If you are a female athlete, or the parent of one, this is the most important thing you’ll read before your next sports season. ACL tears, chronic knee pain, hip instability, and even pelvic floor dysfunction during sports are not just bad luck. For many female athletes, these injuries are preventable.
Dr. Kayla Borchers is a pelvic health and orthopedic physical therapist and the founder of Holistically Well Physical Therapy in Sidney, Ohio. She specializes in female athlete performance, injury prevention, and pelvic floor health!
EPISODE 59 | HOLISTICALLY WELL PODCAST: THE FEMALE ATHLETE INJURY RISK EXPLAINED
Whether you learn best by listening, reading, or watching, there is something for you! You can catch the audio version on the Holistically Well Podcast—available on all your favorite platforms!
Holistically Well Podcast on Apple | Episode 59
Holistically Well Podcast on Spotify | Episode 59
Holistically Well Podcast on YouTube | Episode 59
Female Athletes and ACL Injuries: The Statistics Are Alarming
Female athletes are 2 to 8 times more likely to suffer an ACL tear compared to male athletes in the same sports. That’s not a small gap. That’s a crisis — and yet most middle school and high school programs aren’t doing anything about it.
So why are female athletes at such dramatically higher risk for ACL injuries, knee pain, and hip instability? It comes down to four key factors:
- Wider pelvis and increased knee valgus angle
- Weaker hip and glute stabilizer muscles
- Delayed or poor neuromuscular firing patterns
- Hormonal fluctuations that affect ligament laxity throughout the menstrual cycle
Let’s break each of these down — because understanding why is the first step toward prevention.
The Biomechanics of Female Athlete Injury Risk
1. Hip-to-Knee Angle (Q-Angle) and Knee Valgus
Female athletes have a naturally wider pelvis than their male counterparts. This is a biological design feature — the pelvis widens during adolescence to prepare the body for childbirth later in life. But this biomechanical difference also creates a greater angle between the hip and the knee, known as the Q-angle.
This increased Q-angle is the primary reason female athletes are more prone to knee valgus — when the knees collapse inward during landing or running. Think of it this way: imagine headlights on both of your knees. When you land from a jump, are those headlights shining straight forward? Or are they angling in toward each other?
Knee valgus (inward knee collapse) during landing is one of the biggest predictors of ACL injury in female athletes. And it doesn’t happen because of weakness alone — it happens because female athletes often haven’t been taught how to land correctly.
2. Hip and Glute Weakness — Especially the Stabilizers
In sports like running, the body naturally develops strong prime movers — the hip flexors, hamstrings, quadriceps, and glutes that propel you forward. But lateral and rotational stability muscles are often neglected:
- Gluteus medius and minimus (side glute)
- Deep hip external rotators — including the piriformis, obturator internus, and obturator externus
These muscles are responsible for controlling knee stability during landing. When they’re weak or not activating efficiently, the knee has no support from above — and the ACL takes the hit.
Even elite collegiate and professional female athletes often show surprising weakness in these deep hip stabilizers on evaluation. Strengthening these muscles is a cornerstone of ACL injury prevention for female athletes.
3. Neuromuscular Firing Patterns and Landing Mechanics
Here’s something most sports programs never address: how muscles fire together matters just as much as how strong they are.
When a female athlete jumps and lands, the ideal sequence looks like this:
- The foot absorbs initial ground reaction forces
- A soft knee bend follows
- The pelvic floor descends like a trampoline to manage intra-abdominal pressure
- On the rebound (exhale), the pelvic floor recoils upward
- The deep core engages to support the spine and hips
What commonly goes wrong:
- Breath-holding — the athlete braces the core so hard that the pelvic floor can’t coordinate properly
- Stiff landing mechanics — the ankle, knee, and hip don’t absorb force, so it slams into the low back or SI joint
- No one ever taught them to land — seriously. Most female athletes have never received instruction on proper landing mechanics
This is where physical therapy, neuromuscular training, and landing mechanics drills make an enormous difference. These are trainable patterns.
4. Hormonal Influences on Ligament Laxity
Female hormones fluctuate throughout the menstrual cycle — and those fluctuations directly affect how loose or tight connective tissue and ligaments are.
At certain points in the cycle, ligament laxity increases, meaning the joints are temporarily more vulnerable to injury. This doesn’t mean female athletes should stop training during those times — it means they should train smarter, with more attention to alignment, landing mechanics, and stability work.
Every female athlete on a team may be at a different point in her cycle. Some may not have a cycle at all. This is why individualized education about cycle-aware training is so important in women’s sports.
The Missing Piece: The Pelvic Floor in Female Athletes
Here’s the topic that nobody in the locker room is talking about — but absolutely should be.
The pelvic floor is a group of muscles at the base of the core. It functions as the floor of the entire core canister, connecting the lower body to the upper body. The pelvic floor and the deep core muscles are interdependent — the core cannot fire at full strength without pelvic floor engagement.
And yet, pelvic floor training is almost never included in high school or collegiate athletic programs.
Signs of Pelvic Floor Dysfunction in Female Athletes
Pelvic floor dysfunction doesn’t always show up the way people expect. Yes, urinary leakage during sports is a sign — and it’s more common in young female athletes than most people realize. But it can also appear as:
- Hip pain or hip instability
- Chronic low back pain
- Knee pain
- Tailbone or SI joint pain
- Recurrent injuries that don’t seem to heal
If a young female athlete is experiencing any of these symptoms — especially in combination — pelvic floor function should be assessed.
And no, urinary leakage during sports is not normal. It is a sign that something in the muscle coordination system isn’t working correctly. It’s also not something to be ashamed of — it’s simply information that something needs to be addressed.
Why Pelvic Floor Matters for ACL Prevention
The pelvic floor is the base of the core canister. Along with the diaphragm (top), the deep abdominals (front and sides), and the multifidus (back), the pelvic floor creates a pressurized system that stabilizes the spine and pelvis during athletic movement.
When the pelvic floor isn’t functioning optimally — whether because it’s too tight, too weak, or misfiring — the entire system compensates. That compensation shows up in how force travels through the body. And when force doesn’t travel correctly, injury follows.
This is especially relevant for:
- Landing from jumps (basketball, volleyball, soccer)
- Repetitive single-leg loading (running — which is essentially a series of single-leg hops)
- Rapid direction changes (soccer, lacrosse, tennis)
What Does Pelvic Floor Physical Therapy Look Like for Athletes?
This is one of the most common questions and misconceptions. For young female athletes, pelvic floor PT is entirely external. There is no internal examination involved.
Treatment options include:
- Dry needling through the glutes and deep hip muscles to release tight pelvic floor tissue
- Diaphragmatic breathing retraining to restore proper intra-abdominal pressure mechanics
- Core and pelvic floor coordination exercises
- Landing mechanics and neuromuscular training
- Nutrition and hydration guidance — chronic dehydration can worsen pelvic floor symptoms
The goal is to teach the body how to manage pressure, coordinate breathing with movement, and engage the pelvic floor reflexively during sport.
The Role of Diaphragmatic Breathing in Female Athlete Health
This one sounds simple. It isn’t taught nearly enough.
When we breathe correctly — from the diaphragm — the diaphragm drops on the inhale. This:
- Activates the vagus nerve and the parasympathetic nervous system (rest-and-digest)
- Creates downward pressure into the pelvic floor, which should respond by descending
- Allows the pelvic floor to recoil upward on the exhale
Most athletes — especially as stress increases through adolescence — shift into chest breathing. The diaphragm stops moving. The pelvic floor loses its cue. The whole system becomes dysregulated.
Teaching female athletes diaphragmatic breathing and how to coordinate that breath with movement — during running, landing, deceleration — is one of the most impactful interventions in sports injury prevention.
What Early Intervention Should Look Like for Female Athletes
Imagine if middle school and high school female athletes were taught:
- How to land with proper alignment — knees over toes, no valgus collapse
- How to absorb force through the ankle, knee, and hip rather than slamming into the low back
- How to breathe diaphragmatically and coordinate that breath with athletic movement
- How to engage the pelvic floor reflexively — not consciously squeezing, but allowing the reflex to function correctly
- How their cycle affects their body and how to train accordingly
This isn’t about making sport more complicated. It’s about giving female athletes the tools to perform at a higher level, stay healthier longer, and understand their bodies.
Key Takeaways for Female Athletes, Parents, and Coaches
If you’re a female athlete:
- Non-contact ACL injuries are not random — many are preventable with the right training
- Pay attention to how you land. Knees forward, not caving in
- Learn to breathe from your belly, not your chest
- If you’re experiencing leakage during sport, hip pain, or recurrent injuries — these are worth addressing, not ignoring
If you’re a parent of a female athlete:
- Ask about landing mechanics training and neuromuscular training in your athlete’s program
- Know that pelvic floor PT for young athletes is completely age-appropriate and external only
- Urinary leakage during sport is not normal and is treatable
- Summer is an ideal time for preventative work before the competitive season begins
If you’re a coach:
- Consider incorporating landing mechanics instruction into warm-up routines
- Awareness of the female athlete’s unique risk factors is the first step toward creating a safer training environment
- Partnerships with sports medicine physical therapists who understand female athlete physiology can make a significant difference in your team’s injury rates
How to Prevent Injury with Physical Therapy
Whether you’re dealing with current symptoms or want to get ahead of injury risk before next season, working with a physical therapist who specializes in orthopedic and pelvic health for female athletes is the most direct path to answers!
At Holistically Well Physical Therapy, every provider is trained in both orthopedic/sports medicine physical therapy and pelvic floor physical therapy — so female athletes are treated as a whole person, not in isolated parts. Visit drkaylaborchers.com to schedule a visit or reach out with questions!
