ACL Injuries in Women’s Soccer: What Can Coaches Actually Influence?

Anterior cruciate ligament injuries remain one of the most challenging issues in women’s soccer, not only because of the severity of the injury itself but because of the length of rehabilitation, uncertainty surrounding return to previous performance and the potential consequences for a player’s career.

The subject has returned sharply to the spotlight following confirmation that Portland Thorns and United States midfielder Olivia Moultrie suffered a torn right ACL during training, ending her 2026 NWSL season and creating uncertainty around her preparation for the 2027 FIFA Women’s World Cup. Moultrie is only 20 years old, making the injury another reminder that even highly developed young international players are not immune from one of soccer’s most significant knee injuries.

The important coaching conversation, however, should extend far beyond one player. Women’s soccer continues to professionalise at extraordinary speed, with increasing match demands, greater training exposure, expanding international calendars and rising expectations around physical performance. At the same time, ACL injury remains an area where the science is still developing. Recent research continues to identify a higher ACL injury incidence among female soccer players than male players, while researchers working specifically within professional women’s football have also highlighted important gaps in the evidence and warned against pretending that one simple explanation or intervention can solve the problem. (PubMed)

That distinction matters because the language used around ACL injuries can sometimes create unrealistic expectations. Coaches regularly hear about “ACL prevention programmes”, screening systems that supposedly identify players who are going to become injured, or individual exercises promoted as protection against knee injury. The evidence supports a more responsible position. ACL injuries are multifactorial, meaning that numerous interacting factors may contribute to an injury event, and it is impossible to guarantee that a player will not sustain an ACL rupture simply because a particular warm-up, strength exercise or screening protocol has been completed.

The more useful question for coaches is therefore not whether ACL injuries can be completely prevented, but which factors within the training environment can be influenced to reduce risk while simultaneously making players stronger and better prepared for soccer. This moves the discussion away from fear and towards preparation. Neuromuscular training, strength development, landing and deceleration ability, progressive exposure to soccer-specific demands, appropriate recovery and well-designed return-to-play processes all have a role, but they should operate together rather than as isolated interventions.

This approach aligns closely with the ISSPF Certificate in Soccer Injury, Prevention & Return to Play, which examines injury analysis, injury-risk reduction strategies, screening, movement preparation, rehabilitation, psychology during injury, training-load management and return-to-play processes. The objective should not be to promise coaches that every injury is avoidable, but to give practitioners a clearer framework for controlling the factors they can influence within their own environment.

TAKE THE ISSPF CERTIFICATE IN SOCCER INJURY, PREVENTION & RETURN TO PLAY NOW

Why ACL Injury Risk in Women’s Soccer Cannot Be Explained by One Factor

Research consistently demonstrates that ACL injury represents an important issue within women’s soccer, although the exact estimates vary according to age, playing level, competition and study methodology. A large six-season study involving more than 780,000 player-seasons reported that female soccer players had a 2.79-times higher ACL injury incidence than male players within the population studied. An earlier systematic review focused specifically on football also reported that women experienced a higher ACL injury incidence rate than men, although the researchers stressed that risk estimates depend heavily on how exposure and participation are measured.

These numbers are important, but they should not encourage coaches to search for one biological explanation. Anatomical characteristics, neuromuscular control, previous injury, strength qualities, playing exposure, age, training environment, surface, footwear, fatigue and numerous other factors have all been investigated in relation to ACL injury. In the women’s game, hormonal factors and the menstrual cycle are also frequently discussed, sometimes with considerably more certainty than the evidence currently justifies.

A 2024 systematic review examining menstrual-cycle effects on female football performance found considerable controversy and generally low-quality evidence, with the available research not consistently supporting the idea that different menstrual-cycle phases predictably alter performance. Research into particular hormones such as relaxin has suggested plausible biological mechanisms that warrant further investigation, but this is very different from demonstrating that coaches can accurately predict ACL injury according to a player’s menstrual-cycle phase. For practitioners, individual communication and understanding of symptoms can be valuable, but simplistic rules such as removing players from certain training activities during particular phases of the cycle are not currently supported by sufficiently strong evidence.

This is an important message because female players deserve an evidence-based performance environment rather than one built around assumptions. The ISSPF Professional Certificate in Women’s Soccer Science & High Performance Coachingspecifically addresses the evolving physical demands of women’s football, research trends, menstrual-cycle myths, profiling, load monitoring and integrated high-performance planning. Within the course, Dr Hilary Obert also examines screening and profiling of the elite female player, providing coaches with a way of interpreting individual information without suggesting that screening can predict exactly who will become injured.

The increase in research collaboration within professional women’s soccer is therefore significant. Project ACL was initially established in English women’s football and expanded into the United States in 2026 through collaboration involving FIFPRO, the NWSL, NWSL Players Association, Nike and Leeds Beckett University. The project is deliberately investigating ACL injury through a multifactorial and player-centred approach, rather than beginning with the assumption that one risk factor explains the problem. The US phase began a three-year research process in June 2026, with the broader aim of building a stronger evidence base around professional women’s football. (FIFPRO)

For coaches, the practical lesson is that injury-risk reduction should start with humility. We cannot control a player’s anatomy, genetic characteristics or every unpredictable contact and movement occurring within a match. What the coaching and performance team can influence is the quality of preparation. Players can become stronger, more physically robust, better exposed to high-speed and change-of-direction demands and more capable of controlling the forces associated with landing, stopping and repositioning their bodies during soccer.

Strength, Movement and Training: What Coaches Can Actually Change

Perhaps the most encouraging area of ACL research concerns neuromuscular training. These programmes generally combine several components rather than relying on one exercise and may include strength training, plyometrics, balance, landing mechanics, agility, change of direction and sport-specific movement preparation. A recent systematic review and meta-analysis published in 2026 reported reduced ACL injury odds among female athletes completing neuromuscular training compared with control conditions, while another review focusing on soccer concluded that neuromuscular programmes can reduce lower-limb injury rates and that adherence and quality of coaching are major determinants of effectiveness. (PubMed)

The practical significance is substantial. Injury-risk reduction does not necessarily require a completely separate 30-minute medical programme that sits outside normal soccer training. Movement preparation can be incorporated into the warm-up, strength work can form part of the weekly physical programme and jumping, landing, deceleration and change-of-direction exercises can be progressively connected to soccer-specific tasks. What matters is that these qualities are trained consistently rather than introduced for two weeks after an injury occurs elsewhere in the squad and then forgotten.

Implementation may actually be one of the biggest challenges. A 2026 systematic review examining the real-world delivery of neuromuscular training found that programme effectiveness was strongly related to implementation quality and adherence. Time pressure, competing priorities and insufficient support can reduce compliance, whereas stronger organisational commitment and professional involvement can improve delivery. This is particularly relevant for coaches because the best injury-risk reduction programme on paper has very little value if it is not completed consistently.

Strength development should sit at the centre of this process. Soccer exposes players to large forces during sprinting, jumping, landing, tackling and especially deceleration. A player trying to stop quickly from high speed must manage substantial braking forces through the ankle, knee, hip and trunk. Strength training cannot guarantee that an ACL injury will not occur, but developing the player’s ability to tolerate and control force is a logical component of physical preparation.

Coaches should therefore resist the temptation to think about ACL risk only through isolated knee exercises. Lower-body strength, hamstring capacity, quadriceps strength, calf function, hip strength and trunk control all contribute to how an athlete moves and manages force. The objective is not to make every player demonstrate an identical movement technique, because athletes have different structures and movement strategies, but to increase the physical options available to them when the game becomes fast and unpredictable.

Deceleration deserves particular attention because soccer players repeatedly transition from high-speed movement into stopping, cutting, pressing or changing direction. A technically talented player can still be poorly prepared for the braking demands created by modern football if training predominantly emphasises ball possession in small areas. Coaches who want players to sprint at maximal or near-maximal speed in matches should progressively expose them to those speeds in training, but they should also prepare players to reduce speed effectively and control the subsequent movement.

This creates a direct connection between tactical coaching and injury-risk reduction. An aggressive pressing game requires repeated accelerations, stops, direction changes and reactive movements. A team using a high defensive line may expose defenders to larger-space recovery runs and emergency decelerations. Wide attackers may sprint repeatedly before cutting inside or braking to receive the ball. Physical preparation should therefore reflect the game model rather than existing as a completely separate conditioning programme.

Training load is also part of the equation, although it should be discussed carefully. It is misleading to suggest that there is a universal workload threshold above which ACL injuries occur. Injury does not work that way. However, rapid changes in training exposure, inadequate preparation for competition, excessive fatigue or long periods without exposure to particular physical qualities can all affect how prepared a player is to tolerate match demands. Load management should therefore focus on building capacity and maintaining appropriate exposure rather than simply reducing training whenever injury concerns increase.

The ISSPF Certificate in Soccer Injury, Prevention & Return to Play integrates these different areas through modules on injury analysis, movement preparation, corrective exercise, injury-risk reduction, rehabilitation and training-load management. The course also includes content from Dr Hilary Obert relating to screening and player profiling, helping practitioners understand how objective information can guide individual programmes without turning screening into an inaccurate injury-prediction exercise.

A useful way for coaches to think about screening is to ask whether the information collected will change the programme. Measuring strength, movement, previous injury history or physical capacity can help establish individual needs and guide training priorities. Screening becomes far less useful when the objective is simply to classify athletes as “high risk” or “low risk” without a clear intervention afterwards.

This is particularly relevant in academy and developing-player environments. Younger athletes are still building the strength, coordination and movement experience required for senior football. A recent meta-analysis examining adolescent athletes found particularly high ACL injury risk in female soccer compared with other sports, reinforcing the value of embedding high-quality movement and strength development before players reach the professional level rather than waiting until senior football to introduce it. (PubMed)

Return to Play Is Not the End of the ACL Journey

The difficulty of ACL injury management does not finish when surgery and rehabilitation are complete. For the player, being medically cleared, returning to team training, returning to competition and recovering previous performance represent different stages of the process. These stages may overlap, but coaches should avoid assuming that participation in one training session means the player has fully returned to the physical and psychological demands of elite soccer.

Recent evidence underlines the challenge. A 2026 systematic review and meta-analysis involving 16,905 football players reported a pooled second ACL injury incidence of 21.6% after primary ACL reconstruction. Rates were higher in younger players, female players and cohorts with high return-to-play rates, with the highest pooled incidence found among players younger than 21. The study also reported similar magnitudes of ipsilateral graft injury and contralateral ACL injury, demonstrating why return-to-performance planning must consider both limbs rather than focusing solely on the reconstructed knee. (PubMed)

Earlier research has reached a similar conclusion, showing that younger athletes returning to high-risk sports face a substantial secondary ACL injury burden. This should not be interpreted as an argument against return to soccer, but it reinforces why return-to-play decisions need to progress beyond a calendar-based approach. Time since surgery matters, but time alone does not describe strength recovery, running exposure, change-of-direction capacity, confidence, repeated high-speed actions or the player’s ability to tolerate several demanding training days within the same week. (PubMed)

The final stages of rehabilitation should therefore increasingly resemble the football that the player is preparing to return to. Running exposure should progress towards relevant positional demands, acceleration and deceleration should become increasingly reactive, technical actions should occur under fatigue and pressure and the player should gradually re-enter tactical scenarios involving opponents, decision-making and uncertainty.

This is also where psychology becomes inseparable from physical rehabilitation. Some players return with confidence, while others experience apprehension during tackles, landings or rapid direction changes. A technically successful rehabilitation programme can still fail to restore performance if the player does not trust the knee or remains reluctant to express movements that previously occurred automatically. Coaches, physiotherapists and performance practitioners must therefore create progression rather than simply testing whether the athlete can complete individual exercises.

The communication between medical and coaching staff becomes particularly important during this period. The medical team may understand tissue healing and clinical progression, the performance department may track physical capacity and loading, while the coach sees whether the player can execute the tactical and technical behaviours required within the team’s game model. The player contributes another essential perspective through feedback on confidence, soreness, fatigue and perceived readiness. Return to performance is strongest when these different pieces of information are combined rather than when one department owns the decision in isolation.

Women’s football also needs to consider whether its rapidly professionalising competitive environment is being matched by equivalent investment in medical and performance support. Research published in 2025 examining ACL injuries in professional football reported sex-related differences not only in injury risk but also in treatment and time loss, with the authors specifically arguing that medical framework conditions within women’s football need continued improvement. Another paper described a “professionalisation mismatch”, highlighting how rapidly increasing demands in the women’s game have not always been accompanied by an equally developed evidence base or support structure. (PubMed)

That may ultimately be one of the most important lessons from the current ACL conversation. The growth of women’s soccer should not simply mean more matches, greater commercial exposure and increased training demands. Professionalisation must also include strength and conditioning provision, appropriate medical care, recovery support, player monitoring, access to rehabilitation expertise and time for coaches to implement evidence-based physical preparation.

For grassroots and youth coaches without a large performance department, the principles remain useful. A consistent warm-up incorporating strength, balance, landing, jumping and change-of-direction work can be valuable. Strength development should be viewed as part of soccer development rather than an optional activity reserved for older players. Training should progressively expose players to the speeds and movement demands they will experience in games, while coaches should pay attention to large changes in availability and physical exposure.

Most importantly, coaches should avoid making players fearful of movement. Soccer itself contains unpredictability, contact and high forces. The objective is not to remove those elements from training but to progressively prepare players to cope with them. Stronger players who regularly sprint, decelerate, jump, land and change direction within intelligently designed programmes are being prepared for the realities of the game rather than protected from them.

Olivia Moultrie’s injury has understandably generated headlines because of her age, her importance to Portland and her growing role within the US national-team picture. The more valuable long-term response, however, is to use moments like this to improve what happens on training grounds every week. Coaches cannot promise a future without ACL injuries, and the science should never be presented in that way. What coaches can do is create stronger players, improve neuromuscular preparation, develop movement capacity, manage training intelligently and ensure that players returning from injury are rebuilt for performance rather than simply cleared for participation.

The distinction between ACL prevention and ACL risk reduction may sound like semantics, but it represents an important change in coaching philosophy. Prevention implies certainty that soccer cannot realistically offer. Risk reduction accepts the complexity of injury while still recognising that good coaching, sports science, medical support and physical preparation can make a meaningful difference. For the continued growth of women’s soccer, that evidence-informed approach should become part of normal player development rather than an intervention introduced only after another high-profile ACL injury occurs.

[Editorial image placement: place Image 4 here showing a women’s soccer team training collectively, reinforcing that injury-risk reduction belongs within everyday soccer preparation rather than being isolated from football training.]

The ISSPF Certificate in Soccer Injury, Prevention & Return to Play provides coaches, performance practitioners and medical staff with research-informed insight into injury analysis, injury-risk reduction, movement preparation, rehabilitation, psychology, load management and return-to-play decision-making. Those wanting to explore the wider female high-performance environment can also develop their knowledge through the ISSPF Professional Certificate in Women’s Soccer Science & High Performance Coaching.

TAKE THE ISSPF CERTIFICATE IN SOCCER INJURY, PREVENTION & RETURN TO PLAY NOW

References (7)

Chen, W., Di, Y., Dong, S., Wang, J. and Si, Z. (2026) ‘Neuromuscular training to prevent ACL injuries in female athletes: A systematic review and meta-analysis’, Research in Sports Medicine, 34(3), pp. 338–349.

Gao, Y. et al. (2026) ‘Implementation effectiveness, barriers, and real-world outcomes of neuromuscular training programs for ACL injury prevention in female athletes: systematic review with narrative synthesis using SWiM framework’, Frontiers in Public Health.

Gualtieri, A. et al. (2024) ‘What exercise programme is the most appropriate to mitigate anterior cruciate ligament injury risk in football players? A systematic review and network meta-analysis’, Journal of Science and Medicine in Sport.

Losciale, J.M. et al. (2021) ‘Does sex affect second ACL injury risk? A systematic review with meta-analysis’, British Journal of Sports Medicine.

Norman, D. et al. (2026) ‘Anterior cruciate ligament injury incidence across sex, sport, and competition level: A systematic review and meta-analysis’, Journal of Athletic Training, 61(3), pp. 205–222.

Parker, E.A., Duchman, K.R., Meyer, A.M., Wolf, B.R. and Westermann, R.W. (2024) ‘Menstrual cycle hormone relaxin and ACL injuries in female athletes: A systematic review’, Iowa Orthopaedic Journal.

Wiggins, A.J. et al. (2016) ‘Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: A systematic review and meta-analysis’, American Journal of Sports Medicine, 44(7), pp. 1861–1876.