Why Do Women Tear Their ACL More Often? What I Tell My Patients
Female athletes tear their ACL three to six times more often than men. The four reasons why — anatomy, hormones, landing mechanics and muscle control — and what actually lowers the risk.
When JuJu Watkins — one of the best players in women's college basketball — went down with a torn ACL in the 2025 NCAA Tournament, the reaction was immediate: social media filled up with comments about how "this keeps happening" to women athletes. Paige Bueckers, Azzi Fudd, Olivia Miles — the list of elite women who've suffered the same injury reads like a who's who of the sport.
And the question I hear from patients, parents, and coaches all the time is: why? The honest answer is that it's complicated. But here's what the research actually shows, and what I think about when I'm evaluating a young female athlete in my clinic.
Four reasons the risk is higher
The ACL injury rate in women is roughly three to six times higher than in men playing the same sports. That gap is real — but it comes from several factors working together, not one single cause.
1. Anatomy
Women tend to have a wider pelvis relative to their knee span, which creates a larger Q angle — the angle at which the quadriceps pull on the kneecap. A greater Q angle places more inward stress on the knee with every step, cut, and landing. Women also typically have a smaller ACL and a narrower femoral notch for the ligament to pass through, which means there's less structural reserve when the joint is loaded under stress.
2. Hormones
Estrogen doesn't just affect reproduction — it directly affects ligament stiffness.
At certain points in the menstrual cycle, the ACL is simply not as tight or as resistant to force. FIFA recently funded a year-long study specifically designed to map ACL injury risk across menstrual cycle phases in elite female footballers. The data isn't complete yet, but the scientific interest is serious and growing.
3. How athletes land
Research consistently shows female athletes land from jumps in a more upright posture with straighter knees and less hip and core engagement compared to male athletes. This "quad dominant" landing pattern drives the shinbone forward and loads the ACL far more than a bent-knee, hip-loaded landing would. It's not a flaw — it's a pattern that can be trained and corrected with the right program.
4. Neuromuscular control
Women show measurably lower hamstring and gluteal activation during high-risk movements — the muscles that pull back on the shin and protect the ACL. This is partly biological and partly a training gap that develops during and after puberty.
Prevention works
Here's the part I want every athlete and parent to hear: neuromuscular training programs — things like the FIFA 11+ warm-up or PEP (Prevent Injury and Enhance Performance) — have been shown to reduce ACL injury rates in female athletes by up to 50%. Plyometrics, landing mechanics coaching, hamstring and glute strengthening, and balance work are not optional extras for a high-level female athlete. They are injury prevention.
A note on the numbers
A Harvard study late in 2024 raised a nuance worth knowing. Some of the widely cited statistics on female-versus-male ACL rates may overstate the gap because of how "athlete exposures" are calculated — accounting for team size differences and training-to-match ratios changes the picture somewhat.
Women may still be at meaningfully higher risk, but the raw numbers have likely overstated it. This doesn't change the practical message: training to reduce risk matters. It just means we should be thoughtful about alarming young women out of sports participation based on exaggerated numbers.
How I approach it in clinic
When I see a young female athlete who's had an ACL tear — or who comes in asking "how do I not tear mine?" — my approach starts with movement screening, strength assessment, and a conversation about her sport and training load. I perform approximately 85 ACL surgeries per year and trained at the Hospital for Special Surgery in New York, which handles some of the highest volumes of this injury in the country. Pattern recognition matters, and prevention is always the better outcome.
Frequently asked questions
My daughter plays soccer — should I be worried about her ACL?
Aware, not worried. The risk is real, but it's also modifiable. Make sure her training program includes proper landing mechanics, hamstring and glute strengthening, and neuromuscular work. A good sports physical therapist or athletic trainer can run a movement screen and identify any patterns that need correction before an injury happens.
Is there anything she can do during her cycle to protect herself?
The research on cycle-phase risk is still evolving and not yet refined enough to give specific game-day guidance. What does help is overall training consistency — keeping muscles strong and neuromuscular patterns sharp year-round provides more protection than any single intervention.
If she tears her ACL, will she be able to play again?
Yes, the large majority of athletes return to sport after ACL reconstruction. Return-to-sport timelines average nine to twelve months, and outcomes are excellent when rehab is done properly. The key is not rushing return — re-tear rates are significantly higher when athletes return before their graft has fully matured and their neuromuscular control has been rebuilt.
Are there any surgical considerations that change with high-risk female athletes?
Yes! High-risk athletes need the strongest reconstruction available. This usually means a patellar tendon (BTB) autograft and adding a lateral extra-articular tenodesis (LET) — an additional support on the outer side of the knee that resists the rotational movement that occurs at the time of an ACL injury. Adding an LET at the time of ACL reconstruction significantly reduces the risk of re-tear in high-risk athletes.
If you have questions about ACL injury risk, prevention, or treatment — for yourself or a young athlete you care about — this is a conversation worth having before an injury, not after.
This article is general education, not medical advice for your situation. Every knee and hip is different — talk with your own doctor about your care.