Michael Zazzali: The Female Athlete: ACL Injuries andPrevention

The advent of kids playing sports and often time one sport all year round has become, in a word,dangerous. When I was a kid, I played soccer in the fall and baseball in the spring and summer. Iwould train in the off-season for both sports, mainly consisting of weight training and somecardiovascular fitness. As Dr. Robert Marx from the Hospital for Special Surgery aptly puts, youngathletes today are no longer benefiting from the seasonal break and instead are expected to practicetheir sport year-round. As Dr. Marx states, these are driven by a joy and desire to excel at his/hersport, but over time we are seeing the risks may start to outshine the benefits.

Injury to the anterior cruciate ligament (ACL) is one of the most devastating and potentiallyfunctionally debilitating to the athlete's knee. The ligament is intra-articular (inside the joint) andplays a significant role in maintaining stability to the knee with quick stops, change of direction orrotational movements. The frequency of ACL tears has become an epidemic in the young athlete.Approximately 200,000 ACL injuries occur annually in the United States, leading to nearly 100,000ACL reconstruction surgeries. Although the surgical approaches are more advanced compared to adecade ago and have excellent outcomes, there still is a tendency for earlier arthritic changes in thesurgically repaired knee.

The female athlete requires special consideration as the vast majority of ACL injuries occur withoutcontact. Researchers have reported that female college basketball players were eight times morelikely to injure the ACL than their male counterparts. Others have reported that female soccerplayers were six times more likely to sustain an ACL injury than male soccer players. There aresimilar data for other sports such as volleyball and gymnastics. Females have some uniqueanatomical features that may predispose them to injury, including increased genu valgum (knock-knee alignment), a poor hamsting-quadricep strength ratio, running and landing on a more extendedknee, quadriceps-dominant knee posture, and hip/core weakness. It has been hypothesized thathormonal changes associated with the female menstrual cycle may also play a role due to the releaseof relaxin hormone that induces added laxity to the body's ligamentous tissues.

As a physical therapist in NYC, I treat these athletes postoperatively after their reconstruction hasbeen completed. Current rehabilitation programs following ACL reconstruction are more aggressivethan those utilized in the 1980s. Current programs emphasize full passive knee extension, immediatepartial weight-bearing, and functional exercise. The rehabilitation program will be modified basedon the type of reconstruction whether the patient had a reconstruction using their patellar tendonverses hamstring. The main differences between a normal and accelerated program are the rate ofprogression through the phases of rehabilitation and the recovery time prior to resuming runningand athletic endeavors. Even with the accelerated program it may still take six months for theathlete to begin premorbid athletic activities, and in some cases nine months to a year. It is alsoessential to train the uninvolved side during the course of the patients' rehabilitation, as there is a15 percent occurrence once the patient has an ACL tear of tearing the other side upon returning toplay.

The common mechanism of non-contact ACL injuries is a valgus stress with rotation at the knee,which put simply means the knee is bowing inward on landing or cutting instead of being alignedproperly. This valgus load can often be associated with a rotational stress at the knee, thus, it is vital

for the female athlete to learn through neuromuscular training exercises to control this valgusmoment. Physical therapist Tim Hewitt was one of the first to study the effect of neuromusculartraining on the incidence of knee injury in the female athlete back in 1999. His hallmark study hasled to more research and helped lead the way for more preventative exercises to hopefully helpdecrease the ACL epidemic especially in the female athlete.

Those patients with diagnoses related to their lower extremities, whether they be a competitiveathlete or a weekend warrior, receive an integrated preventative programs as appropriate for theirspecific goals. Before assessment of the knee, however, we also look at strength of the hip and thefoot alignment of the patient. Someone with a flat or pronated foot may be more predisposed to kneeissues due to the affect it has on rotating the tibia bone internally potentially increasing the valgusmoment above. In some cases arch supports or custom-made orthotics may be prescribed. Someoverlapping components are the following: working on a strong core, including exercises to build theabdominals, gluteals and abductors as well as hip external rotator group. These muscle groups areessential in controlling the valgus loads that can induce the ACL injury. In addition, education onoptimal knee alignment that emphasize weight-bearing control to maintain the knee over the secondtoe is critical. Exercises designed to control this movement are: front/lateral step downs (single legsquat), squat, and lunge that the knee stays even with the second toe as one bends the knee.Balance and perturbation training is critical to progress again with alignment always in mind tocontrol the valgus moment while trying to challenge the athlete/patient with dynamic stability drills.These drills can be either on the floor balancing on one leg, to catching a ball and standing on anuneven balance board from different angles for difficulty.

Once the female athlete demonstrates good neuromuscular control and strength of theaforementioned exercises, then she can progress to more sport-specific tasks emphasizing properplyometric drills with a flexed knee and landing again with proper alignment. This can be initiatedon our pilates reformer and gradually increased with spring resistance and then progressing to anupright position and land with body weight, such as during a jump squat exercise. It is essential towork on the eccentric or lengthening phase of contraction in a functional manner (weight-bearing)with the female athlete to help control the adduction and internal rotation (pulling inward) forces onthe thigh/knee.

These neuromuscular exercise concepts of controlling malalignment with cutting, landing andfunctional weight-bearing training are crucial to helping the athlete better protect themselves on thefield. Better dynamic stability via training in the pre-season will hopefully decrease the amount ofACL injuries over the next season. The key is to make certain the athlete is training properly andaware of landing correctly. If they are not landing properly while exercising, they will be feeding intothe problem and possibly inviting ACL issues.

Squat With Medicine Ball

Squat With Medicine Ball

Front View Squat With Medicine Ball

Front View Squat With Medicine Ball

Lunge Side View Demonstrating Proper Alignment

Lunge Side View Demonstrating Proper Alignment

Squat On Rockerboard For Strength/Balance Challenges

Squat On Rockerboard For Strength/Balance Challenges

Pilates Reformer Leg Press Into Squat Jumps

Pilates Reformer Leg Press Into Squat Jumps

Pilates Reformer Leg Press Into Squat Jumps

Pilates Reformer Leg Press Into Squat Jumps

Pilates Reformer Leg Press Into Squat Jumps

Pilates Reformer Leg Press Into Squat Jumps

Michael Zazzali is partner of Physical Therapy Associates of New York, LLC located in Manhattan,N.Y.

For more by Michael Zazzali, click here.

For more on personal health, click here.