KU surgeon edits book on women’s sports injuries

April 12, 2013

By David Martin

Sarah Ford has torn the ACL in both knees playing basketball.

Sarah Ford is serious about basketball. As a freshman at Basehor-Linwood High School in Basehor, Kan., she played on the junior varsity and varsity teams.

During a varsity game in 2012 — it was Valentine's Day — she fell to the floor after colliding with another player. She felt something rip in her right knee. After visiting a chiropractor, she tried to resume basketball activities. But when the knee gave out again, she saw an orthopedic surgeon.

An MRI exam revealed the extent of Sarah's injury. Her anterior cruciate ligament and medial meniscus were torn, and her medial collateral ligament was sprained.

"I had never really gotten hurt before," says Sarah, now 16. "It was really scary to hear that for the first time, hearing that I had to get surgery. I really didn't know what I was in for."

Her rehabilitation lasted 28 weeks. After stabilizing the knee and her strengthening the muscles in her leg, Sarah was looking forward to getting back on the basketball court for her sophomore season. But in October, during a scrimmage, she attempted a layup. Mindful of the injury to her right knee, she made an awkward move to the basket. The result: A torn ACL and partially torn lateral collateral ligament in her left knee.

Sarah, a 5-foot-4 point guard, was devastated to learn that she needed another surgery, another set up of crutches, and that her rehabilitation would cause her to miss the entire 2012-'13 season.

"At least I knew what I was in for," she says.

Positions of risk

Sarah's injuries are some of the most common among female athletes, according to Kim Templeton, M.D., a professor of orthopedic surgery at the University of Kansas Medical Center and the senior editor and co-author of a new textbook, Women's Sports Injuries. In addition to ACL and meniscus tears, Templeton says female athletes are more likely than their male counterparts to suffer from anterior knee pain, or "runner's knee," as well as stress fractures and sprained ankles.

The knee injuries, though, command the most attention, especially as women's basketball and women's soccer have become more visible. Angel Goodrich, a senior on the University of Kansas women's basketball team, has torn her ACL twice. Caroline Doty, a starter on the University of Connecticut's basketball team, which won the national championship on April 9, has torn an ACL three times.

Researchers believe girls and women are anywhere from two to eight times as likely to rupture their ACLs as boys and men who play the same sports. The risk factors are thought to include everything from estrogen to the smaller size of the notch through which the ACL connects to the femur.

"Although those may have some impact on ACL function, no studies have conclusively shown that they cause ACL injuries," Templeton says. "In addition, there is no way to change those variables to decrease the risk of injury.

"The most important factor that affects ACL injury risk is neuromuscular control, meaning what is your inherent way that you run and land from a jump. This is an area that can be changed with appropriate training. Because of the short and long term impact of ACL injuries, the goal is prevention."

Before puberty, girls' and boys' bodies move the same way. After puberty, girls begin to run with their hips turned in, causing the knee to go to the side, which puts stress on the ACL, Templeton says. When they jump, they tend to land flat-footed, with their hips and knees straight. This is most likely because in women the quadriceps, the muscles that straighten the knees, are stronger and fire faster than their hamstrings, the muscles that bend the knees.

It's unknown what causes girls' neuromuscular control to rewire at puberty. But female athletes can try to minimize the injury threat the changes create, Templeton says. She advises female athletes to be mindful of "positions at risk." When jumping, for instance, they should be thinking about landing as light as a feather, on their toes, with their hips and knees bent. Stregthening exercises, to balance the muscles around the knees, also help; but strengthening exercises alone don't work.

Basketball requires so much jumping, cutting and other positions of risk that Templeton has a hard time watching the sport. On occasions when she's attended the Big 12 women's tournament, her eyes have locked on the hips, knees and ankles of the players. "I have no idea what the score is," she says. "I have no idea who is playing. I'm focused on how they're landing."

Templeton is herself a former college athlete. She played tennis while attending Washington University as an undergraduate.

Emulating John McEnroe, Jimmy Connors and other stars of the era, Templeton tried to improve her game through weight training, which was not emphasized the way it is today. Templeton now recognizes that she some of the exercises she performed using the equipment available at the time were not advisable. Leg extensions, she says, are too tough on the knees. A better quadriceps exercise is the leg press. In addition, time needs to be spent on hamstring strengthening.

Today when she's at the gym, Templeton will occasionally say something to a treadmill user who turns in her hips the faster she runs.

Templeton specializes in orthopedic oncology. She sees women in her clinic who are concerned that a tumor is causing the pain in their knee or leg. They are often relieved to learn that it is the position of their hips and knees that's causing the discomfort.

"These are women who have had pain for years," Templeton says. "I'll explain what's going on, and it's like the light goes on. You get them started on physical therapy, and they're not perfect but they're better and can get back to sports and their other activities."

The sex and gender differences in sports injuries are not limited to the lower extremities, Templeton notes. A woman may develop a concussion from a head impact that would hold a man harmless, perhaps because of the difference in the strengths of their necks in responding to the impact.

For younger athletes, Templeton recommends that girls and boys alike resist the pressure to specialize in one sport, which increases the likelihood of an overuse injury. More emphasis, she says, should be spent cross-training, stretching and strengthening.

"It just keeps you in better condition and makes you less likely to be injured," she says.

Back in action

After her first knee injury, Sarah Ford initially thought that she wanted to keep a distance from her teammates as she recovered. But her basketball coach encouraged her to stay close to the program. She went to practices on days when she did not have rehab and kept the stats book during games.

As for the more recent knee injury, she is on schedule to complete the rehabilitation in May. She should be ready for summer leagues and the start of Basehor-Linwood's 2013-'14 season.

The first time she rehabbed from a torn ACL, she felt a sense of accomplishment when the job was done. "Hopefully, this time I will feel the same way and I won't be scared like I was last time and I will just go out there and show everyone that I've gotten better and rehab has helped me," she says.

Dr. Templeton discusses women's sports injuries and ways to prevent them in this video from The University of Kansas Hospital.

Last modified: Apr 12, 2013