Doctors See Big Rise in Injuries for Young Athletes
by Bill Pennington, 2/22/2005, New York Times
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If you’re an avid fan of American youth soccer these days, and especially if you frequent the girl’s games, you’ve seen it and heard it: “My knees hurt.” They wear compression sleeves. They sport metal, post-surgical braces. They wince as they run or kick. It’s real, and it’s alarming. Our girls, especially soccer and basketball-playing girls are experiencing knee injuries in epidemic proportions. Foremost among those injuries are tears of the anterior cruciate ligament (ACL). This small strand of connective tissue runs diagonally from femur to tibia and resists the twisting and pulling apart of these two bones by strong muscular forces exerted at the knee joint.
Injury rates are soaring, particularly in the 15-25 year old age group.
Among high school athletes, the injury rate is more than 1/100, which equates to some 20,000 injuries each year. More than 1 in 10 NCAA women soccer players suffers a serious knee injury. And, of the women who played in the US women’s professional soccer league (WUSA), nearly one quarter tore an ACL at some point in their playing careers. And girls are reportedly 4-6 times more prone than boys to this type of injury. Even more alarming is the increasing number of surgical ACL repairs needed by girls as young as 11 and 12.
Orthopedists are doing all they can to reconstruct these knees and repair these ACLs. Physical therapists, exercise physiologists and athletic trainers are actively rehabilitating these talented young women so they can get back to playing the games they love. But a recent rheumatology report was cause for more concern. It noted an increase in degenerative joint disease in the knees of women in their 30’s who had previously torn ACLs or menisci. What’s more, arthritis ensued whether or not the knee had been surgically repaired and rehabilitated.
The message is clear:
we must work to prevent these injuries in our female athletes!
Since 1985, when the disparity in knee ligament injuries between men and women became evident, more and more researchers have sought to address the questions: Why is this happening to our girls? Can we combat these injuries? How?
The reason why girls are more prone to knee injury has not been conclusively resolved. But the question that naturally arises and forms a framework from which to approach the issue is clear: how are girls different from boys in ways that might put their knees at risk. These differences can be grouped into 2 categories:
extrinsic risk factors (those outside forces which are at work) and
intrinsic risk factors (those inherent in the nature of the gender).
Extrinsic factors include equipment, especially cleat patterns and their interaction with the various playing surfaces, training environment including coaching, and conditioning. Research is ongoing in the area of shoe-surface interaction, spearheaded by manufacturers hoping to find a shoe which facilitates the stopping and starting required in the sport, but reduces the torque on the knee when players cut, turn and land. The reason why girls would be more prone to injury by this mechanism is not completely clear, though boots with rounded cleats to facilitate pivoting are being highly touted.
Training of female athletes and the accompanying conditioning regimens have undergone large changes in the past three decades since Title IX opened more doors for women to participate in competitive sports. More women are playing at higher levels. They are stronger, faster, more skilled and more injury-prone. They are being subjected to more stringent training regimens than ever before. Of course, the model for this training has come from the world of men’s sport and begs the question whether the type and volume of training appropriate for men may need to be modified for women.
Intrinsic factors include anatomic, hormonal and neuromuscular characteristics. Anatomically, women’s wider hips tend to cause their knees to angle inward (known as valgus) and result in greater “Q” angles (a measure of the angle formed between the thigh bone and the patellar tendon and, thus, the torque exerted by the thigh muscle at the knee joint). Research has shown that women whose knees tend toward the valgus position and/or who have larger Q angles are more prone to ACL injury. Women also have smaller musculature and greater flexibility at the knee which may contribute to reduced joint stability and a compromised ACL. However, this cannot be the whole answer because the weaker, non-athletic female population is at lower risk of injury. Clearly, time spent playing at high intensity is an important factor.
Because of the pubescent age at which these injuries are first observed, some have looked to hormonal factors as injury provoking. Estrogen is known to promote ligament laxity, and receptors for estrogen have been identified on the anterior cruciate ligament. However, hormonal modification for purposes of athletic play is not a viable or medically ethical option. Studies continue in this area.
Neuromuscular factors, specifically the response of muscles to electrical signals from the nervous system, do appear to be delayed in girls relative to their male counterparts. And, the strength and order of recruitment of muscle fibers in complex movements tends to show gender discrepancies. This is a very active and exciting area of research which seeks to identify specific biomechanical differences in the sexes which contribute to injury risk. Interventions show promise because these “deficiencies” may be addressed by training programs which modify movement patterns, strengthen or speed muscle response and balance the strength of muscles in the lower extremity in order to better distribute the forces which compromise the knee. Indeed, in 1996, work by Timothy Hewett first highlighted the success of rigorous biomechanical training in girls which brought injuries in line with their male peers.
What can we do to reduce these injuries in our girls?
While the shoe companies and the turf field manufacturers work out ways to address equipment safety, coaches and trainers look at gender-differentiated training, physiologists are looking to modify the biomechanical and neuromuscular factors that clearly put women at risk. Proper conditioning for balanced muscular development, moderate flexibility, joint proprioception, agility, and cardiovascular endurance to prevent fatigue are essential to the health and well-being of all of our athletes - most especially our girls.
Does this sound like it will take away from skills practice time? No. Please do not add more hours of training to your athletes’ already full training schedule! Overtraining (and over-doing) is already a huge problem with our young people. In my experience, overtraining is one of the biggest causes of that initial complaint: “My knee hurts.” The programs that I have designed are already working for hundreds athletes ranging in age from 7 year olds to senior adults. It only takes 10-15 minutes at the beginning of practice. Perhaps it can replace the time the team is already spending running laps for warm up. I individualize each program with the age, developmental stage and performance level of the athlete and their team in mind. Athletes as young as 9 and 10 enjoy a fun, dynamic session where “the three B’s: bending their knees, staying on the balls of their feet and keeping a balanced athletic stance” become second nature. Plus, I make the drills sport-specific and, over a couple of sessions, increase the intensity until athletes can perform them under pressure. The reason for this is simple. We all fall into our old bad habits when stressed, unless we have new good habits.
Does this program require a lot of fancy training equipment? No. These drills can be performed with basic cones and exercise bands at any practice location. The key ingredient is the watchful eye of a coach or trainer who will insist on proper form and intensity from the players as they perfect the training program. Ultimately, your players will be able to monitor their own form, correct it in their teammates, and use it automatically in their play.
Do you want to field a winning team? How about a team of winners? We can’t control how the other team plays, but we can do everything possible to develop healthy, well-prepared players, dedicated to doing what it takes to bring their best game to the field. This won’t happen if they are concerned about being injured. It can’t happen if they are in a knee brace or on crutches on the sidelines. And we want it to keep happening for as long as they have the desire to go out and play.
