ACL Prevention in Female Athletes
ACL Injuries in Females: An Ounce of Prevention…
By Mitchell D. Seemann, MD
Suzy Soccer is an accomplished senior female soccer athlete
at a local high school who has made soccer her life’s pursuit. Since the age of 5, she has toiled on the
grassy soccer fields honing her skills hoping to some day make it BIG: State
Champ, College Scholarship and who knows what else. While her friends were out socializing, she
was
running, lifting, practicing and playing games year round with her school
and club teams. She didn’t mind, because
loved it. Finally, all the hard work
began to pay off. By her junior year she
came to be known as one of the top players in the state. Top college teams began contacting her,
asking if she would be interested in joining their team when she
graduated. She was poised for a breakout
year.
Then, the unthinkable happened. In a routine game, in favorable conditions, while chasing a foul ball she planted her foot on the turf, but her upper body went the opposite way. She felt a “pop,” immediate pain and fell to the ground clenching her knee. She knew it was bad as soon as it happened. Swelling followed and the tears began to flow. A trip to her local orthopedist confirmed her worst fears: an ACL (anterior cruciate ligament) tear. Major surgery. Out for the next 6 months. Goodbye State Championship! Goodbye scholarship!
This scenario unfortunately has occurred all too frequently to female athletes over the past 10 years. More and more, female soccer, volleyball and basketball players are tearing their ACL at an alarming rate. The ACL is a ligament that is a major stabilizer of the knee. When torn in a young athlete, surgery is usually necessary to return to pivoting sports. The rehabilitation is long, at least 6 months. Consequently, such an injury can have a major impact on one’s sports career.
Recent studies from the NCAA have revealed females to have a 2 to 8 times higher ACL injury rate than their male counterparts. An explosion of studies has occurred to figure out the cause of this discrepancy.
Many components have been looked at to try to find a correlation between the high injury rate and the female athlete: anatomic, physiological, hormonal, developmental, environmental, and training factors have all been scrutinized. In the end, however, it would appear that neuromuscular factors are the most important. In other words, the link between the hip, knee and ankle with the surrounding muscle in females is a bit different in females compared to males predisposing them to ACL injury.
In the lower extremity, the hamstrings act to pull the lower leg (tibia) backwards in the knee. The ACL keeps the tibia from moving forward; therefore, the hamstring can protect the ACL from injury. Recent studies have shown deficiencies in the post-adolescent females’ hamstrings. First, their hamstrings tend to be weaker than their male or pre-adolescent female counterparts. In addition, their hamstrings tend to activate slower than normally seen. These two factors remove the protective factor of the hamstrings, placing the ACL at risk.
Other factors contribute to placing increased tension on the ACL. Upon landing from a jump, females tend to land with a straight knee, with little cushion provided by the quadriceps. Also, females tend to be a bit more “knock-kneed” than males. Lastly, their hip muscles are naturally weaker which makes which makes the thighbone angle inward more, increasingly the knock-kneed position. All these factors lead to increased torque (force) across the knee, setting up the female athletes for an ACL injury.
Armed with this knowledge, investigators nationwide have taken the next step to design prevention programs to address this problem. A few years ago Dr. Burt Mandelbaum, an orthopedist in Santa Monica, California, developed the “PEP” program or “Performance Enhancement and Injury Prevention.” Based on the principles outlined above, he developed a series of exercises to decrease the torque across the ACL. This five-step program helps to improve the strength and response time of the hamstrings, improves the circuitry between the muscles and nerves, and finally teaches proper alignment of their lower extremity in a landing or planting position. The components of the PEP program include warm-up, flexibility, strength, proprioception (biofeedback) and activity. Athletes need to be taught proper technique and these exercises are meant to substitute for a normal warm up routine. Properly administered, this program can reverse most of the neuromuscular deficiencies seen in the female athlete.
The PEP program, as well as others, have been studied critically and have fared well. Collectively, results have shown a 70 – 80% reduction in the ACL injury rate in a large population of female athletes. It’s important to understand that these programs help “non-contact” ACL injuries, but will not prevent ACL injuries incurred in a collision. Nevertheless, these numbers are impressive and are encouraging for the female athlete at risk. Recently, with the help of Panorama Orthopedics and trainers in the Health South Outreach Program, the PEP program is being instituted in all 18 high schools in Jefferson County, Colorado. The research, before and after, will be analyzed to ensure the efficacy of the program.
To finish our story, Suzy Soccer was able to get back to soccer after a successful ACL reconstructive surgery. She was offered a scholarship at a local university and her soccer career is back on track. She is currently on the PEP program to prevent further injury.
