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As you may have gathered, Open Court is about many things. We roll in the smart, sports, fun, science, and life - the real things. Time to get our groove into some sports medicine.
Over the next few weeks, we’re going to dive into one of the most dreaded sports injuries: the ACL (Anterior Cruciate Ligament) tear. The stabilizing ligament in our knees is good and strong - until it isn’t. And if you are female, from around age 10 on up, it can snap without warning. Cutting, jumping, and running moves usually spur the injury in females. Males typically have some sort of collision or more obvious violent reason for their knees to go poof.
An ACL tear was the death sentence for an athlete's career.
But no more.
You’ve heard of the stars who have torn their ACLs and gone through hell to come back. Footballers Tom Brady, Odell Beckham Jr. and Adrian Peterson. Soccer players Alex Morgan and Megan Rapinoe. Moment of silence for Rapinoe, who has survived THREE ACL tears and recoveries. NBA players Ricky Rubio, Jamal Murray and Kawhi Leonard have had it. Skier Lindsay Vonn counts it as one of her many injuries over her illustrious career.
Females tear their ACLs at a rate of 3.5 times greater than males in basketball, and 2.8 greater in soccer according to the Journal of Athletic Training. Women have higher rates of ACL tears, across the board, in any sport that is also played by males. Football is the No. 1 injury sport for men. Soccer is tops for women.
A complete ACL tear leads to reconstructive surgery to make the knee joint stable again. Cue the grafts, bone drills and screws, and scars. (If you want to see it in video, here you go.)
It happens. A lot. It’s an injury that occurs in middle school athletes up to Olympians. You fear things will never be the same, because an important part of your body’s original equipment is shot.
I speak from experience, because for moi, it was the act of jumping on a tennis court – going up to hit an overhead - that made my right knee a mess more than decade ago. I went up, with my impressive vertical leap of three ants high, and landed in a spectacular heap. I remember making the shot, sending the overhead down the middle for a winner, and then…things got hazy. I was taking part in a USTA district tournament and felt good. We were winning.
And then I lost it all.
It was nasty damage. Torn ligaments, with the meniscus ripped apart. It took two years and two surgeries, being on crutches for months - unable to stand on the leg at all - plus hundreds of hours of painful rehab to put me whole. The 11-year anniversary of my ACL reconstruction surgery is tomorrow. I celebrate it every year with an internal moment of !holy hell! that happened.
The mental scarring was worse. What happens if I do something, and it tears again without warning? The sound of your knee snapping is strange. There is no warning. Nobody, but you, hears it. Inside your head and bones, it feels like a split-second bomb and wave of warmth moving through you, embedded forever.
And then everything goes quiet. Shock is a blessed thing.
Eventually I was reassembled to factory reconditioning, thanks to skilled sports medicine docs and athletic trainers. I have some titanium screws on the inside, warrior scars on the outside of my knee, and a tiny bit of PTSD in my soul. I am 100 percent back into tennis and as savage as ever. (Meaning, still jumping with the dizzying hops that terrify the world.) But skiing is out.
I was recently reading about how women are still tearing their ACLs way more than men, despite the huge improvements in sports training, diagnostics and understanding of movement. The recent Tokyo Olympics was rife with female athletes who came back from ACL injuries to compete again. Yay for their comebacks, super big boo that they got hurt in the first place.
I turned to Dr. Kristy Smith, a board-certified specialist in Sports Medicine at the Detroit Medical Center, to ask her where we are with ACLs, what she is seeing out in the world, and her thinking about the injury. Smith is a former Jacksonville (Fla.) University volleyball player, who witnessed her teammates going down with ACL injuries. She was lucky to avoid it.
She now is an MD, working in non-surgical sports medicine and helping athletes of all ages. Smith is also board-certified in Emergency Medicine, splitting her time between Sports Med and working in the DMC Sinai-Grace ER in Detroit during the time of COVID.
(FYI: Answers have been lightly condensed for clarity.)
Q: So let’s talk about the biggest lie out there with ACL injuries, the tale of where you are back to play in six months and it is all good. How do you approach that topic?
A: To me, the timeline is always relative, I want my patients who are active athletes to think about the end goal. It may take six months. It may take a year. It may take longer. Some people heal faster, others need more time to get things back. Setting an artificial timeline is not helping the patient recover, because it puts a lot of pressure on them to do something that their body may not be able to do in that span. It is about you, where you are, and where you want to be. There is also the possibility you may not be at the same level after you recover. It all depends on a lot of things in the reconstructive, healing and rehab processes. Things are going to get better, and they can get back to doing what they love. I really want them to see the path forward.
Q: I see the ACL as a complex injury, because it’s not just physical; it’s emotional and mental too. How do you address all of that in the return to play process?
A: The mental and psychological part the ACL injury is critical, and I see that it wasn’t addressed as much as it needed to be in the past. If you are worried you will get hurt again, you are going to move with a hesitation that could lead to injury. You will not be playing with the confidence you need. Just because you are OK means nothing if you cannot believe you are OK.
We address those aspects in our return to play protocols. I had an athlete who tore their ACL playing basketball, while doing a left-handed lay-up. She was nervous for a long time about doing that move again. I got an email from her dad, a video of her doing that move and looking confident. I was so happy to see that. She was doing great in every part of the game, except for that. It was a mental block. Sports psych helped her. That was an amazing moment to share with her, that she made it back all the way.
Q: The ugly truth is, one you have torn your ACL and had the recon, you are at a higher risk to tear it again and get osteoarthritis in that knee. That is a lovely depressing note for people like me.
A: Yeah, that is all true, the studies show athletes who have an ACL injury are 2-8 times more likely to have it happen again. We can trace that back to that happening in the cutting, pivoting from the sport. I just want to stress that the ACL can tear from anything – bowling, cardio activities, golf, to the usual ones like soccer, basketball, volleyball, football and so on.
Q: And for female athletes in this ACL mess?
A: We know more women are playing sports, from earlier ages, so that means there are going to be higher rates of ACL injuries because female athletes are more prone to the injury. As girls are playing sports at younger ages, and specializing in only one sport, we get overuse. So we end up in this place.
The biggest factor for women vs. men in ACLs may be estrogen. Having estrogen means your joints have laxity, you are more flexible – and that can lead to injury. Men don’t have estrogen; they get muscle mass from testosterone. So women come into this with a biological disadvantage. But that obviously does not mean women aren’t amazing athletes. It’s just a factor we need to think of when talking about injury.
Q: The specialization trend, where kids only play soccer or basketball or hockey year-round, is disturbing. Parents pretty much turn their kids pro at 7, thinking it will pay off with a college scholarship or riches down the line. But we know that isn’t true. The athletes who do make it are multi-sport participants and spare the body from the damaging reps. How do you educate parents, when they are convinced (and influenced by coaches) they know what best?
A: I don’t see kids, say under 13, in my practice. But the high school athletes I see, I encourage them to be well-rounded athletes. It makes you stronger in the end. The thought that specializing in sports very young leads to success is not backed up by data. We know that the vast majority of NCAA Division I athletes were multi-sport in high school. And nearly all NCAA athletes are going to go pro in something else in life – like work in a non-pro sports career. So why do something with such long odds? Get an education to get a career. Playing different sports protects the body from injury. If you’re playing volleyball, also then run track. It trains the body in different ways. It stops the overuse cycle. Really, I think we could change the discussion on a lot of sports injuries if we could get the specialization issue to be taken more seriously.
Q: So how do we reframe this conversation? I am sure most parents want their kids to be healthy, happy, and successful – without the injuries.
A: I think we need to reframe everything. We need to have athletic trainers available for youth and school sports teams. We can’t expect coaches to know advanced things like proper kinesiology technique to prevent injuries. Many are just volunteers working with students. They get thrust into these positions and are not fully equipped.
We also must look at how athletes get shaped – a bad coach can leave such a bad stamp on their lives. A bad coach led me to medical school, as they said I would never make it here. I made sure that I did. This has less to do with coaches and schools having medical training in this aspect, it is about their access and willingness to be looking at things differently. Kids are not going to tell a bad coach they are injured, if that coach is preaching playing through pain and hurt.
We're trying to change the conversation, doing seminars for the public and coaches on the ACL, working on the aspects of the injury and the body. You can do things to prevent it. Things like simple exercises. You don’t need a weight room. Work on the hamstring strength, check on the dominance of the quads. We know how to hopefully improve stability and lessen the odds of getting hurt. That’s the message that needs to get out. Let’s be smarter and do better.
Q: I tore my ACL when I was 38. And I am clearly not an elite athlete. Can you clear up the age range for tearing the ACL? Is there a silver lining to getting older, and ahem, losing estrogen?
A: I wish! But that is too simplistic. I have diagnosed a lot of women over 50, or menopausal with ACL injuries. Stuff of daily life, like the patient who stepped off her boat, into the sand, planted her foot, then twisted to walk. Pop went the ACL. I had another woman who was 52 and tore it skiing. It’s not about age, unfortunately, it is about our level of participation as the offending agent for the rupture. Contact sports are still cutting, twisting, and pivoting. So you can always be at risk.
And that’s it for part 1 of the ACL saga. Love your knees!
See you Friday.