There is no consensus on how to remedy the anterior cruciate ligament (ACL) knee injury crisis in women’s football. Maybe because there is no obvious solution. What exactly do we attribute the Rolodex-worth of 2023 World Cup absentees — England duo Leah Williamson and Beth Mead, Canada’s Janine Beckie and Vivianne Miedema of the Netherlands to name a few — to?
The ACL Club has gained six new British members over the past month alone: Arsenal’s Teyah Goldie, Faye Kirby of Liverpool, Manchester United pair Emma Watson and Gabby George, Caroline Weir of Real Madrid and Aberdeen’s Laura Holden.
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How big a role does the menstrual cycle — 2017 research suggests that ACL laxity and risk of injury may increase in the ovulatory phase — have to play?
Do the environments female players grow up in, forging careers on subpar pitches, supported by skeletal medical teams with sometimes scant knowledge of female physiology, mean every player is living on borrowed time in terms of an ACL injury?
What about a rammed fixture list, including an international calendar, condensed by the pandemic years, that will see top players contest five major tournaments (Olympics, Euros, World Cup, Olympics, Euros) in as many years from 2021-25?
Williamson won’t return until after Christmas from an April ACL injury (Clive Rose/Getty Images)
It is difficult to escape the feeling that football would have found a solution by now were this crisis affecting male players to the same extent. Sports science continues to research the mechanics of the female body but that field remains grossly underfunded. It is not hyperbolic to describe this generation of women footballers as guinea pigs.
No wonder so many female players feel like the true mental cost of the game’s ACL crisis is being ignored.
Three of them have spoken to The Athletic in the hope that someone will listen — and that, if the powers that be will not protect them, their fellow players can take measures to protect themselves.
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“Every time I see another (ACL injury), I go through a period of being angry. My heart goes out to that player. I know exactly what they’re going to go through,” says Birmingham City’s Remi Allen, who fully ruptured an ACL for the second time in her career in May 2022 while playing for Aston Villa. The first came at 18 when playing for England, years before the 2018 advent of a professional domestic women’s league. The FA helped to facilitate her recovery then.
“I see the messages players post on social media: ‘I’m going to get my head down, work for this rehab and be really positive’. When I read the messages, I’m like, ‘What’s coming for you is so hard’,” Allen says.
“We’re being let down by the system. If you’re going to keep piling on these games, expect the load of games and training to be sky-high. We don’t have the research. We don’t have enough medical support. We don’t have enough physical performance coaches to support and facilitate it all. We’re being put at risk.”
Allen made 22 appearances for Villa over the past two seasons (Paul Harding – The FA via Getty Images)
Almost 14 years on from that first ACL injury, Allen recalls how, in the third-last match of Villa’s 2021-22 season, history repeated itself.
In the 81st minute at home to Manchester United, she lunged for the ball and her “knee went one way whilst my body weight went the other. I felt like both parts of my legs weren’t attached to each other. The rest of my body spasmed. I had a lot of morphine to try and calm my body down”.
“When you go down with a knee injury, (an ACL) is what you fear the most,” she says.
Confirmation arrived the following Wednesday. With it came the doubts. It was hard enough to come back as an 18-year-old with time on her side. What hope did she have at 31, with just a year left on her contract at Villa? Even if she did make it through, who would offer her a deal?
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“I thought, ‘Is it worth it? Will my body allow it? Mentally, will I cope again?’,” Allen explains. “It was difficult the first time and I felt isolated. In the days and weeks afterwards, I didn’t feel like I could go through with it. I didn’t know if I’d get back.”
Overnight, Allen flipped from being Villa’s ever-present captain to facing 13 months out, her recovery complicated by a second procedure to allow her knee to fully extend again. The laborious process began with basic joint exercises — trying to bend and straighten the affected knee — four to five times a day, before moving on to weight-bearing gym exercises for weeks three to 12.
The more demanding period between months three to eight is, by Allen’s measure, “physically, one of the hardest things ever”.
Team-mates would walk through the gym after their sessions incredulous that Allen was still going. Allen admits her heart would sink each day when she saw the list of exercises she had to re-learn: jogging, changing direction, running at speed.
Allen playing for new club Birmingham in August (Ashley Allen – The FA via Getty Images)
“I spent the first six months in a daze,” she says. “I was doing everything — but in my head, I wasn’t committed to it. I felt so numb and lost with the process. Every time you hit a goal or a target, I struggled to feel positive about it because I knew how much there was more to come. I spent the first six months having a daily battle in my head. But I was able to just sort of survive.”
Attending Villa matches took an understandable mental toll as Allen reconfigured her identity: who was she without football? Playing for Villa had given her a sense of belonging. “To sit in the stands, watch them play and know that you’re not being a part of it — I felt so disconnected and useless,” Allen says.
When Villa declined to renew her contract, she found herself a free agent, for the first time in her career, at age 32.
“A huge part of me felt like a failure and a reject,” Allen says. “That I probably wasn’t good enough anymore. I had a huge debate about whether I should carry on playing or would it be the right time to retire. I wasn’t sure if I was going to get a contract anywhere else. It was a lonely, isolated place.”
Allen’s fears are typical of women’s football outside the top four clubs, where one and two-year contracts are commonplace. The Women’s Super League remains the only full-time league in England. A number of lower-division clubs operate full-time or hybrid models, with many players working outside of football. There are few lucrative contracts to go around. Players are asked to gamble on the slim chance of success in the game — sometimes without a net to catch them if it goes wrong.
Now 20, former Birmingham City defender Lily Simkin made her WSL debut aged 16 but is now without a contract having been released at the end of last season.
Simkin was poised to sign a full-time contract with a Championship club this summer, having spent three weeks on trial during pre-season. But in the final minutes of a friendly, an opponent caught her knee with a high tackle, the force pushing the joint inwards.
Simkin signed for Birmingham’s senior squad in 2019 (Ashley Allen – The FA via Getty Images)
“Straight away, because I wasn’t contracted with anyone, I thought, ‘What does this mean now?’,” Simkin recalls. “‘I can’t get off the pitch. I’m not going to be able to play football in the next couple of weeks’.”
In the physio room the following day, her agent called to tell her that the club were no longer interested in signing her. Then Simkin discovered that none of the club’s female players had insurance.
“I had no idea that was the case,” she says. “They said, ‘You’re going to have to be referred by your GP (regular doctor)’. I’d heard the stories about waiting times (for surgery). It can be years. I haven’t got that time, because I’m unemployed. I don’t go to uni because I was full-time at Birmingham for two years. I’ve gone from being full-time and really excited about joining this new club to suddenly being left with a serious injury and not knowing where to go from it.”
Other clubs withdrew their interest after learning of her injury. “No one’s going to sign a player that’s going to be out for 12 months,” Simkin admits.
Simkin up against Chelsea’s Guro Reiten in 2019 (Morgan Harlow/Getty Images)
Simkin initially used the free National Health Service (NHS) but six weeks of consultations did not result in even a diagnosis.
Her family eventually paid for a private scan and it was discovered the reason she did not hear the popping sound that often accompanies an ACL injury was because the ligament had been ripped completely from her femur (thigh bone). Given the risks to Simkin’s career, she was bumped to the top of the NHS waiting list and had her operation on October 18.
While players with whom she moved up through England youth ranks played an under-23s match in Norway last month, Simkin was preparing for a job interview and researching university courses. Now she is recovering from surgery without a club. “It’s all so new,” she says. “I left school and went into full-time football. I didn’t have a CV. I didn’t have experience in jobs.”
Simkin is speaking out in the hope that players will take out insurance to mitigate the risks they face when playing for or on trial with lower-league teams. “One of the quotes we got for surgery was £15,000,” Simkin says.
She remains a member of the Professional Footballers’ Association (PFA) from her time at Birmingham but those who have never played professionally (in the second-tier WSL Championship or below) are not been eligible for membership of the union. “Women (are) working a full-time job alongside being a footballer to make ends meet because the pay’s not good enough (at those lower levels),” Simkin says.
“This injury could take them out of work. The younger girls are scared to do it and you shouldn’t be scared to play football.”
Hannah Godfrey was the fourth of six Charlton Athletic women’s players to suffer an ACL injury between January 2022 and February 2023. The first had sent shockwaves throughout the squad.
“‘It’s happened at our club’,” Godfrey, now 26, remembers. “That’s when it hits you. You see it happen. You hear the scream. You see when she finds out. It’s honestly heartbreaking. You’re scared it could happen.”
Godfrey played for Tottenham from 2019-21 (Kate McShane/Getty Images)
Then another two players were sidelined with the same injury.
“All these people are so different. One of them is 30 and one is 19. One of them was in training and one was in a game. There’s no correlation. Then my world came crashing down.”
Defender Godfrey had been playing at The Valley, Charlton’s main stadium, in September last year when she became tangled with a Birmingham City striker and her planted foot refused to move. She felt the jerking motion, that telltale pop. “I didn’t want to believe it,” she says. “I was holding my team-mate’s hand, going, ‘I’ve done my ACL’. She kept saying, ‘You’re fine’.”
Days later, the club doctor confirmed that Godfrey had fully ruptured her ACL.
“The tears came straight away,” she says. “I’ll never forget it. The doctor was talking for a good minute, but I didn’t hear anything. I handed the phone to my team-mate and she said, ‘I’m so sorry, can you repeat it all?’’. People will never understand until you hear those words. Football’s all I’ve ever known.”
Initial consultations revealed that Godfrey’s knee was too swollen for immediate surgery. That remained the case for six weeks. “I’d be ready, get my hopes up, go in and the surgeon would shoot me down in seconds,” says Godfrey.
“After surgery, when you’re bedbound and you can’t even get up to go to the toilet without being in pain, it’s mentally tough. I had days spent emotional, crying. I questioned, ‘Why did I go and tackle her?’. ‘Did (the injury happen) because I was on my period? Was it because I had a cold? Had I slept right?’.”
Scotland’s Weir being helped off the pitch after her ACL injury in September (Ian MacNicol/Getty Images)
Her lifeline came in the form of the football academy, Pro 2 Pro, Godfrey built with her team-mate Lois Roche, who was also recovering from an ACL. Between rehab sessions, the pair devised coaching and business plans, and now coach more than 360 players. “It gave me a purpose,” Godfrey says. “We always had something to look forward to, because I no longer had a gameday. I no longer had goals. I had nothing.
“I used to think, ‘If I ever did my ACL, I’m not sure I’d be able to handle it’. I don’t give myself enough credit of how mentally tough and strong I am.
“We need to do more. That’s our livelihood. We give ourselves to the game and it gets taken away in the blink of an eye.”
(Top photos: Getty Images; design: Sam Richardson)