ACL Injuries in Women

 It’s Something In the Way She Moves

Meal plan examples

You have that feeling all too often. You're watching a women's basketball, soccer or volleyball game and you observe, with concern, players stopping short, cutting, planting their feet or landing with their knees hyperextended. You wonder, 'who will it be this time? Which unlucky player will be the one to suffer an injury to her anterior cruciate ligament, with the pain, the costly surgery and the rehabilitation that so often goes with it?

Your apprehension is understandable. ACL injures are substantially more common for women than for men in a variety of sports, including basketball, as data from the National Collegiate Athletic Association (NCAA) show. According to a report of 1998- 99 winter sports injuries from the NCAA's Injury Surveillance System, the ACL injury rate for women's basketball practice workouts was seven times higher than the men's rate, and the ACL game injury rate was five times higher than that for men. For women, 34 percent of reported injuries resulted in restricted participation or no participation for seven days or more. For men, 25 percent of reported injuries resulted in restricted participation or no participation for seven days or more.

Located inside the knee joints, the ACL stabilizes the knee and prevents the tibia from sliding forward beneath the femur, which is known as anterior tibial translation, explains Cedric Bryant, Ph.D., chief exercise physiologist for ACE. "Movements where there is a sudden deceleration, or a hard twist or change in direction, all put stress on the ACL. It's also common for athletes to injure themselves where there is hard planting of the foot, or landing with the knee extended instead of flexed."

Fortunately, there is good news. Due to advances in surgical techniques that are less invasive, an ACL tear isn’t the career-ending injury that it once was. Because there are a number of ongoing research and training programs around the country that are looking closely at the causes of these all-too-common injuries in women athletes, the injury rate is likely to decline.

Recovery Time is Much Shorter
While a decade ago recovery and rehabilitation for an ACL injury might have taken as long as a year, now it may be limited to six months or less. "At one time, physicians did open repairs with a large incision," says Angela Smith, M.D., an orthopedic surgeon and a past president of the American College of Sports Medicine. "They used rigid immobilization after surgery. Now, most surgery is arthroscopic- assisted, so you don’t have the incision down the entire front of the knee. We also don’t put someone in an immobilizing brace; we go for early full range of motion. This way, there is less chance of severe stiffness. You also avoid the horrific atrophy caused by prolonged immobilization.

Of course, a quicker recovery is most likely if the injury is treated and diagnosed properly from the beginning, Smith says. "The first thing to do when an athlete seems to sustain an ACL injury is to have her rest and make her comfortable. If you’re a personal trainer, you’ll want to give first aid and get an appropriate evaluation. If you’re a certified athletic trainer, you may be able to diagnose it. That will be easier to do right away, before there is swelling. An accurate diagnosis is important, because it may not be an ACL injury but a fracture, which you would treat differently."

Smith also points out that, when athletes tear the ACL, they often dislocate the patella as well, and many trainers don’t look for the combination. "When the ACL gives way, it puts the patella in peril. If the athlete has an MRI scan, you will see the typical bone bruising that goes with patella dislocation."

Anatomy, Hamstring Weakness May Be to Blame
Treatment aside, what’s behind the higher incidence in women? And what is being done to prevent it? "Some studies suggest that hormonal factors may be involved,"says Bryant. "During the menstrual cycle, when estrogen levels are higher, the ligaments tend to show some laxity, and offer less protection. When they’re looser, they may not offset tibial translation. However, further research is needed in this area."

In addition, adds Bryant, the femoral notch, through which the ACL is routed, is smaller in women than it is in men, and may pose a problem. "Because there is not as much room, the ACL may rub up against the side, causing fraying. In addition, the ACL itself may be smaller and not as thick. The smaller size means it has less tensile strength, and less ability to handle stress, which may make it more susceptible to injury."

Weak hamstrings may also contribute to the problem, Bryant advises. "The ACL receives assistance from the hamstrings. When the hamstrings contract they help prevent tibial translation. The problem is that women tend to have weaker hamstrings than men. And they tend not to activate them as quickly. For that reason, my advice is to try to restore a normal balance between the hamstrings and the quadriceps. For example, if a woman can do 100 pounds of knee extension, she should be able to do at least 60 pounds of knee flexion."

What about other anatomical factors, such as women’s wider pelvises and the Q-Angle, which is often discussed as a cause of the higher ACL injury rate in women? "I haven’t seen the research that demonstrates that the Qangle is the problem,"Smith says.

It’s All in How You Move
Rather, Smith urges trainers to pay keen attention to biomechanics and retrain athletes accordingly.

Six Chain-reaction Exercises
Gray offers the following examples of chain-reaction exercises from his video, Lower Extremity Performance and Prevention. They are designed to imitate—in a controlled manner —the movements that can be found in different sports. Keep in mind that this is just a sample; there are dozens of variations.

1. The 3-D matrix hop is a tri-plane functional exercise that facilitates the same reaction in a controlled manner that the athlete would experience as she runs forward, cuts to the right, runs forward and cuts to the left. It takes place in the sagittal plane, forward and back, in the frontal plane, side to side, and in the transverse, or rotational, plane, where the athlete rotates off the right leg, propels back, and then off the left leg, and back. Five reps of each, two sets.

2. The 3D matrix lunge calls for the anterior lunge, the lateral lunge to each side, as well as the rotational lunge to the right and to the left. The athlete can also do the 3D matrix lunge with a reach to the foot to integrate the hip and trunk muscles. She can also do the same matrix lunge reaching overhead to integrate some of the benefit of the hips, and facilitate more of a reaction of the lower extremities. Five reps of each, two sets.

 3. Single-leg balance squats call for driving the legs in the sagittal plane, then putting one leg in front and the other leg behind to create a reaction of the entire chain. Next, the athlete can progress by driving one leg to the side in the frontal plane to create a set of needs for the hip, trunk and the lower extremities. Taking the opposite leg and crossing it over provides further dynamic components of the entire chain reaction. Five reps of each, two sets.4

4. The 3D matrix lunge can be made more reactive by doing a mirror matrix. Partners take turns anticipating and following each other as they move through the matrix pattern. Add arm movements to increase the intensity and complexity of this activity.

5. One-legged hopping is an advanced, yet essential, component of the prevention and performance lower-extremity program. Athletes should go through the same type of progression—starting in the sagittal plane, continuing with sagittal anterior/posterior hops and frontal plane medial/lateral hops, and then progressing to transverse plane rotational hops. The rotational hops have a dramatic influence on the entire chain reaction, how the shoulders, the trunk—and especially the abdominals—control what happens with the pelvis, the knees and the feet. 30 seconds in each direction, two sets.

6. Two-legged jumping can be done anterior and posterior in the sagittal plane, right lateral and left lateral in the frontal plane. The athlete can incorporate the rotational jump as well. It is best to progress from a simple jumping pattern to a complex one and, in the process, incorporate all three planes of motion. 30 seconds in each direction, two sets.

"What I suggest is that women learn to move like tennis players. You stay forward on the balls of your feet, taking lots of little steps. You stay in that athletic stance, ready to move, pivoting on the front of your foot, with your knees bent. That's similar to other programs that say don't take one step forward, stop and cut. Or don't grab a rebound, land and immediately try to turn and take off. Instead, you need a three-step stop to dissipate that force, and get those knees bent. Be light like a feather, flexing your knees and bending your ankles when you land."

She also advises athletes to keep their knees over the toes. "It's not only important in preventing ACL injuries, but it seems to be very useful in treating patellofemoral pain, and in treating any medial knee pain. It offers medial ankle and foot protection. It solves a lot of problems." Smith notes that Carol Otis, M.D., who serves on the United States Tennis Association Science Committee, has reported that ACL injuries are very rare in women's tennis. "There are many ways to teach these moves. Bert Mandelbaum, the head physician for USA Women's Soccer, has been incorporating thesemoves into regular warm-ups. And Tim Hewitt, a biomechanist who has studied ACL injuries as foundation director of Cincinnati Children's Hospital, has also developed a training program."

Retraining Is Key
Bryant and other experts agree with Smith that biomechanics and appropriate training programs hold the key to ACL injury prevention in female athletes. "Women need to do some jump training so that they can learn to absorb the force with appropriate flexion of the knees, instead of landing with the knees extended. Also, they should learn to land on the balls of the foot or the toes, rather than on the heel. I'd suggest that trainers take their clients through some agility-type exercises. When women are changing direction, they tend to stand more upright, with less knee flexion."

What trainers need to understand is what the ACL does relative to the knee and the rest of the body,"says Gary Gray, P.T., founder of Functional Design Systems in Adrian, Mich. "Virtually every muscle in the body controls the ACL and the knee. The athlete actually has the least control at the knee. To strengthen the knee and prevent ACL injury, most trainers typically concentrate on knee exercises. But that's the opposite of what you need to do. Instead, consider the fact that the hip, the foot, the trunk and the shoulders all control the knee. If you balance on one foot, and quickly turn your head, your knee would react to that. In fact, it could be the weakness of neck muscles that causes an ACL tear."

In addition, trainers should offer exercises that retrain women to move in all three planes, says Gray. "The movement patterns that women learn early on are very much in the sagittal plane— very much forward and backward. When we get them moving side-to-side or rotationally, the two most important planes, they have great difficulty. They are not given the opportunity to express those movement patterns early on. It is all relative to the kinds of activities that are driven into them, I would say, in the first through fifth grades. You have to learn movement patterns before you can learn skills, and women don't learn to rotate. You won't solve the problem with women and ACL injuries until you solve the cause. The cause is inappropriate training."

For that reason, the exercises that Gray suggests are based on a "chain-reaction approach. "The body is a link system. First, in order to produce force, we have to reduce force and we have to utilize as many joints as possible and utilize all planes of motion. So, all the exercises have a constant interplay between force reduction, pronation, and force production, supination. All of function, all of sport, is three-dimensional; we move in the sagittal plane, the frontal plane and the transverse plane. As a result, training and conditioning programs, as well as prevention and performance programs, must be three-dimensional activities all at the same time to reflect the tri-plane capabilities of the body.

"At the beginning of our program, we really concentrate on integrating the entire body to allow the entire lower extremity of the hip, and the knee and the foot to be successful. As the athlete progresses, we go more for integrated isolation,"Gray says. "Our number-one goal is to have you understand that movement occurs at a subcortical level,"Gray points out. "Everything that the athlete does should be instinctive and oriented toward the task. The focus is on relationships and motion, rather than alignment and position. The most important relationships are those of the ankle, the knee and the hip. Performance is very dynamic; therefore, movement and the exercises need to be very dynamic."

How many sets and reps should the athlete do? The answer depends on the individual—her age, proficiency and whether this is a prevention or a performance program. "The key, here, is to keep it simple and keep it safe. Don't do too much. Don't put too much emphasis on any one particular area; choose from the various categories." Gray also reminds trainers that not everyone will possess the same abilities. "You will see differences in growing, developing athletes when compared with the more mature athlete. The other consideration is progression; each person will learn and progress at different rates. Be certain that the athlete can do the exercise before you progress to something more complex."