Journal of Pediatric Orthopaedics - 2026-07-01 - Journal Article
Raising Awareness: Addressing Knee and ACL Injury Risks in the Growing Sport of Female Flag Football.
Grewal RS, Schmitz MR, Edmonds EW, Bomar JD, Pennock AT
Topics
Key Takeaway
In adolescent female flag football players requiring knee surgery, 87.5% sustained ACL tears, with game-related injury risk nearly quadrupling from 0.17 to 0.64 per 1,000 athlete exposures between the 2023 and 2024 CIF-sanctioned seasons.
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Summary
This study characterized knee injuries requiring surgery in adolescent female flag football players (ages 13–18) across four seasons surrounding CIF sanctioning in California. Of 24 surgical cases, 21 were ACL tears (20 treated operatively), 87.5% were noncontact, 83% occurred on turf, and only 2 athletes had participated in a formal ACL prevention program. Game-related injury rate rose from 0.17 to 0.64 per 1,000 athlete exposures from 2023 to 2024.
Key Limitation
The cohort captures only surgically managed injuries at a single or limited institutional network, introducing selection bias and excluding nonoperative ACL injuries, which substantially underestimates true injury burden.
Original Abstract
BACKGROUND
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.
METHODS
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.
RESULTS
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.
CONCLUSIONS
The rise in participation and injuries emphasizes the need for targeted ACL prevention programs to improve athlete safety.
LEVEL OF EVIDENCE
Level III-retrospective cohort study.