Push to excel

Physical makeup plays part in ACL injuries to female athletes

Published on April 19, 2017

Roy McIntyre points to the anterior cruciate ligament or ACL in a model of a knee joint. Female athletes suffer injury to the ACL more often than males due to their physiognomy, but strengthening certain muscles can help prevent the injury.

©Carol Dunn

NEW GLASGOW – Kendra MacKinnon said she’s the kind of athlete who keeps playing, despite sometimes being in pain. So when the basketball player hurt her knee in a game a year ago in January while playing for the North Nova Gryphons, she continued.

“I think it twisted, it really hurt,” she said. “It was sore for the day, but the next day it was fine.”

She didn’t think too much about the injury as she didn’t have further symptoms.

Then during a tournament last summer, she got hurt again, this time requiring surgery, as she had torn her ACL. “I went to run to get the ball and my knee kind of gave,” she said.

Her physiotherapist, JR Marshall, explains that ACL is short for anterior cruciate ligament, one of two ligaments in the knee, which prevents the tibia bone from moving forward from the femur bone.

When the ACL is overstrained, it can tear. He said the injury usually results in a high level of pain and swelling, and quite often a popping noise will be heard when it occurs.

Marshall, who works at Active Life Physiotherapy in New Glasgow and also with the Pictou County Junior A Crushers and the MacGregors Midget AAA baseball teams, said recovery from such an injury is often lengthy, taking five months on an accelerated program, and up to two years for full functional recovery for high-level athletes.

Marshall said each case is different, but a lot of the recuperation time is spent on restoring the range of motion and building up strength in the muscles around the knee. He said sometimes surgery is required, like in MacKinnon’s case, but sometimes preventative bracing and strength training is enough.

MacKinnon had surgery on her knee in September, and was cleared by her doctor last week to play again as her ACL is now completely healed.

The Lyons Brook basketball player, who recently turned 19, was supposed to play with the Saint Mary’s Huskies women’s basketball team in the fall, but was sidelined because of the injury. She said she was really upset that she got hurt right before her rookie year was set to begin, and with the surgery, was out for the entire season.

It took six months to mend. “It sucks, but I’d rather let it heal fully,” she said.

Torn ACLs are more common in females.

Marshall said research has shown females are more likely to sustain the injury than males in the same sport because of the structure of a female’s pelvis and the way this places a greater strain on the knee.

The injury is most often caused by a stationary foot being planted, followed by a twisting motion. It occurs more often in sports such as soccer, basketball, football and volleyball, said Marshall.

He said females are more predisposed to the injury because they “tend to be stronger in the quad than the hamstring,” with more of an imbalance than in males.

Roy McIntyre has been a physiotherapist for 32 years, 23 of those in private practice at his clinic in New Glasgow. ACL tears are a passionate subject for him. Although he treats a lot more neck and back injuries, with only a “handful” of ACL tears each year, he’s interested in how to prevent these injuries. This stems from seeing it happen three times in person, and how the injury affected the female athletes.

His daughter Shae attended Brewster Academy in New Hampshire, graduating in 2016, and played high-level soccer and hockey there. While watching a soccer game, he saw a girl jump up to head the ball. “She landed flat foot, and I knew she tore her ACL,” he said.

The two others were close friends of Shae’s. “It hits home that way. What’s the chance you see it three times in your life?”

McIntyre said more girls are now playing sports and at higher levels, which has increased serious injuries with female athletes, including a high rate of serious knee injuries.

He said the speed, power and intensity of female sports has increased dramatically in recent decades, and studies show women may tear the ACL at rates three-to-eight times as often as males.

“Straight-ahead sports like jogging or cycling place little stress on the ACL. Sports such as soccer, basketball and volleyball that involve cutting, jumping and changing direction, in which the ACL plays a vital role, puts athletes – particularly females – at greatest risk of ACL injury.”

McIntyre said less than a third of ACL tears involve contact from an outside force such as an opposing player. Most are a result of one-step stop/deceleration, cutting movements, change of direction, landing from a jump with knees straight and a lapse in concentration resulting from a sudden change in the play. 

Preventing injury to the ACL involves having good footwear, learning proper landing and jumping techniques, and improving hip and thigh strength, he said.

Studies show that a program of proper neuromuscular training and conditioning can reduce the level of injury. Critical to this are proper leg and core strength training exercise, balance and speed training (neuromuscular), proper coaching on jumping and landing – absorbing through the ball of the foot, more bending of the knee avoiding landing on a straight knee.

McIntyre said the use of proper cleats for grass and shoes for artificial or indoor surfaces is important. Functional knee bracing may offer some additional protection for athletes in higher risk sports such as skiing, he said.

The amount of "grippiness" of athletic shoes needs to minimize rotation, yet allow traction during cutting and stopping,” he said.

“In summary, girls should build strength in their legs and core, particularly during puberty. They should be taught proper running and jumping and landing techniques. Don't play just one sport year round. Heed pain, even minor ones.”

Specialization can mean more injuries

JR Marshall and Roy McIntyre, two New Glasgow-based physiotherapists, say specialization in one sport year-round is contributing to a higher incidence of injuries such as ACL tears in females.

“Athletes now play their sport year round without time for rest, proper training or exploring other sports,” said McIntyre.

He said a push for athletes to specialize in and play one sport year-round and discounting the effect of puberty on girls’ bodies may result in a high rate of serious injury to a vulnerable knee. 

Marshall said athletes in general are becoming quicker, faster and stronger, playing with more intensity, and when one sport is done all year, there’s more opportunity to get injured.

He said youth should be involved with different sports throughout the year, and he said campaigns such as Get More From Sport show that “different sports are good for the health of kids.”

Get More From Sport is an education campaign developed by Hockey Nova Scotia and Soccer Nova Scotia, with support from Sport Nova Scotia, to promote multi-sport play.

“Studies consistently document the dangers. Dangers to the child’s overall development, danger in terms of injury to growing bodies, and danger from burnout. Unfortunately, these facts are not broadly known and parents are often pushed in the wrong direction. Often the push comes in the form of peer pressure from other sport parents or coaches who are equally uninformed or, worse, from private companies who profit from the hype,” said information from the campaign.