ACL injury in female soccer players: Risk, resilience, and prevention in the modern game

Anterior cruciate ligament (ACL) injury is one of the most impactful conditions in female soccer, with major consequences for knee function, osteoarthritis risk, and professional longevity. As participation and competitive demands in women's football continue to rise, the disproportionate ACL burden has become a critical clinical and public health concern.This narrative review provides a contemporary synthesis of current evidence on ACL injury in female soccer players, integrating data on epidemiology, injury mechanisms, intrinsic and extrinsic risk factors, surgical outcomes, return to sport (RTS), and prevention strategies. Across multiple cohorts, female players sustain ACL injuries at rates two to nine times higher than males, predominantly through noncontact mechanisms. Video analyses indicate that approximately 90% of injuries occur during cutting, pressing, deceleration, or landing tasks.Key intrinsic risk factors include a reduced hamstring-to-quadriceps strength ratio, quadriceps dominance, generalized joint laxity, hip abductor weakness, and longer playing experience. Biomechanical deficits such as dynamic knee valgus, trunk instability, and suboptimal change of direction mechanics further increase susceptibility. Psychological factors, particularly fear of reinjury, also influence movement patterns and RTS.Although ACL reconstruction generally yields favorable outcomes, reinjury remains a major concern in athletes returning to pivoting sports, with reported RTS rates ranging from 70% to 78%. Neuromuscular-based prevention programs, including FIFA 11+-derived protocols, can reduce ACL incidence by 40-45% when consistently implemented; however, adherence and limited sex-specific tailoring remain significant barriers.ACL injury in female soccer players is a multifactorial and largely preventable condition, requiring integrated, sex-specific prevention and rehabilitation strategies to effectively reduce risk and support long-term athletic health.