Anyone who plays rugby will tell you it’s not for the faint-hearted. It’s physical, it’s muddy and sometimes, it’s bloody. But that’s why we love it! We can go out there to do battle with our team mates, express ourselves and come off the pitch exhausted, but smiling. Sadly though, sometimes we don’t come off smiling. We come off injured. It’s the reality of our sport and a risk we’re willing to take. As part of our Player Welfare campaign we’re looking into some of the most common rugby injuries and what we can do to reduce our risk. Knee injuries are among the most common for girls and women who play rugby, or any sport for that matter, and particularly damage to the ACL or Anterior Cruciate Ligament of the knee.
We’ve teamed up with Elisa Nédélec and Dr Kirsty Elliott-Sale from Nottingham Trent University, the two women behind The FAIR-ACL Project – a research project exploring ACL injury in female athletes and the potential links with reproductive hormones. We know there is already evidence to suggest we may be at more risk of ACL injury than our male counterparts, but some of that could also be down to our menstrual cycle and hormonal contraceptive use.
Elisa and Kirsty have kindly answered some of our questions below to shed light on the topic and help us to look after our bodies better while we continue to enjoy rugby.
And if you have experienced an ACL injury in the last three months you may be eligible to participate in the study. Go to https://fairaclproject.isrg.org.uk/ to take part. By doing so you will be contributing to important and valuable research for women’s sport as a whole.
What is an ACL and why is it important?
Let’s make a quick journey to human body anatomy together and have a look at the composition and purpose of the knee which is one of the most complex joints. The knee allows the leg to straighten and bend with minimal side-to-side motion. It is made of bones, cartilage, soft tissues such as ligaments, tendons, and other tissues. To start with, the knee joint is made of three bones: it joins the thigh bone (femur) to the shin bone (tibia). The kneecap (patella) glides up and down along the trochlea of the femur that is located at the bottom and front of the femur. The trochlea looks like a little valley and we can observe the complementary form (like a little hill) on the posterior side of the kneecap.
Now, let’s dive into the joint! The joint surfaces are covered by articular cartilage allowing the bones to glide over each other as the knee bends and straightens. The articular cartilage and the menisci reduce shock and absorb impact when the knee is moving or bearing weight, cushioning bones against impacting each other. The knee’s menisci are two thick pads of cartilage (with a doughnut shape) located between the femur and tibia of each leg. The lateral meniscus is located at the outer side of the knee and the medial meniscus at the inner side of the knee. They also help stabilizing the knee and facilitating smooth motion between the surfaces of the knee. Finally, the ligaments are strong bands of connective tissue connecting either the femur to the tibia, or to the fibula (thin lower leg bone) and have a stabilising role for the knee. There are 5 ligaments in the knee: the anterior cruciate ligament (ACL), the posterior cruciate ligament, the medial collateral ligament, the lateral collateral ligament, and the anterolateral ligament. The anterior cruciate ligament resists anterior tibial translation [meaning that the tibia goes forward when a posterior force is applied to it], and rotational loads.
An ACL injury can occur during an accident or after a specific combination of movements with speed, landing, and change of direction. When your ACL is torn you will no longer be able to control all movements in your knee while exercising.
We are very excited about our FAIR-ACL Project! Please visit our website (link in bio) for more details on our innovative project for female athletes. This is a year long project so please follow us to (i) get involved & (ii) see how we progress. Your input = ⭐️ research! pic.twitter.com/85QkzuVkTN
— FAIR-ACL Project (@fairaclproject) February 11, 2021
Describe the aim of The FAIR-ACL Project and the impact you hope it might have on women’s sport?
Before explaining the core of the FAIR-ACL project, it might be helpful to highlight that “FAIR-ACL” stands for “Female Athlete Injury Registry for Anterior Cruciate Ligaments”.
In the UK, there is no publicly available registry for ACL injuries in female athletes, listing athletes who have received a surgery after their ACL injury (called ACL reconstruction), or those who have opted for a conservative treatment, their sport, their hormonal profile, and their hormonal status at the time of their non-contact ACL injury (for example: Was the athlete in a certain phase of her menstrual cycle when it happened? Was the athlete taking hormonal contraception?). The FAIR-ACL Project collects this information from the injured athletes and the members of their coaching staff, or their medical staff, to whom they might ask more details from. Once our data collection comes to an end, we will analyse the data and observe if there are some patterns where some hormonal profiles might be related to the occurrence of a non-contact ACL injury, in different sports. Then we will share our conclusions with female athletes, coaching staff members, practitioners, and sports governing bodies to help them improve injury prevention programmes in female athletes.
Explain why female athletes are at a higher risk of ACL injury than male athletes.
When exposed to the same sport, several studies have shown that girls and women have a higher incidence rate of ACL injury than boys and men (3 to 6 times more likely, depending on the sport). Many studies have reported that differences in intrinsic risk factors (anatomical, biomechanical, neuromuscular, hormonal, and demographic) between girls/women and boys/men put girls/women at higher risk for non-contact ACL injury. One of the intrinsic risk factors is the different quantity of sex hormones that women and men produce during their lifespan. Sex hormones have multiple effects on physical functioning, especially during adolescence. The ACL might react to some of these hormonal changes and could change its form at certain points of the lifespan corresponding to different hormonal profiles.
The authors of a recent study have also explored the complex issue of ACL injury rate disparity between boys/men and girls/women through the lens of the gendered environment in which girls and women evolve1.
— FAIR-ACL Project (@fairaclproject) April 25, 2021
What are some common causes of ACL injury in rugby?
ACL injuries are amongst the most common severe injuries in sport. They are of particular concern in sports where the motion components are decelerating, as when stopping, cutting, changing directions, or landing a jump. Rugby is characterised as a high-risk sport for ACL injuries being a team sport with contact and collisions, as well as avoidance of collisions between players. Most of the existing literature is about men’s professional rugby union. Therefore, more studies on Women’s rugby with a higher methodological frame must be performed to have a better understanding of the common causes of ACL injury. In men’s professional rugby union, over half of ACL injuries result from a contact mechanism. Most common injury cause is the tackle, with the ball carrier being more often injured than the tackler. For non-contact injuries, a side-stepping manoeuvre with lower knee flexion angle and heel-first ground contact are associated with ACL injury.
At what age are female athletes most at risk of ACL injury and why is that?
Most female athletes sustain their first non-contact ACL injury between 14 and 18 while most of male athletes have their first non-contact ACL injury after adolescence. At puberty, girls begin to be distinct from boys in hormone secretion, and physical characteristics (body composition, joint laxity, and hip and knee control) during sport related activity.
View this post on Instagram
Describe the impact an ACL injury can have on a female athlete and the process for returning to sport.
An ACL injury is the unfortunate result of a multi-factorial equation. Like any other severe injury, an ACL injury cannot be isolated as an anatomic event only and represents a more global system to look at, which makes the prediction of outcomes difficult.
Any ACL injury will have an impact on the life of the injured athlete and will keep her for many months (a minimum of 9 months) off the field for training and competing. It will also have an impact on the future active life of the injured athlete/exerciser who might get re-injured (on the same side or on the other side), develop some early chronic complications, such as osteoarthritis, and might have a reduced quality of life. There is a large range of possibilities regarding the evolution of ACL injuries, and this will depend on a multitude of factors: age, sex, genetics, nature of sport, level of sport practice, injury characteristics, treatment chosen and its timing, rehabilitation pathway, social, professional, and financial environment, lifestyle. For example, female athletes take longer to return to their sport than male athletes. In addition, every person is unique and might respond differently to any step during the rehabilitation process.
ACL injured athletes might feel isolated or lost when it happens. They will need the support of their entire team to follow their best rehabilitation pathway. All steps to take are presented in the very informative and useful guide “The ACL injury journey – a guide for patients” (https://blogs.bmj.com/bjsm/2020/12/22/the-acl-injury-journey/).
What proportion of female athletes who have experienced an ACL injury make a successful return to their sport?
Although female athletes face a greater risk of ACL injury when participating in the same sports as male athletes, research on return to sport rates in the elite female athlete population following an ACL reconstruction is scarce. In the short term (within 12 months after the injury), 50% of injured athletes do not return to their preinjury levels of sport. Nearly 1 in 4 of the young athletic patients (<25 years old) who do return to high-risk sport (such as rugby), will sustain another ACL injury, often within the first few months of their return. The risk of getting re-injured is of particular concern for adolescent girls, who are 2 to 4 times more likely than adolescent boys or older age groups to sustain a second ACL injury.
Is there any early evidence you can share on the potential link between hormones and ACL injury in females?
Our own study, the FAIR-ACL Project, has been launched in December 2020 and will run online until the end of February 2022. Although we have already received many answers, we cannot provide any conclusions or recommendations yet.
After almost three decades of research in ACL injury prevention, several studies have suggested that reproductive hormones variations along the menstrual cycle have an impact on general joint laxity and anterior knee laxity in female participants but without agreeing on a consensus regarding the phase of the menstrual cycle when the greater laxity was observed. A lot remains unknown about the mechanisms involved in the relationship between reproductive hormones and ACL injury.
In practice, a sensible individual approach would be expected as there is a high intra and inter-variability of hormonal profiles between different menstrual cycles and different exercising women or female athletes.
View this post on Instagram
Is there anything we can do to reduce our risk?
More answers will arrive in the next years as the body of research continues to grow. Injury prevention must be done in a common effort from several entities by:
– Improving the quality of research in this area, implementing gold-standard methodology when studying reproductive hormones profiles, implementing additional hormonal profiles (adolescents, hormonal contraceptives other than combined oral contraceptive, pregnant women, pre-menopausal women, menopausal women);
– Developing injury prevention strategies through sports governing bodies and continue the effort to implement these strategies in the weekly routine of the female athletes;
– Supporting female athletes in the professionalisation of their sport. The expansion of women’s sports is happening now, and this is important that athletes receive the best professional environment to perform and evolve safely;
– Opening conversations about menstrual health and risk of injury. It should not be restricted to a gender, but it should be open between all professionals working in sports with female athletes. This should not be a conversation to have only amongst girls/women;
– Listening to your body, monitoring your own health, your menstrual health, your sleep health, your hydration, your mood, anything that occurs outside of your habits. You know better than anyone how you feel. For example, if the element of a training session might feel more difficult than usual, take note of and observe if there is a pattern for few weeks/months;
– Asking for educated advice to professionals and practitioners to learn about injury prevention programmes in your own sport. This is important to be specific to your sport;
– Implementing the advice you have received from the professionals and practitioners as much as possible in your weekly schedule, all year long, in pre-season as well;
– Finally, a simple way to be pro-active: wearing adequate gear (for example, the right shoes for the right surface).
➡️ project explores the effect of reproductive hormones on non-contact ACL injuries in female athletes
➡️first UK study of its nature & could provide hugely insightful findings.
➡️ research that women’s sport needs! pic.twitter.com/v2wHeVnV5Q
— Anna Minter (@AnnaMinter_) February 15, 2021
What would your advice be to coaches of female rugby players who want to better support them – both to prevent injury and assist with their rehabilitation?
To ensure a better support to female rugby players, the surrounding team of professionals and practitioners should be informed and educated about the specific considerations for the population they work with as a starting point. Important general recommendations are explained in Considerations for coaches training female athletes by Guy Pitchers and Kirsty Elliott-Sale3. Additionally, coaches can find a multitude of relevant resources online, on different platforms:
- The AIS Female Performance & Health Initiative (FPHI): https://www.ais.gov.au/fphi
- The Well HQ: https://www.thewell-hq.com/
- The period of the period, by Kelly McNulty: https://www.periodoftheperiod.com/
The latest clinical practice guidelines4 (published in 2018) recommend that all young athletes, especially athletes aged 12 to 25 years participating in high-risk sports (such as rugby), follow an ACL injury prevention programme. One of the following ACL injury prevention programmes could be selected: HarmoKnee, Knäkontroll, Prevent Injury and Enhance Performance (PEP), and Sportsmetrics. Once a programme is selected, participants must have a session duration greater than 20 minutes, have a weekly volume greater than 30 minutes, start in the pre-season and continue through the regular season, and be performed with high compliance.
Sport-specific ACL injury prevention programmes are key to a longer and safer sport practice. The Activate world rugby injury prevention exercise programme5, developed by the University of Bath and England Rugby, is a structured exercise programme to reduce the number of soft tissues injuries and concussions in youth and adult community rugby. The programme is not exclusively an ACL injury prevention programme but targets all most common injuries sustained when playing rugby.
Coaches, teammates, parents and medical staff should be involved when female athletes perform injury prevention programmes and also when female athletes are going through ACL injury rehabilitation. The injured female athlete and the rehabilitation professional should be at the centre of the system during the rehabilitation journey and if/when return to sport is planned. At the final stage of the rehabilitation journey, a smooth transition with sport-specific exercises should be performed. As much as rugby is a team sport on the field, a much-needed team spirit is beneficial when going through ACL injury prevention or rehabilitation.
View this post on Instagram
Explain why you believe the risk of injury shouldn’t be a reason to stop playing the sport we love?
The best way to continue playing a sport while enjoying it and without being afraid of what might happen, is to control the controllables. You might think: ‘How does this translate into real life, on the pitch?’. ACL injury prevention programmes exist and work if they are complied with. Female athletes and their surrounding team (coaches, teammates, professional and medical staff, parents) must be informed about what exists to act against ACL injuries. It’s worth it to be pro-active and prepare strategies to prevent injuries from happening. The same principle applies for ACL injury management before an ACL injury happens. It is crucial to know that treatments exist and which type of rehabilitation pathway to expect.
1 Parsons JL, Coen SE, Bekker S. Anterior cruciate ligament injury: towards a gendered environmental approach. British Journal of Sports Medicine. Published Online First: 10 March 2021. doi: 10.1136/bjsports-2020-103173
2 Gleadhill CP, Barton CJ. Infographic. ACL injury journey: an education aid. British Journal of Sports Medicine. Published Online First: 27 January 2021. doi: 10.1136/bjsports-2020-102273
3 Pitchers, Guy & Elliott-Sale, Kirsty. (2019). Considerations for coaches training female athletes. [Online] Available from https://www.researchgate.net/publication/338126513_Considerations_for_coaches_training_female_athletes
4 Arundale, A.J.H. et al., 2018. Exercise-based knee and anterior cruciate ligament injury prevention. Journal of Orthopaedic and Sports Physical Therapy, 48(9), pp.A1–A25. 10.2519/jospt.2018.0303.