Theories abound on why women have a higher incidence of torn ACLs than men do. A recent study pegs the way women jump and land as the primary factor.
Mentoring in the WUSA isn't just about what happens on the field. Players increasingly are feeding on colleagues' experiences with knee injuries. Sources for information seem at every turn.
A rash of torn anterior cruciate ligaments – eight since the WUSA kicked off, five this season – and scores of lesser knee injuries has plagued the world's top women's league. Nearly two dozen players – including U.S. national team veterans Mia Hamm, Carla Overbeck, Kate Sobrero, Christie Pearce, Sara Whalen, Danielle Slaton and Tracy Ducar – have been sidelined in 2002 by one knee ailment or another.
Whalen, a defender and midfielder for New York, was the fourth high-profile player knocked out for the season by an ACL tear this year. Philadelphia lost forward Rakel Karvelsson during preseason preparations and star midfielder Kelly Smith at the start of June. Midfielder Lindsay Stoecker, Washington's leader, went down on June 15. Whalen was injured 11 days later.
The experts are not surprised.
''Not at all,'' says Dr. William DeLong of the University of Pennsylvania Health System, who works with the Philadelphia Charge and handled Smith's and Karvelsson's ACL repairs. ''I expected to see it last year. … Everyone that does ACL [surgery] knows we're seeing more women than men now. There's lots of theories about what's going on, but we don't know the science behind it. We don't know what is the true incidence of ACL injuries in women and men.''
DeLong is planning a study of MLS and WUSA players to learn more, and there's plenty of places to look, everywhere from the angle of knees to the size of femoral notches to the effects of hormones in the menstrual cycle.
One of the most popular notions is that women's generally larger ''Q angles'' – the angles at which the femur and tibia meet at the knee, determined by the width of the pelvis – leaves their knees susceptible to inward torque when jumping, landing, turning and planting.
''Look at a player like Mia Hamm,'' says Randy Rocha, the Washington Freedom's trainer. ''She's bow-legged, and she's never had this type of ligament injury. She has something different [articular lesion], from wear and tear on the knee. The mechanism isn't the same as with ACL tears.
''Now look at Lindsay Stoecker. She's knock-kneed, and her legs hyperextend, which is another mechanism of an ACL tear. It's another characteristic in females.''
The strength of various muscles surrounding and supporting the knee also are much weaker in women than in men.
''There's some sense,'' DeLong says, ''that maybe the hamstring muscles get overpowered by the quadriceps muscle in women.'' The ratio of strength between the hamstring and quadriceps should be even or close to it. In addition, the ''VMO,'' another supporting muscle, located above the knee on the inner part of the lower thigh, is poorly developed, generally, in women.
''Female skeletons are built differently,'' notes Carolina Courage trainer Cody Malley. ''The significance is that, mechanically, the ACL injury is usually a rotator injury – one bone rotates on the other. … Because of the increased 'Q angle,' more weight comes down on the legs, the knee caves in, the femur will twist on the tibia, and it causes a rupture.''
GENDER DIFFERENCE. Anatomic differences cause women to adopt different posture than men do. ''A new study,'' Malley reports. ''Female athletes carry themselves a little higher. They don't have as low a center of gravity when they're playing – they don't have their knees bent. When knees are in a more-bent position, more a half-squat or quarter-squat, the muscles mechanically stabilize the knee. When legs are straight, the ligaments are much more susceptible to stress.''
Dr. Bert Mandelbaum, who runs the Santa Monica (Calif.) Orthopedic Sports Medicine Research and Education Foundation when he's not seeing to the U.S. men's national team's needs, says the ''real question is twofold, really: Why is it happening? And can we do something about it? And if we can't do anything, what are the long-term ramifications.''
Mandelbaum took part in a study that examined all the possible factors and theories – looking at anatomical, hormonal, environmental and biomechanical factors – before determining that the greatest influence was how women leap.
''Biomechanics and neuromuscular [elements were identified] as the major risk factor,'' Mandelbaum said. ''We reviewed numerous videotapes, and what we found was, occurring in comparison to boys, girls jump and land flat-footed, with their knees in straight or extended positions, their hips in the same positions, and that puts the ACL at very significant risk.''
Everything else, he says, from ''Q angles'' to ovulation to turf and shoe concerns, ''is not a major factor.''
PREVENTION. U.S. women's national team coach April Heinrichs isn't surprised by such findings. Her theory, she says, is that the best and most agile female athletes avoid such injuries. The agile Whalen was hurt, unlike in most ACL tears, after contact rather than in a plant-and-twist situation.
''I think we can all scientifically reduce or anecdotally reduce it to the way women jump and land,'' she says. ''You can't talk about agility without talking about jumping and landing. That's what agility is.''
Mandelbaum says studies in Italy, Kansas and Cincinnati suggested that athletes can be trained ''to be stronger, more agile, to jump and land a different way'' and that incidence of ACL tears could be severely curtailed with proper education and training. The group in which Mandelbaum participated studied the elite Coast Soccer League in Southern California for two years, developing a five-step program (PEP, for ''prevent injuries, enhance performance'') to teach avoidance tactics, increase strength and agility, improve jumping and landing technique and educate players on how injuries occur.
''We developed basically a 20-minute warmup at the front of all club soccer practices,'' Mandelbaum reports. ''In 2000 we found an 88 percent reduction [in ACL injuries]. In 2001, it was 75 percent.''
The next step is a study involving 75 universities in collaboration with the NCAA, FIFA, the Centers for Disease Control and Prevention, and national orthopedics associations.
Texas A&M University's women's program participated in a PEP pilot program last year. ''When it came across the airwaves,'' Aggies coach G. Guerreri said, ''I had to be first in line. We're the poster program for ACL injuries.''
Nine A&M players suffered torn ACLs in an 11-month period, culminating with six losses during the 2000 fall season. After implementing PEP procedures, there were no such injuries in 2001.
''We've taken it far enough that we're actually teaching the motor movements in our camps,'' Guerreri says. ''We have 1,700 kids coming through camp this summer, and they're all being exposed to these ideas, especially the girls.''
EVOLUTION. Why women jump and land and carry themselves differently than men – and differences in their muscle structures – is most likely product of evolution.
''If you go back 100,000 years ago,'' Mandelbaum says, ''you'll find women were usually carrying the babies on their side or back. Men, basically, were hunting and stalking, with knees bent, running over long distances. … Man has evolved to the able to run and jump and cut and pivot and land and stop at high velocity, and women haven't done that.''
It's led to an ACL epidemic among women in all jumping sports, Mandelbaum says. He sees basketball and volleyball players, ''and in other countries, it's happening in netball and team handball. It's the same problem, and also the same statistics.''
It's more common to women's soccer than many believe. Nearly one-quarter of the players in the WUSA have torn ACLs at some point in their playing career; San Jose's Brandi Chastain and Boston's Maren Meinert, two of the league's most capable players, have torn both. So has Santa Clara University's Aly Wagner, who might be the first selection in next winter's draft. And University of North Carolina defender Leslie Gaston, another pro prospect, has undergone five ACL surgeries. She's playing without an ACL in her left knee.
''I'm not having any instability,'' Gaston says. ''I really don't see any reason to get it fixed.''
''I was not aware it was so common,'' says Karvelsson. ''You never think much about it until it happens to you.''
Finding someone to turn to isn't difficult. Karvelsson was there to support and advise Smith when she went down. Whalen, who expects to undergo surgery in late July, has been leaning on Power teammate Christie Pearce, who suffered her ACL tear last August, just before the WUSA playoffs.
''She's someone I look to,'' Whalen says, ''to see if my feelings are normal at this stage, if my outbursts are normal. It's good: She's been through it and come out strong, and it's encouraging to see that. To have her advice makes me feel I'm doing things right.''
Stoecker says cards ''are pouring in from friends who have had knee injuries. It's nice to see someone that you know has torn their ACL and you can't tell at all.''
Similar tales are told throughout the women's game. It's almost as if there were a club, albeit one ''I never wanted to be part of,'' Whalen says. ''It's not like there's a Web site where we all chat all the time, but that might be something we need to start.''
by Soccer America Senior Editor Scott French