Female Soccer and ACL Injuries - Are They Preventable?

With soccer season just around the corner, a lot of people are thinking about one thing.  Is this the season one of my players or child have an Anterior Cruciate Ligament (ACL) injury?  Hopefully the answer is no, but one way you can protect yourself is to become informed and educate yourself.  For example, did you know that female athletes tear their ACLs 3 to 6 times more frequently than male athletes?  Did you also know that 70% of those injuries are the result of non-contact episodes meaning no contact with another player occurred?  Most occur with jump-stops or cutting types of maneuvers and result in over 250,000 injuries in the US every year.  Beside the $5B health care costs, the long term effect on the athlete is even greater.  With 20% have a reoccurrence in 2 years and 79% having OA in 12 years, the downstream impact on quality of life is even greater.  Did you know that you can reduce the potential for this by 88% or even greater with the proper guidance and training program?

There are a plethora of reasons that female athletes are more likely to have an ACL injury than their male counter parts.  The reasons are complex but can be placed into 4 categories.

1. Hormonal – gender specific hormones have a negative effect on laxity and strength of the female ACL.

2. Structural – females have wider hips which results in increased angulation at the knee along with narrow femoral notches.  Both of these factors put increased stress on the ACL.

3. Biomechanical – females tend to have differences in the position of the hip, knee and ankle during performance of landing and cutting tasks.

4. Neuromuscular – there are gender differences in muscular endurance and body awareness.

Some of these factors can be changed and some can not.  Of those that can be changed, 50% can with a proper strength training program that incorporates flexibility, weight training, balance exercises, core training, cardiovascular conditioning and sport specific conditioning.  If performed under the direction of a qualified athletic trainer, physical therapist or strength coach, this has been shown to reduce the potential for ACL injuries by 88%.

So, how do you identify if your daughter or athlete is at risk?  Do you pass the test?

Of the above contributing factors, the ones that are most easily influenced with training are abnormal biomechanics (pathokinematics) noted with landing and the neuromuscular aspects.   So, it is likely after reading the above information; you may be asking yourself, how do I identify this in my daughter or athlete?  You can determine if your daughter/athlete demonstrates some of these pre-disposing factors by going through the 4 following questions.

1. Does she have a history of repetitive lower kinetic chain injuries or back injuries?
1. These are injuries that occur every season on the same side but may be a different joint.  This would include ACL/meniscus/ligamentous knee injuries, patellar tendonitis/IT friction syndrome (tendonitis), chronic ankle sprains/strains, shin splints, hip pain, or back pain, all of which occur on the same side.
2. Has she had a previous ACL injury and participate in a high risk sport?  20% of those who have an ACL injury suffer a second ACL injury in 2 years.  This risk is higher in sports which have a higher incidence of ACL injuries.
3.  Does she have difficulty with sense of body awareness (if unsure, perform the following tests)?
1. Test 1: Have her stand on one leg with the opposite knee slightly bent.  Once stable, have her raise and lower arms in front of her and then out to the side (in a jumping jack motion without jumping up) for 30 seconds.  Repeat while standing on the opposite leg.

                                                    i.     Is she able to perform?

                                                  ii.     What does her form look like?  What is the knee doing during?

                                                iii.     Is there a difference between the right and left?  How much of a difference?

2. Test 2: Standing on one leg with the opposite knee bent to 90 degrees, perform the following movements (with the non-weight bearing knee) while maintaining stability on the stance knee and hip.  After each movement return to the starting position.  First reach straight back – return to start – reach back and across mid-line – return to start - reach back and out to the side.

                                                    i.     How successful was she?

                                                  ii.     What does the other limb doing during motion?  Is it stable?

                                                iii.     Is there a difference between the right and left?

4. Does she demonstrate abnormal movement patterns with landing?
1. Test 3:  During practice, watch jump stops, rebounds, ect and assess what are the knees doing during these motions. 

                                                    i.     When she lands, do her knees go in toward mid-line?

                                                  ii.     As practice continues, does this appear or if present get even worse?

                                                iii.     Does she have a soft or hard landing (should be soft)?

After performing the above tests, your answer should be clear.  The great thing is that all these factors can be addressed and improved.  Meaning the not only is the risk for injury reduced but there is also an impact on athletic performance.  If unsure, you can always see a sports medicine trained orthopedist, physical therapist or athletic trainer for further testing.  Remember, most ACL injuries are preventable with the proper training under the guidance of a qualified athletic trainer, physical therapist or strength coach. 

 References

1. Ahmad, C.; Clark, M.; Heilman, N.; Schoeb, S.; Gardner, T; Levine, W.  “Effect of Gender and Maturity on Quadriceps to Hamstring Ration and Anterior Cruciate Ligament Laxity”.  Am J Sports Med. 34:370-374, 2006.

2.      Beckett M, Massie D, Bowers K, Stoll D. Incident of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train. 1992;27:5862.

3. Brophy, R; Schmitz, L; Wright, R; Dunn, W; Parker, R; Andrish, J; McCarty, E; Spindler, K.  “Return to Play and Future ACL Injury Risk After ACL Reconstruction in Soccer Athletes From a Multicenter Orthopaedic Outcomes Network (MOON) Group”.  Am j sports med.  40:2517-2522, 2012.
4. Chappell, J. D., Yu, B., Kirkendall, D. T., and Garrett, W. E.: A comparison of knee kinetics between male and female recreational athletes in stop-jump tasks. Am. J. Sports Med. 30:261-267, 2002.
5. Chappell, J. D., Herman, D. C., Knight, B. S., Kirkendall, D. T., Garrett, W. E., and Yu, B.: Effect of Fatigue on Knee Kinetics and Kinematics in Stop-Jump Tasks. American Journal of Sports Medicine. 33:1022-1029, 2005.
6. Chaudhari, A. M., Hearn, B. K., and Andriacchi, T. P.: Sport-Dependent Variations in Arm Position During Single-Limb Landing Influence Knee Loading: Implications for Anterior Cruciate Ligament Injury. Am J Sports Med. 33:824-830, 2005.
7. Chmielewski, T; Myer, G; Kauffman, D; Tillman, S.  “Plyometric Exercise in the Rehabilitation of Athletes: Physiological Reponses and Clinical Application”. JOSPT.  36:308-317, 2006.
8. Earl, J; Hock, A.  A Proximal Strengthening Program Improves Pain, Function and Biomechanics in Women with Patellofemoral Pain Syndrome.  Am J Sports Med. 39:154-163, 2011.
9. Giphart, E; Stull, J; LaPrade, R.  Recruitment and Activity of the Pectineus and Piriformis Muscles During Hip Rehabilitation Exercises.  Am J Sports Med.  41:1022-1033, 2012.
10. Grindem, H; Eitzen, I; Moksnes, H; Mackler, L; Risberg, M.  “A Pair-Matched Comparison of Return to Pivoting Sports at 1 Year in Anterior Cruciate Ligament-Injured Patietns After a Nonoperative Versus an Operative Treatment Course”.  Am j sports med.  40:2509-2516, 2012.
11. Grindem, H; Logerstedt, D; Eitzen, I; Moksnes, H; Axe, M; Mackler, L; Engebresten, L; Risberg, M.  Single-Legged Hop Tests as Predictors of Self-Reported Knee Function in Nonoperatively Treated Individuals with Anterior Cruciate Ligament Injury.  Am J Sports Med. 39:2347-2354, 2011.
12. Hart, J; Kerrigan, C; Fritz, J; Ingersoll, C.  Jogging Kinematics After Lumbar Paraspinal Muscle Fatigue.  Jour Ath Train. 44:475-481, 2009.
13. Huegel M, Meister K, Rolle G, Idelicator P, Hartzel J. The influence of lower extremity alignment in female population on the incidence of noncontact ACL tears. Sun Valley, ID: 23rd Annual Meeting of the American Orthopaedic Society for Sports Medicine; 1997.
14. Holm, I; Oiestad, B; Risberg, M; Gunderson, R; Aune, A.  “No Difference in Prevalence of Osteoarthritis or Function After Open Versus Endoscopic Technique for Anterior Cruciate Ligament Reconstruction: 12 Year Follow-up Report of Randomized Controlled Trial”.  Am j sports med.  40:2492-2498, 2012
15. Konopinski, M; Jones, H; Jonhson, M.  The Effct of Hypermobility on the Incidence of Injuries in Elite Level Professional Soccer Players.  Am J Sports Med.   40: 390-402, 2012
16. Kristianslund E, Krosshaug, T.  Comparison of Drop Jumps and Sport-Specific Sidestep Cutting: Implications for Anterior Cruciate Ligament Injury Risk Screening.  Am J Sports Med.   41: 684-688, 2013
17. Lucci, S; Cortes, N; Van Lunen, B; Lucci, S; Ringleb, S; Onate, J.  Knee and hip sagittal and transverse plane changes after two fatigue protocols.  Jour Sci & Med in Sport.  14:453-459, 2011.
18. Mandelbaum, B. R., Silvers, H. J., Watanabe, D. S., Knarr, J. F., Thomas, S. D., Griffin, L. Y., Kirkendall, D. T., and Garrett, W., Jr.: Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes: 2-Year Follow-up. Am J Sports Med. 33:1003-1010, 2005.
19. McCullough, K; Phelps, K; Spindler, K; Matava, M; Dunn, W; Parker, R; Reinke, E.  “Return to High School – and College-Level Football After Anterior Cruciate Ligament Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study.  Am j sports med.  40:2523-2529, 2012
20. Myer G; Ford, K; McLean, S; Hewett, T.  “The effects of plyometric versus dynamic stabilization and balance training on lower extremity biomechanics”. Am J sports med.  34:445- 455, 2006.
21. Padua, D; DiStefano, L; Marshall, S; Beutler, A; Motte, S; DiStefano, M.  Retention of Movement Pattern Changes After a Lower Extremity Injury Prevention Program is Affected by Program Duration.  Am J Sports Med.  40: 355-368, 2012.
22. Quammen, D; Cortes, N; Van Lunen, B; Lucci, S; Ringleb, S; Onate, J.  Two Fatigue Protocols and Lower Extremity Motion Patterns During a Stop-Jump.  Jour Ath Train.  1:32-41, 2012.
23. Quatman, C; Ford, K; Myer, G; Hewett, T.  “Maturation leads to gender differences in landing force and vertical jump performance”.  Am J sports med.  34:806-813, 2006.
24. Sell, T; Ferris, C; Abt, J; Shen Tsai, Y; Myers, J; Fu, F; Lephart, S.  “The effect of direction and reaction on the neuromuscular and biomechanical characteristics of the knee during tasks that simulate the noncontact anterior cruciate ligament injury”. Am j sports med.  34:43-54, 2006.
25. Sheehan, F; Sipprell, W; Boden, B.  Dynamic Sagittal Plane Trunk Control During Anterior Cruciate Ligament Injury.  Am J Sports Med.  42:2145-2153, 2012.
26. Thijs, Y, Pattyn, E; Tiggelen, D; Rombaut, L; Witvrouw, E.  Is Hip Muscle Weakness a Predisposing Factor for Patellofemoral Pain in Female Novice Runners? A Prospective Study.  Am J Sports Med.  39:1877-1890, 2011.
27. Westin, S; Galloway, M; Noyes, F; Corbett, G; Walsh, C.  “Assessment of the lower limb neuromuscular control in prepubescent athletes”.  Am j sports med.  33:1853-1858, 2006.
28. Westin,S; Noyes, F; Galloway, M.  “Jump-land characteristics and muscle strength development in your athletes: A gender comparison of 1140 athletes 9 to 17 years of age”.  Am j sports med.  34:375-384, 2006.
29. Withrow, T; Huston, L; Wojtys, E; Miller, J.  “The relationship between quadriceps muscle force, knee flexion, and anterior cruciate ligament strain in an in vitro simulated jump landing”.  Am j sports med.  34:269-274, 2006.