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  • Writer's pictureThe San Juan Daily Star

The curse stalking women’s soccer

The Women’s World Cup is missing some of the sport’s biggest stars because of a knee injury epidemic. No one can say for sure why it’s happening, or how to fix it.

By Rory Smith

The third time around, Megan Rapinoe’s reaction to a potentially career-ending knee injury went no further than an eye roll. She had torn her ACL. She could reel off the recovery schedule from the top of her head. She could see, crystal clear, the next nine to 12 months spooling out in front of her.

The surgery, the painstaking rehab, the grueling weeks in the gym, the anxious first steps on the turf, the slow journey back to what she had once been. As she considered it in 2015, she felt something closer to exasperation than to despair. “I was like, ‘I don’t have time for this,’” she said.

The first time had been different. She had torn the ACL in her left knee at age 21, when she was a breakout star in her sophomore year at the University of Portland. At that time, she felt what she called “the fear” — the worry that it might all be over before it had begun.

A year later, she had done it again: same ligament, same knee, same arduous road back. It did not stop her from doing all that she had dreamed of doing. She turned pro. She was named to an all-star team. She represented her country. She won a gold medal at the Olympics. She moved to France. She played in two World Cups. She won one of them.

And then, during a training session in Hawaii in December 2015, months after her 30th birthday, it happened again. This time, it was the right knee, and this time, her reaction was different. “It changed for me as I got older,” she said. “That one was like an eye roll. ‘This is annoying. I know what it is going to take to come back.’ But generally, I think there’s this fear. Is this going to be the end? Am I going to come back from this? Am I going to have pain forever?”

Over the last year or so, that fear — and the searching questions it prompts — has coursed through women’s soccer. The sport has at times seemed to be in the grip of an epidemic of ACL injuries, one so widespread that at one point it had sidelined a quarter of the nominees for last year’s Ballon d’Or.

Alexia Putellas, the Spain midfielder who won that award and the consensus pick as the best player of her generation, has recovered in time to grace the World Cup, the sport’s showpiece event. But many other stars have not. They will, instead, spend their summer at home, nursing their injuries, cursing their luck.

The list is a long one. Catarina Macario, the U.S. forward, tore the ACL in her left knee last year and could not regain her fitness in time. She will not be present in Australia and New Zealand. Nor will two of the stars of the England team that is hoping to dethrone the United States: The team’s captain, Leah Williamson, and its most productive goal-scorer, Beth Mead, both fell victim to ACL injuries this season.

The Olympic champion, Canada, has lost Janine Beckie. France has not been able to call upon Marie-Antoinette Katoto or Delphine Cascarino. The Netherlands, a finalist in 2019, is without striker Vivianne Miedema.

Miedema herself pointed out that, this season alone, almost 60 players in Europe’s five major leagues had torn their ACLs. “It is ridiculous,” she said earlier this year. “Something needs to be done.”

Working out precisely what that might be, though, is more complicated than anyone would like.

Lack of Knowledge

There is fear, of course, for players who are enduring those long weeks of recovery, but it is not the only type of fear. In Europe particularly, over the last 12 months, the sheer scale of the issue — the numbers of players being struck down by torn ACLs — set off a psychological contagion.

A number of national associations, as well as local offices of FIFPro, the global players’ union, reported inquiries from active players — those who had seen teammates or opponents or friends condemned to months on the sideline — seeking reassurance, solace or even just basic information.

“The players are asking for research,” said Alex Culvin, FIFPro’s head of strategy and research in women’s soccer. “We’ve had a lot of feedback from players saying they feel unsafe. You saw it last season — at times, players were not going in for tackles as they normally would because they were worried about injury.”

The problem, Culvin said, is there is not enough research available for anyone to give the players clear answers. European soccer’s governing body, UEFA, has been running an injury surveillance study on men’s soccer for more than two decades. The women’s equivalent has been operating for only five years. “That lack of knowledge creates fear,” Culvin said.

It is established fact that women are more at risk of sustaining an ACL injury than men. Quite how much more at risk is a little murkier. Martin Hagglund, a professor of physiotherapy at the University of Linkoping in Sweden, puts the risk at “two to three times greater, based on a systematic review of studies.” Culvin goes a little higher: Some studies, she said, suggest the risk for women could be “six or seven” times as great as that for men. “There is a real range,” she said.

The issue of why that might be is more contested still. Traditionally, much of the research has focused on biology. “There are obvious anatomical differences” between men’s and women’s knees, Hagglund said. Not just the knees, in fact — the whole leg. Some studies have suggested that women’s ACLs are smaller. There are differences in the hips, the pelvis, the engineering of the foot.

As a paper published in the British Journal of Sports Medicine in September 2021 pointed out, though, the instinct to focus purely on physiological explanations is both rooted in and serves to reinforce the misogynistic stereotype that “women’s sport participation is dangerous predominantly due to female biology.”

It also runs the risk, in Hagglund’s mind, of turning a blind eye to the host of other issues that may have played a part in depriving the World Cup of so many of its brightest lights this month. “The focus on anatomical differences means we have left out the other parts, the extrinsic factors,” he said. It just so happens that those are the ones that might, feasibly, be addressed.

The Right Fit

Laura Youngson is always surprised, even now, by the number of players she encounters who have convinced themselves that soccer cleats are designed to be uncomfortable. “That’s the perception,” she said. “That they’re supposed to feel like that, and that women, in particular, are just supposed to put up with it. They’re really not meant to be like that.”

For a long time, like everyone else, Youngson just accepted that her soccer shoes never seemed to fit quite right. Then, after organizing a charity game on Mount Kilimanjaro in 2017, she realized that she was not alone. Even the professional players on the trip had the same complaint. She saw an opportunity — both a business one and a moral one — to put it right.

Since then, the company she founded, Ida Sports, has conducted extensive research to produce the first custom-made women’s soccer cleats. They found that women tended to have narrower heels, wider toe areas and higher arches. (Their feet are also more likely to change than men’s are, particularly during and after pregnancy.) That means they “interact differently with the ground,” something that Ida Sports has tried to remedy by redesigning the sole of the shoes she makes.

There is also enough evidence to suggest that the shape and structure of women’s feet may make them more susceptible to injuries, both chronic and acute, including ACL tears. Youngson does not claim to have a silver bullet for the knee injury epidemic, nor does she believe that wearing better-fitting shoes will end the problem on its own.

“But there is definitely an opportunity for further research,” she said. “People are doing great work studying hormones and behavior and other things. We know boots and surfaces. There are definitely recommendations that we would make. The issue is, how do we keep more players on the pitch? Even if it is for a 1% gain, it is worth it.”

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