Introduction: Anterior cruciate ligament (ACL) injuries pose significant challenges to football (soccer) players resulting in prolonged absence from play and immediate and long-term disability. Notably, female football players are at a substantially higher risk than their male counterparts. Several predisposing factors have been proposed, including fatigue, whose role remains unclear. Due to the lack of consensus and conflicting findings in the current literature regarding the role of fatigue in ACL injuries, this study aimed to explore the relationship between player in-match exposure and ACL injury occurrence in professional female football matches Methods: This was a prospective cohort study involving professional female football players who suffered ACL injuries during official matches during the 2021-2024 seasons. Identification of ACL injuries involved media reports including online searches for official statements and interviews. Follow-up verification of time within game-play, including video and substitution minutes, was conducted post-report. Results: A total of 185 ACL injuries during official matches were identified. Within the first 33 minutes (min) of play, 50% of ACL injuries occur, with the majority (70%) occurring within the first 47 min. A notable peak occurrence between the 15th and 35th mins of match exposure was observed. A significant difference in the pre-and post-45 min (first and second half) of gameplay was noted (p=0.02) with survival analysis showing a declining risk of ACL injury as the game continued, resulting in a 25% likelihood of injury occurring after the 54th min of gameplay. Discussion: A critical vulnerability window for ACL injury was identified in the 15-35 min of the game, which may coincide with higher-intensity physical demands. This heightened match intensity may elicit acute or transient manifestations of fatigue, potentially impacting neuromuscular control and decision-making, albeit cumulative match fatigue may result in reduced intensity and risk. The timing of ACL injuries in women's football is similar to that in the professional men's game, suggesting similar mechanisms. Impact/Application to the field: Knowing the timing of ACL injuries in women's football is of paramount importance for injury prevention and optimal player management. Within the match, cumulative fatigue doesn't seem to be a risk factor for ACL injuries. The peak occurrence of injuries in the early match (15th to 35th minute) suggests that pre-match player readiness to perform warrants future research. This prompts stakeholders—policymakers, coaches, medical staff, and players—to reconsider fatigue-related ACL injury risk factors, including mental and transient manifestations, as well as season-long and travel-related fatigue impacting player readiness. Furthermore, recognising that acute or transient fatigue could contribute to ACL injuries emphasises the need for continuous monitoring of player fatigue levels and implementing targeted interventions to manage fatigue during matches effectively. These findings highlight the intricacy of injury prevention and underscore the necessity of a holistic approach that integrates biomechanical, physiological, and tactical factors to safeguard player health and performance on the field.
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