Female Athletes’ Achilles Heels?  Their Knees

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Alexa Yow of Farmington was the captain of her high school soccer team at Loomis Chaffee high school and is a forward on her premier team, which recently won the State Cup.  Given her talent, she had good reason to believe that one day she’d play on a Division I college team. But last June, during the State Cup finals, it looked like those plans might be derailed.

“I was trying to keep the ball from going out,” Yow recalled. “My foot landed, but my body kept twisting. I heard my knee pop.”

Yow had an MRI (magnetic resonance imaging), which confirmed what she and everybody who saw the accident already suspected: she had ruptured her anterior cruciate ligament (ACL), the central ligament that stabilizes the knee and controls the pivoting motion.

It’s an injury that has become almost epidemic among female athletes between the ages of about 14 to 22 who play sports that involve running, quick lateral movement, pivoting and jumping—soccer, basketball, and lacrosse.  At the University of Connecticut Medical Center more than 200 ACL surgeries are performed yearly, mostly on female athletes, and on Yow’s premier team alone, five girls have torn their ACLs in the past two years.

It’s been determined that for a host of reasons, female athletes are three to 10 times more likely to tear their ACLs in a non-contact injury than their male counterparts. This has led to research into what’s causing this disparity, conferences to share information and come up with solutions and heath programs tailored to the female athlete. At Yale-New Haven Hospital, for example, the new Women’s Sports Medicine Program was launched last February. Director Karen Sutton said 20 percent of her practice involves ligament injuries of the knee, with ACL injuries being the second most prevalent one.

“It’s one of those freak injuries,” said Lindsay Destefano, assistant professor in the athletic training program in the Department of Kinesiology at UConn. “If you land on a rock and turn your ankle, you know what happened, but ACL injuries are scary because you can’t explain what happened. Why that cut and not another one?”

“Besides a severe concussion, I’d say an ACL tear is the injury that female lacrosse, soccer and basketball players most fear,” said Sutton.

Why Female Athletes?

The reason female athletes are more vulnerable to this injury than male athletes is equally baffling. “We’re not exactly sure, but we know it’s multifactoral,” said Robert A. Arciero, chief of the sports medicine division of the Department of Orthopedic Surgery at the UConn Health Center.

The leading theory, according to Arciero, who does about 90 ACL surgeries a year, is the difference in the way male and female athletes land, turn and react to an unanticipated change in direction or balance. “Girls have different firing patterns,” he said. Other theories are that girls’ pelvises are wider; their cores are less stable; their ACLs are smaller; and the notch through which the ligament connects with the femur in the upper leg is smaller, leaving less room for the ACL to absorb the energy. Yet another theory is that it’s hormonal; estrogen may cause the tissues in female athletes to be looser and more relaxed.

“The two things we know for certain,” Arciero said, is that “a female athlete’s risk of injury increases after she hits puberty and that genetics plays a role. If one of your parents tore their ACL, you are more likely to. There’s a genetic predisposition.”

An ACL tear is almost always a season-ending injury. Surgery is the recommended course of treatment if the athlete wants to play sports at a competitive level. The procedure involves a graft from either the patient’s own patellar tendon or a cadaver, followed by months of post-operative physical therapy. In addition, many surgeons want their patients to wear a brace for months after they return to their sport, which impedes their ability to perform at a pre-injury level. In Yow’s case, she also had a partial tear of her meniscus, so surgery had to be delayed while the meniscus healed and the swelling in her knee went down. During that time, Yow did almost daily physical therapy to strengthen her knee muscles prior to surgery.

“It’s devastating to patients. There have been a lot of tears shed in my office when I give the [ruptured ACL] diagnosis,’ said Sutton.

Given the prevalence of ACL injuries and the toll it takes on an athlete’s career – UConn basketball star Caroline Doty rode the bench last season after rupturing her ACL for the third time; Shea Ralph tore hers five times – researchers around the world are working on ways to help women avoid this injury. “We go on ACL retreats every other year and share thoughts on how we can solve this,” said Destefano.

What The Research Shows

Research initially focused on the anatomical and hormonal differences between male and female athletes. But, Sutton said, researchers are now studying neuromuscular differences. Using what’s called the box jump test and taking videos and putting electrical devises on subjects’ muscles, researchers observe the athlete’s body alignment from the front and side while landing from a jump off a two-foot-high box. Then they compare their findings with the landing style of male athletes.

“Girls have a different muscle firing pattern,” Arciero said. “They land in a more vulnerable position, more knock-kneed, which puts their ACL at risk. When boys land, their legs are straighter, so more of the force is absorbed by the hips, quads and hamstring.”

Based on these observations, trainers are now working with female athletes to rewire their muscle memory so they can relearn certain basic moves, such as landing. The good news is that it appears to be working. Training regimens, such as the Santa Monica ACL Prevention Program, and a similar strength and conditioning initiative at Duke University, have reported significant reductions in the number of ACL injuries. The key, experts say, is to get buy-in from athletes, coaches and parents so the players are encouraged, ideally starting in middle school, to repeat these exercises so often it becomes automatic.

“It’s like learning to shoot a foul shot,” said Destefano. “It takes time to learn the right technique, and then you have to do it over and over and over. It takes a lot of repetition. before it becomes automatic.”

The other encouraging news is that new surgical techniques are resulting in a lower failure rate and more stable knees. “We’re trying to reproduce the ACL with our surgery exactly the way God planned it the first time,” Arciero said.

While researchers don’t have all the answers yet, they believe they’re on the right track. “It’s almost like a grass roots effort,” said Destefano. “It’s not just about doing the exercises; it’s about getting the kids to be able to evaluate a good and bad landing themselves, the same way they know whether they’ve made a good or bad pass.”

In the meantime, athletes like Yow serve as a reminder that with hard work, it is possible to come back from an ACL injury stronger than ever. Yow will wear a brace through the summer, but in the fall she is attending Columbia University, a Division I school, and will play on the women’s soccer team.

At a recent tournament in New Jersey, Yow watched as an all-too-familiar scene unfolded: Her teammate, in pursuit of the ball, collided with a player on the other team and fell to the ground. She was helped to the bench, and somebody fetched a bag of ice, but she was done for the game, and the next day everyone’s fears were confirmed: she had torn her ACL.

What’s Yow’s advice to her and the other injured female athletes who are sure to follow? “It’s just devastating, but don’t give up. It’s a long process, and it really sucks, but it’s worth it. It makes you realize how much you love the sport.” She thought for a moment before adding, “It’s changed me as a person. I know that I can push myself if I really want something.”



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