Knee injuries in female athletes reaching ‘astronomical’ levels

More women and girls than ever are year-round, multisport athletes, leading to overuse injuries that have reached astronomical levels.

More than 20,000 high school girls suffer a serious sports-related knee injury each year in the United States, according to the Chicago-based Children’s Memorial Institute for Sports Medicine. Girls are up to seven times more likely to injure their anterior cruciate ligament (ACL) than boys in similar sports.

“The number of knee injuries among young female athletes has reached epidemic proportions,” said Dr. James Elliott, an orthopedic surgeon at Ortho Montana, which is affiliated with St. Vincent Healthcare. “We are seeing players from all the high school soccer, volleyball and basketball teams. The injuries cut across every discipline.”

Dr. Peter Millett, an orthopedic surgeon and a partner at the internationally-renowned Steadman Clinic in Colorado, underscores Elliott’s message, saying ACL tears in young women and adolescents are reaching “alarming numbers.” Millett has served as a team physician for the U.S. Ski Team and a consultant to the Montreal Canadiens, an NHL team. He is a member of the steering committee for the national campaign called “STOP Sports Injuries.” The goal is to better understand, prevent, and treat sports injuries in youth.

For one Billings physician, it isn’t that complicated.

“With year-round and multisport participation, many of our young athletes do not have time for recuperation, and injury potential increases dramatically,” said Dr. Michael Willis, orthopedic surgeon at Billings Clinic. “Those injuries can be lessened through appropriate seasonal adaptation, adequate nutrition and by paying attention to signs and symptoms of overuse.”

Vicki Carle, Skyview High School volleyball coach, said she would build into the school district’s athletic calendar at least two weeks of down time between sports so the young athletes could rest.

“They just go from one sport to another to another,” Carle said. “The underlying pressure pushes kids to too much activity. … balance is key.”

The increase in knee injuries has catapulted the acronym ACL into the daily lexicon, but what is it?

The ACL is one of four major ligaments of the knee. It prevents excessive motion of the knee joint. Patients say it felt like their knee “giving out.”

Why women are more susceptible to ACL tears in unclear. But many orthopedic surgeons seem to agree the underlying reasons are at least five-fold:

Year-round participation without time for rest and repair could lead to overuse injuries related to fatigue and “wear and tear.”

The gap between young men and women participating in sports has significantly diminished, likely the effect of the passage of Title IX in 1972, which mandated equal funding to men’s and women’s athletics in federally funded educational facilities.

Girls tend to have less neuromuscular control of knee motion than boys while performing certain athletic tasks, such as landing from a jump or suddenly changing direction.

The speed, power and intensity with which female athletes are playing have dramatically increased.

There are numerous anatomical and hormonal differences between men and women.

Less than one-third of all reported ACL injuries involve contact from an outside force such as an opposing player or goalpost, Elliott said. Most are non-contact injuries, the result of a sudden change in direction, cutting movements, landing from a jump with inadequate knee and hip flexion or a lapse of concentration.

More people are hurt playing soccer, in part because of its increasing popularity, according to the Archives of Internal Medicine. Between 2000 and 2006, the number of female soccer players around the world increased by 19 percent to 26 million.

Young women are also tearing their ACLs playing basketball, volleyball, participating in physical education, running track or even during a pick-up game at open gym.

Damage to body and mind

For some, an ACL injury can be a life-changing event. Such injuries often require surgery and/or months of rehabilitation and physical therapy. For many, it means sitting on the sidelines for an entire season and an incomplete recovery. College scholarships can hang in the balance as do some of the young athlete’s dreams of becoming the next Mia Hamm. The mental and emotional effects can be as harmful as the injury.

Most injured athletes will go through a grieving process that involves denial, anger, bargaining, depression and acceptance. “As a surgeon, I try and help them along this road and try to get them to acceptance as quickly as I can,” Millett said.

Young athletes who are talented enough to possibly earn a scholarship at the college level often have much of their identity wrapped up in being an athlete, said Dr. Robyn Odegaard, founder and president of the New Jersey-based Champion Performance Development. She is a sport psychologist and team development consultant.

“When an injury sidelines them, particularly when it means they may not play at the next level, they are likely to start to question who they are as a person. If I am not a star volleyball player, who am I?” Odegaard said.

This issue manifests itself as general anxiety, melancholy or depression. Left untreated, these concerns can negatively affect academic performance, relationships and even the athlete’s willingness to perform the rehabilitation essential to return to the game, Odegaard said.

It may take an athlete eight months to fully recover from an ACL tear and subsequent surgery and perhaps a year or longer before one’s performance returns to top form, said Millett. Most surgical results allow athletes to return to play.

“Many turn this adversity into a positive and find strength in their injury and recovery that translates into deeper desire, a stronger work ethic and performance improvements,” Millett said. “This really is amazing to see when this type of transformative determination occurs.”

Others who may not be able to get back to sports are inspired after their injury and channel their energy into academics and have become orthopedic surgeons, sports medicine doctors, physical therapists or athletic trainers.

The personality of the injured athlete will play a role, said C. Craig Stewart, a professor in the Department of Health and Human Development at Montana State University in Bozeman. “The more competitive an individual is, the more they are likely to attack rehabilitation as they did competition,” he said. “However, like competition, they need strong, knowledgeable support from a coach, trainer and teammates.”

Though many of the factors associated with the incidence of ACL tears in female athletes are not able to be modified, biomechanical research has shown that the incidence and risk can be reduced by incorporating neuromuscular retraining programs for ACL prevention, according to Willis.

The long-term follow-up of programs that have been in place for greater than 10 years shows a significant reduction in ACL tears in women who have been through the program, but the rates remain higher than in male counterparts. The data also support initiation of ACL prevention for athletes in seventh to ninth grade for optimum effect. These programs are readily available in Billings and have largely been employed in school athletics as a routine warm up.

“For those of us in sports medicine, we hope that long-term results locally will reflect those seen nationally,” Willis said. “Unfortunately, young women in sports remain at increased risk, but we would never discourage participation in sports; the long-term benefits certainly outweigh the risk of injury.”