Knees in need: Female athletes much more susceptible to damaging one of the body's most complex joints

By FAITH MOLDAN / Bigfork Eagle

Charlene Miller wiggles her arm in a wave-like motion as she sits in the Bigfork High School gym recounting how she tore her ACL.

"It feels like you have a noodle leg," the BHS senior said.

Miller is not alone. Six other BHS girls basketball players have torn their ACLs in the past seven years as well. The frequency of the injury in Bigfork athletes isn't an isolated occurrence, but there is no real solution to eliminating ligament and knee injuries in athletes — specifically females.

The Injury

It has happened in soccer games, basketball practice and basketball games for the Vals. Whitefish High School Activities Director Jackie Fuller said the Lady Bulldogs recorded one tear during girls soccer this fall and a re-injury in girls basketball. Six years ago, Dr. Albert Olszewski of Flathead Valley Orthopedic Center in Kalispell witnessed three point guards blow out their knees at the girls Northwestern A Divisional basketball tournament.

"I was totally out of control," Avery Vogel, another senior on the Vals' basketball team, said of the moments leading to her ACL tear. "My shin went one way and my quad went the other." Vogel tore her ACL during a 3-on-3 tournament in Whitefish the spring of her freshman year.

Olszewski and Dr. Kim Stimpson of Northwest Orthopedics and Sports Medicine agreed that some sports are more prone to ligament injuries, such as football, basketball and soccer. They said skiers are also more likely to tear a ligament and injure their knees.

"Females are three times more likely to injure their ACL in basketball and six times more likely in soccer," Olszewski said. "Girls are playing basketball and soccer as hard or harder than boys."

Stimpson said girls are four to eight times more likely to tear their ACLs than males. He added that his office sees about 20 athletes with ACL tears each year, which he estimated is average.

"It comes in spurts. Some years are worse than others," he said.

Olszewski added that the majority of ligament tears come from non-contact injuries when the person makes a sudden change in their angle or stops on a dime. Stimpson said not as many ligament injuries are seen during track and field season, golf, tennis or wrestling.

"It's hard to compare non-contact and contact injuries," Kathleen Ingalls of Bigfork Physical Therapy said.

When the injury is caused from contact it tends to be more forceful and a bigger injury, according to Ingalls and therapists Michael Close and Ingalls. Those injuries affect more than one part of the knee including different ligaments (ACL, MCL) and the meniscus. That trio is known as the terrible triad. One easily comparable fact between contact and non-contact injuries is that people stand a 50 percent higher chance of injuring their other knee if their tear is from a non-contact injury.

Many Theories

Why is there almost immediate mention of females being more prone to ACL tears? Because it's true and has been for years, according to experts.

"Girls have had a higher incident of knee injuries for quite some time," Olszewski said. "There are a lot of theories as to why."

One theory is the biomechanical structure of the female body. Because their hips are wider, women's knees angle closer together whereas men's knees are straighter and they are not as knock-kneed.

"Women have a tendency to hyperextend their knees more and put stress on the ligaments," Olszewski said.

Females are also quad-dominant, which means that while men's quads are 1.5 times strong than their hamstrings a woman's quads are three times stronger. Add that to the fact that the ACL is smaller in females, and girls' muscle mass is not as high as a man's and there's an obvious problem.

"It's multi-factorial," Stimpson said. "We don't have a clear understanding of why. All we know is boys are not girls."

Also studied is a possible neurological factor. Olszewski said that it has been found that men and women will both land in a crouched position when they jump from a table-top height.

"Have them jump from a bench or step and the man still lands crouched or with his knees bent, but women land standing straight. It's the same thing we see with jump stops."

Another possible factor is women's menstrual period.

"There's a slight increase of injury just before and after a woman's menstrual period," Olszewski said, but no reason as to why has been found.

Injury Care

Once an injury occurs, there's a 24-hour window that most doctors give for the injured person to see if the pain decreases at all. Lessened pain may mean that the ligament was only strained and not torn. That still means work must be done to help the ligament back to its previous healthy status.

A torn ACL doesn't require immediate surgery, but the majority of athletes opt for surgery and rehab during the offseason. Sometimes that's just not possible.

Miller, who tore her ACL during practice this basketball season decided to put off surgery and attempt to compete in track and field in hopes of gaining a sports scholarship. She guessed that her current rehab workouts are pretty similar to the exercises others do after surgery.

Jaylee Haveman and Vogel both underwent surgery after their injuries. Haveman had patella tendon surgery, while Vogel had hamstring surgery.

Stimpson said the operation to repair the ligament tear has evolved over the years to one that is much better at reproducible results and a good outcome.

"You feel a lot of loss," Haveman, who stepped and turned causing her ACL to pop out laterally during basketball divisionals her sophomore year. "I had the whole summer to rehab. It's mentally and physically draining."

Close echoed Haveman's statement.

"It's a huge commitment of time after surgery."

Many athletes fall into the four to six month area of coming back after surgery, but Stimpson said they're closest to being back to 100 percent almost a year after the initial injury and surgery. Athletes work themselves back to that 100 percent range with a combination of physical therapy and exercises on their own, according to Stimpson. He said 90 to 95 percent of their rehab is done with a therapist two to three days a week while maintaining a daily program at home.

"There are some rehab programs," Stimpson said. "There's no cure as long as they're playing sports. If you don't rehab and rehab correctly, it's almost not worth the surgery."

Vogel came back after six months of rehab.

"I was ready to go at five months but waited until the sixth. I was really timid," she said of her return the hardwood.

Prevention Possibilities

"The best way to care for an injury is to prevent it," Olszewski said.

When asked if they, in hindsight, saw anything they could have done differently to help prevent their injuries Haveman, Vogel and Miller answered with a resounding and quick yes.

"Agility is important," Vogel said. "You have to know how to come down with your knees bent." She said the Vals work on just that with different drills and stretches before each practice. Hammond said he instituted the leg and ankle stabilization drills from trainers, strength coaches and other coaches two years ago.

"I don't know if we are preventing any injuries with these things. All we can do is try," Hammond said. "I have never had a mediocre athlete tear their knee. It has always been the exceptional athlete — the fast, strong, aggressive kid. Some say its because the girls don't lift enough or build enough strength in their legs. I don't think it's that specific. Charlene (Miller) was very strong and lifted a lot. All these kids would be considered in good shape and strong."

Fuller, who is also the Lady Bulldogs' head volleyball coach, said she uses a system of plyometrics and weight training with her athletes. Olszewski and Stimpson agreed to the importance of having both plyometrics and weight training to prevent injuries. Stimpson said weight training was just as important as learning sport specific drills and techniques such as jumping, running and cutting.

"Coaches have to teach girls how to jump stop crouched and round corners," Olszewski said. Stimpson said they also need to keep the athletes strong and keep them from getting too fatigued.

Bigfork's coaches are doing their part in preventing injuries not just with stretches and drills before practice, but also with encouraging athletes to participate in the school's speed and strength class.

"The class started four or five years ago," Bigfork cross country and track and field coach Sue Loeffler said. "We started it to help those two to three-sport athletes who weren't able to get to the club." Loeffler said she also includes speed and strength training into practices. "We just need to make sure they're focusing on strengthening."

"Tell all the girls in the world to strengthen their legs," Haveman said.

Close said Bigfork's coaches are doing a good job researching injury prevention and searching out help but have more to do.

"Excellent strides have been made."