THERE is no one definitive reason that has yet been found to explain why female footballers are more susceptible to ACL injuries than their male counterparts, and in the absence of hard facts, conjecture often fills the gap.

The rapid pace at which the women’s game has moved from a largely amateur environment to a professional one seems to be a factor, and is part of the reason why it is only now that we are starting to see hard data dripping through from various studies – such as those conducted by UEFA – that will in time add more substance to educated theories, and disprove some others.

If anyone in Scotland is well placed to assess those potential factors and how much weight should be placed in them, then it is Dr John MacLean, who has been working with athletes of both sexes for over 30 years.

As well as a long and storied stint as the doctor with the men’s national team, Dr MacLean is the chief executive of the Hampden Clinic, and is the vice-chairman of UEFA’s Medical Committee. Therefore, he is able to separate the facts as we know them from fanciful theories and give an informed assessment of why female footballers are currently picking up ACL injuries with such frequency, with at least 12 cases in the SWPL over the past season alone.

Is it the pitches?

One area of concern has been the high exposure of female players to astroturf pitches, with teams very often training and playing on synthetic surfaces. But Dr MacLean doesn’t believe that artificial grass plays a significant role.

“The UEFA research shows that with the modern artificial turf, the injury incidence isn’t significantly greater than on grass,” he said. “It was before, but not now.

“I think it’s hard to say that pitches are a factor now, because the science doesn’t necessarily back that up.

“It would be wrong to say that there is good study evidence to suggest that the pitches are a factor, because it doesn’t appear in the UEFA studies, which are across Europe.

“If you look at Scandinavia, a lot of their players will predominantly play on astroturf, and they don’t have a significantly higher rate of ACL injuries in either men or women than countries who traditionally play more on grass.

“If we think back to the original astroturf pitches which were essentially concrete, it’s night and day to what is available now.

“I think the evidence would be that modern pitches, whatever ‘G’ quality you have got, and particularly the hybrid pitches, there’s no science in the UEFA stuff that says injuries are more likely.

“And most of them now are of a reasonably good standard.”

Are women really six times more likely to suffer such injuries, as widely reported?

“There has been more and more research into ACL injuries in the last 20 years, and in particular, in women’s football over the last 10 years. The data is starting to come.

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“People bandy figures about, but most people accept the overall risk is two to three times higher for ACL injuries in women. They also seem to get these injuries at a comparatively younger age compared to male footballers.”

Does wearing boots designed for men have any significance?

“That’s definitely a factor, and it ties in with the biomechanics. If you think of the biomechanics of the way a person’s pelvis is, that then has an effect on what the foot position is, and where that foot position is has an impact on what happens further up.

“So, people who present with knee pain, it can be caused by their foot overpronating or whatever. We use our podiatrist in the clinic more and more now to do biomechanical assessments of people that are presenting in a slightly different way. Why are they injured when you wouldn’t expect them to be?”

Does the menstrual cycle play a part?

“There have been three or four areas identified where women differ from men, such as the hormonal side, the anatomy and biomechanics side, and then what people call the conditioning side – the neuromuscular function.

“Football is a sport where you can understand with the nature of how we play the game, particularly now when it is much faster, studs can get planted in the ground and then with twisting, you can see why it happens.

“The mechanisms are the same for males and females, but there are a couple of anatomical things that differ. The female ACL tends to be smaller in diameter, and the kind of notch bit in the bone tends to be a bit smaller in women.

“They tend to have a broader pelvis, which affects the biomechanics of the way that they run and the way that they twist and turn, so there are anatomical reasons why women are perhaps more likely to get these injuries.

“The one that has got the biggest interest at the moment is menstrual cycle and hormonal factors. There is some evidence that when women are in the middle of their cycle when their oestrogen level goes up, the higher level of oestrogen may lead to more joint laxity. So, the soft tissues around the joint get a bit more lax and stretchy, and provide a bit less support.

“There is a bit of evidence that you are more likely to have an ACL injury at that point, but it’s a bit conflicting because some other studies have suggested it may be worse at the time of menstruation.

“At the moment though, it seems to be that higher oestrogen is a factor, and obviously males aren’t going to have that peak of oestrogen.

“The other thing that people talk about is neuromuscular function. That is our general co-ordination, and that fits into the development of women’s football, particularly in Scotland.”

Will that development, particularly with an improvement in coaching, help reduce the risk?

“The FIFA 11+ has been around for about 10 years, and that was probably one of the first scientifically proven studies that took a group of individuals - they had a control group that didn’t do it, they had the intervention group that did it - and they saw a reduction in the number of significant muscular skeletal injuries in the group that did that pre-hab.

“They do take 15 to 20 minutes, so you need coach buy-in, coach ed is really important. If you have got part-time players who have a two-hour let at Oriam, and that is all you have got twice a week, it is quite difficult to fit in everything that you need to do. So, you need well educated coaches who understand the benefit of it.

“There is no doubt, whether it is women’s football or men’s football at a lower level, when they have more access to better facilities, to increased staff, to better educated coaches who understand the importance of that prehab, then there will be a reduction in the number of injuries.

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“The SFA do a great job in coach education. I do sessions on their licenses which are a bit more medical, but the physios and the sports scientists will talk about the importance of doing it.

“We need good sports science and good physios in our clubs. Player education is also important so that they aren’t just doing this for 15 minutes twice a week, they are actually doing it every day.

“Now I know a lot of them will be working full-time, but you have to have 15 minutes in the day where they can do that.

“We need to get people in there with that knowledge encouraging these habits. If we do all that balance, that core stability, that stabilisation and muscle strength, then we can get better control over our knee so that if we do land awkwardly, then we have that muscle support round about it that stops our knee from twisting.

“If those muscles are strong enough to hold it in place, it can stop the ACL from pinging.”

What support is there currently for female players who suffer an ACL injury?

“Most of these players will require surgery, which is costly. They will need prolonged rehab, and we know that individuals who have torn their ACL have an increased risk of early osteoarthritis.

“The key thing after ACL surgery is to have a formal rehabilitation plan, and for someone to manage the athlete, the player, through that plan.

“The average time out used to be around 12 months, then it came down to nine, and some are as quick as six or seven. But generally speaking, most are about the nine-month mark.

“There are different phases of that. So, what clubs need is access to a physiotherapist, somebody with experience of rehabilitating that kind of injury.

“Within club licencing in recent years, in both the men’s and the women’s game, there has been a sea change in recent years where the standard and expectation of the medical staff that clubs should have has gone up dramatically.

“So, we are seeing more and more of the women’s teams in the SWPL having an in-house physio that will be there for training, and they will have access to external people too.

“A wee word for the Hampden clinic too, we have a relationship with all the national associations where they can get access to our physios, the gym, the hydro pool at a discounted rate.

“So, clubs who don’t have that in-house physio support can get access to it. If they are a wee bit distant from Glasgow, there is a really good network of good sports physios around Scotland.

“Nowadays there is good access. There is an issue over cost, but for a relatively small cost you can have the support you require. You don’t have to see a physio three times a week, you are just getting told what to do and then going back to be instructed on the next stage.

“In the last five years there has been a notable increase in the medical and sports science support within clubs as they have progressed.”