Preventing ACL injury in female athletes


Last year, when Kelsey Bertamus learned she had torn her ACL and would need a bone graft before reconstructive surgery could be done, she couldn’t say she was surprised.

At the time of her injury, Beltamus was a junior and playing soccer at Northwestern University in Illinois. Earlier in her career, she had been the leading soccer scorer for Lakeville South High School. During her high school career, she had already torn her ACL twice, shattered her femur and torn her meniscus—all within five years. “I had almost come to expect it,” she said. “The constant abuse to my body and the rehabilitation schedules due to soccer were wearing on me.”

Bertamus, now 21, no longer plays the sport she loved. While her accumulation of injuries may seem extreme, large numbers of female athletes are experiencing tears in their ACL’s and causing doctors, physical therapists and coaches to stress the importance of prevention.

The end of a season

The anterior cruciate ligament (ACL) is located in the middle of the knee. Besides stabilizing the knee joint, the strong band of tissue also connects the thighbone (femur), to the shinbone (tibia). ACL injuries happen when the ligament tears.

Athletes often experience these injuries while playing sports that involve sudden stops, twists and changes in direction, such as soccer, basketball, volleyball, downhill skiing and tennis.

“It’s that planting and then pivoting that causes stress on the ligaments, leading to tears,” said Dr. Maria O’Connell, owner and chiropractor at Eagle Trace Wellness Center in Burnsville.

Bertamus didn’t feel much pain immediately after she hyperextended her leg on the soccer field, tearing her ACL for the first time in May 2005. “But I noticed something was very wrong as I tried to stand up and walk,” she said. “I had to be helped off the field because I could not stabilize my knee, and it would give out beneath me.”

The star forward underwent reconstructive surgery using a hamstring graft and returned to soccer four months later. At the time, Bertamus was optimistic about getting back on the field. “I was only 15 and still had my high school and college career ahead of me,” she said. She shattered her femur a month later and had a metal rod temporarily inserted in her leg.

In recent years, the ACL injury has made headlines for plaguing female athletes. Since more girls and young women are participating in athletics than ever before, it makes sense that their injuries are increasing. However, medical professionals are quick to point out that female athletes are predisposed to experience an ACL injury.

Dr. Sarah Lehnert of Burnsville’s Fairview Sports and Orthopedic Care reported that females have four to six times the incidence of ACL tears as their male counterparts. “All told there are more males tearing their ACL’s,” she said. “But when you look at percentages, females have a higher risk.” The higher total number of males involved in sports explains the discrepancy, Lehnert said.

Several ideas exist as to why females have a higher risk of tearing their ACL’s. “But the theory which seems to make the most sense,” Lehnert said, “is the fact that women tend to rely heavily on their quadricep muscles in the front of the thigh to stabilize their leg. They tend to have weaker and slower hamstring contractions, so they end up in a knock-kneed position when pivoting, cutting and landing a jump.” This position strains the ACL and makes it tear, she said.

During Bertamus’ rehabilitation, she worked to build up certain muscles to keep the tear from happening again. “My trainer had me strengthen my hamstrings to near the level of my quadriceps in order to avoid hyperextension,” she said, adding that she also did exercises to strengthen her core and relearned how to run.

Hormonal differences also seem to play a role in increased female injury, O’Connell said. “Women in their child-bearing years have more hormones keeping their ligaments loose and lax, which leaves them more susceptible to injuries,” she said, noting that most of the athletes she treats for ACL injuries are females in their late teens and early twenties.

As head soccer coach at Eagan High School, Mark Obarski has witnessed firsthand the upsetting effects of injuries on his young athletes for more than a decade. “Over the years, we’ve had several players who have torn their ACL’s,” he said. “They’re definitely out for the rest of the season.”

Treating and preventing ACL injuries

A doctor may perform an X-ray, MRI, ultrasound or arthroscopy (inserting a fiber-optic viewing scope into knee) to determine the severity of an ACL injury and its proper treatment. Reconstructive surgery using tissue from the patient or from a cadaver is often necessary for athletes who experience serious ruptures, as Bertamus did. Afterward, the patient undergoes physical therapy, designed to help him or her regain range of motion and strength, said Lehnert. For less serious injuries, some doctors use alternative methods to treat the patient, such as cold laser therapy or acupuncture.

Besides eating a healthy diet, O’Connell recommended that serious athletes have their vitamin D levels tested. Vitamin D, present in sunlight and some foods, is helpful in maintaining bone mass. “A good portion of Minnesotans are deficient,” she said, citing the state’s distance from the sunny equator. In her practice, O’Connell also uses Active Release Technique (ART to treat these injuries). The massage technique, popular with runners and NFL teams, works with the muscle and tissue around the knee to create stability and has the patient actively move through the range of motion. ART helps to treat muscles worn down from repetitive movement, O’Connell said. Obarski often notices overworked muscles on his soccer team. “The thing about high school sports is that overuse comes into play a lot,” he said. “When you see kids tired and fatigued, that’s when a lot of injuries happen.”

Many other treatments used in rehabilitation can be implemented as prevention measures against sports-related injuries. Most medical professionals agree that exercises focusing on balance, agility, and those that make an athlete more aware of her body (called “proprioceptive” exercises, should unquestionably be a part of every athlete’s routine. Exercises that keep athletes conditioned, increase bone density and assist in avoiding overall injury, include stretching, core strengthening, weight training and plyometrics. Learning to jump and land correctly, along with utilizing equipment such as a BOSU ball, wobble board or even a Wii Fit balance board, are beneficial in preventing injury.

“As far as ACL prevention goes, athletes of all ages need to have strength, endurance, agility, coordination and speed,” affirmed Elizabeth Smith, a certified athletic trainer and physical therapist at Fairview Sports and Orthopedic Care. “It’s multifaceted,” she said. “It’s all about maintaining a properly balanced program throughout the year.” Smith added that athletes need to condition their bodies even in the off-season. Just as Bertamus experienced multiple related injuries in her knee, O’Connell warned that one injury may create a domino effect. “A torn hamstring can cause a sprain in the knee,” she said, underscoring the importance of general conditioning.

Although it’s important to integrate exercise into workouts and warm-ups, the instruction needs to be done by someone who has been properly trained, Smith said. She explained that muscles are crucial in controlling the forces on a joint that might make the ligaments vulnerable to injury. She is one of the two physical therapists in Minnesota who is certified in Muscle Activation Technique (MAT), a biomechanically-based method of evaluating and treating muscle imbalances. Treatment includes low-grade isometrics and precise manual therapy to jump start muscles and restore their function. Like ART, the technique can be used for rehabilitation and as a prevention tool.

“MAT is an excellent technique to consider with our ACL population who might develop muscle imbalances during growth spurts and hormonal changes,” Smith said. Fairview also offers a post-rehabilitation program called “Next Step,” which focuses on sport-specific training to transition the athlete back into playing.

Getting back in the game

Especially for high school and college athletes, taking the time necessary for recovery is often the most frustrating part of an injury. “Typically, going from ACL reconstruction back to high intensity sports, such as soccer, takes five to six months,” Lehnert said.

“It’s always really hard, regardless of what injury it is, to not be able to play,” Obarski said. “The kids are so competitive and enjoy the game so much. It’s difficult to have to sit on the sidelines.” As a coach as well as the father of two daughters and three sons, Obarski said he understands the importance of putting a player’s health first. “With high school sports, it’s a quick season, and kids need to take care of themselves, especially when you mix in the academic component with everything else going on.” He said he stresses hydration and proper sleep to his team; he tries to be aware of players who may be overworking their bodies.

Fighting through a cycle of devastating injuries and grueling rehabilitation, Bertamus returned again and again to prove herself on the field. She became the leading scorer in school history and racked up top honors during high school that included a state championship in 2007 and a place on the all-state team her freshman, junior and senior year. However, by Bertamus’ seventh surgery, she had missed over two and a half years of playing. “I definitely did not feel comfortable on the field the way I used to,” she said. “Mentally, it was a struggle.” After her third ACL tear last year, she made the decision, along with her coach, trainer and doctors, to take a medical redshirt from Northwestern University.

Now a senior at Northwestern, Bertamus is studying biological sciences and environmental policy/culture and plans to attend veterinary school. She exercises by doing controlled weight-lifting and running straight ahead. She encourages athletes to start prevention early and to play smart with their bodies. “I definitely miss playing soccer, but I don’t miss the pain and frustration of constant injuries and rehabilitation schedules,” she said. “I do get a pang of nostalgia every time I step on a soccer field, but I know that the choice to take a medical leave was the safest choice for my body.”

Laura Murray is a freelance writer and comtributor to Focus Magazine. Photos by Rick Orndorf