HomeHealthMental HealthEpidemic of ACL injuries in women’s soccer brings a mental-health reckoning

Epidemic of ACL injuries in women’s soccer brings a mental-health reckoning

Marlee Nicolos had thought it was almost a foregone conclusion that one day she would tear an ACL. It seemed to happen to everyone, and it would happen to her one day.

That didn’t soften the blow when the Santa Clara women’s soccer goalie suffered a knee injury at the end of her freshman season. When she ripped it again in September 2021, it just seemed cruel.

“It’s a club I didn’t want to be a part of,” she said. “But now that I’m here, I’m so proud of everyone who went through it.”

While studies have shown how common these injuries are in athletes, in the hundreds of thousands each year, and particularly in female soccer players, who are four to six times more likely to tear an ACL than their male counterparts, researchers and medical professionals are beginning to just understand their mental toll.

Getting injured in sports is its own form of loneliness; a player not only loses her ability to participate in something she is really good at, but also a sense of community. Sure, she can spend time with teammates and attend games, but that’s not the same as when she’s contributing.

That’s one reason why 40% of athletes who tear their ACL in the aftermath deal with anxiety and depression, according to the Stone Clinic.

The sports world is facing a mental health reckoning. This story is part of a series exploring the challenges we face at all levels of competition and how they are being addressed.

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Stanford forward Emily Chiao’s history of knee trauma did not prepare her for the mental rigors of the nine-month rehab after tearing her ACL moments in the first game of the 2021 season.

“It’s really traumatic, like I pushed (the play) completely out of my mind,” said Chiao. “Then sometimes I would think, lying in bed, this is what happened at that moment. I never wanted to watch the video and still haven’t. I can play it all in my head.

“An ACL is really daunting in general,” she said. “You have to learn to deal with the fact that you wake up in bed and can’t lift your leg. It feels like you reach a milestone every day.”

About 34% of football players who tear an ACL do it a second time. A study in the Journal of Athletic Training said that any primary ACL injury triggers a cascade of altered neuromuscular control that affects the risk of a second injury.

The second time around, Nicolos wasn’t as shocked by the changes she couldn’t control — the fact that her legs were different sizes when her muscles retracted, for example — and tried to focus on the grueling process of rebuilding leg strength.

Between her past experiences and the growing list of soccer players in her life who could provide qualified advice, it felt like a new rite of passage.

“I had a little comfort in knowing what to expect,” said Nicolos. “It’s sad, but it’s part of women’s football. I have so many friends who have done it.”

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Above: Santa Clara goaltender Marlee Nicolos has torn an ACL twice. Left: USF freshman midfielder Cade Mendoza (17) suffered an ACL injury while still in high school.

Scott Strazzante, staff photographer / The Chronicle

Nicolos, a communications student who will play for two more seasons with Santa Clara, made a movie about ACL recovery after her second injury for one of her classes.

“Once it’s happened to you, it’s close to your heart,” she said.

For some, like Jordan Angeli, it happens three or more times.

“Everyone always called me mentally strong,” said the former Santa Clara (2004-2006) player who now works as an analyst at Columbus MLS broadcasts. “And then I struggled mentally, and I thought wow, if that’s me, it must be hard for everyone. No amount of mental toughness will get you through this. You have to learn how to put some of those thoughts aside.”

The Journal of the American Academy of Orthopedic Surgeons cited a study stating that “ACL-injured patients were seven times more likely to experience depression compared to their baseline and were found to experience mood disturbances and decreased self-esteem.”

Angeli’s first two surgeries were within a year of her graphic surgery not being done correctly the first time. She ripped it again on a non-contact play when going up for a header, and a third time when she was tackled in her first professional season.

“I knew it wasn’t supposed to feel that way,” she said.

In her isolation, Angeli found fellowship in the physical and mental trauma of ACL repair. She founded the ACL Club in 2015 and a podcast that highlights athletes who have gone through the injury.

“I felt like people craved community,” she said. “It’s traumatic when you feel it. Your knee is essentially dislocated and then the ACL is torn. That’s a feeling you never want to feel again. It’s such an unnatural feeling.”

While ACL recovery times are faster and surgeries less invasive than in decades past, the rise in prominence among elite female athletes can be attributed to year-round play in a single sport from a young age, said Nirav Pandya, UCSF associate professor. Orthopedic Surgery.

“The hardest part was at lower levels,” said Pandya. “I’ve seen girls who needed surgery and I’m like, God, you’re 10 years old and you just tore your ACL.”

Santa Clara's Sally Menti (right), recovering from an ACL injury, is on the sidelines with teammate Lucy Mitchell, who is recovering from an ankle injury.

Santa Clara’s Sally Menti (right), recovering from an ACL injury, is on the sidelines with teammate Lucy Mitchell, who is recovering from an ankle injury.

Scott Strazzante, staff photographer / The Chronicle

Year-round, female athletes who play soccer or basketball have a 5% chance of tearing their ACL each year they participate in their sport. That represents a 20% chance of tearing an ACL while playing high school football.

The collegiate careers of USF freshmen Hannah Burns and Cade Mendoza will all be post-ACL recovery. They had both already committed to play for the Dons when they got injured.

Some dedicated athletes worry about losing their scholarship if they get injured in high school. Mendoza said the USF assured her she was not at risk, but the fear still lingered in her mind.

“There was nothing you could do, you can’t reverse it,” she said. “I definitely cried here and there.”

Mendoza and Burns bonded over their injuries at various points during recovery. They both also received advice from senior Marie Marlow, who tore her ACL last season.

“We comforted each other because football is our life, and now you’re so abruptly out of it,” said Mendoza. “It’s a glass box, you can see it, but you can’t get in.”

Burns’ trial was particularly challenging; she was not operated on until three months after the initial injury. She started practicing on her own, but watching the Dons from the sidelines has been both a blessing and a curse to her mental recovery.

“It was difficult at first,” she says. “We have home games that you go to and it makes you want to play. The first few months were the hardest, trying to wrap your head around how this happened.



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