Understanding the Bio-Mechanical and Fascial Mechanisms of ACL Rupture in the Female Footballer
- paula8883
- Oct 27
- 9 min read
By Paula Esson | Sports Scientist & Bowen Technique and MSTR®️ Instructor.
Progress, not perfection.
For the last 30 years working with athletes, ACL injuries have captured my professional attention due to their ability to alter the trajectory of their career or stop it in it's tracks completely, often at a young age. The interest began with basketball and has now focused on football.
The main motivation to reduce the incidence, improve the treatment of and perfect the rehabilitation to the best of our ability. Remaining continuously curious in the changing flux of reasoning, science and the relatively new contributions of neuro-science.
The ACL – More Than a Ligament
The anterior cruciate ligament (ACL) is a dense, collagen-rich structure running diagonally through the centre of the knee joint.
It connects the posterior aspect of the femur to the anterior intercondylar area of the tibia, stabilising the joint by resisting anterior tibial translation and rotational loads.
But the ACL is not just a passive cable — it’s richly innervated with mechanoreceptors, linking directly into the body’s proprioceptive and fascial systems. Through these neural and fascial pathways, it constantly communicates tension, load, and position to the brain.
Mechanoreceptors in the ACL serve both protective and functional purposes:
Functional (Proprioceptive). Where the joint is in 3D time and space.
Provide real-time sensory feedback to the spinal cord and brain about joint angle, velocity, and tension.
Help maintain joint stability by triggering reflex activation of stabilising muscles (e.g. hamstrings firing to prevent anterior tibial translation).
Facilitate motor control and co-ordination during dynamic activities like running, cutting, and jumping.
Protection and guarding.
When tension exceeds normal physiological limits, Golgi-like receptors and Ruffini endings initiate reflex inhibition of agonist muscles and co-contraction of antagonists — a built-in injury-prevention mechanism.
(These can all be compromised if there are adhesions, collagen damage, or acual scarring / scars )
Free nerve endings detect pain and tissue disruption, promoting protective withdrawal and inflammation signalling.
Why Female Footballers Are at Higher Risk
Research shows female players are 3–6 times more likely to rupture their ACL than male counterparts. Several interlinked factors contribute:
Biomechanical patterns: Greater dynamic knee valgus (the inward collapse of the knee during landing or cutting).
Pelvic structure: A wider pelvis increases the Q-angle, altering femoral and tibial alignment.
Hormonal influences: Oestrogen fluctuations can affect ligament laxity.
Fascial tension lines: Altered myofascial continuity from hip to foot changes how forces are transmitted and absorbed.
Neuromuscular timing: Delayed activation of gluteal and hamstring stabilisers increases anterior shear forces at the knee.
Appendix scars / Abdominal scars / Caesarians / Previous knee surgery for menisci repairs / inguinal hernias and even more distal contributions such as wearing braces on the teeth, ankle sprains and strains amongst many more. All of these need to be mapped in clinic to give a thorough and true impression of the presentation.
The Mechanism of Injury
Most ACL ruptures are non-contact and occur in split-second decelerations, pivots, or landings. Typical scenario:
A player sprints to intercept, plants one foot, twists the upper body toward the ball, and the knee gives way with a “pop.”
Key positions where rupture or sprain occurs:
Knee near full extension
Foot fixed or planted (5G pitches are causing some concern with the nature of the blades on the football boots adding to torque when planted).
Valgus and internal rotation of the femur over a relatively externally rotated tibia. 45% of females are born with one or both legs valgus and internally rotated.
Hip adduction and internal rotation, increasing load through the medial fascial line
Trunk rotation or lateral flexion away from the planted leg
Trunk extension and rotation away from the planted leg.
At this moment, ground reaction force exceeds the tensile capacity of the ACL, and the fascial continuity of the superficial front line, spiral line, and deep front line (as per Myers’ Anatomy Trains) all experience a violent distortion.
Fascial Perspective: The Ripple Effect
An ACL rupture is not isolated to the knee. The fascia connects the plantar fascia → calf → hamstrings → pelvis → spine. When the ACL tears, the spiral fascial line undergoes sudden recoil, influencing:
The iliotibial band and tensor fasciae latae (tightness or inhibition)
The gluteus medius/minimus (loss of lateral hip control)
Thoracolumbar fascia (altered trunk rotation)
Contralateral shoulder tension (as the kinetic chain compensates)
The MSTR®️ approach to scar tissue, adhesions and alterations in electrical transmission within the slide / glide and contractions have helped considerably in recovery, permitting a subtle yet, highly powerful re-organisation of the tissues and correct "patterning and recruitment. This is a valuable tool in treatment and rehab. Primarily with the actual ACL surgical scar affecting. :
1. Fascial Restrictions
Adhesions: Collagen laid down in healing can cross-link excessively, binding layers of fascia, skin, and underlying tissues together.
Loss of Glide: The normal slide-and-glide between fascial planes (e.g., superficial, deep, visceral) becomes restricted.
Altered Tensile Balance: The fascial web compensates around the restriction, causing asymmetrical tension throughout the body (the “tug” effect).
Reduced Elasticity: Scar tissue lacks the viscoelastic quality of normal fascia, reducing the tissue’s ability to store and release kinetic energy.
.Sagittal T2-weighted magnetic resonance image with fat suppression of the left knee, demonstrating an intact anterior cruciate ligament graft (white arrow) and a moderate joint effusion (orange arrow). Localised knee joint arthro- fibrosis (circle) is visualised extending from the anterior cruciate ligament graft into the anterior aspect of the knee joint, adjacent to the avulsed infrapatellar plica (black arrows).
Female Professional Footballer (KSI Iceland 2025)
2. Mechanical and Structural Impacts
Distorted Biomechanics: Movement patterns adapt around the restriction — e.g., altered gait, joint loading, or posture.
Compensatory Strain Patterns: The body compensates by over-recruiting other muscle groups, leading to overuse and pain elsewhere.
Altered Joint Alignment: Chronic fascial tension can subtly rotate, elevate, or tilt joints (especially pelvis, shoulder, and ribs).
Reduced Range of Motion: Scar stiffness limits mobility locally and globally.
Myofascial Pain: Trigger points form as a secondary effect of fascial tension and altered proprioception.
3. Neurological and Sensory Effects
Mechanoreceptor Disruption: Scars alter Ruffini endings, Pacinian corpuscles, and Golgi receptors that detect stretch and pressure, changing sensory input.
Proprioceptive Confusion: The brain receives distorted information about body position and movement.
Nerve Entrapment or Drag: The scar may tether a nerve within the fascial matrix, creating neuropathic sensations (burning, tingling, itching).
Altered Sympathetic Tone: Chronic tension around scars can stimulate the sympathetic nervous system (fight–flight), increasing muscle tone and inflammation.
Neuroplastic Changes: Persistent altered input from scarred tissue can cause cortical remapping (the brain’s body map changes, reducing control or awareness in that area).
4. Circulatory and Lymphatic Impacts
Microvascular Restriction: Compression of capillary beds reduces oxygen and nutrient delivery.
Venous Return Impairment: Congestion around scar tissue can cause swelling or heaviness.
Lymphatic Flow Disruption: Impaired drainage increases local inflammation and delays healing in adjacent tissue.
Temperature Regulation: Reduced perfusion can make the area feel colder or more hypersensitive.
8 months post ACL repair. July 2025.( St. Mirren Striker. Scotland ). Significant lymphatic pooling around the Vastus lateralis and the patellar. This is drained every 4 weeks using MSTR®️ and lymphatic Bowen.
5. Emotional and Energetic Aspects
Stored Cellular Memory: The body may retain emotional trauma from the injury or surgery within the fascial matrix. "Fascial" unwinding or involuntary fascial waves, movements / stretches have been witnessed during treatment of ACL recovery. This is a fascinating area of science that needs further research .
Altered Body Image: Scars can subconsciously affect how a person perceives their body and moves through space. Even changes in positions of important tattoos affecting aesthetics and confidence are real observation and conversations. Clothing change sfor example not being able to wear dresses that expose the scar.
Protective Bracing: The nervous system may maintain subtle guarding around the area, even long after healing.
7. Global and Systemic Effects
Postural Compensation Chains: A scar anywhere (e.g., ankle, abdomen, head -there is a recent focus on concussions, head injuries and ACL occurrence.) can transmit fascial tension throughout the kinetic chain.
Chronic Pain Syndromes: Persistent tension and altered neural input can contribute to fibromyalgia, tension headaches, or fatigue syndromes.
Reduced Efficiency of Movement: Energy leaks through inefficient fascial transmission, increasing fatigue and effort.
Altered Gait Patterns: shifting the centre of gravity or pelvic rhythm.
This explains why post-injury athletes often show whole-body asymmetry, not just knee dysfunction. Although interestingly the asymmetry did not show up as a negative on strength assessment in the lab, it's dynamic impact is visible.
Psychological Impact.
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 ACL's— set off a psychological contagion.
I have cleared 7 separate ACL surgical repairs with semi-tendinosis as the graft location in the last year, all fit to play. When the time came to commit to the match, there is real resistance to tackle, chase, jump and turn rapidly. A percentage of the this "noise" can be reduced using P-DTR®️ (proprioceptive deep tendon reflex), to regulate the nervous system, however it runs deeper into hormones ( these are mapped to correlate training and match intensity to their menstrual cycle. , relationships, personality, environment, culture and many factors that we navigate daily with the players.
Assessing and preventing.
The VALD™️ health systems have allowed us for the first time to assess four key areas pre and post ACL surgery.
The Nordic hamstring curl gives us real time data on how the hamstrings are firing and loading - highlighting clear discrepancy in strength ratios post- surgery.
Force plate vertical jumps in repeated intensity,. and movement screening to capture valgus and internal rotation at the knee and other fascial / muscular patterns and recruitment.
All of the above now gives us a baseline to measure the efficacy of interventions and help the player both psychologically and physically return to the game. From a preventative point of you this is going to be a game changer moving forwards.
Future courses in MSTR®️ and The Bowen Technique practitioner training can be found at these links.
References
Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. Am J Sports Med.1995. PubMed+2SAGE Journals+2
Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict ACL injury risk in female athletes: a prospective study. Am J Sports Med. 2005. PubMed+1
Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. Am J Sports Med. 1999. PubMed
Crossley KM, Patterson BE, Culvenor AG, et al. Making football safer for women: a systematic review and meta-analysis of injury prevention programmes in women’s football. Br J Sports Med. 2020. British Journal of Sports Medicine
Bizzini M, Impellizzeri FM, Dvorak J, et al. FIFA 11+: an effective programme to prevent football injuries. Br J Sports Med. 2015. British Journal of Sports Medicine
Silvers-Granelli HJ, Mandelbaum BR, Adeniji O, et al. Does the FIFA 11+ reduce ACL injuries? Am J Sports Med. 2017. PubMed
Sadigursky D, Braid JA, De Lira DNL, et al. The FIFA 11+ injury prevention program for soccer players: a systematic review. BMC Sports Sci Med Rehabil. 2017. BioMed Central
Mancino F, Zampogna B, Papalia R, et al. Anterior cruciate ligament injuries in female athletes: epidemiology, risk factors, prevention, and outcomes. EFORT Open Rev. 2024. PMC
Parsons JL, Coen SE, Bekker S. ACL injury: towards a gendered systems approach. Br J Sports Med. 2021. British Journal of Sports Medicine
Ardern CL, Ekås GR, Grindem H, et al. 2018 IOC consensus statement on prevention, diagnosis and management of paediatric ACL injuries. Br J Sports Med. 2018. British Journal of Sports Medicine
Montalvo AM, Schneider DK, Webster KE, et al. ACL injury risk in sport: systematic review & meta-analysis of incidence by sex and sport classification. J Athl Train. 2019. PMC
Wojtys EM, Huston LJ, Lindenfeld TN, Hewett TE, Greenfield ML. Association between the menstrual cycle and ACL injury. Am J Sports Med. 1998. PubMed
Dos’ Santos T, Jones PA, Williams JH, et al. Effects of menstrual-cycle phase on neuromuscular/biomechanical surrogates of ACL risk: systematic review. PLoS One. 2023. PLOS
Parker EA, Kimmerling K, DiPaolo J, et al. Menstrual-cycle hormone relaxin and ACL injuries in female athletes: a scoping review. Orthop J Sports Med. 2024. PMC
Wiggins AJ, Grandhi RK, Schneider DK, et al. Risk of secondary ACL injury in younger athletes: systematic review & meta-analysis. Am J Sports Med. 2016. PMC
Patel AD, Mandalia P, Stone OD, et al. Does sex affect second ACL injury risk? Systematic review with meta-analysis. Br J Sports Med. 2021. British Journal of Sports Medicine+2PubMed+2
Webster KE, Feller JA. Exploring the high reinjury rate in younger patients following ACL reconstruction. Am J Sports Med. 2016. Ovid
Faude O, Junge A, Kindermann W, Dvorak J. Risk factors for injuries in elite female soccer players. Br J Sports Med.2006. PMC
Seyedi M, Daneshjoo A, Karimizadeh Ardakani A, et al. Effects of FIFA 11+ on kinematics and neuromuscular ACL-risk surrogates in adolescent soccer players. Sci Rep. 2023. Nature
Kerman MT, Rahimi A, Yazdi Z, et al. Effects of FIFA 11+ Kids on biomechanical ACL-risk factors. Int J Environ Res Public Health. 2023.
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