There is no consensus on how to treat anterior cruciate ligament (ACL) knee injuries in women’s soccer. Maybe because there is no clear solution. What do we call those missing from the 2023 World Cup Rolodex – England’s Leah Williamson and Beth Mead, Canada’s Janine Beckie and Netherlands’ Viviane Miedema to name a few?
The ACL club has gained six new British members in the past month alone: Arsenal’s Teyah Goldie, Liverpool’s Faye Kirby, Manchester United pair Emma Watson and Gabby George, Real Madrid’s Caroline Weir and Aberdeen’s Laura Holden.
Manchester United defender George has suffered an ACL injury.
How big a role does the menstrual cycle — a 2017 study found that ACL laxity and risk of injury may increase during ovulation — play?
Does this mean that every player is living on borrowed time in terms of ACL injuries, with areas where female players have thrived, forging careers on subfields, sometimes supported by orthopedic teams with knowledge of female physiology?
What about a packed fixture list, including an international calendar with top players competing in five major tournaments (Olympics, Euros, World Cup, Olympics, Euros) from 2021-25?
It’s hard to escape the feeling that if this crisis was affecting male players, football would find a solution. Sports science continues to investigate the mechanics of the female body, but this field has not received much funding. Describing this generation of female footballers as guinea pigs is not hyperbole.
It’s no wonder many female players feel the true mental cost of the game’s ACL crisis is being ignored.
The three of them spoke to the athletics in the hope that someone would listen – and if the powers that be didn’t protect them, their allies might take steps to defend themselves.
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“Every time I see another (ACL) injury, I go through a period of anger. My heart goes out to that player. Birmingham City’s Remy Allen, who tore her ACL for the second time in her career while playing for Aston Villa in May 2022, says she knows exactly what they are facing. The first came when she played for England at 18, years before the 2018 professional indoor women’s league. FA then helped her recover.
“I see the messages the players post on social media: ‘I’m going to keep my head down, I’m going to work on this recovery and I’m going to be really positive. “When I read the messages, I get the feeling, ‘You’re going to have a hard time,'” Allen says.
“We are angry with the system. If you keep piling on these games, expect the load of games and training to skyrocket. We don’t have the research. We don’t have enough medical support. We don’t have enough fitness trainers to support and facilitate everyone. We are being exposed to danger,” he said.
Almost 14 years since his first ACL injury, Allen recalls how history repeated itself in the third final match of Villa’s 2021-22 season.
In the 81st minute of Manchester United’s home game, she lost the ball. It felt as if both parts of my legs were not attached to each other. The rest of my body shook. I had a lot of morphine to try to calm my body down.”
“When you go down with a knee injury, it’s the (ACL) you’re most afraid of,” she says.
The confirmation arrived next Wednesday. With it came doubts. It was hard to turn back time as an 18-year-old girl by her side. What hope did she have at the age of 31, with just one year left on her contract at Villa? Even if she does this, who will offer her a contract?
ACL Injuries in Women’s Soccer: Why They Are High Risk and Preventable?
“Will he swallow?” Will my body allow me? Will I be able to cope mentally again?’ Allen explained. “The first time was difficult and I felt alone. In the days and weeks that followed, I didn’t feel like I could get through this. I didn’t know if I would come back.”
On the night, Allen was ruled out as Villa captain for 13 months, with her recovery complicated by a second procedure to have her knee stretched again. The grueling process began with basic joint exercises – to bend and straighten the injured knee – four to five times a day, before three to 12 weeks of weight-bearing gym exercises.
The more demanding period, between three and eight months, is, by Allen’s measure, “physically, one of the hardest things ever.”
We have teammates who still walk through the gym after their sessions in amazement. Allen said her heart sinks every day as she looks at the list of exercises she has to relearn: running, turning, sprinting.
“I spent the first six months in shock,” she says. “I was doing everything – but inside myself, I wasn’t committed to it. I felt so numb and lost in the process. Every time you hit a goal or a target, it was hard to feel positive about it because I knew how far ahead it was. I spent the first six months in a daily battle in my head. But I survived.
Attending Villa matches left her with an unfathomable mental dilemma as she restructured her identity: who was she without football? Playing for Villa gave her a sense of belonging. Allen said: “To sit in the stands, watch them play and know you’re not part of it – I felt so disconnected and useless.
When Villa refused to renew her contract, she became a free agent for the first time at the age of 32.
Allen says: “A big part of me felt like a failure and a rejection. “Maybe I wasn’t good anymore. I had a big debate about whether I should continue playing or whether it would be the right time to retire. I wasn’t sure I would take a contract anywhere else. It was a lonely, isolated place.
Allen’s fear is that women’s football is outside the top four, where one- and two-year contracts are the norm. The Women’s Super League is the only full-time league in England. A number of junior clubs operate full-time or hybrid models, with many players working outside of football. There are few lucrative contracts to go around. Players are asked to gamble on the small chances of success in the game – sometimes without having a net to catch them if it goes wrong.
Former Birmingham City defender Lily Simkin, now 20, made her WSL debut aged 16 but was out of contract at the end of last season.
Simkin is set to sign a full-time deal with the Championship club this summer, having spent three weeks on trial in pre-season. But in the final minutes of the friendly, an opponent caught her knee with a high tackle, the force pushing the joint inward.
“Immediately, because I didn’t have a deal with anyone, I thought, ‘Now what does this mean?'” recalls Simkin. I thought. “‘I can’t get off the field. I can’t play football for the next two weeks.
The next day, in the physio room, her agent calls and tells her that the club is not interested in signing her. Then Simkin discovered that none of the club’s female players had insurance.
“I didn’t know that was the case,” she says. “They said: ‘You’re going to be referred by your GP’. I have heard stories about waiting times (for surgery). It could be years. I don’t have that time because I’m unemployed. I didn’t go to uni as I was in Birmingham full time for two years. “I went from being full-time and I was really excited to join this new club and suddenly I got hit with a serious injury and I don’t know where I’m going to go from there.”
Other clubs have withdrawn their interest after learning of her injury. “Nobody signs a player with 12 months to go,” Simkin said.
Simkin initially used the free National Health Service (NHS) but after six weeks of consultations, not even a test was available.
Her family eventually paid for a private scan and the reason she didn’t hear the popping sound that often accompanies an ACL injury was because the ligament had completely torn from her femur (thigh bone). Given the risks to Simkin’s career, she was dropped from the top of the NHS waiting list and underwent the operation on October 18.
Simkin was busy with job interviews and studying university courses while England’s youth players played an under-23 game in Norway last month. She is currently recovering from surgery without a club. “This is all new,” she says. “I dropped out of school and went into football full-time. I didn’t have a CV. I had no work experience.
Simkin is talking about the assumption that players will take out insurance to cover the risks they face when playing against minor league teams or playing for tryouts. “One of the quotes we got for surgery was £15,000,” says Simkin.
She has been a member of the Professional Footballers’ Association (PFA) since her time at Birmingham, but those who have never played professionally (second-tier WSL Championship or below) are not eligible for membership. “Women (at these lower levels) are working full-time alongside being a soccer player to make ends meet because the pay is not enough (at those lower levels),” Simkin said.
“This injury can put them out of business. The younger girls are afraid to do this and you should not be afraid to play football.
Hannah Godfrey was the fourth of six Charlton Athletic women’s players to suffer an ACL injury between January 2022 and February 2023.
“‘It happened at our club,'” recalls Godfrey, now 26. “That’s when it hits you. You’ll see it happen. You will hear the noise. You will see when you know. It is truly heartbreaking. You’re afraid it might happen.”
Then two other players were sidelined with the same injury.
“All these people are very different. One of them is 30 and one is 19. One was in practice and one was in a game. There is no relationship. Then my world came crashing down.
Defender Godfrey was involved in a fight with a Birmingham City striker while playing at Charlton’s main stadium, The Valley, in September last year and her prosthetic leg refused to move. She felt the vibrating movement, that telltale pop. “I didn’t want to believe it,” she says. “I was holding my teammate’s hand and saying, ‘I did my ACL. ‘You are fine,’ she continued.
Days later, club doctor Godfrey confirmed she had completely torn her ACL.
“The tears came immediately,” she says. “I will never forget it. The doctor talked for a good minute but I heard nothing. I handed the phone to my teammate and she said, ‘I’m so sorry, can you repeat all that?’ She said to me. People will never understand until you hear those words. All I know so far is football.”
An initial consultation revealed that Godfrey’s knee was too swollen for immediate surgery. This situation lasted for six weeks. “I’ll be ready, get my hopes up, go in and the surgeon will shoot me in seconds,” Godfrey said.
“When you’re bedridden after surgery and can’t even get up to go to the bathroom without being sick, it’s hard on your mind. I had days where I was emotional, crying. ‘Why did I go and meet her?’ I asked her. “(The injury happened) because I was on my period? Did I have a cold? Did I sleep properly?’
Her lifeline came through the soccer academy Pro2Pro, which Godfrey built with teammate Lois Roche, who was recovering from an ACL. In between rehab sessions, the pair devised coaching and business plans, and have now coached more than 360 players. “It gave me a purpose,” said Godfrey. “We always had something to look forward to, because I don’t have a game day. I no longer had a goal. I had none.
“I thought, ‘If I ever get my ACL done, I’m not sure I’ll be able to handle it.’ I don’t give myself enough credit for how mentally strong and resilient I am.
“We have to do more. This is our livelihood. We give ourselves to the game and it gets taken away in the blink of an eye.
(Top photos: Getty Images; Design: Sam Richardson)