Mary Fowler’s ACL Injury: A Reminder That ACL Prevention and Rehab Needs More Than Surgery and Strength

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A Devastating Blow for the Matildas

22-year-old Mary Fowler recently ruptured her ACL during a non-contact moment in the FA Cup semi-final. Manchester City forward will now miss the rest of the 2025 season and possibly the 2026 Asian Cup. As a footballer I personally got quite fired up about the ongoing amount of ACL injuries specifically in women's football and why coaches/surgeons/physios continue to place their focus on “Gold standard” prevention and rehabilitation treatments that continue to lead to the same outcomes for athletes.

ACL injuries are devastating — physically, mentally, and emotionally. But what if I told you there’s more to managing and preventing these injuries than just focusing on just the knee physically.

ACL Injuries

Historically, ACL rehab has centred around surgery and progressive strength work (which definitely has its place). But ACL injuries don’t happen in isolation — they’re the result of multiple intersecting factors:

● Biomechanical

● Psychological

● Social

● Environmental

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The latest research tells us we must consider the whole athlete to both recover well and prevent re-injury or even injury in the FIRST place.

Physical & Biomechanical Risk Factors

Let’s start with the physical side:

● Sex differences: Female athletes are 2–8x more likely to rupture their ACL than males — due to hormonal influences, joint laxity, neuromuscular control and biomechanics (BJSM, 2022).

● Load management issues: Poorly planned increases in game intensity or training volume are a major driver of injury, especially in growing athletes or professionals juggling club and national commitments.

● Movement patterns: Valgus knee collapse, poor trunk control, and fatigue-related compensations during landing or cutting are commonly seen in high-risk athletes.

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Psychological & Social Load

New research shows that ACL injury recovery is strongly influenced by mental and emotional readiness, not just “quad” strength.

● Fear of re-injury is one of the biggest barriers to returning to sport.

● Athlete identity loss — the sudden change from “starting player” to “injured” or “on the bench” can cause depression, anxiety, and isolation.

● External pressure from coaches, fans, and self-imposed expectations can delay healing or promote early return before readiness.

In other words, nervous system sensitivity + social pressure = a system under threat. And a threatened system is not a system ready to perform.

Preventing ACL Injuries: Proactive Load & Mental Readiness

ACL injuries don’t always come out of nowhere. Many occur in athletes whose physical or psychological systems were already under strain. This is why load management and mental readiness screening aren’t just rehab tools — they’re powerful prevention strategies that are not targeted enough.

● In elite sport, GPS data and wellness questionnaires help monitor cumulative fatigue, training spikes, and athlete mood. But even at the grassroots level, coaches and clinicians can track workloads using simple session-RPE (rate of perceived exertion × time), flagging sudden increases in volume or intensity — especially during growth spurts or tight competition periods.

● For adolescents and amateurs, educating young athletes and parents about recovery, nutrition, and signs of overload (like persistent soreness, reduced enthusiasm, or poor sleep) is key. Early interventions here reduce the risk of both injury and burnout.

● Psychologically, tools like the ACL-RSI (Return to Sport after Injury) scale can be adapted pre-season or mid-season to check in on confidence, motivation, and fear — all of which correlate with neuromuscular readiness and risk of non-contact injury.

Proactive strategies like these build resilient, adaptable athletes — not just stronger knees.

What the Latest Evidence Tells Us

● Psychological readiness is a stronger predictor of successful return to sport than strength measures alone (BJSM, 2022).

● Rehab should target motor control, confidence, and contextual loading — not just isolated physical tasks.

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The Takeaway

Mary Fowler’s injury is a tough reminder not just for professional athletes but amature and adolescents as well that ACL injuries are multifactorial, and recovery / prevention is never JUST about surgery or physical recovery alone.The “Gold standard” needs to put more emphasis on other contributing factors such as load management and psychological readiness from both prevention and rehabilitation perspective.

To reduce injury risk and improve rehab outcomes, we need to:

● Monitor load carefully (identify training spikes)

● Improve strength and movement patterns

● Support psychological recovery

● Consider hormonal and biomechanical risk factors in women

● Treat the whole person, not just the knee

● Educate athletes regardless of tier regarding alternative forms of management and prevention not just “correct” warm up (FIFA 11+ etc)

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At The Biomechanics, we believe in movement-based rehab that respects both science and the human behind the injury. If you need help along your ACL or sports injury journey, we're here to help.

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References

1. Ardern, C. L., Glasgow, P., Schneiders, A., Witvrouw, E., Clarsen, B., Cools, A., ... & Bizzini, M. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine, 50(14), 853–864. https://bjsm.bmj.com/content/50/14/853

2. Ardern, C. L., Ekås, G. R., Grindem, H., Moksnes, H., Anderson, A. F., Chotel, F., ... & Engebretsen, L. (2022). Rehabilitation after anterior cruciate ligament and meniscal injuries: A review of current practice and future directions. British Journal of Sports Medicine. https://bjsm.bmj.com/content/early/2022/08/09/bjsports-2022-105495.full.pdf

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4. Hainline, B., Reardon, C. L., et al. (2019). Mental health in elite athletes: International Olympic Committee consensus statement (2019). British Journal of Sports Medicine, 53(11), 667–699. https://bjsm.bmj.com/content/53/11/667

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6. Owoeye, O. B. A., Akinbo, S. R. A., Tella, B. A., & Olawale, O. A. (2014). Efficacy of the FIFA 11+ warm-up programme in male youth football: A cluster randomised controlled trial. Journal of Sports Science and Medicine, 13(2), 321–328. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4000474/

7. Reardon, C. L., Hainline, B., Aron, C. M., et al. (2020). Psychological factors and persistent pain in athletes. British Journal of Sports Medicine, 54(4), 216–217. https://bjsm.bmj.com/content/54/4/216.full.pdf

8. Silvers-Granelli, H. J., Mandelbaum, B. R., et al. (2017). Does the FIFA 11+ injury prevention program reduce the incidence of ACL injury in male soccer players? Clinical Orthopaedics and Related Research, 475(10), 2447–2455.

https://link.springer.com/content/pdf/10.1007/s11999-017-5342-5.pdf

9. Zwerver, J., Diercks, R., Willems, W. J., & Reijman, M. (2023). Healing of acute anterior cruciate ligament rupture on MRI and outcomes after non-surgical management with the Cross Bracing Protocol. British Journal of Sports Medicine. https://bjsm.bmj.com/content/early/2023/06/13/bjsports-2023-106931.full.pdf

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