Introduction: Female footballers are at high risk of sustaining lower limb injuries, with some of the most prevalent and severe injuries being hamstring strains, hip/groin pain, and knee ligament sprains. However, there is currently limited evidence to guide injury prevention strategies and injury risk assessment testing in female footballers. The aim of this study was to assess risk factors for ACL, hamstring, and hip/groin injuries in elite female footballers. Methods: Data were collected from 321 elite female Australian Football, soccer, and Rugby League players during pre-season. Players underwent field-based assessments of isometric hip adductor and abductor strength (ForceFrame), eccentric knee flexor strength during the Nordic hamstring exercise (NordBord), countermovement jump (CMJ) on dual forceplates (ForceDecks), and a single-leg triple vertical hop (TVH) using a makerless motion capture system (HumanTrak). Players were subsequently followed for injuries for 18 months. Risk factors were identified prospectively using simple and multiple logistic regression and decision tree learning. Results: A total of 12 anterior cruciate ligament (ACL) ruptures, 17 hamstring strains, and 12 hip/groin injuries were recorded. Risk factors for ACL injury included prior ACL injury (standardised odds ratio [OR]=12.3, P<.001), lower body weight normalised adductor torque (OR=2.1, P=.028), greater body weight normalised CMJ peak force (OR=1.9, P=.013), lower CMJ impulse (OR=2.0, P=.037), greater triple vertical hop knee frontal plane projection angle (OR=2.3, P=.014), and greater triple vertical hop lateral trunk flexion (OR=1.7, P=.038). Multiple logistic regression and decision tree models classified ACL injured players with high accuracy (sensitivity=67% and 75% respectively, and specificity=88% and 100% respectively). Risk factors for time-loss hamstring injury included smaller stature (OR=1.8, P=.030), greater between-leg asymmetry in CMJ peak force (OR=2.0, P=.011) and eccentric impulse (OR=1.9, P=.016). There were no statistically significant risk factors for hip/groin injury. Discussion: This is the first study to explore risk factors for lower limb injury in elite female Australian football codes. These results provide insight into the potential modifiable factors associated with subsequent injury in elite female footballers, which may inform player testing batteries and the design of targeted injury risk reduction strategies.
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