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Dr Alex Culvin: Are we asking the right questions on ACL injuries?


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Alexia Putellas Imago1013081201h
Dr Alex Culvin

Dr Alex Culvin

Dr Alex Culvin is a former professional footballer who played for the likes of AZ Alkmaar, Everton, Leeds United and Liverpool. She is currently Head of Strategy and Research (Women’s Football) at FIFPRO.

When I was a footballer, every club I played with had at least one or two ACL injuries a season. It’s something that has always been present in football.

Interest in ACL injuries has become more pertinent as the professionalisation of women’s football has increased. We’re not seeing more ACL injuries now per se – we’re seeing more discourse and critical discussion around not only what an ACL injury is, but the impact that it has more broadly on the football landscape and football ecosystem.

First and foremost, it's heart-breaking for players such as Marie-Antoinette Katoto, Catarina Macario, Beth Mead, Vivianne Miedema, Leah Williamson and more, who are enduring lengthy lay-offs and going to be missing tournaments such as the Women’s World Cup. But at the same time, there is hysteria about wanting to identify a silver bullet on why these ACL injuries are happening. The problem with scrambling for a definitive why is that we overlook the multifactorial issues that exist when thinking about an ACL injury.

There needs to be an acknowledgement from all stakeholders – players, fans, media, FIFA, UEFA, FIFPRO, whoever – that these ACL injuries are significant, but they are more importantly at the detriment of a player's physical and mental health; not to mention their career prospects when we consider this injury leaves players out of the game for at least nine months.

There must be an acknowledgement of the multifactorial issues of an ACL injury – not simply from a sports science perspective, but also analysing the wider conditions and holistic risk-factors. If you think about women's football as a space where professionalisation is growing at an exponential rate in some countries and the professional obligations on players are increasing, questions then need to be asked about facilities, travel, workload; staff around the players that are either preventing or treating these ACL injuries, and whether these professional obligations are met with sufficient standards where ACL injuries occur.

The day-to-day conditions that players experience is sometimes ignored because attention on this topic often pivots to: ‘This is an ACL injury, therefore it's medical’. What is overlooked, though, is the lack of holistic research done on conditions; the real quality control issue that we have in women's football around the game.

There is a real breadth of complexities and nuances to an ACL injury that gets overlooked. In the reaction of Leah Williamson’s injury, the Twitter space subsequently exploded for example. Leah had played five games in 21 days before sustaining the injury, which in terms of workload and rest, meets the 72 hours minimum between games that FIFPRO recommends – that in itself adds to public scrutiny around women's workload without necessarily having the information on it. We can't say for sure that one correlatively impacts the other, it's too simplified. Yes, we can and should look at a cumulative workload, but we should also look at the conditions and ask: are players currently being treated and looked after in the best possible way?

We can't prevent all ACL injuries from happening, but the non-contact ones that are unpreventable, we need to be asking: what are we doing to protect players here?

“What is overlooked is the lack of holistic research done on conditions; the real quality control issue that we have in women's football”

— by Dr Alex Culvin

In some ways it’s important to remove the emotion on what seems like an explosion of ACL injuries on big-name players, and instead start looking critically around the conditions in which these ACL injuries are occurring.

The scientific research that exists on women's footballers is not a big database. But establishing causes and commonalities is only half the problem and doesn’t tell the full story. We can't say for sure that there are more or less ACL injuries now in women’s football, the data remains inconclusive. But what we can say is: consistently, there is a lack of research. Not only is there a lack of research, but there is also a lack of implementation of existing research and a lack of regulation around best-practice guidance.

Yes, there may be some existing protocols. But the questions that then need to be asked: are clubs implementing them? Are they regulated? Are federations really understanding the complexities of the problem, and subsequently pushing this agenda to protect the health and integrity of players?

The question for me is not: are there more or less ACL injuries nowadays? Instead, the question should be: what are the conditions in which this is occurring? It's not the regularity that's the sole problem – it's the lack of understanding of how it occurs, why it occurs, and how we better protect the wellbeing of players.

There needs to be a concerted, constructive, multi-stakeholder approach to this critical, acute problem. It’s impacting multiple parties – from UEFA and FIFA to players, clubs, and leagues, all of whom have a stake in the game – and so the isolated approach we currently have on this issue needs to stop.

It is also important to acknowledge that there is a commercial impact when it comes to ACL injuries. We advocate for more investment into the players through better working conditions to ensure sustainable economic growth of the game but, at the same time, not consistently having the best players on the pitch, particularly during the biggest moments the sport has to offer, also affects our game’s ability to continuously leverage its growing popularity and the popularity of the players.

Football is a short, precarious career and should a player miss a substantial proportion of it through an injury that could be – in some cases – prevented, means they may miss out on a significant moment in which they could be capitalising on their talent and visibility. Nike will be gutted not to have Leah Williamson, one of their marquee athletes, leading England at the Women’s World Cup, the biggest sporting event for women in the world. They lose out as much as anyone else with an investment in the tournament.

Vivianne Miedema ACL
Vivianne Miedema
Leah Williamson England
Leah Williamson
Marie Antoinette Katoto France
Marie-Antoinette Katoto receives treatment
Beth Mead Arsenal
Beth Mead suffers an ACL injury

Starting at the top, we need to collaboratively come together to think about solutions, which then needs to be filtered down to guidelines, which are then properly implemented. With robust process, over a period of time we'll then be able to assess if they actually reduce the amount of ACL injuries.

A multi-stakeholder approach acknowledges that ACL injuries are everyone’s responsibility. Fundamentally, though, it should be player-centric and player-driven when it comes to solutions; what bad practice players encountered, what good practice they encountered. There should be an ambition to really offer solutions to this critically acute problem in women's football.

People are funding research. FIFA have funded research around this. But it's about how that research gets taken and implemented. We can't just have research that exists in the sphere of academia – there needs to be a deliberate attempt to condense, apply and regulate it. There needs to be accountability mechanisms in place for clubs and national teams because this is the welfare of players that we're talking about – and, for me, that has been lost in the discourse of ACL injuries in women’s football.

What qualifications do support staff at women’s clubs have? What access to facilities do players have? How is important data around player health communicated from club to national team? And are these practices consistent and informed?

The value that we're placing on support staff, facilities and all conditions, is disjointed. That in turn means that quality control becomes a real issue. If players are being pre-habbed, are they being led and researched by experts who work in elite high performance and specialise in women’s physiological health? Often that isn’t the case in women’s football.

As FIFPRO we’re the outsiders on the inside with regards to stakeholders, those in governance and administrative positions. We can talk all we want about what we think, but everybody needs to be led by:

  • The players
  • Scientists and experts related to holistic health
  • Experts in women’s physiological health

Then, it's up to the stakeholders to do their job once we have the information and think about global solutions to this global problem.

No single lens will solve this issue, which is why it's so important to have a collaborative approach to protect the health and wellbeing of players.