When the Dutch national team kick off the World Cup against Portugal on Sunday morning at half past nine Dutch time in New Zealand, Vivianne Miedema is at home in London watching television. The Orange team’s top scorer is out of a finals for the first time since 2015 with a cruciate ligament injury. She won’t be in the stands until August 20 in Sydney, Australia, if the Netherlands reach the final. “In that regard, I’m just a supporter of success,” Miedema said earlier this month after the farewell game in Kerkrade against Belgium. As a special guest, she was briefly part of the World Cup selection.
Miedema is certainly not the only top international player to miss the World Cup in Australia and New Zealand due to a knee injury. Her team-mate and life partner Beth Mead also suffered a cruciate ligament injury last year and leaves a void in the England squad. Besides the two Arsenal strikers, Leah Williamson (England), Marie-Antoinette Katoto, Delphine Cascarino (France), Carolin Simon (Germany), Nadia Nadim (Denmark), Ludmila (Brazil) and Katie Rood (New Zealand) were eliminated. This is just a selection of players whose knee ligaments were badly damaged in the run up to the World Cup.
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Knee injuries are a topic of conversation with the Dutch national team ahead of the World Cup. “I don’t regret not having played everything this season at Paris Saint-Germain. Because many others who have always participated in everything are now injured,” says forward Lieke Martens. Midfielder Danielle van de Donk finds it painful that a number of stars are missing. “When you see so many top players falling around you, it does something to you. It’s time to investigate thoroughly.
Research by UEFA
The call for research is certainly not new. In the past, the development of knee injuries in women has also been studied in various countries. According to a study published in August 2019 University of Tampere study that the number of anterior cruciate ligament injuries in Finnish children under the age of eighteen doubled between 2004 and 2014. The researchers found the greatest increase (143%) in girls aged thirteen to fifteen.
UEFA, which has in the past commissioned dozens of studies of knee injuries in men, asked Swedish orthopedic surgeon and European Football Association medical adviser Markus Waldén to examine the women. Data from the last five years on injured players at top clubs such as Manchester City, Olympique Lyonnais, FC Barcelona, AC Milan and Ajax shows that each top team has to deal with 0.75 anterior cruciate ligament injuries per season. This is two to three times more than for men. Nevertheless, it seems to Dutch internationals that it happens much more often. Miedema: “There are already five at Arsenal alone. It seems like everyone has their turn at some point.
According to sports physician Edwin Goedhart, the answer to the question of why knee injuries occur more often in women playing football is not easy to answer. “The UEFA survey does indeed show that there is a difference, but it has not shown that there is really a huge boom at the top,” explains the KNVB medical officer. “Knee injuries sometimes come in patches. Suddenly you hear it from all sides. But in recent months it has been much less. So to some extent there is simply a misconception.
According to Goedhart, who in the past has also had to deal with a female team as AZ’s chief of medical staff, that doesn’t change the fact that further research is “always good”. These are very serious and major injuries that mean players are sidelined for an entire season, he says. “It is difficult to determine exactly what the problem is, because you have to deal with many different factors which can play a role. Many cases would therefore have to be considered separately from each other. I can already tell you: you will not succeed. Even with hamstring injuries, of which there are many more, it’s hard to pinpoint.
Goedhart is familiar with the theories that women injure themselves because they sometimes have a wider pelvis, hormonal factors play a role, and the female body is less resistant to heavy loads. “All of that may be true, but you just haven’t found a solution with that,” Goedhart says. “Because how many women walk around on top with a wide pelvis? Does it make sense to do a pre-activation before an upcoming period? Shouldn’t you be doing this anyway? And the number of women who actually play more than fifty matches per season is not very high. But let’s not underestimate the mental aspect either. Is a player comfortable in her own skin? Is it sharp?”
Tennis ball on a saucer
Goedhart tries to create more clarity with “a mini-lecture” on knee complexity. “Let’s look at the hip: it’s built in such a way that it hardly ever comes apart. The knee is a whole different story. It’s like having a tennis ball on a saucer. Stability must come from three elements: bone, ligaments and muscles. The bone does nothing in this case. And cruciate ligaments aren’t made for playing football. So it has to come mostly from muscle strength and control,” says Goedhart. “Then we talk about, for example, learning good landing technique. Do the players know how to fall to avoid injury?
According to Goedhart, the lack of movement of current generations is part of the problem. In his eyes, today’s children learn to manage their bodies much less intelligently. He gives an example from his own childhood. “Before, we had a very high slide on our playground. There were no rubber tiles at the end. No, just a dimple. And if it had rained, there would have been a puddle in it. So when you came down you were busy with different things. You didn’t want to go too fast. And not too soft either. And you wanted to keep your feet dry. Now there are only low slides and the municipality removes the lower branches of trees to prevent climbing. Children are simply much less versed in motor skills. And that is reflected on the football field. In my opinion, this is where the main source of problems lies.
According to Danielle van de Donk, women’s football is catching up at such a rapid pace that the female body is sometimes not trained enough for it. With all its consequences. “I hurt my knee myself when I went from training twice a week with the boys to almost every day with the women when I was sixteen,” says Van de Donk. “The load has only increased with the overloaded playing schedule. It’s up to FIFA, UEFA and the associations to find the right balance. Because as a footballer, you don’t just cancel a big tournament.”
In this regard, Vivianne Miedema has paid her due. In her head, she sometimes remembers the fatal moment of December 15, 2022, the day she tore a cruciate ligament during a Champions League match against Olympique Lyonnais. Miedema is momentarily off balance due to a feint that suddenly causes her body to move side to side. She immediately sensed that something was wrong. Miedema: “I knew almost immediately that I was going to miss the World Cup. I lasted eight or nine years and now my limit has been reached. Entertainment now comes before players’ health. And of course it shouldn’t be.” Despite everything, Miedema will try to take advantage of the World Cup. “I’ll set the alarm early in the morning to go and see. It will still hurt sometimes. But I hope so We come from very far away and I can still make the long journey.
A version of this article also appeared in the newspaper on July 21, 2023.
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