ACL tears keep sidelining women’s basketball stars. What’s going on?

DURHAM, N.C. — JuJu Watkins stood on the sideline inside Duke University’s Krzyzewski Center, wearing Team USA gear from head to toe. While everyone else was in uniform, though, the USC star was in an all-blue hoodie with the USA logo on the back. Instead of practice shorts, she wore matching sweatpants.

The top bun Watkins is known for on game days was lower and pulled to the back. As every other player at the USA Basketball national team training camp last month hustled up and down the court, she watched, unable to participate because of a torn ACL suffered in last year’s NCAA tournament.

“I would love to be playing, but this is just where I’m at right now,” Watkins said. “I’ve accepted that, just continue to work every day. I’ve learned a lot throughout this process just about myself and about the game.”

The biggest name in college basketball won’t take the floor this season. She’s just the latest in a long line of prominent female players — in college and the pros — to fall victim to an ACL tear in recent years.

Paige Bueckers. Azzi Fudd. Ashlyn Watkins. Chloe Kitts. Olivia Miles. Cameron Brink. Georgia Amoore. Courtney Vandersloot. Sydney Colson. Jordan Horston. Nika Muhl. Katie Lou Samuelson. Kristi Toliver.

The 15th-ranked Maryland Terrapins have three players out this season with a torn ACL: Bri McDaniel, Lea Bartelme and Ava McKennie.

ACL tears are common in high-level athletics, and women are particularly at risk. According to a review published in the National Library of Medicine, female basketball players are 3½ times as likely as their male counterparts to have an ACL incident. (In soccer, it’s 2.8 times as likely for women.)

With medical capabilities and understanding advancing by the year, an ACL tear is no longer a career-ender. However, the higher risk for women raises a question: What can be done to prevent this common occurrence?

Physiological differences

Vehniah Tjong, an associate professor of orthopedic surgery at Northwestern University, cites several physiological reasons women are more susceptible to ACL injuries. One of the biggest factors is the tendency to have valgus knees, better known as knock knees, which means the knees angle inward when standing. This causes women to jump and land more upright, with more knee extension, Tjong said. Men tend to land with more flexion and core control, with lots of knee bend and the chest close to knees in a flexed form.

“Just from these learned landing mechanics, females then are just more predisposed to tearing their ACL because ACLs are more at risk when your knee is more straight, when your knee is hyperextended,” said Tjong, a physician for the Northwestern football team and the U.S. women’s national soccer team.

That’s just one part. Surgeons and athletic trainers point to imbalances in the gluteal and quadriceps muscles and how they affect the way women jump and cut and place stress on their ligaments. The width of their hips and pelvis also could play a role in the injuries. There’s even debate about whether hormonal differences are connected to a higher risk.

Basketball — with players jumping, quickly changing directions and trying to adjust to movements of other players within their space — amplifies the risk.

“We have to start educating kids from a younger age on how their body works, what muscles they need to stretch, what muscles they need to activate,” said Elise Caldwell, an athletic trainer and performance coach working in the D.C. area. “ … If you’ve been doing the wrong cutting techniques since the age of 10, it’s going to take thousands of repetitions of doing it the right way for your body to naturally start cutting the right way.”

Minimizing risk

Steps can be taken to reduce the risk of ACL tears, including a variety of publicly available jump-training programs. These can start around adolescence as kids begin to get bigger and stronger. Tjong pointed to programs that focus on activating muscles that women aren’t particularly adept at working.

Many in the medical community suggest eliminating specialization, in which athletes focus on one sport year-round. Having a variety of athletic endeavors lessens the repetitive stress from the same actions and also develops other muscles and movements. At the college level and in the professional ranks, medical teams featuring athletic trainers, physical therapists and other support staffers provide significant help.

“We have a really good body of knowledge that says if you do these programs and you do these programs regularly, they work,” said Amy Arundale, the director of movement, science and innovation for the Washington Wizards.

Arundale said resources play an important role in prevention and recovery. Those resources go beyond equipment and facilities. They include enough staff for individual programs to be developed and implemented. An ideal setup is a team-based approach that includes athletic trainers, physical therapists, strength and conditioning staff, surgeons, coaches and even a sports psychologist working together to design plans for individual athletes.

But women’s sports historically have received less funding than men’s sports. The WNBA players association believes this affects injury prevention and recovery, and it is advocating for more resources as it fights for a new collective bargaining agreement. The current deal requires organizations to have just one team physician and one full-time athletic trainer. The NBA, by comparison, requires at least two lead team physicians, one head athletic trainer, an assistant athletic trainer and a head strength and conditioning coach.

A person with knowledge of the WNBA players’ stance, speaking on the condition of anonymity to discuss private conversations, said that the current requirements were inadequate and that players have had issues with having to wait to get treatment, not having enough staff available and not having someone coordinate between different medical entities.

“This feels like a culmination of a lack of investment or a lack of attention to the female body in medicine,” the person said, “particularly on folks who are athletes and, yes, a lack of investment in the infrastructure that keeps athletes healthy. This really does feel like, ‘How are you valuing these assets and their bodies and their livelihoods?’ … This just feels like another example of the devaluation, frankly, of the contributions of these athletes. And it has to change.”

For one example, the NBA’s Indiana Pacers list eight full-time medical staff positions. The WNBA’s Indiana Fever, owned by the same organization, lists three.

The mental component

Watkins doesn’t talk much about her injury, at least publicly. She has declined interview requests on the subject but held sessions at the USA Basketball camp. Still, she didn’t give a ton of insight into the nine months since she drove to the basket in the second round of the tournament against Mississippi State. As Watkins began to gather with two defenders in her space, she collapsed and grabbed her right knee, rolling on the floor in pain. She was carried off the court by a pair of staffers.

Since, Watkins repeats the phrase “taking it all one day at a time.” She did say Bueckers has provided some support, having gone through the injury herself in 2022 and missing an entire college basketball season. Bueckers, who overcame her injury to become an NCAA champion at Connecticut and the WNBA rookie of the year with the Dallas Wings, reached out to Watkins and continuously checks in with her.

“It sucked, but everything happens for a reason,” Watkins said. “For me, personally, just kind of getting over that mental curve I guess has been the biggest [thing]. I don’t really know what that looks like for other people, but I think just coming to terms with it as soon as you can and try to have a positive mindset as much as possible.”

At Maryland, McDaniel knew what was coming when she tore her ACL last January. This was her second ACL tear — her first came in high school — and she anticipated the long, monotonous road in front of her.

Life becomes repetitive, and the mind plays games. There are times when you just want it to be done. There are times when you think you’re further ahead than you are — and a setback can be deflating. There are times when it doesn’t seem you’re making progress. And despite plenty of evidence suggesting otherwise, there are times when a little voice questions whether you will ever be the same.

“It makes you be in your head a lot,” McDaniel said. “My first time was the worst experience I ever had.”

Rehab isn’t linear, and sometimes it forces tough choices. Last month, McDaniel decided not to return to the Terps this season. She had been ramping up to play in January but instead opted to redshirt, saying, “I am not where I need to be.”

The mental toll can be heavy and can affect an athlete’s approach to rehab. Sports psychologists have become prevalent on medical staffs, and injury recovery is a big reason.

Also valuable for players such as McDaniel and Watkins is looking halfway across the country and seeing a post-ACL success story.

Miles, the TCU star, recently became the third player in Division I history to post three consecutive triple-doubles. She missed the entire 2023-24 season with a torn ACL. And she sounds relieved when she thinks back to her injury.

“I’m satisfied because I’m healthy at the end of every game,” Miles said. “It doesn’t matter if I have zero points or 25 points. Being hurt has taught me to value each possession, each game. If I make it through 40 minutes healthy, it’s a win for me.”