women & sports injuries (including acl tears in female athletes)

Women & Sports Injuries

William I. Sterett, M.D.Vail Summit Orthopaedics

970-569-3240

Emma Kellner, PT, DPT, SCSHoward Head Sports Medicine

970-262-0179

Or . . .The Things I Think I Know

After Almost 20 Years with the Women’s US Ski Team

William I. Sterett, M.D.USOC Team Physician

2014, 2010, 2006 and 2002 Winter OlympicsHead Physician, US Women’s Alpine Ski Team

Medical Director, VVSCVail Summit Orthopaedics

What We WillTalk About Today

u Do Women Really Have A Higher Injury Rate In All Sports?

u Anatomical Factors Leading To Higher Injury Rates

u Performance Factors Leading To Higher Injury Rates

u Differing Treatment Plans Based On Risk Factors


u Lots To Possibly Talk About In a Future Seriesu Concussionsu Dehydrationu Female Athlete Triad

For ExampleConcussions Among

Alpine and Freestyle Skiers

u 2080 injuries reported in 7 World Cup Seasonsu 12% were injuries to the

head and face

u Concussions - 82% of these hand and face injuries

u 24% were Severe

u Alpine vs Freestyleu Twice as likely to sustain a

Concussion in Freestyle

u Snowboard in between Freestyle and Alpine

u Freestyle > Snowboard>Alpineu Concussion Risk

u Women had a Higher Concussion Incidence than Men

u 1.5x higher

u Across all 3 disciplines

Br J Sports Med 2014


u Today We Want To Focus Onu Knee Injuries That

Are Season Ending

u Prevention Strategies

DEPENDING ON THE SPORT, WOMEN ARE AT MUCH HIGHER RISK TO

SUSTAIN A SEASON ENDING INJURY

Lets Use ACL Tears as an ExampleTypically Season Ending

Sport Males Females

Basketball 1 3.5

Volleyball 1 3

Soccer 1 4

Recreational Skiing 1 6

World Cup Skiing 1 1

Time-Loss Injuries on the World Cup Circuit

All Injuries

Injuries Among World Cup Ski And Snowboard Athletes

Alpine Skiing

u 30% have a time-loss injury per seasonu 11% have severe injuries

u >28 days off

Snowboarding

u 38% have a time-loss injury per seasonu 14% have severe

injuries

u >28 days off

Scand J Med Sci Sports 2012

ACL Injuries on French Alpine Ski Team 397 Racers 191 Men, 188 Women

u Overall ACL Injury Rateu 28% of Men and 27% of Women Sustained AT LEAST

One ACL Tearu ACL Injured Racers Had A 39% Risk Of Sustaining

Another ACL Tear During Their Career.u Men And Women Racers Had Similar Injury Ratesu World Cup Ski Racing Is About The Only Sport With

Similar ACL Injury Rates In Females And Males

Pujol et al, AJSM 2007

379 Skiers on French Alpine Ski Team

u 19% Incidence Of Re-rupturing The Same Kneeu >30% Incidence Of Tearing The ACL On The

Opposite Kneeu Mean Number Of Surgeries After ACL Injured

u 2.4

u Higher ACL Injury Rate, Re-injury And Bilateral Injury Rate In Racers Ranked In The Top 30 In The World

Pujol et al, AJSM 2007

Competitive Female AthletesThis is the World I’ve Been Living In

LETS TALK

RISK FACTORS

ANATOMICAL RISK FACTORSBULLET POINTS, NOT COMPREHENSIVE

u Valgus Or “Knock Kneed” Alignment More Common In Females

u Hyperlaxity Much More Common In Femalesu Loose Jointed

u Congenittal

ANATOMICAL RISK FACTORSBULLET POINTS, NOT COMPREHENSIVE

u Otheru Narrow Notch

u Smaller ACL Than Men

u Size Of ACL Relative To Size Of Athlete

u Menstrual Cycleu 3x Higher ACL Injury

Rate During Competition In The Pre-ovulatory Phase

Valgus or Knock Kneed

Women are Typically 40 More Valgus than Men

Is Valgus Bad?u Women Have A Wider

Pelvis (Relatively) And Therefore Need To Have Their Knee In More Valgus To Balance Out

u Knock Kneed Athletes Live With Their ACL On “Stretch”

u Valgus Knees Are At Much Higher Risk Of Sustaining An Injury To The ACL

Hyperlaxity

Congenitally Loose JointedThere’s actually Criteria For This

Hyperlaxityu Women Have A

Much Higher Incidence Of Congenital Hyperlaxity In The General Population Than Menu Shoulders That

Dislocate

u Knee Caps That Dislocate

Loose Jointed Athletesu Much Higher Risk Of

Sustaining An ACL Tear

u Much Higher Risk Of Re-tearing A Reconstructed Knee

Loose Jointed Athletesu Athletes With A Torn ACL

Were 4.5 X More Likely To Meet The Criteria For Being Loose Jointed Than Athletes That Had Not Torn Their ACL

u Good News – Much Lower Risk Of Developing Arthritis Down The Line In Patients With Hyperlaxity

HyperlaxityThis Is What We Look For

NEXT RISK FACTOR FOR WOMEN

Anatomic Risk FactorsNarrow Notch

Here’s Why a Narrow Notch is a Big Deal

The Bone of the Notch Will Pinch the ACL During Twisting or Hyperextension

Other Anatomic Risk Factorsu ACL Size

u The Male ACL Is Roughly 30% Larger Than The Female ACL

u Female Athletes Are Often Similar In Size To Their Male Counterparts

u Especially In High School Sports

u The Forces The Knee Sees Due To Twisting Injury May Be Equal In Men And Women

u Smaller ACL Must Be A Risk

Other Anatomic Risk Factors

uMenstrual Cycle1. Menstrual Phase2. Pre-Ovulatory Phase3. Ovulatory Phase4. Post Ovulatory

Phase

Other Anatomic Risk Factorsu Menstrual Cycle

1. Menstrual Phase

1. 3-5 days

2. Pre-Ovulatory Phase

3. Ovulatory Phase

1. Mid-Cycle

2. Roughly two days

4. Post Ovulatory Phase

1. Progesterone Increases

Pre-Ovulatory Phaseu 3x Higher ACL Injury Rate In

Female Athletes During the Pre-Ovulatory Phase

u Ligaments Often More Lax In General During Pre-ovulatory Phase

u Evidence Is Weak But May Be Multi-factorialu Hormonal Ligamentous

Laxity

u Energy-fatigue

u Relative Anemia

Now On To Athletic Factors Pre-disposing

Women To Season Ending Injuries

Athletic Factors2 Biggies

1. Landing “Strategies”

2. “Dynamic”Valgus


uLanding “Strategies”u Looking at you from

the side

uWomenu Tend to Land More

Straight Legged

uMenu Land With More of a

Flexed Knee


u Straight Kneeu May “Pinch” The

ACL Against The Notch

u Narrow Notch

u Hyper-extension

u Flexed Kneeu More Protective

Of The ACL


u“Dynamic”valgusu Looking At You From

The Front

u Knee Caves In During Landing


u “Dynamic”valgusu May Be Due To Weak

Glutesu Knee Cap Needs To Go

Over The Second Toe During Landing

u Can Pinch The ACLu Narrow Notchu ACL May Already Be On

Stretch From Being Born Knock Kneed

CAN WE START PUTTING THIS ALL

TOGETHER??

THE INCREASE IN ACL INJURIES IN WOMEN IS MULTIFACTORIAL

ANATOMICAL RISKS

Combined With

ATHLETIC RISKS

u STRAIGHT LEG LANDING

u KNEE “DIVES” IN

u FOOT EVERTS OR PRONATES

Leads To 2-8 X Higher Season Ending ACL

Injury Rates In Female Athletes

Bottom Lineu Loose Jointed

uKnock Kneed

uPoor Landing Mechanicsu SUPER HIGH RISK WITH CUTTING, JUMPING TWISITING

SPORTS

u MALE OR FEMALE

EMMA IS GOING TO TEACH US SOME

PREVENTION STRATEGIES

BUT FIRST JUST A COUPLE OF SLIDES ON DIFFERING TREATMENT

STRATEGIES FOR WOMEN ATHLETES

THE TREATMENT PROBLEMu Women Tear Their ACL

More Frequently Than Men

u Women That Are Knock Kneed Or Hyper Lax Are At Much Higher Risk Of Re-tearing Anything We Reconstruct

u Look at the French Ski Team

Working on the Problemu Cadaver Grafts For The ACL

Have An Unacceptably High Re-rupture Rate In Young Athletic Women

u Patellar Tendon Grafts

u Lower Re-rupture Rate

u But…. Ski Racers And Jumping Athletetes Are Very Hesitant Because Of The Risk Of Developing Patellar Tendonitis

u Hamstring Grafts Are Loved By Ski Racers

u Higher Re-rupture Rate In Hyperlax Females Unfortunately

u May Even Contribute To Increased Hyper-extension

Working on the Problem

u Quadriceps Tendon Graft To Replace The ACLu I Tend To Use This As My

Graft Of Choice In The Hyper-extenders, And Revision Situations

u More Successful Graft in Patients with Generalized Ligamentous Laxity

Kim et al 2010

With More Women Playing Sports,

Maybe This is All Just Evolution

Evolution of Man

The Evolution of Women

THANK YOU!!!WE NEED TO THINK OF, AND TREAT, OUR FEMALE ATHLETES DIFFERENT

THAN WE TREAT OUR MEN

women & sports injuries (including acl tears in female athletes)

Health & Medicine