Fay: Can ACL tears be prevented in female athletes?
By Robert Fay, Special to The Journal News September 25, 2015
When Maddy Cooper heard the “pop” and went down on the field she knew what it meant.
Cooper, 17, plays defense on the varsity lacrosse team at Rye Country Day School. Playing defense last spring, she sprinted after a loose ball with an opposing player.
“As I finally got the ball, I jumped up in the air, and as I landed she bumped into me,” Cooper said. “When I landed, that was when my knee turned in, and I instantly heard and felt a pop.”
Cooper already knew that thousands of young women athletes like her wind up in operating rooms every year with a torn-up knee, or more precisely, with a ruptured anterior cruciate ligament.
“My first instinct whenever I got injured in any sport was ‘I hope it’s not the ACL.’ When I first heard the pop and felt something in my knee, I knew something was wrong,” Cooper said.
Of the 150,000 ACL injuries that occur in the United States each year, female athletes between the ages of 15 and 19 account for the largest number of them. According to various estimates, women suffer torn ACLs between twice and eight times as often as men. Maddy’s turn came in June, when she underwent surgery for a torn ACL at the Hospital for Special Surgery in Manhattan. It will be eight months before she can play lacrosse again.
The ACL is one of four primary ligaments that connect the bones that comprise the knee joint. Located in the middle of the knee, the ACL connects the shin bone (tibia) to the thigh bone (femur). It stabilizes the knee and prevents the lower leg from sliding too far forward. The vast majority of ruptures, especially in girls, are not caused by contact but by stopping suddenly, changing direction rapidly, or landing a jump incorrectly. They occur most often in soccer, basketball, lacrosse and gymnastics.
A torn ACL requires surgery and six to nine months of recovery and rehabilitation. And having torn an ACL once increases vulnerability to a second rupture and the risk of early onset of osteoarthritis in the knee. These short- and long-term consequences have spurred the development of conditioning programs designed to protect girls’ knees. A good preventive program can now reduce the risk of a torn ACL by as much as 80%.
There are several factors that make girls more prone to ACL injuries. Hormonal differences play a role as surging testosterone in boys at puberty makes them stronger and gives them more muscle mass to support and stabilize the joints. Girls also use their muscles differently than boys. They have less neuromuscular control of the knee and they tend to use the quadriceps muscles more than the hamstrings when they land a jump or change direction, which strains the ACL. These differences can be mitigated with proper conditioning.
A good injury prevention program starts with a thorough screening. Using measurements and tests of strength and balance, we can determine the level of risk. We can then tailor a plan that starts with exercises performed at home 2-3 times per week to normalize strength imbalances and improve knee stability.
The second phase constitutes exercises that take 10-15 minutes, also 2-3 times per week, supervised by the team coach and incorporated into regular warm-ups. These might include the following: lunges to improve overall leg strength and balance;
monster walk to strengthen hips and help keep knees in alignment; hamstring dead lift to strengthen hamstrings relative to quadriceps; and plyometrics, including squat jumps, broad jumps, and hopping that use rapid, powerful movements that first lengthen a muscle then shorten it, a contraction cycle that increases muscular power.
Supervision ensures that exercises are performed with proper form. For example, girls must learn to land a jump softly rather than stiff-legged while maintaining alignment.
“I’ve been doing physical therapy for a long time now, since before I had surgery,” Cooper said. She’s been doing so much work that the surgically repaired knee is as strong as her healthy knee. “Had I been doing exercises before… it definitely could have been preventative.”
With an investment of a few minutes several times a week, girls can reduce their risk of injury and improve their performance while building strength and endurance that will support a healthy athletic career for years to come.
Robert Fay, PT, MHSc, OCS, STC, CSCS , clinical director and owner at Armonk Physical Therapy & Sports Training, has more than 20 years of clinical experience in orthopedics and sports medicine including working with college and professional athletes.