THE ODDS AREN'T GOOD

For female athletes and knee injuries,

THE ODDS AREN'T GOOD

Tuesday, February 18, 2003

BY ERIC F. EPLER
For The Patriot-News

There was senior Lauren Pears, stiffening on de fense during a typical bas ketball game on a typical Tuesday night in January.

Cumberland Valley assigned a ton of responsibility to the 5-7 guard, who helped deliver one PIAA championship and stood steadfast on delivering another.

Pears lived for these moments: a rival's gym, winning streak on the line, a division title just around the corner, her father watching from the sidelines. Ready to go.

That was senior Lauren Pears, clutching a left knee that had been so swift and steady just seconds before.

She recognized the sound when it broke free. In that instant, Pears traded the rest of her high school basketball career for another round of surgery -- and the scar it leaves -- and months of rehabilitation.

All the remnants of a ruptured anterior cruciate ligament.

"I was just moving backwards on defense and went to plant my left foot when it got tangled. Then I heard it," said Pears, a Patriot-News Big 15 selection who tore the ACL in her right knee three years ago in an AAU game.

"I knew exactly how bad it was because I've felt it before. But today was my best day," Pears added recently. "There is almost no swelling [post-surgery] and I feel like I'm way ahead of schedule."

Pears will mend just in time to start her freshman campaign at the University of Pennsylvania. Much like former Elco star Ashli Schwab, who suffered a torn ACL in the 2001 District 3-AAA final, did before heading to Penn State.

But both are part of the growing number of female athletes, some at the pinnacle of their classification, who have suffered life-changing, non-contact ACL injuries.

And who continue to be at high risk for another.

It is estimated that one in every 10 collegiate female athletes and one in every 100 high school female athletes will suffer a major knee injury each year. The Mid-Penn Conference has certainly witnessed its share over the past 12 months.

Trinity lost Samantha Ramus in last year's District 3-AA tournament.

Amy Reed suffered a similar fate at Gettysburg.

Mechanicsburg lost a pair of budding stars in Autumn Hilsinger and Megan Alexander.

Gone at Big Spring was Randy Jones.

All suffered ACL injuries on the basketball court. Many more were claimed in the violent, cutting sports of soccer, gymnastics and volleyball.

"Certainly, part of the epidemic is the sheer increase in the number of females participating in athletics, but despite that fact, there is still a serious issue to address," said Penn State team physician Wayne J. Sebastianelli.

"It's a difficult situation for most because the vast majority of these incidents are non-contact. It is probably 90 to 95 percent."

Some of the casualties may, in fact, be a direct result of Title IX of the Education Assistance Act, which increased female participation in college sports nearly 800 percent since its 1972 inception.

But the incidence of all ACL injuries among female athletes has grown at such an alarming rate - and at substantially higher ratios when compared to male athletes - that sports physicians and orthopedic surgeons are now forced to search for more definitive answers.

Several causative factors have been suggested, but the reasons behind this discrepancy are not known.

The reality of anatomy:

Medicine has made advances in the last decade in treating ACL injuries but it still struggles with the vulnerability of female athletes, who are two to eight times more likely to suffer the ligament injury, according to a recent study by the NCAA.

"I definitely think that it is multi-factorial, but the combination of a narrow notch in the knee, the Q-angle and muscle development are the most prevalent," said Dr. John Thompson of Central Pennsylvania Orthopaedics.

"Females tend to hyperextend their joints and that person is going to put more stress on their ACL. If their legs are straight when they land from a jump, ACLs can tear because of the increased landing force.

"If you overwhelm the dynamic [muscles and tendons] stabilizers in the knee, then you force more load on the ligaments. When that occurs, the ACL can fail."

According to Thompson, a narrower femoral notch, a bony structure that houses the ACL, is a significant culprit in regards to injury. Even the slightest movement can cause a "shearing effect," or pinching of the ligament.

A wider pelvis, which creates a dangerous angle between the femur and the tibia (shinbone) -- the ACL connects these two bones and prevents the tibia from sliding forward -- also may predispose females to ligament stress.

The abnormal increase in inward force on the female knee puts the soundness of the ACL in jeopardy. It is this Q-angle that can create a more pronated, or flat-footed position, as well.

In addition, men have more lean muscle mass than women and tend to rely more on their muscles to restrain joint forces around the knee. Women depend more on their ligaments.

The American Academy of Orthopaedic Surgeons reports that nearly 60 percent of ACL injuries in female basketball players occur when landing from a jump, so these increased forces, at precarious angles, can multiply one's potential for injury.

"A lot of it is just bad technique," adds Sebastianelli, who consulted on the Schwab case, one of the few where direct contact occurred.

"By just going from a sitting to a standing position, you increase your body weight 3.5 times and all that force goes through your hips and knees.

"That number is increased ten-fold while landing from a jump from a standing position. Even without a significant number of points against you, that's more than enough."

One key extrinsic factor, those originating outside of the knee joint, on the highly researched subject is the strength ratio between an athlete's hamstrings and quadriceps.

"Males typically have a 70 percent strength ratio, where the hamstring is about 70 percent of the quad. In females, we see that ratio at about 20 to 30 percent," physical therapist Ken Lennington of First Choice Rehabilitation said.

"That is dangerously low because while the quadriceps allow the tibia to move forward, the hamstring works to pull it back, thus protecting the knee."

With males and females mobilizing these muscles differently, a balance must be maintained, says Lennington, otherwise the stabilizing forces are lost.

In addition, a majority of doctors and researchers agree that females seem to exhibit a greater general joint laxity than males, and that even those female athletes skilled enough to play at high-intensity levels have muscles that react to motion at a slower pace, thus heightening their risk for ligament injuries.

Hormonal factors:

In the past five years, researchers have focused greater attention on identifying the link between estrogen levels and non-contact ACL injuries.

"There is obviously a role that it plays, but its clinical significance is really unknown," said Thompson.

"I believe the statements regarding the hormonal response, at this stage, are theory. Because of the difficulty in isolating that response, it makes this terribly difficult to determine why the female is pre-disposed to all of this."

Sebastianelli agrees.

"There could indeed be a period of time during the normal cycle when the balance of estrogen and progesterone could lead to susceptibility," said Sebastianelli.

"There are wonderful studies going on right now, but some previous studies offer bad technique. Can we find an acceptable number of subjects to fit all requirements? Can we get them at the same point in the hormonal cycle? They are barking up the right tree."

Recently, a study at Penn State showed that muscular strength was not affected during the female cycle. However, there was a slight weakening of the ligaments during the ovulatory stage, or mid-cycle.

Though it may be too soon to correctly predict how estrogen receptors in the ACL react during the female cycle, Dr. Edward M. Wojyts of the University of Michigan, considered one of the leading experts on this issue, and three other participating facilities recently concluded that females are three times more likely to injure their ACL during mid-cycle.

Preventive measures:

Unfortunately, no one can completely eliminate their chance of suffering an ACL injury. But those females who participate in those bone-jarring, stop-and start-sports mentioned earlier can significantly reduce their risk potential.

"Obviously, contact ACL injuries are unavoidable and we are stuck with anatomy. But there are protective steps one can take to help cut down the number of non-contact incidents," said physical therapist Gary Karkuff, who partners First Choice Rehabilitation with Lennington.

"Much like you see upper-body faults in pitchers and swimmers, conditioning programs will help correct lower-body faults in basketball, soccer and volleyball players."

One benchmark program, Sportsmetrics, developed by Dr. Frank R. Noyes of the Cincinnati Sportsmedicine and Orthopaedic Center, showed substantial progress in reducing knee injuries in female athletes.

A study published in the American Journal of Sports Medicine found that untrained female athletes were 3.6 times more likely to suffer ACL injuries than those completing the six-week Sportsmetrics program.

These findings have prompted many colleges and professional franchises to adopt similar programs, or design more rigorous ones of their own.

The women's basketball program at the University of Connecticut, last year's NCAA champions, uses one of the most progressive programs in the nation.

While injury rates at the high school level -- nearly two-thirds of female soccer-related ACL injuries occur between the ages of 15 to 18 -- continue to soar, coaches may be wise to adopt a program to supplement simple weight training and running exercises.

"It's so important to strengthen those muscles around your knee," added Thompson.

"Having one fault can lead to another, and so on. That's why there is extensive rehabilitation after ACL surgery for athletes, so the muscles can adapt to withstand the cutting moves, rotations and forces involved in their sport."

Lennington and Karkuff's jump program, an intensive six-week plyometric training clinic which applies the same principles and techniques of Sportsmetrics, begins with a rigorous screening process called a Hyper Mobility Test.

Nine steps identify faults and target potential problem areas in the feet, hips, knees and spine, among others. Subjects are disciplined in proper jumping and landing techniques, aimed at dispersing landing forces and increasing overall agility.

"About 60 percent test positive for faults on the jump-down test," said Lennington. "These are skills that not only will help reduce your chances of injury, but they can add a few inches to your vertical leap and add overall core strength."

Now more than 30 years after the passing of Title IX, female athletes are competing at the highest levels of competition and at breakneck speeds. Studies have shown that a concentration on better training techniques can significantly reduce the odds of knee injuries. ERIC F. EPLER: 255-8180 or eepler@patriot-news.com