Female athletes struggle with ACL injuries

It was a play Lake Forest (Ill.) soccer star Rachel Quon had made
thousands of times before. As a sweeper, she was always chasing the ball
back toward her goal line. This time she planted her left foot, pivoted and
kicked with her right leg to clear the ball back upfield.

She ran two more steps before she heard -- and felt -- a pop in her right
knee. In the milliseconds before she fell to the ground, a few fleeting thoughts
went through Quon's mind: Maybe it was my MCL. Please let it be my MCL. Don't
let it be my ACL.

Her wishful thinking was crushed when searing pain and a follow-up crack
sealed the deal -- her ACL was torn. Quon hit the turf hard, breaking her right
collarbone, to boot.

"I was worried that was the end of my career," Quon says. "I knew I wanted
to play again, but I wasn't sure if I'd be able to come back. You hear about
players who come back strong, but you also hear about players who don't."

Waubonsie Valley (Aurora, Ill.) midfielder Bri Rodriguez watched Quon
tumble to the ground from across the field. It was early July 2007, and the
two Illinois natives were training with the U.S. Soccer U-16 Girls' National
Team at Seton Hall University in New Jersey. Though they played at different
Chicago-area high schools, they were friends who played together with the
Eclipse Select Club.

Less than a year later, Rodriguez heard a sound like knuckles cracking as
she planted with her left foot, pivoted and cleared the ball with her right foot
early in the first half of Waubonsie's state quarterfinal win over Maine South
(Park Ridge, Ill.) last May.

"I knew I hurt something," says Rodriguez, the 2007-08 Gatorade Illinois
Girls' Soccer Player of the Year. "But I didn't think it hurt that much, so I didn't
think it was my ACL."

After crumpling to the ground, Rodriguez got back up with the help
of a trainer. She jogged and juggled a soccer ball on the sideline and soon
declared herself fit to return to the game. As she planted her left leg for a
corner kick just moments after returning to the field, her knee gave out again.
Rodriguez stayed down this time, her left ACL torn.

The anterior cruciate ligament, one of four ligaments that stabilize the
knee, is a rubber band-like fiber no bigger than your pinky. It runs through
the center of the knee joint, attaching the thigh bone (femur) to the shin bone
(tibia). When torn (usually the result of jumping, landing or sudden changes in
direction), the ACL causes the shinbone to slide forward onto the thighbone
and the knee to give out. Rapid swelling typically results in pain so severe it
sidelines athletes.

Quon and Rodriguez put two faces on a frightening statistic. Recent
studies show that young female athletes are up to eight times more likely to
tear their ACLs than young male athletes. According to the Centers for Disease
Control and Prevention, nearly 30,000 girls age 19 and younger suffered ACL
injuries that required surgical repair in 2006.

"This injury is of epidemic nature in terms of incidence and occurrence in
females versus males," says National Athletic Trainers' Association president
Marjorie Albohm, a certified athletic trainer.

It takes major reconstructive surgery and up to a year of rehab to bounce
back from an ACL tear, but Albohm says most victims eventually return to
their sports at full strength. There's no better example than Candace Parker,
who since suffering a torn ACL in high school has won the Naismith Award as
the nation's top college player as well as WNBA MVP and Rookie of the Year.

While research cannot pinpoint a definitive cause for the higher numbers
of ACL tears in female athletes, there are many contributing factors. When
athletes of either sex hit puberty -- typically around the time they're freshmen
in high school -- they're asked to train harder than ever before. But girls often
have bodies unequipped for such vigorous training.

As a boy's testosterone level increases, he naturally adds muscle and
gets stronger. But as a girl's estrogen level increases, she adds more fat than
muscle while her ligaments become more lax and susceptible to injury.
Subsequently, girls don't naturally develop muscle necessary to keep their
joints in safe and stable positions.

Another factor is anatomical. The pelvis bone on females is wider than
on males, increasing the angle at which the femur attaches to the tibia. The
steeper the angle, the more the knees rotate in and the bottom of the legs
splay out, causing a knock-kneed stance that puts excess stress on the ACL.

Also, as girls develop, their neuromuscular response becomes less precise
than that of boys. When girls decelerate, suddenly change direction, jump or
land, their ligaments and bones absorb most of the impact. In boys, muscle
absorbs the majority of the impact.

"ACL tears happen to girls that are in good physical shape and they
happen because their movement patterns are not ideal," says Dr. Letha Griffin
of the Peachtree Orthopaedic Clinic in Atlanta. "Instead of playing with their
hips and knees bent, girls play more upright. And in that position, with any
quick, pivotal move there is a chance an ACL may be torn."

However, most doctors and athletic trainers believe that with education,
many ACL tears in girls can be prevented. If girls start training programs early
enough and do them with regularity, they can develop their hamstrings,
quadriceps and gluteal muscles and learn to accelerate, decelerate, jump,
land and cut in a much safer manner. To put it bluntly, they can learn to move
more like boys, with their hips and knees bent and their body balanced over
their lower extremities.

"We can't change anatomy, but we can change the way girls move
neuromuscularly," says Griffin, a spokesperson for the American Academy of
Orthopaedic Surgeons. "But we have to get on them all the time."

To that end, Griffin's AAOS and Albohm's NATA joined forces in March to
release a public service campaign aimed at educating athletes, coaches and
parents on the ease and importance of ACL injury prevention.

Most programs designed for preventing ACL injuries take just 20 minutes
per session to complete, yet neither Quon nor Rodriguez regularly participated
in any such program with their various teams.

"Sometimes at the Olympic Development Programs, they will have us focus
on dynamic warm-ups, but it's not something we do all the time," Quon says.
"I've only done it four or five times in my soccer career," Rodriguez adds.
The end result was that both girls, two of the best high school soccer
players in the country, underwent complete ACL reconstructions.

During surgery, the damaged ligament is replaced with a tendon graft,
most commonly from a piece of the athlete's own hamstring or patellar
tendon. Every now and then, a cadaver graft is used.

Once implanted, the graft first dies because it's not connected to any
blood supply. Thereafter, it serves as scaffolding upon which the body will
gradually grow a surrogate ACL. This "ligamentization" process cannot be
rushed, turning ACL rehab into a painful ordeal that can last between six
months and a year.

Quon had to postpone her ACL surgery for a month while her collarbone
healed enough to handle several weeks on crutches. Once she underwent the
ACL reconstruction, Quon began an extensive rehab process that included
physical therapy three times a week.

It took her four months to start running again and about seven
months to start playing. Through it all, Quon also had to deal with
emotional challenges.

"I was angry and sad," she says. "I was at my highest peak at National Team
camp and I knew I'd have to start all over again. Rehab was very painful and
one day I broke down and started crying. But once I got it out I realized I had
to focus on getting better."

Not long after Quon returned to the field, Rodriguez went in for surgery
last June. She had the knowledge of Quon's experience to prepare her for
what to expect, yet rehab was still difficult.

Starting the day after her surgery, Rodriguez had physical therapy
appointments three times a week up until this past December. On days she
didn't go to PT, Rodriguez still had exercises to perform on her own. In all,
recovery proved to be a seven-day-a-week job.

"I cried every day for the first three weeks when my therapist would bend
my knee," Rodriguez says. "Later on, the most frustrating thing was how much weaker my left leg was than my right leg."

Quon was cleared to play in March of 2008. It took her a few months to get her game back, but by
November she was back to her old self while playing with the United States silver-medal team at the U-17
Women's World Cup in New Zealand.

Now Quon believes she's stronger and better than she was before surgery.
Rodriguez, who was cleared to play in January, has the same hopes. She has recovered fully but
says her knee still feels weaker than before. And from a soccer perspective, her skill level lags behind
what it once was.

"I just need to play more," she says.
Both girls are playing their senior soccer seasons at their respective high schools this spring and
preparing for college in the fall. Quon will play for Stanford, while Rodriguez will play for West Virginia.
"Girls need to know an ACL injury is not the end of the world," Quon says. "I'm 100 percent now. You
can always come back. Just don't ever give up."

Lindsay Berra writes for ESPN The Magazine and ESPN GIRL Magazine.