Photo: Michael Willson/AFL Media
A torn anterior cruciate ligament (ACL) is arguably the most dreaded injury in sport, and for good reason. Following a gruelling rehabilitation process that often exceeds a year, up to 30% of players suffer a subsequent ACL injury. Those who manage to keep their ligaments intact often battle to return to pre-injury performance levels and also have to contend with an increased risk of straining their hamstring. In retirement, many ACL-compromised athletes are diagnosed with osteoarthritis and endure persistent deficits in quality of life.
There’s no doubt that avoiding ACL injury is in the best interests of players and teams alike, but that may be more difficult for some than others - a consistent trend across most sports is that ACL injury rates are higher in women than they are in men. Nowhere else is this gender discrepancy as pronounced as it is in Australian football, with players in the national women's league (AFLW) up to 9.2 times more likely to sustain an ACL injury than their male counterparts in the AFL. Five years on from the inception of the AFLW, more girls and women are playing footy than ever before, necessitating a measured approach to ensure that the ACL problem isn’t one that grows at the same pace as the participation.
Why are women at a higher risk of ACL injury?
Our ability to curtail the AFLW cruciate ligament conundrum hinges on the accurate characterisation of the injury mechanism, and the successful identification of factors which predispose women to the injury.
There are certain positions where the ACL is vulnerable, and AFL footy is abundant with opportunities to hit them. Video analysis reveals that the majority of AFLW ACL injuries occur during changes of direction, rapid linear decelerations or single-leg landings with a flexed trunk. Compounding evidence indicates that women may reach these risky positions more frequently than men, and once they’re in those positions, they may be more susceptible to injury due to anatomical, neuromuscular and hormonal influences.
The list of variables falling under these three risk categories is longer than Ben Brown’s runup, and includes factors like altered mechanics of the hip and trunk and a greater reliance on quadricep than hamstring strength in high-force situations than men, alongside less modifiable anatomical factors. More recently, there’s been an increased focus on hormonal influences, with fluctuations during the menstrual cycle potentially mediating knee laxity and ACL injury risk. As a result, multiple sporting teams are actively tracking cycles and adapting training accordingly, with the AFLW also funding research into the area.
But for every study indicating strong predictive power of internal risk characteristics, there’s a review tempering our expectations, and the lack of clear consensus on some of the contributing factors is a testament to the complexity of the injury.
Notably, history indicates that when it comes to women in sport, a lack of opportunity has always been more of a barrier than biology. By focusing primarily on the internal parameters of injury risk, research has largely failed to account for how external factors have helped boost the ACL odds in the wrong direction. Zooming out to look beyond the biology in the context of ACLs in the AFLW was first proposed by Dr. Aaron Fox (and colleagues), and his seminal piece in the British Journal of Sports Medicine adds compelling context to the physical risk factors.
The infancy of the pathways
By the time men are drafted into the AFL, they’ve typically played over a decade of footy, accumulating thousands of hours of exposure to the unique demands of the game, and in doing so, developing safe movement patterns, a tolerance to high-risk positions, and sport-specific timing. By contrast, prior to the inaugural AFLW season in 2017, budding female sports stars generally pursued more accessible, structured and socially-accepted pathways in sports such as netball and basketball, both of which offered a comparative wealth of grassroots participation opportunities, and had national leagues established thirty years ago. As a result, very few of the first crop of AFLW stars consistently played footy throughout their youth, leading to large windows without exposure to the game, and potentially augmenting the risk of ACL injury.
As Dr. Fox points out, evidence in support of this theory comes from dancing, where females do not display the same high-risk landing mechanics as female team sport athletes, and there are no differences in these landing mechanics between males and females, likely as a consequence of similar access to opportunity and training pathways from a young age.
Indeed, there are multiple cases of athletes sustaining a career-ending ACL injury in their very first AFLW game, and the pathway problem is only exacerbated by the league requiring clubs to list a number of cross-coders who haven’t played competitive footy in 3+ years. It’s not an automatic injury sentence, and there’s a lot of hype about players who are elite at multiple sports in their youth - rarely a weekend passes without mention of Scott Pendlebury being a walking bucket before opting for the Sherrin over the Spalding. However, a key factor is the difference in the length and recency of the windows without exposure to the demands of competitive footy.
The good news is that grassroots footy is now more accessible than ever, and it won’t be long before an AFLW draft class enters the system following uninterrupted access to a local league throughout their teenage years.
The limitations of the destination
The presence of the AFLW is a major win for the sport, but the league has some teething problems. The 2021 season ran for twelve weeks including finals. Across the 85-day pre-season period, teams were permitted to schedule a maximum of 15 hours of training per week spread across four training sessions, which was reduced to ten hours across three sessions during the season.
So what happens for the rest of the year? The part-time league means that AFLW players don’t have the luxury of leaving their car at the MCG for a post-grand final world tour. With the average player set to net around $23,904 in 2022, the reality is that HECS debts and mortgages don’t care much for pro-rata, and so cash remains a limiting factor. In the off-season, some players get more game exposure in the state leagues, while others are juggling voluntary training with plying their original trades, whether that’s as a school teacher or moonlighting for the Australian basketball team in Tokyo like Richmond’s Tessa Lavey.
The money issues ripple beyond salaries too, trickling down to factors like infrastructure and access to staff, which explains why the AFL aligned the AFLW teams with existing clubs, rather than going for the WNBA approach of primarily standalone organisations. While the pooling of resources certainly appeases some of the struggles associated with a brand new league, around 80% of ACL injuries in the AFLW occur during pre-season or the first half of the playing season. Further, in soccer, higher leagues have significantly better injury recurrence rates compared to lower leagues. Collectively, this highlights the importance of consistent access to quality staff for sufficient periods of preparation - something that isn’t necessarily guaranteed in the current AFLW system.
So what can we do about it?
Theoretically, an approach to injury prevention which targets both the biological risk factors for ACL injury and their external influences will be most effective. This approach should include an emphasis on pathways, programs and visibility.
1. Pathways and Programs
Much of the hard work here is done, thanks to the availability of pathways. But we can’t settle for the mere existence of opportunities, and should now shift our focus to maximising the quality of them.
Exposure to quality training is a potent weapon against injuries, with research indicating that injury prevention training programs reduce non-contact ACL injury occurrence by a whopping 66% in female athletes. This may not be news to AFLW teams, however in soccer, there are reports that prior to their first ACL injury, only 12% of female players completed injury prevention programs and only 34% of them engaged in formal strength and conditioning. This may indicate a problem at lower development levels of women’s sport, which is precisely where building a foundation is most important. At the youth and grassroots levels, a lack of coach education, limited time with players, or restricted access to facilities can be significant barriers to implementation of programs. That’s why it’s important to note that even more general neuromuscular training is also effective in reducing injury risk, simply by including exercises that should be in any good program anyway, including plyometric contacts, eccentric strength development and training of co-ordinative capacities. The fact that these programs don’t just reduce injury incidence but also improve general athletic performance should convince even the most old-school coaches that they’re a worthwhile time investment at all levels of the game.
If you’re a player or coach reading this and you’re not sure where to start - now is the time to prioritise the stockroom over the showroom, so be wary of the instagram coaches and start with the AFLW Prep to Play manual instead.
2. Money → Visibility → More Money
After decades of criminally low investment, money is now progressively being funneled into women’s footy, with the league recently committing to the establishment of an AFLW side for all 18 AFL teams by the end of 2023. Aside from effectively doubling the opportunities for Essendon to disappoint their fans, this also sets the tone for the renegotiated collective bargaining agreement due to come into effect in the same year, which is likely to feature a salary boost. But there’s more that can be done to grow the game than just direct injections of cash - a recent report indicated that an increase in visibility could triple the revenue from women’s sport, potentially reaching £1bn annually in the United Kingdom alone by the end of the decade.
Soberingly, It’s no secret that women’s sport faces an uphill battle for exposure. After all, of Melbourne’s 35 sporting statues, there are 29 males, 3 females and 3 horses (sadly, it’s not a Betoota article). But there are promising early signs - minimising the overlap between the AFL and AFLW seasons has encouraged fans to quench their summer thirst for footy by tuning into the women’s game, and it’s growing every year. In 2021, the AFLW had 155,908 attendees and 6.1 million total TV viewers (a 49% increase from 2019), with 20% of these being first timer consumers. The growth of women’s footy is not alone, with more Americans tuning in to the most recent women’s world cup final than the men’s world cup final, and uncoincidentally, the women’s national team has generated more revenue than the men’s US national team.
So what can we do? It’s as simple as consuming and supporting women’s sport in any way, shape or form. The more people who tune in, post about it, talk about it, buy jerseys, go to games and follow platforms giving a voice to athletes, the faster women’s sport catches up to where it belongs. Increased visibility of the league produces a wealth of opportunities which should ultimately trickle down into lowering the future injury risk through increased consumption, increased advertising, increased money, increased salaries leading to more full-time opportunities and better access to qualified and available staff year-round.
The End Game
Women’s footy has come a long way in a very short space of time - so much so that athletes from some Olympic sports can only dream of the opportunities now on offer in the AFLW. There are certainly far more success stories than ACL injuries across the first five years, with a 100% increase in participation rates (including a 330% increase in Queensland since 2014), a new legion of fans, and a fresh host of visible role models for the next generation to look up to. But even in 2021, we’ve still got some way to go before women in sport are afforded equal opportunity - the NCAA apparently just discovered that it’s not only men who lift weights, and only 11% of coaches involved with the Rio Olympics were female (with no growth in this number since London). The opportunities we provide now will dictate how much these numbers will shift for the next generation.
At the end of the day, nobody is suggesting that biology isn’t a factor in the divergent risk of ACL injury between men and women. But by beginning to address how external circumstances feed into and augment these biological risks, we’re one step closer to levelling the playing field.