Rangers' Tess Middag on ACL injury hell, and lowering risk for women

“People always say injuries come at a bad time, but I thought mine was particularly bad timing as that was the month before the Euros started in my home country, The Netherlands,” Middag said.

To make matters worse, as strange as she knows it sounds, her team went on to win the tournament without her.

The experience though gave her a first insight into a challenge that regrettably, an increasing number of players in the women’s game are having to face up to.

Estimates vary on how much more likely female players are to suffer ACL injuries, with some studies suggesting they may be six times more likely to sustain an ACL tear than their male counterparts, while even at the conservative end of the scale it is reckoned to be at least three times more likely. In the SWPL alone this year, there is thought to have been 12 separate instances of a player suffering an ACL injury.

Again, Middag knows these risks all too well. Barely a year after returning to the pitch following a gruelling 10-month rehabilitation, it happened again.

That is part of the reason why the midfielder, now at Rangers, has taken up a role with the PFA Scotland management committee. She is well placed to ensure that the needs of female players are being met in such trying circumstances, when both adequate physical and mental support is vital.

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“The first time I did my ACL [when at Manchester City] I really struggled with the fact I missed out on the Euros in The Netherlands,” she said.

“And the fact ‘they’ won it – which is a weird way to put it as I was part of the team for six or seven years – that almost made it hurt even more.

“I didn’t think that people in England at that time really understood the impact that it had back home, and that it was such a life-changing moment for everyone involved, the players and staff.

“They got a public parade, they got honoured by the King, and it was all those things that I was missing out on. I just didn’t think people understood what I was missing.

“I think they do now after last summer, and everyone who missed out on last summer’s Euros probably knows now how massive that was for me.

“To be honest, that was a big part of the mental challenge. Also, my relationship broke off at that time just when I got injured, so that wasn’t great. It just felt that there was a lot of things coming together at the one time.”

It is in situations such as these that PFA Scotland hope to intervene.

“Luckily, PFA Scotland are already on it,” Middag explained. “A couple of months ago, they appointed David McCracken as wellbeing officer, and I think it’s important in general to focus on the mental side of the game because it is so important.

“We tend to focus more on the physical part, the tactical and technical parts, so that was a great move.

“He has got in contact with every male and female player playing in the Scottish leagues that suffer from a long-term injury, and asks if there is anything he can do for them. Even if it is just a chat once in a while, I think that can be very beneficial.

“Just talking from my own experience, it was nice to speak to someone who is away from the club, an outsider if you like but who does understand the impact that long-term injury has on you as a person.

“It’s such a big part of your identity being a footballer, and then not to feel like one for such a long period of time, it just makes you wonder ‘who am I if I’m not a footballer?’

“David helps massively with that, or Chris Higgins who also works for the PFA as the education officer.

“I think what a lot of girls end up doing is maybe a course or study just to keep their mind off the injury for a little bit.

“Unfortunately, injuries are part of the game, and ACL injuries specifically are a common thing, especially among female players, so it is good that the PFA is aware of that and tries to offer as much mental support as possible.”

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You may assume that because Middag was at one of the biggest clubs in the world in Manchester City when she suffered her first ACL tear, that she would have access to the best treatment and support available. Not so.

The staff and facilities available to even City’s women’s team at that time were sparse, raising concerns over just what treatment players at clubs in Scotland - who can only dream of such resources - are able to access.

“I was under contract at Man City at the time, one of the biggest clubs in football, so there was a good support network in place,” she said.

“There was no question of who was going to pay for surgery or even where I was going to do my rehab, which unfortunately isn’t always the case in football. Especially women’s football.

“As much as Man City is a great club with great facilities, it always comes down to the number of staff and the quality of the staff you have available for the women’s team as well.

“For the women’s team at the time we had one physiotherapist, and she had just joined the club that summer. So, when I got injured, she was new.

“She came from a male rugby team, so she didn’t have too much experience of working with women and working in football.

“Physically, my knee didn’t feel great. It was quite warm and swollen at times, and the physiotherapist didn’t quite recognise that. It was more of a high-performance mentality, where they would just give me an injection or anti-inflammatories, and I just had to push ahead with the program.

“I felt like I was working a bit too hard. The days would go from 8am until 4pm, and I was in the gym that whole time. Doing your rehab obviously means a lot of hard work, but I felt like I probably did too much and there wasn’t enough recovery.

“My knee would react, but rather than lowering the load, we just kept going. I had to say no to using an injection to get the liquid out, but even the anti-inflammatories, that just made me doubt whether we were approaching it the right way.

“So, there were a lot of different challenges on top of not really feeling part of the team anymore because you have different training times and can’t join the girls on the pitch.

“So, yeah, that was quite tough.”

The second time around, Middag found herself in an even more precarious position, and saw first-hand the dark side of the women’s game.

“That was a bit tricky because Man City didn’t offer me a new contract, and I signed a pre-contract at West Ham, but I then got injured with the Dutch national team,” she said.

“So, that was a bit more difficult around who was going to pay for my surgery, and where I was going to do my rehab.

“I wanted to make sure that it never happened again, so I wanted to ensure that it was all done right this time. Luckily, it all worked out in the end, but it took me a lot of time and effort in those first few weeks to try and organise everything.

“West Ham offered me a lower contract than they had initially offered me, because they knew I was going to be out for a while, so I saw some of the ugly side of football in that period.

“It’s always a bit of a vulnerable position to be in when you tear your ACL, because you know you are going to be out for the majority of the season, and you have to see how you come back from it.

“So, despite being under contract again for another big club, West Ham had only started their women’s team that year. It’s a big club in terms of the men’s team, but every time a club starts a women’s team it’s like they almost have to reinvent the wheel.

“It mainly comes down to budget, and at the time that I signed the pre-contract, West Ham didn’t even have a physiotherapist. So, I was asking who was going to be doing my rehab.

“I ended up doing it back home in The Netherlands with a guy that only works with ACL patients, not just in top sport but in amateur sports as well.

“I highly trusted him because he sees around 200 ACL patients a year, so he understands that part of the body, whereas a club physiotherapist will have a very broad knowledge of the body, rather than specifically the knee or the ACL.

“Luckily we found a way to make it work between my physiotherapist in Amsterdam and West Ham, and I’ve been fit ever since the summer of 2019. So, that’s four years now.”

A big part of that, Middag believes, has been a commitment to injury prevention, and ensuring that things such as pre-activation routines have become an essential part of her daily routine.

While theories abound for the prevalence of ACL injuries among women, from their biomechanics , the effect of the menstrual cycle, the width of their pelvis to the fact they are wearing boots designed for men, Middag is a firm believer that the increasing professionalisation of the game in Scotland can help reduce the startling numbers we have seen this season.

“One hundred percent,” she said. “At Rangers we are very lucky when it comes to things like pre-hab, that’s a massive part of our training day. We spend around 20 minutes doing individual preparation, and then a team warm-up in the hall that is about 40 minutes.

“We always start with band work to strengthen your knees and ankles, because we know that playing football puts a lot of stress in our ligaments and tendons, and we need to activate them as much as possible before we go out on the pitch and put our bodies through a highly demanding range of motion.

“It’s probably a budget thing, and also a knowledge thing, but then again, we probably still don’t know the full extent of why it is happening. At Arsenal at the moment, they have four ACL injuries, and I don’t think there is a lack of knowledge or a lack of money there, per se.

“It’s a complicated one, but if we think about the Scottish league, then the better we can prepare our players as athletes, the more we can reduce the risk of getting injured.

“When I got injured, fatigue probably also played a part. When it comes to ACL injuries we have to talk about the calendar and the amount of rest the players are getting. We are going to play more and more games, especially the girls that play for their countries, and we have to make sure they get enough rest as well.

“Again, going back to Scotland, it would be great for every player in SWPL 1 at least to be able to live their sport as a full professional if that was something they wanted, and that for me has to involve more than just a couple of evening sessions and a game at the weekend.

“That will require better facilities and a better knowledge across the board of pre-activation, because I definitely feel that’s a crucial part of injury prevention.

“A couple of months ago there was a researcher who came to Rangers and did foot scans. She is currently researching female feet, basically, to try and highlight the difference between male and female feet.

“I think it is good that it is at least something that is on people’s radar. The researcher told us there are some generic differences between male and female feet. I believe that female feet are a bit broader, so that changes the way boots would be made for women.

“One thing she said that wasn’t entirely reassuring is that the only thing we know for sure is that all the boots we are wearing have not been made for women.

“So, like everything else with the ACL issue, it’s probably still at the trial-and-error stage, but I am all for looking into everything we can, whether it is our menstrual cycle and its influence or football boots.

“Anything we can try to use to our advantage, I think we should take it, because having gone through an ACL rehab twice and knowing its impact, I’d like to avoid doing it again.”