- The Washington Times - Monday, November 3, 2003

The first day University of Maryland midfielder Jen Biscoe stepped onto the soccer field after rehabilitating her torn ACL, she tore it again.

Miss Biscoe, a 21-year-old senior, says she heard the telltale pop and knew she was headed for more surgery.

She isn’t alone. Proportionally, women suffer more ACL (anterior cruciate ligament) injuries than men. Thanks to a greater number of women playing sports at professional and amateur levels, the numbers of wounded female athletes is rising.

The American Academy of Orthopaedic Surgeons reports that female athletes playing certain sports like soccer and basketball are three to four times more likely to injure their ACLs then their male counterparts. Other experts put the figures much higher.

Doctors don’t know for certain why the numbers differ between the sexes, but they have several suspects that may be to blame.

Dr. Wiemi A. Douoguih, an orthopedic surgeon at the Washington Hospital Center, says biology may be a culprit.

“A number of studies suggest an increased ‘Q angle,’ the measure of the angle between the tibia and thigh bone, that may predispose [women] to ACL injuries,” Dr. Douoguih says.

Women also may have less muscle protection in their knees than men, and in some cases, differing skill levels also could contribute to these injuries.

ACLs can suffer partial or complete tears, but each usually demands surgical correction, Dr. Douoguih says. The injuries typically involve sports such as soccer, volleyball, basketball and team handball, he says, games in which pivoting movements are common.

An ACL recovery can take many months, and the initial injury often doesn’t involve any blunt trauma. A good number of tears happen without contact.

“You can sustain very high loads to the ACL with noncontact, … up to six to eight times the body weight, and even greater,” Dr. Douoguih says.

Miss Biscoe, sixth on the university’s all-time career assist list, discovered that on two occasions. Both of her tears happened when she simply planted her foot incorrectly.

The soccer standout has endured five knee surgeries — all on the same knee. She needed three procedures to remove ganglion cysts and two operations to repair her twice-torn ACL. The cysts, which occur more often in women, may or may not have had something to do with the ACL tears, she says.

The rehabilitation process involves a variety of exercises designed to restore one’s knee to its old self.

“After the surgery, you get your straightening and extension back to normal. Otherwise, scar tissue builds in, and you’ll walk with a limp,” she says.

Then the heavy lifting begins.

Post-surgery, “you lose your muscle,” she says. “You have to build your quads, hamstrings and calves back up.”

District-based personal trainer Jacquie Drews says such work starts conservatively with core exercises — from the sternum to the pelvis — and gradually works toward weight-bearing moves.

“If clients approach their training sessions as a place in which to get body awareness regarding their strength and mobility, they’ll be more successful,” she says.

First, the injured person is seen by her orthopedist and physical therapist, who begin the healing process. Then someone such as Ms. Drews enters the picture.

Ms. Drews will work with isolated exercises to strengthen the knee area, and she will watch her client’s gait to make sure it, too, is progressing normally. The body’s post-injury compensatory movements must be broken.

“If part of you isn’t working, the body looks for the most efficient way to get something done,” she says.

The results of rehabilitation often are promising.

“I’ve seen people come back to full capacity, if not stronger,” she says. “That goes for ACL injuries and knee replacements.”

Dr. Letha Griffin, team physician at Georgia State University, says hormones also may play a role in women’s propensity for ACL tears.

“We know that hormones are very much intricately related to tissue healing and other kinds of metabolic processes of repair,” Dr. Griffin says. “It seems natural they’re involved with this as well.”

That said, “There’s not even good data that says these injuries occur predictably at any particular time of the month,” she adds.

Simple body position also might make women more susceptible to injuries.

“[Women] tend to play in a more upright posture,” she says. Jumping tests between young men and women show women hold their upright posture more.

“The upright posture favors the big muscles in the front of your leg,” she says. “If you land with your hip and knee bent, that’s gonna hold your knees stable.”

In older, nonathletic women, ACL tears and knee-replacement surgery also can occur, she says, but they’re typically linked to obesity.

“Women are knock-kneed; they carry that weight off balance,” she says. “Degenerative arthritis of the knee is more of a women’s problem.”

The surgical procedure involved in ACL injuries is more reconstruction than repair, says Dr. Kenneth Fine, director of sports medicine at George Washington University and its athletic teams’ physician.

“You don’t sew the torn ACL together; you use something else to make a new ligament,” Dr. Fine says. That could mean using the central third of the neighboring patella tendon, hamstring tendons or applicable tissue from a cadaver.

Athletes can return to the playing field about six months after the procedure, but, Dr. Fine says, it takes a couple of years for new ligaments to mature fully.

“There’s some controversy as to when you allow people to go back into competition,” he says. “The most aggressive rehabilitation protocol, … assuming you meet all the goals, is that you go back as early as four months.”

Women aren’t helpless when it comes to preventing ACL injuries.

Dr. Douoguih says women can protect their knees by performing sport-specific and plyometric exercises — the latter movements emphasizing jumping, sprinting and explosive moments often used in sports.

For Miss Biscoe, the hardest part of her rehabilitation was staying on the sidelines. She says she didn’t hesitate to return to the soccer field after her second ACL operation in March 2001.

“I wanted to get back out there so badly,” she says.

Today, she appears fully healed from her surgical procedures.

“I’d say I’m pretty much back where I used to be,” she says.

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