Female soccer players are four times more likely to tear the anterior cruciate ligament (ACL) in the knee than their male counterparts. Women basketball players are twice as likely to suffer the injury as men. In fact, in sports that involve excessive jumping, planting, cutting and rapid change of direction (soccer, basketball, volleyball, skiing) the incidence of injury in women is from two to eight times that of men.

Those scary statistics mean women are far more likely to experience this painful and possibly sports career-ending injury or require surgery and rehabilitation to repair it. For players, coaches, parents and trainers, it is critical to understand what factors predispose women to this risk and learn how to prevent it if possible.

Sports therapy professionals with the Seton Family of Hospitals will present a free seminar designed to provide information on what happens during an ACL injury, why it occurs more often in female athletes and how to prevent the injury to all who are accountable for player safety: The player herself, the coach and the family.

Over the last 30 years elite womens sports have proliferated since the 1972 Title IX act was adopted that allowed women to participate in athletic events without discrimination. As a result, there has been a huge increase in girls and women participating in high intensity competitions that produce elite players. Those young women pursuing high school, college or professional sports need to be aware of the risks and know what they can do to reduce them.

"This injury occurs most often when no contact is involved," says ABPTS Certified Sports Physical Therapist Bob Kunkel, LAT, PT, SCS, of Seton Northwest Sports Medicine. "The player is running down the field, plants one leg and turns in the other direction. The plant leg is out of proper alignment. The foot is turned out with the ankle and knee turned in. We call it the position of no return. Severe ligament damage can occur due to the combined forces on the knee." Up to 70 percent of ACL injuries involve no contact.

Understanding ACL Injuries

The primary function of the anterior cruciate ligament (ACL) is to prevent the lower bone of the leg from moving too far forward or turning too far in rotation. When the ACL is overstretched, it can tear away from the bones to which it is connected. Many times, the ligament on the inside of the leg, the medial collateral ligament (MCL), which provides stability to the inside of the knee, and the medial meniscus, the cartilage that allows smooth movement of the joint, also are damaged. When all three are involved, the situation is often referred to as the 'terrible triad' because most likely surgery and rehabilitation will follow with possibly mixed results.

"Although surgical repair of the ACL has advanced substantially, it still involves grafting a tendon from another part of the body, intensive rehab and usually at least six months of recovery before the new tissue is strong enough to handle the physical intensity of play. For athletes, the time away from play is emotionally devastating," adds Nora Traves, MS, PT, Director of Rehabilitation Services. Nora's daughter is a competitive soccer player currently recovering from an ACL injury.

GoodHealth.com's online medical encyclopedia has more detail on anterior cruciate ligament (ACL) injures and how they are treated.

Why Women Are More Vulnerable

"Since 1990, more young women have been participating in competitive and recreational sports, which have resulted in female athletes suffering an increased incidence of ACL injuries. Several research studies began looking for the reasons why female athletes have higher incidences of non-contact ACL injuries," comments Petra Place, PT, a pediatric orthopedic and sports medicine physical therapist at Dell Children's Medical Center of Central Texas.

The studies identified the following:

Body differences. Women have a wider pelvis than men beginning about age 11 that tends to increase pressure on the inside of the knee. The ACL tends to be smaller and the groove containing the ligament (femoral notch) is more shallow. They also have less well-developed thigh muscles and a tendency toward inward-pointing knees (knock knees). These factors increase the risk of ACL injury when landing after a jump.

Muscular differences. Compared to men, women have less muscular strength, less well-developed thigh muscles and use the muscles in the front of the thighs (quadriceps) more for stability. Women's thigh muscles also take longer to develop muscular force than in men. These factors place greater stress on the ACL.

Ligament laxity. Compared to men, women have more laxity in knees and other joints, resulting in greater hip rotation and knee extension. The result is in inward curve of the knee when the leg is straightened, making it more difficult for the muscles in the back of the thigh to protect the ligament. Looseness in the knees also make ACL injury more likely. The differences in ligament laxity may be due to changes in hormone levels, although how they affect the ACL is unknown.

Prevention Protocol

Ongoing research also indicates that preventive training programs can be effective in lowering the incidence of ACL injuries in women up by 60 to 80 percent.

A good prevention program consists of:

• Warm up (to allow the muscles to prepare for activity)
• Stretching (to prepare for full range of motion)
• Strengthening (to improve leg strength and assist with muscle stability)
• Plyometrics (explosive exercises to build power, strength and speed with critical emphasis on soft landing with slight knee flexion)
• Agility building (to enhance ability to function in competitive situations)
• Cool down (to allow for gradual muscle elongation)

One such program was developed by a group of Santa Monica orthopedic surgeons that has been adopted and promoted by the LA84 Foundation and underwritten by surplus funds from the 1984 LA Olympic Games. The Foundation provides access to free coaching education resources, including one specifically designed to reduce ACL injuries.

ACL Injury Prevention: Responsibility

It is important for players, parents and coaches all to be aware of potential preventive strategies and practice them. Ages 11 or 12 for young female athletes is an optimal time to begin. Here are some things each group needs to know and practice.

Players

• Understand that you must practice preventive strategies until they become automatic.
• Learn safe biomechanics and incorporate them into your play.
• Train smarter, not harder.
• Learn how to jump and land correctly.

Parents

• Understand there is inherent risk to playing sports (change the risk factors you can, but recognize that some can't be changed)
• Encourage improved body mechanics, strength, conditioning
• Become knowledgeable about risks, potential preventive strategies and help teach.
• Communicate the importance of prevention to coaches.

Coaches

• Adopt preventive approach to practice sessions.
• Develop observation skills to recognize athletes that are at greater risk.
• Teach better body mechanics.
• Start work on training before the competitive session begins. Six weeks before the season starts is ideal, but it is never too late to start.

Seton Rehabilitation Services

The Seton Family of Hospitals offers rehabilitation services for patients of all ages and all conditions, including sports injury rehabilitation. It also sponsors various clinical education seminars throughout the year to benefit the community. A qualified sports therapist is available at all Seton Physical Rehabilitation Services sites. In addition to our Sports Medicine Center at Seton Northwest, which is one of the premiere facilities in Central Texas, we are proud to announce our new Pediatric Therapy Program At Dell Children's, with top-of-the-line treatments to help kids overcome injuries and disabilities.