ACL injury epidemic plagues Women's World Cup

-By Samantha Lewis of ABC NEWS

When Denmark made their return to the Women's World Cup after a 16-year absence, veteran forward and 100+ cap international Nadia Nadim was sitting at her home in Louisville, Kentucky, wrapped up in blankets as she watched her teammates defeat China 1-0 in their opening game.

She should have been there. She wanted to be there. She had worked so hard to be there.

But after suffering from two anterior cruciate ligament (ACL) tears since 2021, she knew she wouldn't make it back in time for what would have been her first - and probably her last - World Cup.

"I was prepared mentally. I knew that I wasn't going to be ready," she said.

"Of course, it's a big tournament. It's crazy. I've been on the national team for over 100 caps, played for around 12 years, and I've never been to a World Cup. This would have been my first.

"I was happy for the team who made it, and that's the point of sports. Life goes on. It looks cool though. I'm not going to lie - I love the fact that it's grown so much.

"That's the one part that hurts the most: I want to experience that atmosphere with the national team where you have 70-plus thousand people watching you play. That must be magical.

"That part is upsetting. For my career, that would have been a great cherry on top. But if it's not meant to be, then it's not meant to be."

Nadim is one of more than two dozen high-profile national-team players who have sat out this World Cup all because of the same injury.

Others include Vivianne Miedema (Netherlands), Beth Mead and Leah Williamson (England), Marie-Antoinette Katoto and Delphine Cascarino (France), Catarina Macario and Christen Press (USA), Janine Beckie (Canada), Hanna Glas (Sweden) and Giulia Gwinn (Germany).

Over the past two years, ACL tears have swept through women's football like a bushfire.

A list compiled by Twitter account ACL Women Football Club listed almost 200 players at the elite level who had torn the dreaded ligament, from Ballon d'Or winners to Olympic gold medallists and European Championship title holders.

It is a well-known fact that women athletes are more at risk of suffering ACL injuries than male athletes.

Exactly why, and by how much, varies depending on what you read.

Some studies and articles say twice as likely.

Others say six or seven times.

So common have ACL injuries become over the past World Cup cycle that one is immediately suspected whenever a player goes down clutching their knee. To many women in football, the injury has become a looming spectre; a nightmare lurking just around the corner of the next game.

A number of national associations, as well as FIFPro, the global players' union, reportedly noticed a jump in the number of enquiries from players seeking reassurance, information, or support after witnessing or hearing about friends, teammates or other players across the sport struck down by the injury.

"The players are asking for research," Alex Culvin, FIFPro's head of strategy and research, told The New York Times.

And for good reason.

In the World Cup's opening round, Haitian defender Jennyfer Limage tore her ACL (as well as her meniscus) in her country's debut game against England after going in for a tackle that twisted her knee in just the wrong way.

And earlier this week, when Denmark faced England, Lionesses midfielder Keira Walsh was stretchered from the field after her studs got stuck in the turf. Replays showed the Barcelona player mouthing the words, "I've done my knee," as the physios rushed to her side.

While scans confirmed Walsh had escaped an ACL tear, the fact the injury was her - and everybody else's - first thought shows how common they've become.

Part of the fear stems from how innocuously the injuries can occur.

Nadim knows.

Her first ACL tear, which she sustained in September of 2021, came after a player slid into her planted leg, her body going one way as her knee went the other.

Her second came almost exactly a year later in almost exactly the same way, but this time involving the other knee, with a defender barrelling through and falling on top of her leg as she motioned to shoot.

"It was super heartbreaking," she said, "but sometimes it's not in your hands. But the way I twisted, and someone falling on my knee, happens one in a billion times. And it just happened that day."

The overwhelming questions and doubts among players like Nadim reflect the void of knowledge in this space, the historical lack of research on a problem that hasn't been taken seriously by the medical and sports science industries because it has disproportionately affected women.

That is something that FIFA is trying to fix.

FIFA's chief women's football officer Sarai Bareman revealed earlier this year that the governing body had put together a specific task force to focus on ACL injuries as well as other medical and physiological concerns that affect women footballers.

"It's devastating to see some of those big names that will miss out on a tournament of this magnitude because of injury," Bareman said.

While the internal physiology of women's bodies - from the width of the pelvis or the feet to the size or strength of the knees - has occupied most research attention in the past, new theories and frameworks are being developed that take the external cultural contexts of women athletes into account.

Increasingly, there is also some evidence to suggest menstruation and fluctuations in hormones make some bodies more susceptible to the injury.

Chelsea FC, home to Matildas captain Sam Kerr, now tailors its training programs to sync with particular phases of players' respective menstrual cycles, and several national teams at this World Cup are following suit.

Player overload and underload is a major factor, too.

There is currently an unprecedented footballing calendar of five major tournaments in five years from 2020 to 2025, which has brought an increase in competitive match minutes and international travel for the players whose teams have qualified.

While the number of games is increasing, the scheduling of those games - including the amount of time players are given to prepare and to recover afterwards - causes stress on their increasingly fatigued bodies, which are not taken care of in the same way their male colleagues' bodies are due to smaller squad sizes, fewer staff members, and limited access to resources.

Nadim, who is a qualified doctor, is on the front line of these competing demands increasingly placed on women footballers.

"It's a multi-factorial problem," she said.

"One of them is the quality of the ground you play on. Secondly, the women's game has become so professional that the pressure in terms of physical pressure players are undergoing has gone so high so quickly, but everything around it hasn't really followed.

"When you play that amount of games, you need to have the best medical people around you, hours of massages to treat you. But that's not really the case [for players currently]. When you fly, you're sitting in weird positions. All of these affect your body where you don't have enough time to recover."

"Our bodies are different from male players. And, unfortunately, everything we do, it's almost like you have a box that's been built for a male player and [you're] trying to fit a female athlete in it.

"It's crazy if you see how many young players are tearing their ACLs these days because they go from zero to 400, but physically we're not built [for that] yet."

Nadim is one of many players joining other kinds of initiatives such as ACL United - an education and awareness campaign run by Medibank working to shine a light on the occurrence of knee injuries in women's sport and sharing prevention programs so women and girls can do everything they can to avoid the injury.

"There is some research going on, but we need to have more people unite to speak about it so it has a bigger voice," she said.

"We can start having prevention programs. We can be aware that girls need more strength and stability around their knees and their cores. When they're in the menstrual cycles, we need to be aware of that. So education is a big one.

"Improving the quality around footballers is important, as well. We shouldn't have to play on [artificial] turf anymore. We need the medical staff who understand and have the resources and time to treat athletes as they deserve.

"These are some of the things that are easy to touch and to change, and if you do that, it'll have a huge impact.

"What FIFA can all do is implement programs in clubs and national teams where athletes are more aware of how their bodies work."

This Women's World Cup is paying the price for the historical lack of research and investment into women athletes, depreciating its overall value by robbing it of its biggest stars.

- This story first appeared on ABC