Leah Williamson. Vivianne Miedema. Marie-Antoinette Katoto. Beth Mead. These people have much in common.

Some of these similarities include them all being highly-rated women’s soccer stars. They will also all not participate in the upcoming Fifa Women’s World Cup, owing to suffering serious anterior cruciate ligament (ACL) injuries in the lead-up to the tournament.

This pattern of women’s soccer players either rupturing or tearing their ACL, which is located in the knee area, has long been a mystery. A few theories exist as to why the injury is more prevalent in female athletes. Particularly those who play contact sports such as soccer and rugby.

These suppositions range from the lack of transformation in relation to the design of equipment such as playing boots and the fits and cuts of kits, to the physiological changes that women experience during the menstrual cycle, among other things.

When it comes to the theory of ACL injuries being linked to the menstrual cycle, research is still ongoing and is yet to bear any conclusive evidence indicating that this is truly the case.

Hypothesis

The hypothesis is that when the levels of hormones such as oestrogen rise during the menstrual cycle, it can impact the stability and strength of certain joints. Potentially making them laxer and increasing the probability of injury during this time.

However, until more research is done, it is all just speculation, as Shilene Booysen — who currently serves as technical advisor in South Africa’s senior women’s soccer side (Banyana Banyana), but is also a qualified performance analyst and coach — told Daily Maverick.

“If you look back, there have been a lot of ACL injuries over the last couple of months, especially since just after the Women’s European Championships,” Booysen said on the sidelines of Banyana’s pre-World Cup training camp in Johannesburg on Wednesday.

“A lot has been done to investigate it, but I don’t think it’s enough to find conclusive evidence linking it to the menstrual cycle,” she shared with Daily Maverick.  

Shilene Booysen during the Banyana Media Day on 28 June 2023 at UJ Auckland Park in Johannesburg. (Photo: Sydney Mahlangu / BackpagePix)

“It’s really important that more studies be done to see where the ACL [injuries in women’s soccer players] specifically come from. Because we can speculate, and there’s been a lot of speculation, but definite studies need to be done in order for us to really find the reasons. Which might be a couple. It might not be just one reason, but a few reasons that contribute to that,” Booysen stated.

One of the players impacted by the serious knee injury leading up to the World Cup — Mead — told global players’ union Fifpro earlier in 2023 that much more urgency is needed in pinpointing the root cause of this type of injury.

“It’s important that we as a collective try to get more done for ACLs and the research into them. It is way too common in the women’s game. If that ever happened in the men’s game, a lot more would have been done sooner,” the England and Arsenal striker said.

Of course, with research picking up as women’s sport continues its rise globally, the definite answers are hopefully coming closer to being revealed.

Athenea del Castillo (left) of Spain in action against Leah Williamson of England during their Uefa Women’s Euro 2022 quarterfinal match in Brighton, UK, on 20 July, 2022. Williamson will not participate in the upcoming Fifa Women’s World Cup, owing to anterior cruciate ligament injury. (Photo: EPA-EFE / Vince Mignott)

Nonetheless, this trend often negatively impacts female athletes and can induce performance anxiety. This, in turn, can affect their ability to perform to their best around the time of their cycle, due to fear that they may incur serious injury.

“We’re teaching our players that when you’re on your menstrual cycle, you’re not sick. Your body’s just going through certain things, but you’re not sick. So, you can still [perform],” Booysen told Daily Maverick.

Dressed for success

There is no denying that injuries, unfortunate as they may be, are part and parcel of playing sports. However, concrete research indicates that female athletes are two to eight times more likely to fall victim to ACL injuries, as compared to their male counterparts.   

With professional sport associated exclusively with men for so many decades in the past, another possible contributor is something like what the players wear on the field of play.

Soccer boots are still largely designed for men’s feet. So too are things such as shorts, neglecting the natural build of women as compared to men. This often results in the athletes playing in items which are uncomfortable and not conducive to them reaching their full potential.   

“We’ve always done preventative measures. But we’ve been doing a lot more of that. Stabilising the core. Making sure that our players understand that the female physiology is very different to the male physiology,” Booysen continued.

“Wearing the right footwear [is also important]. Making sure that we train in the right facilities. Because a lot of it has also contributed to [such serious injuries] … Which are not just ACLs.”

Proactive Banyana

Heading to a tough soccer World Cup campaign, Banyana Banyana coach Ellis has recruited former Highlands Park conditioning coach Simonè Conley, with the ACL injury and menstrual cycle component in mind.

“We’ve seen all the injuries that have been happening around the world. With some potentially related to the menstrual cycle… She’ll be one of the people working the menstrual cycle. To help us know how to treat players during training when they go on their menstrual cycle,” Ellis told journalists.

Conley will work closely with the likes of Booysen during South Africa’s second appearance at the women’s World Cup, where the African champions will aim to improve on their debut appearance in 2019.

At that time, Banyana scored just one goal, conceded eight and failed to register a single point. With all these hands on deck, it is hoped that the reigning African champions can string together better performances.

As for opportunistic naysayers who might use the prevalence of ACL injuries in female soccer players (when compared to their male counterparts) as ‘evidence’ that women should not play sport, Booysen did not mince her words.

“People who say that are living in the dark ages. We are here to stay,” she said. DM