Raising Awareness: Addressing Knee and ACL Injury Risks in the Growing Sport of Female Flag Football.

Abstract

The rapid growth of girls' flag football, officially recognized by the California Interscholastic Federation (CIF) in 2023, has led to increased knee injuries, particularly anterior cruciate ligament (ACL) tears. This study evaluates knee injury rates during the inaugural CIF-sanctioned seasons, characterizes injury patterns, and highlights the need for targeted prevention strategies. This retrospective descriptive study included adolescent female flag football players (ages 13 to 18) who underwent knee surgery between 2021 and 2025. Data from the first 2 CIF-sanctioned seasons and the 2 preceding seasons were analyzed. Injury, surgical, and demographic characteristics were recorded. Postinjury follow-up assessed field conditions, injury circumstances, and preventive measures. Twenty-four athletes met the inclusion criteria (mean age 16.1±1.0 y). Most injuries were noncontact (21/24) and occurred during games (17/24), on turf (20/24), and under dry conditions (19/24). Common mechanisms included pivoting, changes in direction, or sudden stops (18/24), and jumping/landing (4/24). Most injuries occurred on offense (18/24) and during the middle of games (11/24). Of the 24 injuries, 21 were ACL tears (20 treated surgically), while 3 were non-ACL injuries (2 meniscus tears and 1 MPFL injury). Only 2 athletes reported participating in an ACL-injury prevention program, and 11 received training in landing and cutting techniques. Most athletes wore cleats (20/24) at the time of injury. The 2024 game-related injury risk was 0.64 per 1000 athlete exposures, increasing from 0.17 in the 2023 season. The rise in participation and injuries emphasizes the need for targeted ACL prevention programs to improve athlete safety. Level III-retrospective cohort study.