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Who was the first player you pictured when you read the title? I would bet for most of you it would have been someone famous. Perhaps Lionel Messi or Ronaldo (Brazilian version or Portuguese)? I would also bet that it would have been a male?

I pictured European Champion, England Lioness and Chelsea forward Lauren James. Her brother Reece is also an England player. Talented family!

Despite the social media noise, it’s not anterior cruciate ligament injuries that are the most common injury in professional women’s football. As with men’s football, it’s hamstring strains.

The problem

Just like their male counterparts, hamstring strains top the injury charts in the women’s game, accounting for 12% of all reported injuries in elite cohorts [1]. We talk a lot about ACLs, but hamstrings are the most common injury with fewer headlines.

Most prevention models were designed from male data. That’s a bias baked into our protocols [2, 3]. We understand hamstring injury mechanisms reasonably well, but we haven’t fully adapted our strategies to the female athlete.

Epidemiology

In elite women’s football, epidemiological depth still lags behind the men’s game [1]. Physiology, biomechanics, and possible hormonal influences are underrepresented, which matters when you want targeted prevention and better return to play (RTP) decisions. The pattern is familiar by now: promising data, not enough of it in women, and too much extrapolation from men [2, 3].

Anatomy that matters: the female pelvis and the hamstrings

Increased anterior pelvic tilt can leave hamstrings and gluteals chronically lengthened; increased femoral anteversion often rides alongside gluteus medius weakness; gluteus maximus weakness shows up again and again; pelvic width relative to femoral length changes alignment and loading; females typically have lower passive hamstring stiffness, higher joint laxity, and greater resistance to skeletal muscle fatigue [4].

Clinically, that means we don’t always need to ‘stretch more’; we often need better pelvic control, stronger glutes (maximus and medius), and rehabilitation and prevention strategies that respect sex-specific stiffness profiles.

At the muscle level, architecture matters: semitendinosus is especially sensitive to exercises involving large musculotendinous length changes; biceps femoris and semimembranosus have unipennate/bipennate arrangements with different functional and injury profiles [5]. That should inform assessment and exercise selection.

Two injury archetypes

There are two distinct hamstring strain archetypes with different tissues and timelines [6]:

1) Sprint type: high speed running, typically biceps femoris long head.

2) Slow stretch type: extreme lengthening (high kick, slide, splits), often involving the free proximal tendon of semimembranosus.

Slow stretch injuries often look less dramatic but take longer to return to play [6]. Label the mechanism early; it sets rehab pace and tissue focus. Also note that a shorter distance to the ischial tuberosity may be associated with longer RTP [8].

Risk factors: what you can and can’t change

Non-modifiable predictors remain familiar: older age and previous hamstring injury carry the greatest risk, especially within the first year post-RTP. On the modifiable side, single metrics haven’t delivered reliable prediction: isolated strength deficits or imbalances can matter but don’t predict injury [9].

The system is a risk

A key insight from the UEFA Women’s Elite Club Injury Study is that extrinsic factors dominate the modifiable risk picture: