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When UConn's star point guard Caroline Doty tore her left ACL for the third time last year, she didn't even know she did it. "I went up for a left-hand layup and landed ... and I felt it kind of shift. It didn't even feel like a pop," she told reporters. "I shook it off and kept playing, and the next day it got really stiff. That's when I knew that something was terribly wrong."
The season-ending injury made national headlines. The buzz wasn't about how Doty had suffered some freakish streak of bad luck, but rather how her debilitating ACL hat trick was, well, old hat, in the world of women's sports.
Doty was just one of a tidal wave of ligament blowouts that has come in the wake of Title IX and the sea of young women playing sports. Statistics show female athletes are two to eight times (depending on the sport) more likely to suffer a hobbling knee injury than their male peers, a disadvantage that robs them not just of on-field ability, but also confidence, stress relief that comes from sports and long-term mobility. But before you go cursing out your genetic makeup, know this: The injury is easy to avoid.
"We know that women have muscle imbalances and movement patterns that put them at a higher risk for these injuries," said Holly J. Silvers, MPT, of the Santa Monica Sports Research Foundation. "And, though schools and clubs have been slow to implement prevention programs, we know we can decrease the number of ACL injuries that are occurring."
In her latest pilot study with the Pepperdine basketball program, Silvers' PEP plan (Prevent injury and Enhance Performance) reduced ACL injuries 100 percent -- the players had zero blown ligaments, compared to their usual two per year. In a separate study of more than 2,100 female soccer players, among those practicing PEP training for a year, there were two ACL tears compared to 32 blown ligaments among those doing no preventative training -- an 88 percent reduction. Clearly, smart physiological tweaks can prevent this mid-leg mechanism from messing with your game.
What to do about this 'girl problem'
A few of the factors that make our ACLs (and MCLs and menisci) more susceptible than men's for non-contact injury are out of our control. Our undulating hormones may make our connective tissues more lax at certain times of our cycle. We have wider hips that make us more likely to be a bit knock-kneed and at risk to cave in and tear the ACL when we jump and land. And we're just smaller. The ligament itself is smaller, as is the notch through which the ligament connects to the femur.
But many factors are well within our control if we're willing to adjust, said Robin West, M.D., an orthopaedic surgeon at the University of Pittsburgh Medical Center's (UPMC) Center for Sports Medicine, who created an ACL injury prevention iPhone app based off the PEP plan and Sportsmetrics (a similar plan).The risk factors ACL experts say are within a woman's control:
Quad dominance. Women rely on their quads to do movements like squatting, jumping and landing, rather than the bigger, stronger glutes, West said. As a result, they land with straighter knees and put more shearing force on those ACLs.
Ligament dominance. No one really knows why, but our muscles fire late, usually three-tenths of a second after the ligaments have absorbed the initial landing impact. "Doesn't sound like much," said Laura Ramus, PT, ATC, at the Detroit Medical Center. "But it's the difference between a safe landing and a blown ACL."
Leg imbalance. Women tend to have one leg that is significantly stronger than the other.
Core weakness. Women often have poor core strength compared to their legs, so when they stop quickly to kick or change directions, their trunk keeps going bringing a lot of weight with it in the opposite direction.
The healthy knee Rx
Too often coaches try to ease ACL woes by sending their female players to the weight room. But the fix isn't about simply making them stronger, notes Ramus, citing powerhouse Serena Williams as an example. "She's as strong as they come. But when she jumped off a box, her knees collapsed inward [an ACL risk] because she had the imbalances and movement pattern problems." To address these, ACL injury protection plans focus on not just strength, but more important hip and core stability.
"Your butt acts as the steering wheel and stabilizer for your lower extremities," Silvers said. It needs to be strong, especially in the outer glutes. It also needs to snap into action before your legs in order to keep your pelvis rock steady and to allow your thighs to go where they're supposed to go rather than collapsing inward. A strong core helps keep it all in line. PEP and similar programs improve strength, stability and movement patterns through a series of exercises and drills that address the imbalances, improve coordination and make firing the right muscles in the right order second nature.
The best part? It takes just 15 or 20 minutes three times a week. "We recommend doing it as part of your warm up," Silvers said. That way you start fresh and end ready for action.
Put some PEP in your step
Warm up your muscles by jogging (or briskly walking) forward, side-to-side and backward for about five minutes. Stretch your calves, quads, hamstrings, inner thighs and hip flexors. Then include lower body and core exercises to strengthen the muscles that stabilize the hips and knees; plyometrics (jumping) and agility drills to build explosive power and train your muscles and ligaments to land properly and stretching to maintain a healthy range of motion. The following abbreviated routine will get you started. Find a full workout here. You'll get results in six to eight weeks.
Walking lunge (one minute or three sets of 10 reps)
Strengthens the thigh (quadriceps) muscles and improves balance and stability.
Take a giant step forward and lunge forward leading with your right leg. Drop the back knee straight down, keeping your front knee over your ankle (you should be able to see your toes). Push off with your right leg and lunge forward with your left leg, repeating the move. Control the motion and try to avoid your front knee from caving inward.
Single toe raises (one minute or two sets of 30 reps)
Strengthens the calf muscle and increases balance.
Stand up with your arms at your side. Bend the left knee up and maintain your balance. Slowly rise up on your right toes with good balance. You may hold your arms out ahead of you in order to help. Slowly repeat for a full set and switch to the other side.
Scissors jump (30 seconds or 20 reps)
Increases power, strength, and stability.
Lunge forward leading with your right leg. Keep your knee over your ankle. Now push off with your right foot and propel your left leg forward into a lunge position. Be sure your knee does not cave in or out. It should be stable and directly over the ankle. Remember the proper landing technique; accept the weight on the ball of your foot with a slight bend to the knee.
Bounding run (about 40 yards)
Increases hip flexion strength and boosts power and speed.
Starting on the near sideline, run to the far side with knees up toward chest. Bring your knees up high. Land on the ball of your foot with a slight bend at the knee and a straight hip. Increase the distance as this exercise gets easier.
Bridging with alternating hip flexion (30 reps)
Strengthens outer hip muscles and glutes.
Lie on the ground with your knees bent and feet on the ground. Raise your buttocks up off the ground and squeeze. Lift your right foot off the ground and make sure that your right hip does not dip down. Lower your right foot and repeat the move to the left. Continue alternating for a full set.