Exploring the disproportionate impact of ACL injuries on female handball players and evidence-based prevention strategies
It's a scene that plays out on handball courts with alarming regularity: a sudden change of direction, an awkward landing, and then—the devastating pop. A talented athlete crumples to the floor, clutching her knee. For countless female handball players, this moment marks the beginning of a grueling journey through surgery, rehabilitation, and the psychological battle to return to sport. The anterior cruciate ligament (ACL) injury has become one of the most significant challenges in women's handball, ending promising careers and threatening the long-term joint health of athletes worldwide. As the sport grows in popularity, understanding and confronting this epidemic has never been more critical.
Handball stands out as one of the most demanding Olympic sports, characterized by high-intensity movements, rapid directional changes, and frequent player collisions. Unfortunately, these very attributes that make the game exciting also contribute to its distinction as having one of the highest injury rates among team sports 1 . Within this landscape, ACL injuries have emerged as a particularly devastating problem, with female athletes bearing a disproportionate burden of risk.
The statistics paint a concerning picture. Research reveals that female athletes suffer ACL injuries at a rate 2-8 times higher than their male counterparts participating in the same sports . This disparity is particularly pronounced in handball, where the dynamic, pivoting movements create perfect conditions for non-contact ACL tears.
A sobering study of German professional handball revealed that 46.3% of ACL injuries were actually re-ruptures 8 , highlighting the vulnerability of athletes returning to play and the potential shortcomings in our current rehabilitation and prevention approaches.
Higher ACL injury rate in females vs males
Of ACL injuries are re-ruptures
Higher risk in 2nd division vs 1st division
Female athletes typically have a different skeletal structure than males, including a wider pelvis that creates a greater angle between the thigh bone and shin bone (Q-angle). This altered alignment increases stress on the knee during cutting and landing maneuvers .
Women tend to have smaller ACLs and a more narrow femoral notch, which may predispose the ligament to impingement and failure .
The hormonal environment also appears to play a crucial role. Fibroblasts in the ACL contain estrogen receptors, and elevated estrogen levels have been shown to affect ligament laxity .
Perhaps the most modifiable risk factors lie in the movement patterns specific to female athletes. Years of research have identified several "dominance" patterns that increase ACL vulnerability 2 :
To understand the true scope of the ACL epidemic in handball, we look to the landmark SWEREX study—a comprehensive investigation that tracked ACL reconstruction rates across Sweden's highest-level athletes. This research offers crucial insights into the sport-specific risk patterns that inform today's prevention strategies.
The SWEREX team adopted a meticulous approach, linking data from the Swedish National Knee Ligament Registry with seasonal information from six sports organizations 4 . The study focused on higher-level athletes—those competing in the top two divisions of team sports—across a multi-year period.
Athletes
Athlete Seasons
Athlete Exposures
The SWEREX findings confirmed what many in sports medicine had long suspected: female handball players face among the highest ACL injury risks in sport. When compared to football, handball showed comparable incidence rates in both females and males 4 .
Perhaps the most revealing finding was the significant difference between competition levels. Second-division female athletes had a 1.7 times higher ACL reconstruction incidence rate compared to their first-division counterparts 4 . This suggests that access to resources—quality training facilities, medical support, and prevention expertise—may play a crucial role in mitigating risk.
The sobering statistics around ACL injuries in women's handball are only half the story. The more encouraging chapter lies in the development of effective prevention strategies that can significantly reduce risk when properly implemented.
A substantial body of evidence supports the effectiveness of neuromuscular training programs in reducing ACL injury rates. Well-designed programs have demonstrated remarkable effectiveness, with some studies showing ACL injury reduction of up to 67% in female athletes in controlled settings 5 .
Focusing particularly on hamstrings, glutes, and core musculature
Controlled jumping and landing drills to develop proper mechanics
Enhancing joint awareness and stability
Rewiring cutting and pivoting patterns under controlled fatigue
The emerging solution to implementation challenges is co-creation—involving coaches, athletes, and medical staff collaboratively in program design 5 . This approach recognizes that effective prevention must be:
Involve coaches in program design from the beginning
Make exercises engaging and performance-focused
Embed prevention into regular training sessions
Implement programs consistently throughout the season
Perhaps the most significant long-term concern is the dramatically increased risk of post-traumatic osteoarthritis. Research indicates that knee osteoarthritis develops within 10-20 years after injury in the majority of patients, even after successful surgical reconstruction 2 .
The psychological toll of ACL injuries is increasingly recognized as a critical component of the injury burden. The protracted recovery process—often lasting 9-12 months or more—can lead to various psychological challenges 5 .
Return to pre-injury level
Sustain re-injury
Confronting the ACL epidemic in women's handball requires a multidimensional approach that spans scientific research, coaching education, and structural support. The evidence clearly indicates that effective prevention is possible—but not without addressing the implementation gap that has limited the real-world impact of proven interventions.
The way forward must include continued research into sport-specific risk factors, particularly focusing on the unique demands of handball. It requires coaching education that integrates prevention principles seamlessly into performance training. Most importantly, it demands a cultural shift that views ACL prevention not as an optional extra, but as an essential component of athlete development.
For the next generation of female handball players, the goal is clear: to preserve the dynamic, explosive qualities that make the sport spectacular while eliminating the disproportionate risk that currently shadows the women's game. Through collaborative effort and shared responsibility, a future with fewer ACL tears is within reach—a future where talented athletes can develop their skills without the looming threat of a preventable career-altering injury.