One of the most significant anatomical contributors to ACL injury in female athletes is the narrower intercondylar notch, which is directly associated with a smaller ACL, potentially reducing its tensile strength and increasing its susceptibility to injury [1]. Studies have also shown that a narrower notch elevating the risk of damage by causing ACL impingement on the medial border of the lateral femoral condyle when combined with a valgus load [1,5]. One study suggested that those with a narrower notch have a more vertical coronal orientation of the ACL, which potentially influences the loads it experiences [6]. This combination of anatomical predispositions significantly heighten the likelihood of ACL tear, particularly during the high-impact motions common in football [3,5,7].

Posterior tibial slope (PTS) is another anatomical factor influencing knee biomechanics, with an increased PTS of 10° or more significantly elevating anterior tibial translation (ATT) and ACL strain. This alteration places greater stress on the ACL, increasing the risk of injury, particularly in female athletes, who tend to have steeper tibial slopes than their male counterparts [1,8,9]. Studies have demonstrated a strong linear relationship between PTS and ACL loading, where steeper slopes result in increased ligament strain, potentially leading to ACL tear. Furthermore, excessive PTS has been associated with a higher risk of ACL graft rupture following reconstruction, with patients exhibiting a PTS greater than 12° facing up to an 11-fold increase in graft failure rates [8-10].

Clinical and biomechanical research suggests that interventions such as slope-reducing tibial osteotomies may provide protective benefits, particularly in cases of ACL reconstruction or revision surgery [9]. Additionally, training strategies focused on improving knee flexion control during high-risk movements such as pivoting, cutting, and jump landings are crucial for athletes with an increased PTS. By addressing the impact of tibial slope on ACL injury risk, these findings underscore the importance of individualized screening and targeted prevention strategies to reduce injury rates in female football players [4,8,10].

An increased lateral femoral condyle ratio (LFCR) has emerged as a significant anatomical risk factor for ACL injury, particularly in female athletes. The lateral femoral condyle plays a crucial role in knee stability, with its posterior curvature and articular surface influencing tibiofemoral mechanics [11]. Studies have shown that individuals with a higher LFCR are at greater risk for both primary ACL injuries and failed ACL reconstructions. This is due to the increased posterior condylar depth, which alters knee kinematics and contributes to excessive rotational instability. In female athletes, the mean LFCR is consistently higher than in males, further explaining the disparity in ACL injury rates between males and females [11,12].

Additionally, greater posterior condylar depth may lead to increased length and anisometry of lateral knee structures, such as the anterolateral ligament and lateral collateral ligament, exacerbating knee instability near full extension where non-contact ACL injuries most frequently occur [11,12]. The association between elevated LFCR and contralateral ACL injury risk highlights its role in recurrent injuries can guide treatment decisions, indicating which patients undergoing ACL reconstruction might benefit from additional procedures, such as extra-articular tenodesis, to improve knee stability. Further biomechanical and prospective clinical studies are needed to validate the impact of LFCR on ACL injury prevention and surgical outcomes [11,13,14].

Preventive strategies play a crucial role in mitigating ACL injury risk, particularly in female football players who face a significantly higher incidence of these injuries compared to their male counterparts. Structured injury prevention programs that incorporate neuromuscular training, plyometrics, proprioceptive exercises, and strength conditioning have been shown to be highly effective [4,10,15]. Studies have demonstrated that such programs can reduce ACL injury rates in female athletes by up to 45%, while specific interventions like the FIFA 11+ warm-up program have been associated with an approximately 20% reduction in overall football-related injuries and a 65% decrease in ACL injuries [4,15]. These programs emphasize key injury prevention techniques, including improving landing mechanics, enhancing core and lower limb strength, and promoting better knee alignment during dynamic movements [4,10,15].

Despite compelling evidence supporting these interventions, their real-world effectiveness is often limited due to poor adherence, inconsistent implementation, and lack of long-term integration into regular training regimens. Research suggests that the actual injury reduction rate can be as low as 13% when these programs are not applied systematically, highlighting the urgent need for improved education, structured reinforcement, and leadership involvement from coaches, trainers, and medical teams. Additionally, studies indicate that a minimum of six to eight weeks of consistent neuromuscular training is required to induce measurable protective effects, reinforcing the importance of sustained engagement [10,12,15].

Beyond training modifications, screening for anatomical and biomechanical risk factors can further enhance injury prevention efforts. Female athletes with increased posterior tibial slope, and greater lateral femoral condyle ratio may benefit from individualized intervention plans that target their specific vulnerabilities [4,12,15]. Furthermore, research suggests that proprioceptive and strength-based training should be coupled with fatigue management strategies to reduce the risk of ACL injuries, as neuromuscular control tends to deteriorate under conditions of physical exhaustion [4,12].

To maximize the effectiveness of ACL prevention programs, a multidisciplinary approach involving sports scientists, physiotherapists, and medical professionals is essential. Implementing tailored programs that account for individual athlete risk factors, reinforcing compliance through education, and ensuring long-term commitment from teams and organizations will be critical in reducing ACL injury rates and improving long-term athletic performance in female football players [4,12,15].