As recently as 20 to 30 years ago, when an athlete heard the doctor say “torn anterior cruciate ligament,” those words were followed with more bad news like, “you’ll be rehabbing for the next 12 to 18 months.”
Though advances in medical research have allowed for a much shorter rehab time for today’s ACL tears — the average rehab time is now six months according to two local doctors — the injury itself can still be devastating for the athlete.
This holds especially true to female athletes, who are, depending on the sport, four to eight times more likely to suffer a torn ACL than males.
There are many theories, some more controversial than others, as to why females are more likely to suffer the injury — the menstrual cycle and female hormones can cause ligaments to soften; females are physically smaller than males, which makes them more susceptible to injury; female athletes jump and land differently than males — but the fact remains, ACL tears can and will occur.
However, there are steps which can be taken to prevent an ACL tear. It’s a matter of making coaches, athletes and athletic trainers aware of the different preventative measures that can be taken.
“The biggest issue is prevention,” said Dr. Amy Borrow, an orthopedic physician and surgeon at Georgia Sports Orthopedic Specialists in Gainesville. “That’s any orthopedic physician’s main goal. Contact injuries you can’t prevent, but most ACL injuries to women are non-contact — they just land wrong or turn wrong and tear their ACL.”
One of the more accepted theories as to why females are more likely to tear their ACL is they use their quadriceps more than hamstrings to stabilize their knees when jumping, landing or changing directions. Having quads stronger than hamstrings can create a weak link that leaves the ACL vulnerable.
“Women don’t absorb impact as well because they don’t get as low to the ground (as men do) for a center of gravity, and that strains ligaments,” Borrow said. “If you look at children when they run and jump, they land the same way. But once they hit puberty, you start to see changes in males and females and how they move.”
Borrow suggested puberty as the best time for female athletes to begin core-strengthening exercises. There are many different exercise programs, but the main goal is for females to create balance between the quad and hamstring muscles and become aware of their bodies and how they move.
Examples of prevention exercises include jumping off an 8-12 inch box under the supervision of a physical trainer to learn proper form, stretching the quads and hamstrings, leg presses, squats and hamstring curls among many others. There are websites, such as aclprevent.com, that offer exercise programs.
Whichever program is chosen, incorporating core-strengthening exercises early in a female athlete’s life is crucial. If she waits until high school to begin preventative exercising, it could already be too late.
Just ask Benjie Wood.
He was coach of Johnson High’s girls basketball team when five players tore their ACLs and another tore her posterior cruciate ligament during 2001-02 season.
“It was absolutely gut-wrenching,” said Wood, now the boys basketball coach at North Hall. “You always go back and look at what you could have done better to prevent it, but it was a horrible experience.”
Exercises were previously in place at Johnson designed to help prevent ACL injuries. But after the first Lady Knight, senior Lori Vaughn (now Smallwood) suffered the injury just before the start of the season, Wood gradually saw his roster dwindle from 14 players to eight by season’s end.
“Actually, it was 7 1/2,” Wood joked. “Lori came back at the end of the season and was basically on one wheel.”
Before the injuries, Johnson was one of the state’s better teams in Class AAA. Remarkably, and despite all the injuries and a 14-14 record, the Lady Knights qualified for the state tournament on a last-second shot in the Region 7-AAA tourney.
“It felt like we had won state,” said Smallwood, referring to the Lady Knights after winning the state tourney qualifier. “We were pretty beaten up and no one thought we could do it. The way we celebrated (after the game), you would’ve thought we’d won (state).”
Dressing just eight players, the Lady Knights were eliminated in the first round of the state tournament by Westminster.
“That was a resilient bunch,” Wood said. “It was a very rewarding experience because of how they dug down deep and persevered.”
When someone suffers an ACL injury, there are two different types of surgical procedures that can repair the knee. While some doctors specialize in one method, Borrow chooses the best one based on the patient’s lifestyle.
The first option is to take a tendon from the patient, either from the hamstring or patella tendon, to serve as the new ACL. This is known as an autograft. The other option is an allograft, which uses donor tissue from a cadaver.
With student-athletes, Borrow believes the best option in most cases is an autograft.
“That’s the current thought process because it’s their own tissue and, generally speaking, a cadaver is not as good in quality,” she said. “It’s hard to find a cadaver that is as young as a 16-year-old. You’re likely to get one from someone in their 20s or 30s or sometimes older.
“Also, your body tends to heal faster with your own tissue.”
Once the new ACL is in place, rehab can begin, in some cases, as soon as the next day. That’s the biggest difference between the ACL tears of today and yesterday. In the 1980s, some people’s knees were kept in braces, or even placed in a cast, for up to six weeks after surgery. But now that research on the injury has evolved, most patients can begin rehab within seven to 10 days after surgery.
Mike Clanton is the president of the Georgia Athletic Trainers Association, head athletic trainer at Brenau University and director of sports medicine for Pro Therapy. When he’s working with student-athletes on rehabbing an ACL tear, he puts them on the same core-strengthening exercise program used to prevent the injury.
“You want strengthening in the hamstrings to make sure they can use them strong and quickly,” said Clanton, “strengthening of abdominals for control of center of gravity, which helps prevent inverted positioning of the knee. We work to keep the hips strong and we do jump training and agility drills.”
While the average rehab time is six months, there are some cases in which the student-athlete can return earlier.
In Smallwood’s case, she returned after just four months of rehab because, being a senior, it was her final chance to earn a college scholarship.
“I wasn’t released to come back, but my parents could release me,” Smallwood said. “It wasn’t completely healed, but I played. I couldn’t bend my knee all the way and I wore a brace. I could only play one game in a set of back-to-backs because my knee would get tired and I couldn’t run as much.”
Coming back from the injury too soon, not properly following the rehab program or just returning to athletic action brings the risk of re-tearing the ACL. It’s also common for a female athlete to tear the ACL in her other knee, which is what Smallwood did her freshman year playing at Piedmont College.
In fact, of the five Lady Knights who suffered ACL tears during the ’01-02 season, all five either re-tore the same ACL or tore the other one.
That’s when the injury can become a real problem.
“It gets harder to do an autograft because eventually you run out of their own tissue,” Borrow said. “That’s when an allograft becomes the first option (in student-athletes).”
Although an allograft is not usually recommended for athletes, it is often used for less athletically active patients or manual laborers who need to return to work because the recovery time is shorter. The method is also common for athletes who have their ACL reconstructed due to a second tear.
Another benefit to the allograft is it’s less painful because there is no removing portions of the hamstring or patella tendon to form a new ACL.
When Smallwood tore her other ACL at Piedmont, she had an allograft because she didn’t want to go through the pain she experienced from the autograft. She eventually retired from basketball after her junior season when a teammate tore her ACL for a second time.
“I decided I was ready to move on to other things,” said Smallwood, who is now married and a teacher at Flowery Branch Elementary. She also coaches rec league basketball.
Courtney Newton, currently playing basketball at the University of South Carolina and a former Flowery Branch High standout, has torn her ACL three times — twice in her right knee — since 2005. She’s had four surgeries on her right knee and another on her left — all allografts.
“I feel like I’ve been rehabbing my whole life,” Newton said.
While spending summers rehabbing her knee on campus, she took advantage of the circumstances and graduated early. Still on scholarship after five years — she redshirted her freshman season — she’s currently working on a doctoral degree in counseling.
She also intends on playing her senior season this year.
“I love the game and I want to put myself in a position to play if I can,” Newton said. “If it doesn’t work out, it doesn’t work out, but I’m going to give it a go one more time.”
The long-term risk for Newton, Smallwood and others who have had multiple ACL surgeries is arthritis.
“It’s not as devastating of an injury as it was in terms of lost time or losing scholarships,” said Borrow, “but it certainly is when dealing with later life needs. Multiple surgeries become a major issue down the road with arthritis.
“That’s why prevention is so important.”