Female ACL Injury Prevention: Why Women Tear More — and How the FIFA 11+ Program Works

The numbers are stark

In soccer, basketball, netball and AFLW, female athletes are 3 to 8 times more likely to tear an anterior cruciate ligament than males playing the same sport at the same level. In adolescent girls aged 14–18, ACL injury rates have been climbing in Australia over the past decade as participation grows. Most of these tears happen in non-contact situations — a landing, a cut, a sudden change of direction — which is exactly why they're preventable. You can't always avoid being tackled, but you can train the way you land, cut and decelerate.

Why women tear more — the four factors

The risk gap isn't 'fragility.' It's a stack of modifiable and non-modifiable factors:

• Anatomical: A narrower femoral notch can mean less room for the ACL during pivoting. A wider pelvis (Q-angle) places more valgus moment at the knee.
• Hormonal: Oestrogen and relaxin affect ligament laxity across the menstrual cycle. The pre-ovulatory phase shows higher injury rates in some studies.
• Biomechanical: Under fatigue, female athletes tend to land with more knee valgus (knee caving in), more hip adduction, and a 'stiff' knee. This is a learned and trainable pattern, not destiny.
• Training history: Many girls reach high-level competition with less cumulative exposure to jumping, landing, cutting and gym-based strength work than boys of the same age. The neuromuscular system isn't grooved yet.

Anatomy and hormones we can't change. Biomechanics and training history we absolutely can — and that's where injury rates drop.

What is FIFA 11+?

The FIFA 11+ (also called '11+') is a structured, evidence-based 20-minute warm-up program developed by FIFA's medical research centre with Norwegian, American and Swiss research institutes. It has three parts:

• Part 1 (running): Slow running with active stretches, hip and torso movements. ~8 minutes.
• Part 2 (strength, plyometrics, balance): Six exercises (Nordic hamstrings, planks, single-leg balance, squats, jumping) progressing through three levels of difficulty as the team gets fitter. ~10 minutes.
• Part 3 (running): Sprints with planned changes of direction. ~2 minutes.

It replaces — not adds to — the team's normal warm-up. That's the key to compliance. Coaches who try to bolt it onto an existing warm-up usually drop it within weeks.

The evidence base

Soligard et al. (2008, BMJ) ran a cluster-randomised trial across 1,892 teenage female footballers in Norway. Teams running FIFA 11+ at least twice per week showed a 32% reduction in overall injuries and a 50% reduction in severe injuries. Silvers-Granelli et al. (2017) studied US collegiate male soccer (different cohort, same program) and saw a 46% reduction in injury rates. Meta-analyses of neuromuscular training programs more broadly suggest 30–60% reductions in ACL injury specifically when programs are well-implemented.

The catch: the programs only work when teams do them. Compliance below 1.5 sessions per week shows little effect. This is a coaching commitment, not a one-off workshop.

The six 'big rocks' of female ACL prevention

If your team can't run a full FIFA 11+ every session, drill these six things consistently:

• Drop-jump landing technique — knees track over toes, soft landing, hips back. Cue: 'land like a ninja, not like a sack of bricks.'
• Single-leg deceleration — sprint and stop on one leg in a balanced position; progress to cutting at 45° and 90°.
• Nordic hamstring curls — the single most evidence-backed hamstring injury prevention exercise; also protective at the knee.
• Side plank with hip abduction — gluteus medius drives knee alignment in landing and cutting.
• Bulgarian split squats / single-leg RDLs — unilateral strength is more sport-specific than bilateral squat numbers.
• Hopping in multiple planes — forward, lateral, rotational — under fatigue.

The strength layer on top

FIFA 11+ is a brilliant baseline. For girls playing at higher levels — rep teams, NPL, talented identification programs — supplementary gym-based strength work 1–2x per week adds meaningful protection. The big rocks: back squats, trap-bar deadlifts, Nordics, Copenhagen adductor planks, calf raises. Strength buys you tolerance to the forces sport puts through the knee. Strong athletes get injured less; injured strong athletes recover faster.

Menstrual cycle awareness — not a reason to bench

Some research shows higher ACL injury rates in the pre-ovulatory phase of the menstrual cycle when oestrogen is rising. This is a topic to be aware of, not anxious about. The practical implication for clubs and coaches:

• Normalise period tracking among athletes (apps make this easy).
• Don't push absolute peak loads on the day before a known high-laxity day if a player already feels off.
• The bigger drivers of ACL injury — fatigue, poor warm-up, deconditioning, fear-driven 'stiff' landing patterns — are still bigger levers than cycle phase.

Local sport in Cabramatta and Southwest Sydney

From Cabramatta Rovers junior girls through to NPL teams in Liverpool, Fairfield and Bankstown, the same patterns play out: pre-season is short, training is heavy on skill and light on jumping/strength, and the first big injury usually hits in round 3–6 when fatigue catches a deconditioned chassis. Building 20 minutes of FIFA 11+ into every training session — and a gym session per week through pre-season — would shift those numbers locally.

What if she's already torn it?

Prevention transitions into rehabilitation. The principles overlap — single-leg strength, landing mechanics, decelerative control — but the timeline and progression are different and the criteria for return to sport are non-negotiable. See our ACL return-to-sport testing post and our non-surgical ACL management piece. The ACL Comeback Program is the structured 9–12 month plan we use with our own clients.

For coaches, parents and team physios

• Commit to 2x/week FIFA 11+ from pre-season onwards.
• Add 1x/week supplementary gym strength for any girl playing more than 2 nights of competitive sport per week.
• Treat landing technique as a core skill, the way you treat first touch.
• Get a baseline single-leg hop and Y-balance screen each pre-season so risk is tracked, not assumed.
• Don't drop the program once injury rates fall — that's how they come back.

Book an ACL prevention screen

We run individual and small-group ACL prevention screens for adolescent and adult female athletes — landing assessment, single-leg strength, hop testing — and build a 12-week plan from there. Book at Evolve Physio & Mastery, Cabramatta. We work with players and clubs across Liverpool, Fairfield, Canley Heights, Bankstown and Southwest Sydney.

References: Soligard et al. 2008 'Comprehensive warm-up programme to prevent injuries in young female footballers' (BMJ); Silvers-Granelli et al. 2017 'Efficacy of the FIFA 11+ injury prevention program in the collegiate male soccer player' (Am J Sports Med); Sugimoto et al. 2015 meta-analysis of neuromuscular training and ACL injury in female athletes.