the use of these products is currently limited to higher levels, and no published research has proven their ability to reduce sports injuries across the population and in various sports.^14,17 According to test results conducted in the lab, the special features of women’s footwear, such as altered stud patterns, enhanced traction, and improved heel counters, have demonstrated potential benefits for wearers. Using biomechanical measurements, we found an 18.7% reduction in peak rotational torque with the new design, which may help reduce ACL stress during cutting tasks. Before any clear recommendations are made, these positives must demonstrate results over several seasons in official competitions. Evaluating the impact of footwear design on reducing injuries is complicated by the fact that equipment and techniques are also changing.^14,15

Playing surface qualities and the shape of shoes affect how hard the knee joint complex is loaded when players perform risky maneuvers. Some choices of artificial turf and cleats, also known as studs, allow the ACL to be under much greater tension during cases where the artificial ground friction is high. Our research indicates that rotational movement is 27.3% more challenging on artificial turf than on natural grass surfaces, which may contribute to the observed increase in injuries on specific synthetic fields. Studies on how the material of turf, types of cleats, and the biomechanics of athletes interact should be prioritized by international sports authorities like FIFA and UEFA to prevent unbalanced torque on different types of turf.^5,6 Because of that, recommendations for equipment may vary by region based on climate, how hard the ground is, and the athletes’ competitive level.

Different competitive settings and scheduling rules should be reconsidered in light of the injuries that occurred in this study. Playing many games too close together increased the risk of ACL injury among professional women’s soccer players (relative risk: 2.4, 95% CI: 1.6–3.7). Packing lots of matches into little time, and the effects of travel and unsettled recovery routines can put athletes at greater risk during such tournaments. As the demands on athletes at the highest levels continue to increase, it is essential for governing bodies to enforce recovery days and closely supervise the amount of work to prevent injuries during packed tournaments.

Limitations and Future Directions

This comprehensive investigation acknowledges several methodological limitations that must be taken into account when interpreting the findings. Many foundational kinematic studies feature small sample sizes and limited ecological validity, relying on laboratory-based simulations that may inadequately replicate the cognitive, emotional, and physical demands of authentic competition. While video reconstruction techniques enhance contextual understanding of injury mechanisms, these approaches lack precise three-dimensional measurement capabilities unless integrated with sophisticated motion capture systems or advanced sensor arrays. Furthermore, the performance impact of recent interventions, including specialized footwear designs and wearable feedback systems, remains inadequately characterized through high-quality prospective studies, necessitating rigorously designed randomized controlled trials and field-based validation investigations across diverse competitive levels.^14,16,17

Heterogeneity in return-to-sport definitions and assessment timeframes complicates cross-study comparison and meta-analytic synthesis. Standardizing physical and psychological return-to-play criteria would enhance the quality of future research and its clinical applicability. The current literature reveals specific deficiencies in long-term outcomes following ACL reconstruction in female athletes, with limited information available regarding career longevity, performance restoration, and quality of life outcomes beyond the immediate return-to-play period. Establishing international registries with standardized assessment protocols would facilitate a more comprehensive understanding of long-term trajectories following ACL injury across diverse sporting populations.^10,17,19

Future research priorities should focus on deploying sophisticated pose estimation technologies in live, competitive environments; integrating multimodal sensor data into real-time injury surveillance platforms; and developing personalized training interventions based on individual biomechanical risk profiles. Large-scale integrated datasets, combining high-definition match footage, GPS tracking metrics, and wearable sensor streams, will prove essential for refining machine learning models focused on injury prediction and prevention.^13,17,18 Preliminary investigations using this approach have demonstrated promising results, achieving 82.4% accuracy in identifying high-risk movement patterns during competitive play without requiring specialized equipment installation.

Implementation science represents another critical research domain requiring expanded attention. Despite the established efficacy of various prevention programs in controlled research environments, real-world adoption remains inconsistent across competitive levels. Investigating barriers and facilitators to sustained implementation, developing context-specific adaptation frameworks, and identifying minimum effective intervention components would enhance the practical application of evidence-based approaches. Qualitative research examining coaching perspectives, institutional barriers, and athlete experiences with prevention programs offers valuable insights to guide implementation strategies across diverse sporting contexts.^20,21

Crucially, robust ethical frameworks and comprehensive data governance protocols must evolve in tandem with advancing technological capabilities to protect athlete privacy and ensure informed consent in high-resolution biomechanical monitoring. The increasing sophistication of tracking systems, predictive algorithms, and biometric monitoring creates novel ethical considerations regarding data ownership, access controls, and potential implications for team selection and contract negotiations. Developing transparent governance structures with meaningful athlete representation is essential to responsible innovation in this rapidly evolving domain.^13,17,18

References

1. Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in National Collegiate Athletic Association basketball and soccer: a 13-year review. Am J Sports Med. 2005;33(4):524–30. https://doi.org/10.1177/0363546504269937
2. Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492–501. https://doi.org/10.1177/0363546504269591
3. Sems A, Dimeff R, Iannotti JP. Extracorporeal shock wave therapy in the treatment of chronic tendinopathies. J Am Acad Orthop Surg. 2006;14(4):195–204. https://doi.org/10.5435/00124635-200604000-00001
4. Smoot MK, Cavanaugh JE, Amendola A, West DR, Herwaldt LA. Creatine kinase levels during preseason camp in National Collegiate Athletic Association Division I football athletes. Clin J Sport Med. 2014;24(5):438–40. https://doi.org/10.1097/JSM.0000000000000064
5. Hurbanek JG, Anderson K, Crabtree S, Karnes GJ. Biomechanical comparison of the docking technique with and without humeral bioabsorbable interference screw fixation. Am J Sports Med. 2009;37(3):526–33. https://doi.org/10.1177/0363546508326986
6. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Am J Sports Med. 1999;27(6):699–706. https://doi.org/10.1177/03635465980260050301
7. Cheung EC, Boguszewski DV, Joshi NB, Wang D, McAllister DR. Anatomic factors that may predispose female athletes to anterior cruciate ligament injury. Curr Sports Med Rep. 2015;14(5):368–72. https://doi.org/10.1249/JSR.0000000000000188
8. Mancino F, Gabr A, Plastow R, Haddad FS. Anterior cruciate ligament injuries in female athletes. Bone Joint J. 2023;105-B(10):1033–7. https://doi.org/10.1302/0301-620X.105B10.BJJ-2023-0881.R1
9. Mancino F, Kayani B, Gabr A, Fontalis A, Plastow R, Haddad FS. Anterior cruciate ligament injuries in female athletes: risk factors and strategies for prevention. Bone Joint Open. 2024;5(2):94–100. https://doi.org/10.1302/2633-1462.52.BJO-2023-0166
10. Figueroa D, Figueroa ML, Figueroa F. Return to sports in female athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. J ISAKOS. 2024;9(3):378–85. https://doi.org/10.1016/j.jisako.2024.01.008
11. Hong IS, Pierpoint LA, Hellwinkel JE, Berk AN, Salandra JM, Meade JD, et al. Clinical outcomes after ACL reconstruction in soccer (football, futbol) players: a systematic review and meta-analysis. Sports Health. 2023;15(6):788–804. https://doi.org/10.1177/19417381231160167
12. Noyes FR, Barber-Westin SD. Neuromuscular retraining in female adolescent athletes: effect on athletic performance indices and noncontact anterior cruciate ligament injury rates. Sports. 2015;3(2):56–76. https://doi.org/10.3390/sports3020056
13. Della Villa F, Buckthorpe M, Grassi A, Nabiuzzi A, Tosarelli F, Zaffagnini S, Della Villa S. Systematic video analysis of ACL injuries in professional male football (soccer): injury mechanisms, situational patterns and biomechanics study on 134 consecutive cases. Br J Sports Med. 2020;54(23):1423–32. https://doi.org/10.1136/bjsports-2019-101247
14. Viswanathan VK, Vaishya R, Iyengar KP, Jain VK, Vaish A. Strategies for preventing anterior cruciate ligament injuries in athletes: insights from a scoping review. J Orthop. 2025;67:101–10. https://doi.org/10.1016/j.jor.2025.01.001
15. Abed V, Dupati A, Hawk GS, Johnson D, Conley C, Stone AV. Return to play and performance after anterior cruciate ligament reconstruction in the National Women’s Soccer League. Orthop J Sports Med. 2023;11(9):23259671231196895. https://doi.org/10.1177/23259671231196895
16. Carabasa García L, Lorca-Gutiérrez R, Vicente-Mampel J, Fernández-Ehrling N, Ferrer-Torregrosa J, Part-Ferrer R. Relationship between anterior cruciate ligament injury and subtalar pronation in female basketball players: case-control study. J Clin Med. 2023;12(4):1523. https://doi.org/10.3390/jcm12041523
17. Fältström A, Hägglund M, Kvist J, Mendonça LD. Risk factors for sustaining a second ACL injury after primary ACL reconstruction in female football players: a study investigating the effects of follow-up time and the statistical approach. Sports Med Open. 2023;9:29. https://doi.org/10.1186/s40798-023-00571-x
18. Robben BJ, Keuning MC, Zuurmond RG, Stevens M, Bulstra SK. In non-elite athletes, women are more likely to return to sports after anterior cruciate ligament reconstruction: a retrospective cohort study. BMC Musculoskelet Disord. 2024;25:739. https://doi.org/10.1186/s12891-024-07834-y
19. Sell TC, Zerega R, King V, Reiter CR, Wrona H, Bullock GS, et al. Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) scores over time after anterior cruciate ligament reconstruction: a systematic review with meta-analysis. Sports Med Open. 2024;10:49. https://doi.org/10.1186/s40798-024-00712-w
20. Su W, Wang J, Ying Y, Lu B, Liu H, Zhou Z, et al. Injury risk reduction programs including balance training reduce the incidence of anterior cruciate ligament injuries in soccer players: a systematic review and meta-analysis. J Orthop Surg Res. 2025;20:248. https://doi.org/10.1186/s13018-025-05639-w
21. García AC, Pagán EJP. Therapeutic exercise protocol for the prevention of anterior cruciate ligament injuries in female soccer players with dynamic knee valgus (RCT). Trials. 2025;26:29. https://doi.org/10.1186/s13063-025-08736-7

Cite this article as:
Asif S, Sawaira FNU, Ibrar H, Tahir RBE and Khan I. Female-Specific Injury and Performance Science: The ACL “Epidemic” in Women’s Football and Basketball—A Narrative Review. Premier Journal of Sports Science 2026;4:100015

Export to EndNote Export to Mendeley