ACL injuries in professional football (soccer): Women face higher risk, later surgical care and longer time loss compared to men

PURPOSE: The study analysed unique data on anterior cruciate ligament (ACL) injuries among German professional female and male team sports over seven consecutive seasons with the aim of identifying sex specific differences regarding ACL injury risk, burden and treatment strategies. METHODS: This prospective observational open cohort study analysed unique insurance data on all complete ACL ruptures from female and male players with at least one competitive match appearance in the two highest divisions of German professional football. The long-term study covered seven consecutive seasons between 2014/15 and 2020/21 and included complete ACL ruptures registered by clubs or physicians with the German statutory accidental insurance for professional athletes (VBG) as part of occupational accident reporting. RESULTS: In total, 131 out of 2965 female players (4. 4%) and 95 out of 2639 male players (3. 6%) sustained an ACL injury. Mean ACL injury prevalence in female football was 3. 0% (95% confidence interval CI 1. 8-4. 3) with an increasing trend over time. Mean ACL injury prevalence in men's professional football was 1. 6% (95% CI 0. 8-2. 3). The overall match incidence in female players was 0. 91 ACL injuries per 1000 h of match exposure (95% CI 0. 72-1. 11). The overall match incidence in male football was 2. 5-fold smaller (0. 37 ACL injuries per 1000 h of match exposure (95% CI 0. 28-0. 47). Almost all ACL injuries (99. 2%) were treated surgically. Patellar tendon grafts were used more often in male players compared to female players (p < 0. 001). The mean period between the day of an ACL injury and the day of surgery was significant longer in female (median 19 days interquartile range IQR 22) than in male players (median 6 days (IQR 8, p < 0. 001). Overall, female players had significant longer time loss after ACL injury and after ACLR compared to men (p < 0. 001). The total secondary ACL injury rate after RTP was 31. 7% for female players and 32. 1% for male players. Female players were significantly younger at their retirement compared to males (26. 7 ± 4. 2 vs. 33. 5 ± 3. 3, p < 0. 001). CONCLUSION: The ACL prevalence and match injury risk is higher in female players compared with males. Moreover, the present study shows an increasing trend for both parameters in German female professional football. One out of three players, irrespective of sex, sustained a second ACL injury over a median follow-up of six years. However, women end their careers earlier than men after an ACL injury, which could understate the actual extent of the second ACL injury rate in women. While sex-specific care would be advisable, access to medical treatment still seems to be limited in women's football. Therefore, the therapeutic and medical framework conditions in women's football should be aligned first. LEVEL OF EVIDENCE: Level II.