We asked Coach Emylee to give us some insight into female knee injuries and here is what she had to say.
I remember jumping on a trampoline at the old gymnastics joint down the street when I was six, the coach looks at my mom and goes, “Boy, does she have a long life of athletics in front of her.” Growing up I was usually the strongest of the girls, most of the boys too. I was invincible, but aren’t we all at that age? I played my way through most all of the sports a kid could play, gymnastics, soccer, swimming, and volleyball. I was flexible, strong and hardly ever got hurt. But no one ever told me I was more susceptible to a knee injury than the boy next to me…
According to most studies, one in particular by Natalie Voskanian, from the National Institutes of Health, about anterior crucial ligament ruptures (ACL tears), Voskanian states that female athletes are 3.5 times more likely to have an ACL tear than male athletes are. Further research shows that the gender discrepancy comes from the differences in neuromuscular adaptions and biomechanics related to landing techniques. In other words, women and men are built differently and when we jump, we land differently than men do.
Dr. Timothy Hewett, Director and Associate Professor at the Human Performance Laboratory at the Cincinnati Children’s Hospital says, “females have measureable neuromuscular imbalances that cause us to control our knees like ball-and-socket joints attached to lose springs, whereas male knees act more like hinge joints attached to stiff springs.”
“I have found the in my 10 years of coaching CrossFit that women are particularly bad at knowing and identifying how their bodies should move,” Ashley Andrews, Head Coach and Owner of CrossFit Nika said. “For example, hamstring, latissimus dorsi and glute muscles are some of the hardest for them to identify and then move in the proper sequences in order to achieve said movement. “
Flash forward 10 years…
I’ve finally made it to the world of collegiate volleyball. I have trained for years and years, I am a well-oiled machine, I run fast, I lift heavy weights, I jump out of the gym, I can place a ball anywhere on the court, and everyone in the gym knows by the sound when I hit the ball. Everything is great.
Its 21-24, Barton College vs. Limestone College. My libero sets me up for a back row attack, I approach, and swing, attack, and I land. Hard! On the ground, my knee is shot, my kneecap is twisted, it looks dislocated. I can’t straighten my leg, I’m screaming, so is my team, but they are screaming cause I got the point. They haven’t noticed I am rolling on the floor in pain. When they do, it gets really quiet in the gym, the only sound is me sobbing. I didn’t do anything crazy or out of the ordinary, I just landed wrong.
I’m still invincible, there’s no way I could have torn my ACL. Not me. That would never happen to me. I was convinced I was fine.
The day after there was no pain. I could walk on it just fine, I remember telling my coach, “Look coach, I can walk! I’ll be fine! We can just wrap my knee really tight and I can play tonight…” His response was merely a headshake and a pained smile.
About a week later I finally got my MRI results. I sat in the athletic training center, watching the trainers face for any sort of early sign of the news to come. She breaks the news; it’s the all mighty, very common ACL tear with a torn lateral meniscus and a sprained MCL (medial collateral ligament). It was the beginning of the end of my collegiate volleyball career, and eventually my college career at Limestone College.
What could we have done to keep athletes like myself and other women in their game? Whose fault was it that I had torn my ACL? It surely couldn’t have been anything I did.
There are so many things to consider when trying to figure out what exactly is the main cause of women being more susceptible to knee injuries. Research has focused on the differences in levels of conditioning, femoral notch size, ACL dimensions, skill level, Q angle (a measurement of the angle between the quadriceps muscles and the patella tendon that is used to provide information on the alignment of the knee joint), and hormones. Most studies done on these conditions have resulted in more questions than answers. There are so many variables, but some of these things are just un-modifiable. So, we must shift our focus on the things we can fix.
Differences in landing techniques and neuromuscular recruitment patterns, which refers to the activation of additional motor units to accomplish an increase of contractile strength in the muscle, is something that can be fixed with a simple training program.
Andrews, “implements a protocol of awareness of the muscle and how to engage the muscle. For example, in our CrossFit Varsity program we start with physically identifying the area and how it should work in relation to movements such as deadlifts and explosive activities such as box jumps. Teaching the young ladies how to first tighten the muscle and engage the muscle with something like a roman deadlift has been very beneficial.”
Dr. Hewett attributes female’s disposition to knee injuries to having four neuromuscular imbalances: ligament dominance which is decreased dynamic mind-muscle control, quadriceps dominance is increased quadriceps recruitment and decreased hamstring strength, leg dominance is side-to-side differences in strength and core instability, increased trunk motion. These imbalances can be corrected through training programs tailored to each specific problem area.
Ligament dominance can be corrected through a neuromuscular training program that will teach the athlete that the knee is a single plane hinge, rather than a ball and socket joint that we discussed earlier. The athlete must learn to control the knee through the coronal plane, which is the front side of the body (see image below).
Quadriceps dominance can be corrected through exercises that cause the quads (knee extensors) and the hamstrings (knee flexors) to work together. The athlete must work to develop the correct firing patterns in her hamstrings while also using her quads. If the athlete can re-educate herself to peak the flexor/extensor firing patterns, she will have a greater chance at protecting the ACL.
Dominant leg imbalances are more common through everyone, men included. Humans tend to have a favored side of the body. A training program that progressively uses double then single movements through the training phases can counteract this.
Lastly, core stability, increasing your core can be done hundreds of different ways. Bosu ball exercises, one-armed farmers carries, and toes to bar can be implemented in to preventative programs.
We can target high-risk individuals by identifying the intrinsic (anatomic, hormonal, biomechanical, and neuromuscular) and extrinsic (physical and visual hesitations, bracing and shoe to surface interactions) variables.
Andrews says, “We like to start her athletes as young as possible learning the foundations of movements. We find that maturity is required for strengthening movements more than a particular age. As we do not load athletes with weight before they can demonstrate control both physically and mental under stress. However, all athletes no matter what age or maturity level can begin to learn to identify muscle engagement and resistance work with bands has been shown to help all athletes. For example, band hamstring curls with varying band sizes, range of motions and repetition schemes.”
I wake up in a hospital bed, drowsy, and thirsty. I can’t feel my left leg at all due to the nerve block the doctors gave me before the surgery. They tell me I can’t bend my knee or bear any weight on it for the next six weeks due to the repair done to the lateral meniscus. Little did I know that these next six weeks would be the most miserable, painful days of my life.
It was the beginning of winter in South Carolina, and I didn’t have a vehicle at the time. I lived with six girls, and only two of them had vehicles. How was I to get to class? Go to bathroom? How am I supposed to do anything?
The next couple weeks were filled with missed classes, peeing myself, literally, and the atrophy of my poor left quadriceps.
My last semester at Limestone was nothing but a blur, a long, depressing blur. I failed all of my classes, stopped getting out of bed, and I stopped talking to my team mates.
Rehab went well, until I stopped going. I thought I could do it on my own. Who was I kidding?
Not every athlete has the knowledge of peer reviewed scientific articles to help them understand the fact that more females are susceptible to these kinds of injuries. What can we do to spread the word that there are things we can do to help mitigate this problem?
Coach Ashley, as I call her, does a great job in the gym working with her female athletes to increase their hamstring strength. She believes that we can increase knowledge through better coaches training, blog posting, workshops for all ages and various social media outlets.
According to a peer reviewed journal in the Knee Surgery, Sports Traumatology and Arthroscopy a prospective controlled study of 600 soccer players in 40 different semiprofessional leagues were studied to test the preventative measures of gradually increasing proprioceptive training on four different types of wobble-boards. Throughout three seasons, 300 players were told to train 20 minutes a day with five different phases of the wobble board, while increasing difficulty. A control group of 300 players from other comparable teams trained normally and received no special proprioceptive training. Both of these groups of soccer players were evaluated clinically with MRI, tomography and arthroscopy for possible ACL injuries after three full seasons. Researchers found an incidence of 1.15 ACL injuries per year in the control group and .15 injuries per year in the proprioceptive trained group (P<0.001).
I have read numerous articles that have had the virtually the same results. If all it takes is to have our athletes balance on a board to prevent stories like mine, then why haven’t implemented this sooner?
To end my story, my ignorance of rehabilitation came back to bite me. I ended up tearing my ACL again by stepping off a skateboard.
I had my second knee surgery and I had very much so learned my lesson. “Listen to your doctors” I told myself.
While this major volleyball fall I had was over 5 years ago, I can still feel the pain in most things I do. Sometimes a step in the wrong direction leaves me in pain for the next three days.
I have recently started pursuing a certification in personal training and CrossFit coaching. If there is something I can do in life, it would be to help young girls be able to finish their athletic careers the right way, and not end up in a hospital bed, like me.