Female athletes weak in the knees?


Mar. 4--They say you can hear the pop, but Carly Iulo remembers the sound she heard last September as more of a thud. She initially thought -- and hoped -- her kneecap was dislocated.

But it was worse than that.

The anterior cruciate ligament in Iulo's left knee ruptured, bringing an end to her club soccer season and putting her sophomore season at Hilton Head Island High School in danger.

Iulo won't be alone in spending more time in physical therapy than on the soccer pitch this spring. Six players from southern Beaufort County's four girls high school soccer teams are out with torn ACLs as the season gets under way, indicative of a national trend that shows female athletes -- and particularly those who play basketball or soccer -- are at the highest risk for ACL injuries.

Hilton Head Christian Academy coach Ernie Suozzi will be without two starters -- junior Abby Page and sophomore Erika Sonberg tore their ACLs during basketball season and are out for the soccer season. Hilton Head Preparatory School's Kate Brunori also tore her ACL during basketball and will miss the soccer season. Two Bluffton High School starters, Adrianna Jesuino and Devon Coccuzza, also are out with torn ACLs.

"I had always heard about it," Bluffton High School girls soccer coach Jerry Parker said. "But I had never been plagued by it until now."

That could be because Parker was a longtime youth soccer coach before taking over the high school program last year. According to an article by Michael Medvecky, an orthopedic surgeon at Yale-New Haven Hospital in Connecticut, the rate of ACL injuries is about the same among boys and girls before adolescence, but the rate in girls begins to spike around age 12.

Wil Crapps, a physical therapist at Drayer Physical Therapy Institute on Hilton Head Island, said he treats about three times as many girls with ACL injuries than boys, and it isn't unusual to see a large number of girls with ACL injuries this time of year.

"It kind of goes in waves, depending on what sport is in season," said Crapps, who is treating Iulo, Sonberg, Page and Brunori. "When soccer season rolls around, or basketball season rolls around, we tend to see more from the female side."

WHY FEMALE ATHLETES?

Studies have shown female athletes have four to 10 times as many ACL injuries as their male counterparts, according to an article by orthopedic surgeon Robert McAlindon of the Hughston Sports Medicine Foundation. Additionally, most female ACL injuries are non-contact injuries that occur when landing from a jump or quickly changing direction. Although the reasons for the higher rate of ACL injuries among females are not clear, McAlindon says there are several prevailing theories. Among them:

--The ACL moves within the intercondylar notch, a compartment in the knee joint through which the ligament passes to connect the femur and the tibia. Because women have a narrower notch than men, their ACL movement is more limited and the ligament is in more danger of being pinched and ruptured by the two rounded ends of the femur.

--Another risk factor for ACL injuries in females is their greater "Q angle," the angle at which the femur meets the tibia. The width of the pelvis determines the size of the angle, and because women have a wider pelvis, their Q angle is greater. At a greater angle, the ligament absorbs more of the force each time the knee twists. So a twisting injury in a male's knee might result in a stretched ACL, while the same type of injury in a female might rupture the ligament.

--Female athletes also tend to have less muscle strength in proportion to bone size than their male counterparts, so when participating in the same sporting events -- and thus being subject to the same twisting and loading forces in the knee joints -- the ACL takes on more of the load and is at more risk.

--Some doctors have suggested hormonal differences can account for the higher rate of ACL injuries among females, and recent studies show female athletes might be at more risk during their menstrual cycles. Female hormones allow for greater flexibility and looseness of muscles, tendons and ligaments, which helps prevent many injuries by enabling certain joints and muscles to absorb more impact before being damaged. But it can have the opposite effect on an ACL, causing the other ligaments and muscles around the knee to be so loose that they cannot absorb the stresses put on them and putting more pressure on the ACL. Studies have shown that during the menstrual cycle, varying hormone levels can cause the knee to be even looser, making ACL tears more common.

LONG ROAD BACK

Unlike many ligament injuries, ACL injuries do not heal themselves with rest and immobilization. The only way to regain stability in the knee is reconstructive surgery. ACL replacement surgery is a minimally invasive surgery in which a ligament or tendon is taken from another place in the body and grafted in place of the ACL.

Strengthening the graft enough to return to competitive sports requires significant rehabilitation, and most athletes don't return sooner than six months after surgery, though Crapps said the return time is dependent on the individual athlete.

The rehabilitation happens in three stages. After an initial strengthening phase, the graft actually weakens around week seven, according to Shawn Zink, Hilton Head High's athletic trainer, and rehab has to be scaled back for the next eight to 10 weeks.

"That's the hardest time of rehab, because around week seven, they've usually got their full range-of-motion back, they should be walking around without crutches, they're able to walk and do some of their normal activities of daily living," Zink said. "But at that same time, the graft is at its weakest point, so you can't be out doing a bunch of things that you shouldn't be doing, because you're just going to blow that graft right out."

Iulo is in the final stage of her rehabilitation, conditioning her quadriceps and hamstrings and working on plyometrics, jump training and balancing activities, as well as sport-specific exercises. She is aiming for an April 1 return to action, which would mark six months since her surgery.

"That's what I'm shooting for," Iulo said. "But I plan on going the full six months before I go back."

When she returns, Crapps said Iulo will need a functional brace for about a year, and she shouldn't expect to be back at full speed before the brace comes off.

"Obviously, they're not going to be back to 100 percent for a while," Crapps said. "Usually I tell them, don't expect to be 100 percent for the first year. You hope you can get them back as quickly and as good as you can. But you want them to be safe, especially with girls like this who have so much potential to go farther with soccer. You don't want them to mess it up again."

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Copyright (c) 2008, The Island Packet, Hilton Head Island, S.C.

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