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, identify injury patterns, and inform targeted prevention strategies.
Hypothesis:
The introduction of CIF-sanctioned female flag football has been associated with an increased incidence of non-contact knee injuries, particularly ACL tears.
Methods:
This retrospective descriptive study included adolescent female flag football players (ages 13-18) who underwent knee surgery between 2021 and 2025. Data from the first two CIF-sanctioned seasons and the two preceding seasons were analyzed. Injury, surgical, and demographic characteristics were recorded. Post-injury follow-up assessed field conditions, injury circumstances, and preventive measures.
Results:
Twenty-four athletes met inclusion criteria (mean age 16.1±1.0 years). Most injuries were non-contact (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). ACL reconstruction was performed in 20 of 24 cases. 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 1,000 athlete exposures, increasing from 0.17 in the 2023 season.
Conclusion:
The rise in participation and injuries emphasizes the need for targeted ACL prevention programs to improve athlete safety given the fact that ACL injury rates exceeded other high risk sports such as women’s soccer and lacrosse.