When the Dutch national team starts the World Cup against Portugal on Sunday morning at half past nine Dutch time in New Zealand, Vivianne Miedema is at home in London in front of the television. The top scorer of the Orange squad is missing for the first time in a final tournament since 2015 due to a cruciate ligament injury. She will only be in the stands on August 20 in Sydney, Australia, if the Netherlands reaches the final. “In that respect, I am just a success supporter,” says Miedema at the beginning of 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 international top player to miss the World Cup in Australia and New Zealand due to a knee injury. Her teammate and life partner Beth Mead also suffered a cruciate ligament injury last year and leaves a gap in the England squad. In addition to the two attackers from Arsenal, Leah Williamson (England), Marie-Antoinette Katoto, Delphine Cascarino (both France), Carolin Simon (Germany), Nadia Nadim (Denmark), Ludmila (Brazil) and Katie Rood (New Zealand) have been eliminated. It is just a selection of players whose knee ligaments were badly damaged in the run-up to the World Cup.
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The knee injuries are a topic of conversation with the Dutch national team in the run-up to the World Cup. “I am not sorry that I did not play everything this season at Paris Saint-German. Because many others who always participated in everything are now injured,” says attacker Lieke Martens. Midfielder Danielle van de Donk finds it painful that a number of stars are missing. “When you see so many top players fall over around you, it does something to you. It is time for a thorough investigation.”
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 study from the University of Tampere that the number of anterior cruciate ligament injuries in Finnish children under the age of eighteen doubled from 2004 to 2014. The researchers saw the greatest increase (143 percent) in girls between the ages of thirteen and fifteen.
UEFA, which in the past commissioned dozens of studies into knee injuries in men, has had the Swedish orthopedic surgeon and medical adviser to the European Football Association Markus Waldén look at the women. Data from the past five years of injured players at top clubs such as Manchester City, Olympique Lyonnais, FC Barcelona, AC Milan and Ajax shows that every top team has to deal with 0.75 anterior cruciate ligament injuries per season. That is two to three times as much as for men. Nevertheless, it seems to the Dutch internationals that it happens much more often. Miedema: „There are already five at Arsenal alone. It seems like everyone gets a turn at some point.”
According to sports doctor Edwin Goedhart, the answer to the question why knee injuries occur more often in women playing football is not easy to answer. “The UEFA investigation indeed shows that there is a difference, but it has not shown that there is really a huge boom at the top,” explains the medical manager of the KNVB. “Knee injuries sometimes come in patches. Suddenly you hear it from all sides. But in recent months that has been much less. So, to some extent, there is simply a misconception.”
According to Goedhart, who in the past also had to deal with a women’s team as head of the medical staff at AZ, this does not alter the fact that further research is “always good”. These are very serious, major injuries that mean that 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 that can play a role. So you would have to look at many cases separately from each other. I can already tell you: you will not succeed. Even with hamstring injuries, of which there are many more, that is difficult to determine.”
Goedhart knows the theories that women get injured because they sometimes have a wider pelvis, that hormonal factors play a role and that the female body is less resistant to heavy loads. “That may all be true, but you didn’t just find a solution with that,” says Goedhart. “Because how many women walk around in the top with a wide pelvis? Does it make sense to do pre-activation before an upcoming menstruation? Shouldn’t you be doing that anyway? And the number of women who really 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 she sharp?”
Tennis ball on a saucer
Goedhart tries to create more clarity with “a mini-lecture” about the complexity of the knee. “Let’s look at the hip: it is built in such a way that it almost never dislocates. The knee is a whole different story. It’s like having a tennis ball on a saucer. The stability must come from three things: the bone, the ligaments and the muscles. The bone does nothing in this case. And the cruciate ligaments are not made for playing soccer. So it must mainly come from muscle strength and control,” explains Goedhart. “Then we are talking, for example, about learning a good landing technique. Do players know how to fall to avoid injury?”
According to Goedhart, the lack of movement of the current generations is part of the problem. In his eyes, children today learn to deal with their bodies much less intelligently. He gives an example from his own childhood. “We used to have 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 be a puddle in it. So when you went 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 the trees to prevent climbing. Children are simply much less well versed in motor skills. And that is reflected on the football field. In my view, that is where the main source of the problems lies.”
Catching up
According to Danielle van de Donk, women’s football is catching up at such a frantic pace that the female body is sometimes not sufficiently trained for it. With all its consequences. “I injured my knee myself when I switched from training twice a week with the boys to almost every day with the women at the age of sixteen,” says Van de Donk. “The load has only become heavier with the overcrowded playing calendar. It is up to FIFA, UEFA and the associations to strike the right balance. Because as a footballer you don’t just cancel a big tournament.”
In that respect, Vivianne Miedema has paid her dues. In her mind she sometimes goes back to the fatal moment on December 15, 2022, the day when she tore a cruciate ligament in a Champions League match against Olympique Lyonnais. Miedema is momentarily off balance due to a feint that causes her body to suddenly move from left to right. She immediately sensed that something was wrong. Miedema: „I knew almost immediately that I would miss the World Cup. I lasted eight or nine years and now my limit was reached. Entertainment now comes before player health. And of course that should not be the case”. Despite everything, Miedema will try to enjoy the World Cup. “I will set the alarm early in the morning to go and have a look. It will still hurt at times. But I hope so we come very far and I can still make the long journey.”
A version of this article also appeared in the newspaper on July 21, 2023.