Knocks on the Knee

What female athletes need to know

By Dr Mitch Shulman

Aline*, a 30-year-old recreational tennis player, entered the emergency room hobbling on her left leg and supported by her partner. I could already guess what was wrong. Women participating in sports featuring sudden stops and starts like basketball, tennis, and soccer have as much as five times greater risk of injuring their Anterior Cruciate Ligament (ACL) than men.

The ACL, a tiny band of fibrous connective tissue at the front of the knee, keeps the knee stable. Other joints in the body have a strong bony structure to keep things in place. In the knee, the bone of the thigh (femur) rests atop the two bones of the lower leg (tibia and fibula) with only the muscles and ligaments to hold everything in place. That explains why the ACL is vulnerable in the first place, but it doesn’t explain why female athletes have a higher risk of ACL injuries than men.

As boys move through puberty, higher levels of testosterone enable them to gain muscle and become stronger at the price of being less flexible. Girls, under the influence of estrogen, tend to put on fat rather than muscle and have looser ligaments. The result is that they are more flexible but at an increased risk of injury if they don’t make an extra effort to build up muscle to stabilize their joints. Girls also tend to run in a more upright posture and, because of their wider hips, are more likely to have knock-knees — both increasing risk.

In Aline’s case, right after a sudden stop on the tennis court, she felt something pop. She immediately crumpled to the ground in pain and had to be helped off the court. One of the mysteries of ACL injuries is why an everyday motion that’s been safely done so many times would suddenly result in injury.

I examined Aline’s knee. It was tender, swollen and seemed to move too much, front to back. We did an x-ray to rule out broken bone, and since we can’t see ligaments on an x-ray, we ordered an MRI. Her leg was put in a splint and she was given crutches while waiting to see the orthopedic surgeon. If her ACL was actually torn, she might need surgery. On the other hand, physiotherapy and a brace might be enough. Time and how aggressive she was in her sports would decide.

Given the fact that these injuries are so common in female athletes, research is being done to see how to avoid them. From these studies it appears that developing the abdomen and core muscles will help. Teaching girls to run with knees bent and bodies low to the ground could go a long way, as well as incorporating side-to-side shuttle runs, backward walks, walking lunges and any exercise that improves balance.

* Fictitious name

Dr. Mitch Shulman is an attending physician in the emergency department of the MUHC, assistant professor in the Department of Surgery at McGill Medical School and a regular medical contributor to television and radio.

Summer 2014, Vol 6 N°3

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