by Miho J. Tanaka, MD, Special to SportsMD.com
The rise of women in sports today has more momentum than ever. Women athletes continue to excel and break barriers during this exciting era of change. Since Title IX, we have seen an exponential rise in the number of female athletes, and with this, we as orthopaedic surgeons have witnessed an epidemic of anterior cruciate ligament (ACL) injuries in women, a number that has doubled each decade. This has not only been due to the increase in sports participation, however. We now know that female athletes are up to 8 times more likely to tear their ACL than male athletes, leading to season-ending, if not career-ending, injuries.
What many don’t realize is that the majority of ACL injuries occur without a collision. Greater than 70% of ACL injuries are noncontact in nature, occurring as a result of a deceleration event such as pivoting or landing from a jump, when the knee buckles and gives way. Rates of noncontact ACL injuries are much higher in women than in men. Gender differences in muscle strength and control of the muscles that protect the knee during pivoting, cutting and landing activities can contribute to this increased risk of ACL injury in women.
This risk factor appears to be modifiable, and studies on the implementation of preventative exercise programs to address such deficits have reported significant reductions in the number of ACL injuries in female athletes. While it was previously argued that the evidence supporting injury prevention was mixed, a recent study by Webster and Hewitt summarized the existing studies with a meta-analysis and reported that overall, ACL injury prevention programs led to a 67% risk reduction for noncontact ACL injuries in female athletes.
Many types of injury prevention programs exist, but the basic concepts within all of these are the same: athletes should target muscle balance and strengthening, and increase control of the hip and trunk muscles during landing activities. The hamstring muscles are agonists of the ACL, meaning that the muscle supports the function of the ACL. Many female athletes are quadriceps dominant, meaning that their hamstrings are relatively weaker than their quadriceps muscles, placing them at risk for injury. Because the risk of knee injury can be increased when there is poor trunk control, when the hips and core do not support the balance of the body when landing or pivoting, much of ACL injury prevention also focuses on strengthening the hips and core muscles.
While the research is still ongoing in terms of finding the ideal method to screen for the highest risk athletes and target them to reduce this risk, the message is clear: prevention can be more effective than treatment of ACL injuries when it comes to extending an athlete’s career. Preventative exercises to address these elements of balance, strengthening and hip/core control can be incorporated into an athlete’s daily warmup routine. Most importantly, these exercises must be performed on a regular basis to be effective.
Currently, most educational and athletic systems have yet to incorporate a standardized injury prevention protocol in youth programs, and there continues to exist a lack of awareness in the general community about this topic. Very few female athletes seem to be aware of their increased risk for ACL injury, or even that preventative measures exist. In a world where our female athletes are becoming increasingly competitive, shouldn’t we be teaching them how to stay in the game? As a sports community, we owe it to these women who are continuing to break barriers in their respective sports to challenge this current state, by investing in the education of our future athletes to keep them healthy and injury-free. This means supporting research in women’s health and programs that raise awareness about sports injuries and prevention in female athletes, because the future success stories of these girls could someday be the makings of sports history.
Dr. Miho Tanaka is Former Director and Founder, Women’s Sports Medicine Program at Johns Hopkins Hospital and Incoming (July 2019), Massachusetts General Hospital, Harvard Medical School. Follow her on Twitter at @DrMihoTanaka.
Cover Image: Courtesy Caldwell Athletics