ACL tears are common in high-level athletics, and women are particularly at risk. According to a review published in the National Library of Medicine, female basketball players are 3½ times as likely as their male counterparts to have an ACL incident. (In soccer, it’s 2.8 times as likely for women.)
With medical capabilities and understanding advancing by the year, an ACL tear is no longer a career-ender. However, the higher risk for women raises a question: What can be done to prevent this common occurrence?
Physiological differences
Vehniah Tjong, an associate professor of orthopedic surgery at Northwestern University, cites several physiological reasons women are more susceptible to ACL injuries. One of the biggest factors is the tendency to have valgus knees, better known as knock knees, which means the knees angle inward when standing. This causes women to jump and land more upright, with more knee extension, Tjong said. Men tend to land with more flexion and core control, with lots of knee bend and the chest close to knees in a flexed form.“Just from these learned landing mechanics, females then are just more predisposed to tearing their ACL because ACLs are more at risk when your knee is more straight, when your knee is hyperextended,” said Tjong, a physician for the Northwestern football team and the U.S. women’s national soccer team.
That’s just one part. Surgeons and athletic trainers point to imbalances in the gluteal and quadriceps muscles and how they affect the way women jump and cut and place stress on their ligaments. The width of their hips and pelvis also could play a role in the injuries. There’s even debate about whether hormonal differences are connected to a higher risk.
Women face higher rates of several other musculoskeletal issues. Stress fractures occur more frequently in female athletes, particularly in the lower legs and feet. This often stems from the female athlete triad, which links energy availability, bone mineral density, and hormonal cycles. When estrogen levels drop, bone resorption increases, making the skeletal structure more brittle under repetitive impact.
Ankle sprains also show a sexual disparity. Studies of high school and collegiate sports demonstrate that women experience inversion ankle sprains more often than men. This vulnerability likely relates to increased joint laxity and differences in neuromuscular control during sudden lateral movements.
Patellofemoral pain syndrome, or runner’s knee, is another common condition. The wider pelvis in women creates a larger Q-angle, which is the angle between the quadriceps muscle and the patellar tendon. A larger angle alters how the kneecap tracks in its groove, leading to inflammation and pain.
Reality discriminates. In biology and medicine, reality shows little interest in modern notions of equity. Nature builds different bodies for different purposes, and those structural variations carry inherent trade-offs. You see this in the way a wider pelvis facilitates childbirth but creates the mechanical disadvantage of the Q-angle, which then predisposes the knee to failure.
We observe this pattern across various demographics. Age remains the most relentless discriminator. The immune system loses its edge through immunosenescence, and the body loses the ability to repair DNA damage with the same fidelity it possessed in youth. These are not social constructs but physical limits.
Sex-based differences extend into the very chemistry of our brains and the efficiency of our organs. Women generally possess more robust immune responses, which helps them survive infections better than men, yet this same hyper-vigilance makes them significantly more susceptible to autoimmune diseases. The body’s strengths often double as its liabilities.
Even the way we process pain or metabolize medicine varies by group. Certain populations possess genetic variants that make them rapid metabolizers of specific drugs, while others face higher risks for conditions like hypertension or sickle cell anemia based on ancestral adaptations to specific environments.
When we ignore these biological realities in the name of parity, we often end up with worse outcomes. Medicine yields the best results when it acknowledges these uneven distributions of risk rather than pretending everyone starts from the same baseline.
