11/6/2009
Written By: Lynn M. Lindaman, MD, P.L.C., Lindaman Orthopaedics
Category: Health & Fitness  

Several decades ago the implementation of Title IX prompted a surge in female participation in intercollegiate and interscholastic athletics.  With the swell in number of female athletes, this was accompanied with an increase in injuries to female athletes.  As data was accumulated over the years, it appeared that certain injuries were increasing more dramatically than the increase in participation.  Early on, thoughts were that this was due to non-conditioned or “nonathletic” women participating in “athletic” sports.  However, as participation increased into younger and younger years and the high school and collegiate athlete was coming in as a well-experienced, well-conditioned veteran athlete the incidents of certain injuries did not decrease, in fact, the rate of injuries actually increased.  The one that seems to have increased the most and is causing the most concern due to the significance of the injury is the injury to the anterior cruciate (ACL).  Over the last ten to fifteen years as data has been collected, we have observed that not only is the rate of injury to the anterior cruciate ligament increasing faster than the rate of increased athletic participation by women, but the injury to the anterior cruciate ligament, may be some five to ten times greater for women than for men.  That is, for female athletes competing at the same intensity level and in the same sport as men, they may be five to ten times more likely to injure the anterior cruciate ligament than men are.  Another interesting fact that has emerged is that the anterior cruciate ligament injuries in women are almost universally “non-contact.”  That is, it is not like in a football, where a running back is getting rolled up on by a 270 pound linebacker and having the ligaments ripped out of his knee. In the females, with soccer and basketball being the biggest offending sport, these athletes are by themselves merely making a cutting, moving and turning movement with no external contact at all when the anterior cruciate ligament tears.

This disparate incidents of ACL injuries for women compared to men, obviously got us looking for why?  If we could answer the question why, then there may be a means to correct this cause and prevent many of the injuries. 

Numerous studies have focused on the hormonal differences between males and females.  They have focused on the actual size of the anterior cruciate ligament in males versus female.  They have looked at the strength of the hamstrings and quadriceps in males versus females with respect to the body weight.  They have looked at the difference in the shape of the knee and the alignment of the bones, males versus females, to see if these relate to the increased incidents of anterior cruciate ligament injuries in females compared to males.  There have been various suggestions of correlations, but nothing that has proven to be definite and more importantly nothing that we as physicians or coaches could do anything about.  What has been observed, however, is the exact way that the non-contact injury occurs, both in males and in females.  That is, hyperextension, rotation and valgus forces on the knee.  This is something we potentially can do something about from the standpoint that, if we can keep the athlete’s knee going into this position, then we can impact the incidents of anterior cruciate ligament injuries.

The entire focus of the injury prevention techniques and mechanics is to reduce the stress on the anterior cruciate ligament by keeping the joint aligned properly and by absorbing the energy into other muscles, bones and joints rather than into the anterior cruciate ligament.  Since the prime stresses on the anterior cruciate ligament come when the knee is in hyperextension or in valgus (knock-kneed)  the goal of this is to make sure that the knee avoids these positions and the athlete stays with a straight knee, that is, the knee out over the foot, not the knee inside of the foot and the slightly flexed knee, particularly when landing or cutting and turning.  

As these “ACL injury prevention” techniques have evolved, the fascinating “side effect” of this program is that the mechanics and the position of the athlete happen to be exactly the same mechanics and position that optimize jumping, cutting and turning and is sometimes referred to as a “power position” for an athlete.  Numerous physical therapy and sports fitness and conditioning programs have conditioning programs to try and condition the athlete to take the stresses off the anterior cruciate ligament.  Likewise, there is a move among sports medicine physicians and strength and conditioning coaches and specific sports coaches to incorporate this as part of their pre-season and pre-practice strengthening and conditioning programs.  As such, this is becoming increasingly available to athletes.  While there are numerous programs around, to avoid sounding as if I am advocating for one physical therapy or conditioning business, I would like to refer you to the informational and instructional video that was developed jointly with the University of Iowa Orthopaedics and Sports Medicine Department and the Iowa High School Athletic Association.  It can be found by going to the Iowa High School Athletic Association’s website at www.iahsaa.org following the link on the left-hand menu to “Sports Medicine and Wellness,” following that menu to “Prevention and Treatment” and lastly to the next menu that takes you to the anterior cruciate ligament prevention video.  In this video there are several video clips indicating the science and rationale behind the injury prevention program, as well as the specifics for warm-ups and drills that should help achieve the results in this program.
I think it is a very beneficial program for not only the female athletes, but for the male athletes as not only does it provide prevention for non-contact anterior cruciate ligament

injuries, but it also as a “side effect” trains and conditions them in proper jumping, cutting and turning mechanics, which will benefit their athletic performance, regardless of the protective effects on the anterior cruciate ligament.