Michael Zazzali: The Female Athlete: ACL Injuries and

Prevention
The advent of kids playing sports and often time one sport all year round has become, in a word,
dangerous. When I was a kid, I played soccer in the fall and baseball in the spring and summer. I
would train in the off-season for both sports, mainly consisting of weight training and some
cardiovascular fitness. As Dr. Robert Marx from the Hospital for Special Surgery aptly puts, young
athletes today are no longer benefiting from the seasonal break and instead are expected to practice
their sport year-round. As Dr. Marx states, these are driven by a joy and desire to excel at his/her
sport, but over time we are seeing the risks may start to outshine the benefits.
Injury to the anterior cruciate ligament (ACL) is one of the most devastating and potentially
functionally debilitating to the athlete's knee. The ligament is intra-articular (inside the joint) and
plays a significant role in maintaining stability to the knee with quick stops, change of direction or
rotational movements. The frequency of ACL tears has become an epidemic in the young athlete.
Approximately 200,000 ACL injuries occur annually in the United States, leading to nearly 100,000
ACL reconstruction surgeries. Although the surgical approaches are more advanced compared to a
decade ago and have excellent outcomes, there still is a tendency for earlier arthritic changes in the
surgically repaired knee.
The female athlete requires special consideration as the vast majority of ACL injuries occur without
contact. Researchers have reported that female college basketball players were eight times more
likely to injure the ACL than their male counterparts. Others have reported that female soccer
players were six times more likely to sustain an ACL injury than male soccer players. There are
similar data for other sports such as volleyball and gymnastics. Females have some unique
anatomical features that may predispose them to injury, including increased genu valgum (knock-
knee alignment), a poor hamsting-quadricep strength ratio, running and landing on a more extended
knee, quadriceps-dominant knee posture, and hip/core weakness. It has been hypothesized that
hormonal changes associated with the female menstrual cycle may also play a role due to the release
of relaxin hormone that induces added laxity to the body's ligamentous tissues.
As a physical therapist in NYC, I treat these athletes postoperatively after their reconstruction has
been completed. Current rehabilitation programs following ACL reconstruction are more aggressive
than those utilized in the 1980s. Current programs emphasize full passive knee extension, immediate
partial weight-bearing, and functional exercise. The rehabilitation program will be modified based
on the type of reconstruction whether the patient had a reconstruction using their patellar tendon
verses hamstring. The main differences between a normal and accelerated program are the rate of
progression through the phases of rehabilitation and the recovery time prior to resuming running
and athletic endeavors. Even with the accelerated program it may still take six months for the
athlete to begin premorbid athletic activities, and in some cases nine months to a year. It is also
essential to train the uninvolved side during the course of the patients' rehabilitation, as there is a
15 percent occurrence once the patient has an ACL tear of tearing the other side upon returning to
play.
The common mechanism of non-contact ACL injuries is a valgus stress with rotation at the knee,
which put simply means the knee is bowing inward on landing or cutting instead of being aligned
properly. This valgus load can often be associated with a rotational stress at the knee, thus, it is vital
for the female athlete to learn through neuromuscular training exercises to control this valgus
moment. Physical therapist Tim Hewitt was one of the first to study the effect of neuromuscular
training on the incidence of knee injury in the female athlete back in 1999. His hallmark study has
led to more research and helped lead the way for more preventative exercises to hopefully help
decrease the ACL epidemic especially in the female athlete.
Those patients with diagnoses related to their lower extremities, whether they be a competitive
athlete or a weekend warrior, receive an integrated preventative programs as appropriate for their
specific goals. Before assessment of the knee, however, we also look at strength of the hip and the
foot alignment of the patient. Someone with a flat or pronated foot may be more predisposed to knee
issues due to the affect it has on rotating the tibia bone internally potentially increasing the valgus
moment above. In some cases arch supports or custom-made orthotics may be prescribed. Some
overlapping components are the following: working on a strong core, including exercises to build the
abdominals, gluteals and abductors as well as hip external rotator group. These muscle groups are
essential in controlling the valgus loads that can induce the ACL injury. In addition, education on
optimal knee alignment that emphasize weight-bearing control to maintain the knee over the second
toe is critical. Exercises designed to control this movement are: front/lateral step downs (single leg
squat), squat, and lunge that the knee stays even with the second toe as one bends the knee.
Balance and perturbation training is critical to progress again with alignment always in mind to
control the valgus moment while trying to challenge the athlete/patient with dynamic stability drills.
These drills can be either on the floor balancing on one leg, to catching a ball and standing on an
uneven balance board from different angles for difficulty.
Once the female athlete demonstrates good neuromuscular control and strength of the
aforementioned exercises, then she can progress to more sport-specific tasks emphasizing proper
plyometric drills with a flexed knee and landing again with proper alignment. This can be initiated
on our pilates reformer and gradually increased with spring resistance and then progressing to an
upright position and land with body weight, such as during a jump squat exercise. It is essential to
work on the eccentric or lengthening phase of contraction in a functional manner (weight-bearing)
with the female athlete to help control the adduction and internal rotation (pulling inward) forces on
the thigh/knee.
These neuromuscular exercise concepts of controlling malalignment with cutting, landing and
functional weight-bearing training are crucial to helping the athlete better protect themselves on the
field. Better dynamic stability via training in the pre-season will hopefully decrease the amount of
ACL injuries over the next season. The key is to make certain the athlete is training properly and
aware of landing correctly. If they are not landing properly while exercising, they will be feeding into
the problem and possibly inviting ACL issues.
Squat With Medicine Ball
Squat With Medicine Ball
Front View Squat With Medicine Ball
Front View Squat With Medicine Ball
Lunge Side View Demonstrating Proper Alignment
Lunge Side View Demonstrating Proper Alignment
Squat On Rockerboard For Strength/Balance Challenges
Squat On Rockerboard For Strength/Balance Challenges
Pilates Reformer Leg Press Into Squat Jumps
Pilates Reformer Leg Press Into Squat Jumps
Pilates Reformer Leg Press Into Squat Jumps
Pilates Reformer Leg Press Into Squat Jumps
Pilates Reformer Leg Press Into Squat Jumps
Pilates Reformer Leg Press Into Squat Jumps
Michael Zazzali is partner of Physical Therapy Associates of New York, LLC located in Manhattan,
N.Y.
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