The Impact of ACL Injuries on Young Athletes
On a rainy Monday night at soccer training, Grace, 18, slipped and heard a crack. “I instantly went to the floor and sort of knew that I’d torn it,” she says. “I was quite upset. This is my third ACL.” Due to surgery, and the laborious rehab that follows, an ACL injury can keep an athlete sidelined for an entire year, sometimes longer. “Especially through the middle, like the three-month mark, it didn’t really seem like I would get to that stage where I’d play again,” Grace says.
Oscar, 22, tore his first ACL at 18 years old and his second at 19. The rehab was gruelling. “You think you’re invincible until you’re not,” he says. “You don’t realise how much muscle mass you lose from surgery. Getting back into rehab, I sat on the leg extension machine crying because I physically, well, I mentally couldn’t — I couldn’t do it. It didn’t matter how much weight it was, I’d just sit there and my brain wouldn’t let me do it.”
Ava, 16, is 11 months post-op, and is struggling to make her way back to footy. “I had problems fuelling my body properly, so instead of moving forward and gaining more muscle, I was actually losing it,” she says. “I’d just started running again and that was going really well and then recently I had a pre-stress fracture in my back — that set me back like a month — and now I’m experiencing shin pain. I reckon there for a while, I was wondering how much I really enjoyed playing my sport.”
Grace, Oscar and Ava are just three athletes who have been impacted by this injury, which is now affecting more young people than ever before.
What is the ACL?
The anterior cruciate ligament, or the ACL, is a tough band of tissue that sits in the middle of your knee, connecting the femur (thigh bone) to the tibia (shin bone). The ligament stabilises the knee, stopping it from twisting or sliding too far when landing, pivoting or changing direction. “You could think of it a little bit like a seatbelt that keeps your knee stable,” says Kate Webster, the head of department of sport, exercise and nutrition science at La Trobe University.
Professor Webster has spent a great deal of her career researching ACL injuries and says most of them happen without contact. “You don’t even need somebody to crash into you,” she says. “It often happens when you’re changing direction quickly — you might be moving to the side to dodge an opponent, or landing from a jump, or planting your foot to pivot. Australia actually has one of the highest rates per number of people in the world, and right now younger people have the highest chance of tearing their ACL.”
Why the Increase?
An Australian study that wrapped up in 2015 tracked the rate of ACL injuries over 15 years and found a 74 per cent increase in ACL reconstructions in young people. A more recent study, released in 2022, looked at ACL injury trends over 20 years, showing injury rates are still increasing, and it’s happening fastest in kids under 15, particularly girls.
Partly, this is because more young people including girls are playing high-risk sports like netball, soccer, footy and basketball. Awareness and diagnosis have also significantly improved over time and are contributing to this increase. However, experts believe there are a couple of other things going on here, too; one is that kids don’t spend as much time outdoors as they used to, so their bodies are not as prepared as they should be for playing sport.
“I’m a kid from the 80s,” Professor Webster says. “We spent a lot of time on monkey bars, hard surfaces; we didn’t have, you know, computer games to the same extent. Children and adolescents go from spending a lot of time indoors, in front of screens, computers, gaming, to then playing competitive sport, but [there’s] much less of that free play time.”
At the same time, we are seeing more of something called early specialisation. “Younger people tend to focus on just one sport from a young age and that often equates to longer seasons, extra training and just less free playtime. For young people their bodies don’t then get the chance to build all-round strength.”
Aneeka Smith, a physiotherapist with strength and conditioning gym HPC and the under-19 Australian women’s basketball team, echoes Professor Webster’s concerns. “I think early sport specialisation is a big one,” she says. “If you’re just doing one sport, especially full-time, not having an off-season … that also leads to increased injury risk.”
Preventing Injury
As part of her job, Aneeka works with athletes and coaches to implement injury prevention programs such as Football Australia’s Perform+, Netball Australia’s The Knee Program, and AFL’s Prep-To-Play, which have been shown to reduce the risk of ACL injuries by 40 to 50 per cent. But these programs are not always making their way to grassroots sporting spaces.
“I think there’s still a way to go with the education to coaches,” she says. “Incorporating [the programs] into your warm-ups — it might just be 10 minutes, two to three times a week — has a massive impact. Obviously, we’d rather be proactive than reactive; we don’t want to wait for an injury to occur. If we can get on top of it before something happens, then we can set you up for a really long, successful career in sport.”
Making a Comeback
ACL injuries and reconstructions can have long-term impacts and for some they are career-ending. After suffering an ACL injury, 70 to 80 per cent of young people will return to some form of sport, but only about 60 per cent return to their pre-injury levels of sport.
Grace plans on making her way back, for a third time, and believes finding support and connection is crucial for young people rehabbing long-term injuries. “[I] definitely reached out, I went and saw a sports psychologist,” she says. “Through my second rehab, I included myself with my team a little bit more. Through my first rehab, I didn’t do that and I found it really hard … my mental health with that one, I struggled.”
The second time around, Grace even created a support group to make the process less lonely. “There was quite a lot of girls that I knew [who] did their ACLs at the exact same time,” she says. “[It’s] quite helpful because we were like, ‘Oh, how are you going?’ like, ‘What stage are you up to?’, and kept each other motivated to get back.”
For Ava, returning to footy means rejoining her social group and rediscovering a part of who she is. “I started footy because of my best friends,” she says. “[I’m looking forward to] being able to play again, and just getting out there with a bunch of my good friends … just being able to show everybody how much hard work I put in to get back.”
Returning to sport doesn’t necessarily look the same for each person. Oscar, who had always played footy, decided to hang up his boots at 19 years of age, as the risk of re-injury, which would be followed by another year of rehab, was not worth it for him. “It was difficult to start with — I’d never not played football before — and then, over time, it sort of became easier to deal with,” he says.
Oscar now competes in ultra marathons and is training for a 60-kilometre race and a 100km race in a couple of months. “I love what I do and part of me thinks it was a good thing in a weird way,” he says. “I wouldn’t wish it upon anyone, but it definitely put me onto a path that I probably more enjoy.”
