It was a routine practice, like hundreds before. She jumped up for a rebound during a drill, landed then ... POP. "I heard the pop -- unfortunately," said Allison DeVito, a senior guard for the Winter Haven girls basketball team. "Right after, it scared me more than it hurt."
The pop is what athletes commonly hear when they tear
their anterior cruciate ligament, one of three major ligaments in the knee. When a leg goes one way and the knee doesn't, something has to give, and frequently times it's the ACL.
When she went down, DeVito, at first, didn't know what happened and couldn't straighten her leg. Winter Haven assistant coaches Stacie Shepherd and Rocky Branch went to DeVito's aid, settled her breathing and straightened her leg. Shepherd, who sustained an ACL injury in high school, told her she thought it was an ACL injury. The doctor agreed the next day, and the MRI confirmed it.
"It was black," DeVito said. "There's supposed to be this line where the ACL should be, and nothing was there."
DeVito's injury occurred the week after Thanksgiving last November.
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Esther Smith-Howell warms up on the treadmill before beginning her therapy. Patty Williams, exercise physiologist , checks the machine's controls.
Cher Poff/News Chief
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Once month later, another Blue Devil went down with an ACL tear.
Again, it was all routine. Playing in the Naples Daily News Holiday Classic before Christmas, junior post player Esther Smith-Howell lined up for an inbounds play. Smith-Howell made a cut, ReNata Baker threw her the ball, Smith-Howell stopped and ... POP.
"I guess my leg kept going forward and the knee stopped," she said. "I felt the side separate, but I didn't hear the pop. It hurt, and I was scared."
When she finally saw a doctor about a week later after the team returned from the tournament, she got the news. First believing it to be a torn meniscus (cartilage in the knee), the harsh truth was revealed.
It was a torn ACL.
Two players on the same team, same injury -- a fluke?
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Frontal view of Allison's knee.
Cher Poff/News Chief
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Unfortunately for female athletes, no. The Journal of the American Academy of Orthopaedic Surgeons report that an estimated 80,000 ACL tears occur each year. NCAA statistics show that in sports where both men and women participate, women are two to eight times more likely than men to tear their ACLs.
At Winter Haven High School, those statistics aren't just numbers. They're real people. In addition to DeVito and Smith-Howell, girls basketball players Susan VanHook, Kim Douglas and Dana Ford have had ACL teams since 1994. During that time, only one player on the boys teams, current senior guard Brandon Richard, has had an ACL tear, although Richard tore his twice. And in a survey of area high schools, only one athlete, former Lake Wales girls soccer player Sandra Lee, sustained a torn ACL since the fall of 1999.
So for the Blue Devils basketball teams, girls are five time more likely than the boys team to have ACL tears, right smack in the middle of the NCAA's numbers. It's an alarming figure when you consider that 70 percent of all ACL tears are non-contact injuries.
"They're the worrisome ones," said Dr. Larry Padgett Jr., a leading orthopedic surgeon and Director of Sports Medicine for Gessler Clinic, Orthopedic Division. "They're the ones we're trying to get a handle on."
When you consider that about 50,000 ACL reconstructions are done each year at a cost of $17,000 per procedure, the concern is real -- and expensive. Repairing ACL tears is an $850 million dollar a year industry, and that's just for the surgery.
The most recent study on why women have more ACL tears than men and what to do about it comes from the Hunt Valley Consensus Conference, which consisted of 21 participants representing orthopedic surgeons, biomechanists and athletic trainers. The conference issued its report in the spring of 2000. The study goes far in dismissing some myths as to the causes yet comes up with no definitive reason. It looks at many different contributors like shoes, for example. Shoes give athletes better traction, which can be contributing factors for ACL injuries in general but not why women have a higher rate of them.
The Conference shows that a combination of anatomy and neuromuscular control are leading factors to why girls tear their ACLs, and it has developed a conditioning program it feels could at least help reduce the number of injuries.
DISPELLING MYTHS
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Esther Smith-Howell sets a pick for Alicia Branch against Bartow.
Cher Poff/News Chief
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Like any problem where there is no sure-fire answer, myths develop. In the 1970s, it was thought that knee braces would be effective in preventing injuries. In fact, early studies seem to back up that idea, indicating that a decrease in the number of knee injuries in braced college and prep athletes.
However, later studies couldn't back up that claim, even reporting that the number of knee injuries increased in braced athletes.
The American Academy of Orthopaedic Surgeons issued a position statement on knee braces in 1984, noting that there was no definitive evidence supporting the preventive benefits of braces.
A hot topic the past few years has been hormones. In 1996, estrogen and progesterone receptor sites were found in human ACL cells, suggesting that female sex hormones may play a role in ACL structure.
Estrogen causes ligaments to get more lax, or loose, when estrogen levels increase during a woman's menstrual cycle.
"People started saying should we do something about controlling when the female participates and when they do not," Padgett said. "Of course not, that is ridiculous. So if you don't do that, can you put someone on birth control pills, which keeps their level more consistent, and will that make a difference?"
Padgett said the bottom line is no. In one study involving the U.S. ski team, injuries were tracked and correlated to the female's menstrual cycle to figure out if there was an influence and found there was none.
So we know what aren't causes.
What are?
THE HIP BONE IS CONNECTED TO THE THIGH BONE...AND HOW
This just in -- men and women are built differently. While the difference is great for romance, it's not so great for athletics.
First let's look at where the ACL is. It's located in the femoral notch in the knee, which is under the knee cap and surrounded by the meniscus. The notch size for women is smaller, so there is more of a chance of pinching it. Sounds reasonable, doesn't it?
"Theoretically, it makes sense, but there is no study to prove it," Padgett said. "We think there is an influence, but we don't know what it is."
A more wide-spread anatomical theory is the carrying angle of women's legs. Women have wider hips, which means the thigh bone goes from the hips to the knee at a sharper angle, and are narrower at the knees.
"I hate to use the term, but women are more knock-kneed, and men are more bow-legged," Padgett said. "The other thing is women are more duck-towed, their feet turn out; men are more pigeon-towed, their feet turn in."
The thinking here is that the combination on women-- angles that are higher at the hips and feet that turn out -- puts more stress on the ACL when they land.
The Hunt Valley conference is cautious, however, stating, "The association of anatomic variables with an increased risk for ACL injury is intriguing, but to date, no anatomic variable has been directly correlated with an increased rise for unilateral noncontact ACL injury."
So there.
JUMPING LIKE A GIRL CAN BE DANGEROUS
You throw like a girl might be a comment used disparagingly to criticize someone's lack of athleticism. Inaccurate as it might be with the growth of women's athletics over the past 25 years, it is still just a harmless insult.
You jump like a girl, however, has a more dangerous meaning.
In muscular studies done on athletes, women fire their quads more than their hamstrings, compared to men who fire them equally.
Also men use their butts more. Studies have shown that the buttock muscles (gludious maximus and gludious medious) as well as the hamstrings fire stronger and longer in men than in women.
WHY IS THIS IMPORTANT
When men jump, they land with their hips and knees more flexed. Women will land more straight-legged, which puts more stress and strain on the knees, particularly the ACL.
"Combined with the anatomy differences, you put them all together and you have this girl who goes out and gets hurt more than a guy," Padgett said.
Again, the Conference says more studies are needed to clarify the exact role this plays in ACL injuries, but it also states that conditioning and prevention programs are beneficial.
CAN INJURIES BE PREVENTED?
So what can be done to cut down on the number ACL tears suffered by female athletes? Braces don't help. You can't change the shoes because they're the same for men and women. Unless you're Dr. Frankenstein, you can't change the way women are built.
IT ALL GOES BACK TO CONDITIONING
"What people are thinking is that if we can get all the women's programs from the high school level all the way up to the pros, if we can get them to work on these particular exercise programs, we might be able to drop that risk," Padgett said. "I think it will always be higher than the males because of the anatomy differences, but it will be better."
If conditioning is supposed to help, then that is the cruel joke for the two Winter Haven athletes. Winter Haven girls basketball coach LeDawn Gibson stresses conditioning and puts her players through a rigorous conditioning program.
She used to start conditioning for her players not playing volleyball about a week after school started, putting them through workouts twice a week.
Because of new rules, coaches are now limited to just three weeks before the start of practice for conditioning.
"I think that has something to do with it [the two ACL injuries]," Gibson commented.
The Hunt Valley conference discusses a study that showed the most common mechanism for ACL injuries were planting and cutting (29 percent), straight-knee landing (28 percent) and one-step stop with the knee hyperextended (26 percent). Therefore a three-part prevention program is recommended, featuring stretching, plyometrics (jumping drills) and strength-training drills to address potential deficits in the neuromuscular strength and coordination for the stabilizing muscles around the knee joint.
The program has three phases, each lasting about two weeks:
The techniques phase during which proper jumping techniques are taught, emphasizing correct posture and alignment, straight up-and-down jumps with no excessive side-to-side or forward-to-back movement, soft landings and instant recoil.
The fundamentals phase, which concentrates on building strength, power and agility.
The performance phase, which focuses on achieving maximum vertical jump height.
The program was found to decrease peak landing forces, decrease abnormally bent movements at the knee, increase hamstring power and strength and increase hamstring-to-quadriceps peak torque ratio.
In a study involving 1,263 volleyball, soccer and basketball athletes who trained in the program three days a week, six to eight weeks prior to the season, females athletes who didn't follow the conditioning program had an incidence of knee injury 3.6 times higher than the athletes who did. Even more profound was that the injury rate in the trained females was the same as that in untrained males.
IT'S THE END, IT'S A BEGINNING
Knee injuries used to often signal the end of an athletic career -- at least at a high level. No more. Advancements in techniques to repair damaged ACLs over the past 20 years and advancements in rehabilitation have improved the prospects of athletes returning to a high level of play.
DeVito and Smith-Howell are profiting from those improvements and should reap even more benefits next season when their rehab is complete. For DeVito, that means in college, most likely Alabama-Birmingham. For Smith-Howell, it will be back at Winter Haven for her senior year.
It's of less consolation now, however. While their teammates are enjoying their trek through the season, one they hope ends at the state tournament in Lakeland, DeVito and Smith-Howell must go through the agony of the rehabilitation process and come to terms with being injured.
"It was quite a shock," Smith-Howell said. "It was like, 'I was just playing yesterday.'"
Playing until the .... POP.
