• Dan Kao

Blog Series- Why are Female Athletes Are More Prone to ACL Injuries? (Part 1)

Updated: Apr 11

Part 2 now available

Injuries, unfortunately, are becoming the norm among female sports, don’t look too far and there are always a few athletes in super huge knee braces or sitting on the sidelines fresh out of ACL surgery. And worse, large numbers of these women are having more than one injury or surgery. We know it’s common, we realize it’s a problem; but why is it happening and what can we do to fix it?

Studies show, female athletes are 2-8 times more likely to tear their ACL than their male counterparts [1]. Factors contributing to ACL injury risk in female athletes vary from environmental, structural, hormonal, anatomical and muscular. While we cannot change all of these risk factors, addressing preventable factors and increasing our knowledge towards non-preventable factors can dramatically decrease the incidences of injury.

When I was thirteen years old I tore my ACL playing soccer, and after a year of surgery and grueling rehabilitation, I returned to soccer only to tear my ACL, MCL and meniscus on my other knee. After having my second ACL surgery at age fourteen, we realized my surgeries had failed and the error cost me my knees. Ever since then, I have needed countless surgeries and have done years of research in order to understand why this happened to me, and why it happens so easily to women. In this blog, we’ll briefly see which factors are modifiable factors and non-modifiable, but definitely stay tuned for the next following blogs which take a deep dive into each topic.

In part 2 unmodifiable Variables, I will discuss some of the reasons relating to hormones and anatomy that predispose female athletes to ACL injury. While we cannot change hormones and anatomy, we can learn more about the biomechanics of female athletes and how we can help them as strength coaches. In Part 3, some of the modifiable variables are discussed and in Part 4, you can learn more about how to prevent ACL injury and what exercises or areas of the body are the most important to focus on for young female athletes.

We’ll get you started back on your recovery, faster, stronger and smarter in no time!

Non-modifiable Factors


One might think that the older a female athlete is, the more likely she is to have an injury. But in fact it’s a bit of the opposite; the most high risk demographic for female athletes are those between the ages of 12-17 [2]!


Although no definitive studies showing direct correlation between hormonal changes and ACL injuries, multiple studies suggest that sex hormones and the menstrual cycle have an effect on the ACL and injury rate [3,4,5]. Increases in estrogen may affect the tensile integrity and collagen production [6, 7]. This amounts to increased laxity in joints, particularly to the ligaments where one of their main functions is to provide structural support. Since estrogen levels are regulated in the menstrual cycle, the risk for injuries in female athletes rise and fall depending on when they are in their cycle!

Hips and Anatomical Differences

Male and female hip structure differ in anatomy, specifically in a particular anatomical feature known as the Q angle. The Q angle is the angle measuring for the midpoint of the patella (knee cap) to the anterior superior iliac spine (ASIS) at the front of the hip. The degree of differences in the angles may affect how much forward stress is placed on an athlete’s knees. Other anatomical differences such as knee valgus, knee shape, over pronation at the foot and more may affect injury rates as well [8].

Modifiable Factors

Neuromuscular Imbalances

Neuromuscular control is basically the connection between the brain and muscles telling which muscles to fire and when, and the muscles, tendons, and ligaments providing feedback to the brain. A decrease in neuromuscular control makes an athlete vulnerable because improper or even delayed firing sequencing in muscles lead to compensations in movements or reductions in reaction time which will make the athlete more prone to chronic stress and injury [9]. Fortunately, this is something that can be trained and re-tooled! Many athletes also have compensations related from sitting too much like tight ankles and impaired quad/hamstring function which can also affect injury rates.

Part 2 now available!

Jenna Minecci

9x Surgery Survivor/Strength Coach/Author/Athlete

B.S., CPT, CES, PES, FMS, MWod Pro




Jenna Minecci is a passionate Personal Trainer and Strength Coach dedicated to helping others prevent injury, prepare for surgery and recover exceptionally from any surgery they have. After having 4 ACL reconstructions fail on her as a teenager, she has now had 9 surgeries and counting. Her goal is to educate and empower others facing difficult surgeries and recovery journeys. She currently works at Lifetime Fitness in Atlanta, Georgia where she specializes in Corrective Exercise, Knee Rehabilitation and ACL Injury Prevention.

She is also the author of the book Surviving 7: The Expert’s Guide to ACL Surgery.

Follow Jenna on social media @Jennactive.


Have more questions about your upcoming surgery? Sign up today for your free personalized pre-op consult with a Orthopedic/Spine Nurse Practitioner or Medical Device Specialist today!



  1. Boden, Sheehan. Torg, Hewett. “Noncontact anterior cruciate ligament mechanisms and risk factors.” Sep, 2010. https://insights.ovid.com/pubmed?pmid=20810933

  2. Beck, Nicholas A., et al. “ACL Tears in School-Aged Children and Adolescents: Has There Been an Increased Incidence over the Last 20 Years?” Pediatrics, vol. 137, no. Supplement 3, 2016, doi:10.1542/peds.137.supplement_3.554a.

  3. Wojtys, Edward M, et al. “The Effect of the Menstrual Cycle on Anterior Cruciate Ligament Injuries in Women as Determined by Hormone Levels.” The American Journal of Sports Medicine, U.S. National Library of Medicine, 2002, www.ncbi.nlm.nih.gov/pubmed/11912085.

  4. Myklebust, G, et al. “A Prospective Cohort Study of Anterior Cruciate Ligament Injuries in Elite Norwegian Team Handball.” Scandinavian Journal of Medicine & Science in Sports, U.S. National Library of Medicine, June 1998, www.ncbi.nlm.nih.gov/pubmed/9659675.

  5. Slauterbeck, J R, and D M Hardy. “Sex Hormones and Knee Ligament Injuries in Female Athletes.” The American Journal of the Medical Sciences, U.S. National Library of Medicine, Oct. 2001, www.ncbi.nlm.nih.gov/pubmed/11678515.

  6. Hansen, Mette, and Michael Kjaer. “Sex Hormones and Tendon.” Advances in Experimental Medicine and Biology, U.S. National Library of Medicine, 2016, www.ncbi.nlm.nih.gov/pubmed/27535256.

  7. Smith, Helen C, et al. “Risk Factors for Anterior Cruciate Ligament Injury: a Review of the Literature-Part 2: Hormonal, Genetic, Cognitive Function, Previous Injury, and Extrinsic Risk Factors.” Sports Health, SAGE Publications, Mar. 2012, www.ncbi.nlm.nih.gov/pmc/articles/PMC3435909/

  8. Grelsamer, R P, et al. “Men and Women Have Similar Q Angles: a Clinical and Trigonometric Evaluation.” The Journal of Bone and Joint Surgery. British Volume, U.S. National Library of Medicine, Nov. 2005, www.ncbi.nlm.nih.gov/pubmed/16260666.

  9. Smith, Helen C, et al. “Risk Factors for Anterior Cruciate Ligament Injury: a Review of the Literature - Part 1: Neuromuscular and Anatomic Risk.” Sports Health, SAGE Publications, Jan. 2012, www.ncbi.nlm.nih.gov/pmc/articles/PMC3435896/.

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