Females (especially athletes) have inherent risks for MCL and ACL injury! Here are some ways to reverse that risk!

Welcome back!

Last week I introduced a new series on knee health which included 3 exercises to test your own confidence in your legs/knees during functional movement patterns.  I encourage you to try those out - they are great bench-markers to whether you should be including specific exercises to help make them easier

This week, we are looking at Women's Health, and I would like to discuss the prevalence of knee injuries (particularly ACL tears) among females.  Keep in mind that this is not just for athletes!   There are specific training methods and considerations that all females should be mindful of, and beginning at young age!  Males alike should also be mindful of this injury mechanism, and how to prevent it.   

What is the ACL?

There are four main ligaments that stabilize the knee. The anterior cruciate ligament (ACL) is responsible for stabilizing rotational movements at the knee that occur during cutting and pivoting activities. The ACL is also a secondary restraint to knee hyperextension.

The ACL stabilizes the knee joint in two ways. First, the ligament acts as a passive restraint to excessive movement through its connection to the tibia and femur. Second, the ACL has mechanically sensitive nerve receptors, called proprioceptors, which sense the position of a joint. When a joint starts to exceed its normal range or speed of movement these proprioceptors will send a signal to the brain and spinal cord, which in turn stimulates the appropriate musculature to stabilize the joint.

Mechanism of injury

The incidence of female ACL tears to male is 3.5 times greater in basketball and 2.8 times greater in soccer (sourced here).  An ACL injury usually occurs without contact from another player or object. The most common form of non-contact injury is a deceleration injury, like when slowing down from a fast run, or landing from a jump or a big step. Often it is a combination of forces when planting to cut or change directions, and the ACL cannot withstand the force placed on it, so it tears. This causes the knee to buckle or give out. The ACL also can be torn if the knee is forcefully hyperextended

This is why EVERYONE should be aware of this, not just athletes - it could be during spontaneous play with the kids,  yard work,  an awkward step while hiking, or descending stairs. 

Anatomical and movement landmarks that may increase your risk of ACL injury

Before going into the following list of risks, I just want to state the obvious, and make clear that these risks are not unique to females!   Rather, a combination of these factors as part of the injury mechanism are what is seen most commonly when it comes to ACL tears.

• Increased Q-angle:  Q-angle refers to the inward angle of the femur,  between the ASIS on the hip (see photo 2) and the midpoint of the patella.  Females typically have a greater angle (see photo 1) due to having wider hips.   This wider angle affects overall knee alignment, leaves the knee less capable to dissipate torsional forces properly,  and leaving increased stress on the ACL.   Furthermore, the increased Q angle causes the quadriceps muscles to pull on the patella unevenly, and tracking issues ensue, often causing pain and premature wear (arthritis).   However, Q-angle has always been a poor independent risk-factor.  There's more to it!

• Altered biomechanics:  The biomechanics of the lower extremities change as a result of all of these anatomic differences. In general, females tend to have a more upright posture with less hip and knee flexion. When females land from a jump or a stride, they tend to have more valgus loading, or twisting away from the midline of the leg, causing increased strain on the ACL (see picture)
  • ​TIP:  During any loading of the knee, especially during a squat or lunge,  note the tracking and stability of the knee by watching it closely in a mirror.  If there is inward movement or collapse of any kind with loading means there is a poor supporting strength in the quad and hips.
    

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​Altered Neuromuscular activation.  Gender differences in neuromuscular activation patterns have been reported to contribute, to ACL injury.  Compared to males, females have been found to be less effective in stiffening their knee (sourced here).   As these studies indicate,  this is largely due to less overall muscle strength and endurance, and altered muscle recruitment order, when compared to male counterparts.

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Core Stability:  An efficient “core” provides for a stable base so the lower extremity can function with an optimal kinetic chain to reduce forces and dynamically stabilize against abnormal forces. If the extremity muscles are strong and the core is weak, not enough force will be created to produce efficient movements. It is these inefficient movements and abnormal agonist/antagonist relationship from an unstable “core” that set the stage for injury (sourced here) .

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Proven training method in preventing ACL injury

Prevention programs have now been implemented due to a better understanding of females’ increased risk of ACL injury. Neuromuscular and proprioceptive training have focused on improving landing technique to prevent injury, including but not limited to, minimizing knee valgus, improving balance, agility and core strengthening and more hip and knee flexion. Mandelbaum et al. have advocated a “Prevent Injury and Enhance Performance” (PEP) Program that includes three warm-up activities, five trunk and lower extremity stretches, three strengthening exercises, five plyometric activities and three soccer-specific agility drills.

Click Here for a video highlighting these specific exercises

Multiplanar warmup.  Stay low as you perform each exercise.  Emphasize loading the hips, knees, and ankles equally.

1. Slow jog 100 yards
2. Side shuffle run, 50 yards each direction
3. Backwards jog 100 yards

Activation exercises

1. Walking lunges -focus on stepping forward, and descend into lunge without letting the knee travel beyond the toes
2. Hamstring activation, including standing curls (with ankle weight ideally), or reverse bridge
3. Hip abductions

Conditioning exercises

1. Lateral hops over a line (real or imaginary).  Drop into a partial squat, jump laterally to the side landing into a well supported partial squat.  Repeat
2. Forward and backwards hops, with same positioning as with the lateral hops
3. Single leg lateral hops.  Take same partial squat position and jump laterally over line.  Land and balance on single leg, and then bring other foot down to reestablish a strong two-footed position.  Repeat
4. Vertical jumps.  Drop into low squat (hips down to knee height), and jump for height.  Land and absorb back into the low squat position, and repeat.  Be sure to focus on dropping down into low squat upon landing.  This strengthens deceleration muscles
5. Scissor jumps - like walking lunges, but with a jump and controlled landing with every step.
6. Forward run (faster than a jog) 5 steps,  with 3-step deceleration into a lunge.  Work both legs
7. Lateral diagonal runs - place cones 10-15 yards apart, staggered.  Run towards first cone,  decelerate and plant on outside leg, then change direction towards the next cone
8. Bounding runs

More knowledge and weapons for your arsenal as you stay fit, remain functional, and prevent injuries!  Take this to the gym (or yard, or driveway, wherever you're training these days!)

​Until next time!