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ARE YOU A PARENT OF A FEMALE ATHLETE? DON'T LET THIS HAPPEN TO YOUR CHILD!
YOU CAN FIND OUT IN 3 MINUTES IF YOUR CHILD IS AT RISK FOR A DEVASTATING INJURY...
CLICK HERE!
"You can prevent ACL injury. If you have a daughter who is playing basketball, soccer [or other field
or court sports], then it is crazy if her team isn't undertaking one of the evidenced based warm-ups
targeting lower limb injury prevention." British Journal of Sports Medicine, October 2008
Read The
The Uneven Playing Field by Michael Sokolove in the NY Times Magazine, May 11, 2008
Female Athletes Have Arrived
More women and girls are playing sports than
ever before. The spectacular performance of the women in the 1996 and
2000 Olympics and the popularity of women's professional soccer, basketball,
golf and tennis have had a profound influence on little girls. Forget
about "Be like Mike," instead "Be like Mia!"
The speed, power, and intensity of women's sports have dramatically increased
over the past decade. With this style of play has come an increase in
musculoskeletal injuries. One of the more common injuries is a sprain or
rupture of the ACL (Anterior Cruciate Ligament) of the knee.
Anatomy of the Knee
The anterior cruciate ligament (ACL) is one of four main ligaments of the
knee. It is located inside the knee and runs from the thigh bone (femur) to
the shin bone (tibia).
Its functions are to keep the tibia (shin bone) from sliding
forward on the knee and to stabilize the knee when it twists (rotation).
So in straight-ahead sports like jogging, swimming, and biking,
there is little stress to the ACL. But in the sports that involve cutting,
planting and changing direction (football, soccer, basketball, skiing, gymnasics,
field hockey, ice hockey, wrestling, lacrosse, rugby, tennis) the ACL plays a vital role.
Injury Statistics
According to 1998 injury statistics from the U.S. Consumer Product Safety
Commission, more than 81,600 people injured their knee playing soccer,
and 225,800 sustained injuries in basketball. Gymnastics, soccer and
basketball are followed by field hockey, volleyball, lacrosse and softball
as sports that cause ACL injury in females. (4)
Studies show that women are 2 to 8 times as likely as men to have an ACL
injury. (4)
In 1995, an article was published in the American Journal of Sports Medicine
that found that female basketball players in the NCAA tore their ACLs four
times more often than male basketball players. In the same study, women who
played NCAA soccer sustained ACL injuries twice as often as male soccer
players.
An estimated 200,000 ACL injuries occur annually in the United States.
Approximately 60,000-75,000 ACL reconstructions are performed each year.(6)
Causes of Injury
The reasons why this is the case are not easily explained. It is helpful
to divide these causes into two groups:
1. Mechanisms of Injury
2. Anatomical and Hormonal Factors
Mechanisms of Injury
Most ACL injuries are non-contact related: running and cutting sharply
in a more erect posture than in men, landing from a jump without bending
the knees sufficiently, and playing on surfaces with a high coefficient of
friction. The level of skill and experience of the athlete is always of
significance. Of course, contact injuries like a direct blow to the knee
from the rear or side can cause a tear in the ACL. The tear usually
occurs in the mid-portion of the ligament which is the weakest part.
"Commonly, the athlete runs, suddenly stops, and then turns, thereby
causing a deceleration of the lower limb, a forced hyperextension of the
knee, or a forced tibial rotation...." "Other mechanisms include an
internal rotary force applied to a femur on a fixed weight-bearing
tibia, an external rotation force with a valgus [outward] force,
or a straight anterior force applied to the back of the leg, forcing
the tibia forward relative to the femur." (4)
Noncontact injury
An audible pop often accompanies this injury, which often occurs
while changing direction, cutting, or landing from a jump (usually a hyperextension/pivot
combination). Within a few hours, a large hemarthrosis develops. Patients usually are unable
to return to play, secondary to pain, swelling, and instability or giving way of the knee.
Contact and high-energy traumatic injuries
These injuries often are associated with other ligamentous and meniscal injuries.
The classic "terrible triad" involves a valgus stress to the knee
with resultant injury to the ACL, Medial Collateral Ligament (MCL), and medial meniscus.(6)
Anatomical and Hormonal Factors
1. Intercondylar notch size. This is the groove in the femur through
which the ACL travels. The size and shape of the notch tends to be
smaller in women. This narrowness may predispose women to higher rates
of ACL injury. Not only is this groove smaller in women, but the actual size
of the ACL itself (MRI cross section of the ACL in a man averaged almost
14 millimeters larger than in females at the width of the space through
which the ACL travels) is smaller in women (1).
2. Pelvis size. Women typically have a wider pelvis, which makes the
thigh bones angle downward more sharply than in men. This is called the
"Q" angle. The greater the angle, the more pressure put on the inside
(medial aspect) of the knee. (3)
3. Ligament laxity. Women's ligaments can be more lax (have more give) than
men's ligaments. Also, research has shown that women's muscle tissue is
more elastic than male muscle tissue. Therefore, excessive joint motion
combined with increased flexibility may be an
important cause for women tearing their ACL at a higher rate. (3)
As a women approaches the end of knee extension, the femur glides forward
more than in men. (4)
4. Reflex time. It has been shown that female muscles stabilizing the
knee may take a millisecond longer to respond than their male counterparts.
It is suspected that this small difference in the time of contraction to
protect the knee could also lead to injury. (3)
5. Quadriceps/Hamstring Strength Ratio. The hamstrings reduce forward
motion of the tibia (tibial translation) in synergy with the ACL.
"In men, the hamstring is recruited first to stabilize the knee
during anterior tibial translation. On the other hand, women rely
more on the quadriceps [front thigh muscle] and gastrocnemius [calf]
to resist anterior tibial translation." (4)
Poor hamstring strength in both sexes may be a cause for ACL injury.
If the hamstring cannot balance the power of the quadriceps, then this
imbalance can cause significant stress to the ACL. (3)
6. Hormones. A recent study suggests that changes in estrogen levels
during the menstrual cycle may affect the strength of the ACL. This may
predispose women to the higher injury rate. (3)
Return To Play(5)
A four phase return to play should be followed to safely return the athlete to the
playing field:
1. Functional Balance and Core Strength
a. Normal walking gait
b. Normal running gait with complete range of motion
c. Double leg squat
2. Functional Strength
a. Bilateral symmetry in balance
b. Single leg squat
3. Power
a. Double and single leg plyometric exercises
4. Sport Specific Symmetry
a. Running and jumping training in all planes of motion:
forward/backward, side to side, rotation.
Return to Play Reference:
Back in the Game by Gregory D. Myer, MS, CSCS; Mark V. Paterno, PT, MS, SCS, ATC;
and Timothy E. Hewett, PhD - Orthopedic Tech Review March-April 2005
Injury Prevention: The Good News
Multiple studies have shown that a proper training program can be very
effective at decreasing the rate of ACL injury.
"A training program developed at the University of Vermont Medical School
designed to prevent ACL injuries in skiers demonstrated a 69% decrease in
injuries among ski patrol personnel and instructors who received the
training compared with those who did not. Another prevention program
developed in Cincinnati demonstrated that a six week program of training
could reduce the risks of knee ligament injuries in female athletes.
One of the important aspects of the training program is to train these
athletes to rely more on hamstring muscles than quadriceps, thereby
protecting the knee ligaments. A controlled study of women athletes who
did not participate in the training program compared with those who did
indicated a five times higher incidence of knee injury than in male
athletes. Females who participated in the training had injury levels equal
to or only one or two times higher than males." (2)
How You Can Prevent ACL Injury
1. Proper leg muscle strength and flexibility training
as well as core training.
2. Proper neuromuscular (balance and speed) training.
A proper training program would include squats, lunges, stiff-leg
deadlifts, hamstring curls, and different types of jumping movements.
These jumping movements would progress from:
slow jumps landing on two legs in one plane of
motion
slow jumps landing on two legs in multiple planes
of motion (front to back, side to side, and rotation)
slow jumps landing on one leg in one
plane of motion
slow jumps landing on one leg in multiple
planes of motion
faster jumps landing on one or two legs in
multiple planes of motion
3. Proper coaching on jumping and landing and avoiding any straight
knee landing.
4. Proper footwear and orthotics
if necessary.
See our SPORTS PERFORMANCE TRAINING to get
one on one instruction!
References
1
ACL Injuries in Women
2 New Research Suggests Hormones Put Females at Higher Risk of ACL Injury, NATA
3 Pettineo, et. al. Female ACL Injury Prevention With a Functional
Integration Exercise Model. Strength and Conditioning Journal.
Vol 26 No1, pp.28-33.
4 Back in the Game
5
Anterior Cruciate Ligament Injury
For more information on ACL injuries in women see
Anterior Cruciate Ligament Injuries in Female Athletes:
Why Are Women More Susceptible?
and
Training improves outcomes ACL outcomes in female athletes
for more information.
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ACL Injuries in Female Athletes