Monday, May 12, 2008

Sexism Hurts: ACL Injuries & Women Athletes

Sexism can be simple and obvious (e.g. the FA ban on the women's game, or Man U's Christmas 'Rape' party). More often, it's subtle, complex, and really hard to tackle. Take, for example, the impact of poor medical understanding of women in general on women athletes in particular.

We see this in the alarming frequency with which women athletes who play especially soccer and basketball suffer ACL tears. The ACL tear is a very serious knee injury, requiring complex surgery and a lot of recovery time. (Pictured, right: Danielle Fotopolous, USNWT retired in 2007 after tearing her ACL for the third time in 2006.)

The New York Times Sunday magazine just published a long, in-depth story about young women soccer players, the injuries they sustain, and the difficulty we have in dealing with them (The Uneven Playing Field). The article is adapted from Michael Sokolove's forthcoming book Warrior Girls: Protecting Our Daughters Against the Injury Epidemic in Women’s Sports. (Can I just say: I hate that title. It's so paternalistic! And aimed at the parent-reader, not at the female athlete. How about - Match Fit: Injury Prevention for Young Women Athletes?)

This interesting article is unfortunately wrapped in a sensationalist package. Problematically, Sokolove makes news of the fact that more women are injured as more women play (really?!). The following rhetoric, for example, makes it seem like Title IX is the cause for the increase in 17 year olds needing knee surgery - and as if this were in itself the problem:
This casualty rate [JD: no statistic here, the author just means the number of injuries suffered by a couple of high school teams] was not due to some random spike in South Florida. It is part of a national trend in the wake of Title IX and the explosion of sports participation among girls and young women [No soccer teams = No ACL tears]. From travel teams [these are the club teams not based in the school system] up through some of the signature programs in women’s college sports, women are suffering injuries that take them off the field for weeks or seasons at a time, or sometimes forever. [Unlike men? I mean, of course women suffer career-ending injuries! At least they don't break each other's legs!]

The author then goes on the explain how girls develop differently - e.g. boys get more muscle, but less flexible; girls get more fat but more flexibility. The author's language flirts dangerously close to naturalizing girls and women as weaker, more delicate etc. I'm not the only one to spot this slant.

The main issue in this article, however, is women athletes' specific vulnerability to the ACL tear and the lack of understanding of the specific needs of female athletes - a failure caused not by Title IX, but by the ingrained sexism of medicine and sports culture.

Towards the end of the article, the author interviews Holly Silver, a physical therapist who has developed a knee injury prevention program that should be adopted by all footballers and their trainers.

Silver touches on some possible reasons for the high rate of ACL tears in women athletes: Girls are taught to walk and stand and move through the world differently. We curl around our chests - our bodies become shells, in a way, protecting/hiding everything 'feminine' - those bits are sources of shame, abuse, negative attention. [Ed: Found this note on Kickster, about the reception of the first women's game in 1894: "The British Medical Journal offered its professional opinion that 'we can in no way sanction the reckless exposure to violence, of organs which the common experience of women had led them in every way to protect'."]

One of the beautiful things about playing football is that it forces women to free their bodies from this shell: You can't trap the ball with your chest if you are hiding it from the world. You can't make a good play if your eyes are trained on your feet. You won't have much touch or footwork if your hips are locked.

Pointing to a player with good form, Silver explains

'She moves like a boy....Believe me, that's a good thing.'

In other words, that girl carries herself like an athlete. Girls are not encouraged to adopt this stance (knees bent, butt low to the ground). And so that posture has become synonymous with 'boy'. Boys of course aren't born moving this way - and lots of boys don't carry themselves that way (and are therefore terrorized for 'walking/throwing like a girl'). The point here is that the social inscription of gender is deep: it may be culturally produced, but it is carved into our spines, and worked into our joints. Girls need to unlearn that stuff - as athletes, they sometimes literally need to learn to walk, and run. (FYI: Philosopher Iris Marion Young writes about these issues in her collection of essays, On Female Body Experience: 'Throwing Like a Girl' and Other Essays.)

Silver describes the extraordinary consequence of the way that girls inhabit their bodies as they play sports - if you run with poor posture, your running is not only inefficient, it harms your back, hips, all your joints in fact. As any yoga practitioner will tell you, holding tension in your joints not only makes you less flexible and responsive (slowing your reflexes), it makes you more prone to aches and pains.

My sister coaches girls cross-country and track at Voorhees High School in New Jersey. Her teams have been very succesfull. Injury prevention is a big part of her program. They work on building up their strength in the gym, on minimizing strain to their muscles, on overall health and well-being. For example, she has the girls keep an eye on their iron levels - anemia is a big problem for teenage girls and young women, and can have a big impact on your development as an athlete. She's always looking for the latest information on issues like these, and keys these insights to the specifics of her sport and the people she coaches (teenage girls). Not all coaches approach their work this way.

One must recognize gender differences in order to coach/train/treat athletes well. Those differences may be physiological, metabolic, social and psychological.

For example, athletes in general are loathe to report injuries. Reporting injury or medical problems can be even harder for some girls and women. Here are some reasons why:

*We don't want to seem weak. In a world that reads all physical signs of womanliness as symptoms of the weakness of your sex, getting an injury makes you feel like your body has betrayed you, again.

*Women athletes can be reluctant to own up to the differences gender makes, because admitting to those differences has meant admitting to belonging to the 'weaker sex.' Remember: every girl - even today - will be told at some point that girls can't or shouldn't play or compete. Every girl hears that girls are weak, that they aren't tough. Or that playing a sport makes them mannish - i.e. repugnant. To all of this, players say: Fuck That, and get on with it. So, not only do we not want to seem weak - sometimes we don't want to seem like 'girls'.

*Doctors treat us differently. They don't listen to what we say about our bodies. They read everything through their ideas about our reproductive system. Our experiences with doctors tend to start off bad, and get worse. We have little reason to trust them.

*We are taught to accept certain physical symptoms as 'natural': tiredness (symptom no. 1 of anemia), especially.

*We are reluctant to talk about our bodies - sport is often the only avenue through which we get to talk about our bodies in a way that is neutral, matter-of-fact and empowering. I'll never forget listening to my sisters talk about pre-race bowel-clearing nerves and the humiliating but often hilarious situations that puts you in. As much as their stories made me laugh, I didn't really 'get' it until I started playing football and found myself at Hackney Marshes trying to act cool as we waited for the mens' teams to clear out of the damn bathrooms. Never, ever, go to Hackney, ladies, without a roll. Somehow, I associate that kind of frank and humorous talk about the body with 'jock'-culture. Some of us need encouragement to adopt this kind of attitude.

*Girls aren't always used to thinking of their bodies as something they can control. Except by starving themselves.

Add onto the above the following:
*Many girls and women play team sports on bad fields/in poor facilities.

*98% of sports stores don't carry football boots made for women - and that 2 % will carry maybe two kinds. The overwhelming majority of women wear men's boots, in other words.

*Because women were prevented from playing for so long, coaching/training is modeled after the boys/mens game, and a lot of coaches are not aware of things like the frequency of ACL tears in young women footballers and the conditioning programs which might prevent those injuries.

*We accept the differences in the way that men and women move as 'natural', and so do nothing to raise girl athlete's awareness of poor posture on the field, poor running technique, the importance of being relaxed and having a good stance.

*And, most problematic of all: we don't listen to girls. We don't take their complaints seriously. We dismiss their complaints as teenage melodrama or psychosomatic weakness.

That's a lot of crap to deal with. It's why teaching/coaching/advising girls and women can be harder - but it's also why it's so absolutely rewarding. The things we learn in such settings not only change how we play - they in fact change how we live.


  1. I just finished reading the article in the Sunday NY Times Magazine. I have a knot in my stomach from it! As a middle aged woman, I did not get the chance to play soccer. No women's soccer team at my high school! Articles like this are dangerous! There is not enough 'good science' included! No real statistics! It will only serve to scare parents and crank up the Conservatives to throw women's sports back into the Dark high school years when women didn't even get the chance to compete! I protest vehemently.

  2. i know. one of the reasons athletes in general and women in particular don't like going to see a doctor about an injury is that they often don't think getting us back on the field is a priority. one of my teammates just told me that when she had a cruciate injury her doctor asked her how it happened. when she said 'playing football', he said 'what were you doing that for?' and then laid out a surgical plan which would have ended her playing career forever. she refused to sing the papers authorizing the surgery and went out on her own to find a doctor who has treated english women NT players with the same injury. that doctor made getting her match fit a priority, got her back in working order. shows you how much luck and your own empowerment can impact how your injuries are dealt with!

  3. I thought this was an interesting and useful piece. I coach an O-30 women's team which has had 2 ACL injuries in the 80 or so matches we've played since I got involved. That's two too many and unfortunately neither player managed to make a comeback afterwards, although there were other factors besides the injury.
    I appreciate the ACL injury prevention link and will be taking a look at it.

    Neville Wardle
    Coach, Valley Fire WFC

  4. Jennifer,

    I was thinking of this post the other day when I was walking by my local football pitch during a girls high school soccer game, which featured some fairly aggressive two-foot tackles and some fairly callous treatment from one male coach in particular. It was weird, very stereotypically suburban "walk it off" sort of thing...

  5. Well - I missed the New York Times Articles...just as well. I am doing alittle research now. My daughter (just turned 16) plays competitive soccer and torn her ACL this weekend. We are being positive -- she has made soccer her main focus in life..supposively she will have a 3 to 4 month recovery but from my reading it sounds like it will be longer. However -- I pray that we keep progressing are able to prevent women/girls from becoming injured in the first place. But I think we have a long road ahead of us.

  6. wilsonkb,

    Sorry to hear about your daughter's injury. There is a link on one of my blogrolls to the "PEP" training program for ACL injury prevention - and through that you can find the site for the people who created that program - they are based in Santa Monica, but can probably help you find the leading edge of information on recovery and the prevention of compound injuries, etc.

    Good luck!

  7. I am a 46 year old women and active paragliding pilot. I had a fast landing this past week and fell to my knees. I managed to tear my ACL,LCL,MCL and some meniscus damage.
    I am looking at reconstruction surgery in a couple of weeks and then months of rehab. My OS told me that he sees this injury ingirls at a rate of 6-1 and that not only suprised me, itt frustrated me that it was something I was totally oblivious to. I have been doing a lot of research on my own and there seems to be a strong correlation between torn ACL's and the female menses cycle. I have read that women are far more susceptible to this injury during pre-ovulation (which happens to be right where I was). It makes me wonder if I had the same landing a week or even two weeks later...would I even have an injury? Unhappily, I am grounded for quite awhile! K

  8. There is some thought that the position in which boys and girls "carry" themselves isn't something that is learned, per se, but rather the effects of evolution. Men have been running and crouching and jumping and landing and attacking for eons. Women, not so.

    Is this so? I don't know, I haven't studied it. But it makes a lot of sense. I was never taught how to "carry" myself on the athletic field. It came naturally. Women who have learned strategies in this regard tend to be better off than those who haven't.

    The PEP program also is most worthwhile.

  9. Hi Jennifer,

    It is really an interesting article that you have put here. It shows the way other perceive women in sports. Though the article in the NY times is not completely wrong but the way you have quoted few parts of the article, it has not been put in the right form. Male and Female bodies differ in human beings morphologically, these differences are obvious in form of large pelvis and more laxity in the body. If you think that I am also being a sexist, its not like that but its a fact, these two things mainly along with other anatomical differences between male and female body, like the strength of the ligament as well as the breadth of the tunnel in the thigh bone, where it passes from to its attachments, are different, and this makes women more prone to ACL injuries. But as you know, our work demands certain physical capabilities, I am a physiotherapist and if some one asks me to wrestle or play football, for sure I shall be injured because my body is not prepared for it and just the right kind of training, keeping in mind the physiology of a female body as well as the external factors as you rightly mentioned about the quality of pitches and equipment like the boots can help prevent the injuries. The description of the style of a lady sitting on a bench does not relate to the football injuries as such but sure inadequate training and prevention relates to it. Its really interesting to read your blog on this article.

  10. Thanks for your comment - great to get a professional in this discussion! My point is that we should, as you say, acknowledge physical differences so that we can key preventative training. Thanks for writing in.


Feedback? Let me know what you think. Just an FYI: all comments posted to this blog are recorded, whether I publish them or not. I do not publish generally hateful comments - whether they be directed at me or at players and teams or other readers. I appreciate reader feedback, especially from those whose contributions add nuance and complexity to the story.

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