How does a starting varsity athlete go from being a star to the sidelines for six months to a year? When they feel a pop in the knee and their anterior cruciate ligament (ACL) is completely torn. Just ask Rye High School senior soccer co-captain Christina Benincasa or Holy Child star basketball and field hockey player Adare Kennedy.

 

By Melanie Cane

How does a starting varsity athlete go from being a star to the sidelines for six months to a year? When they feel a pop in the knee and their anterior cruciate ligament (ACL) is completely torn. Just ask Rye High School senior soccer co-captain Christina Benincasa or Holy Child star basketball and field hockey player Adare Kennedy.

Benincasa tore her ACL during the second game of the season. She was going for a loose ball when her cleat got caught in the turf and her opponent pushed her from behind. “I heard a ‘pop’ and then fell to the ground,” she said. Kennedy tore hers in the summer of 2013 during a basketball drill. “I cut and went to pivot off my left foot, but my foot stayed planted while everything from my knee up continued to spin. I heard a pop and immediately sat down; I couldn’t move my knee.” Kennedy also tore both of her menisci, which often happens in conjunction with an ACL tear. Last month, she suffered a partial tear to the ACL in her “good” knee during a field hockey drill. “I felt a tweak in my knee, but did not go down.” This is not unusual, because once you tear one ACL and return to a sport, you are four to six times more likely to tear the same one again or tear the other one.

Four of the five local female high school athletes known to have torn their ACLs during the last three seasons did so playing soccer. All of them tore the ACL in their non-dominant leg, which is typical of this injury in girls, according to sports injury specialists.

ACL injuries are referred to as non-contact and contact. Non-contact injuries account for 70% to 80% of ACL tears and they occur when planting and cutting, landing, stopping suddenly, pivoting and rapidly decelerating. Females are at three to eight times higher risk for non-contact ACL injuries than males playing the same sport. The reasons for this disparity range from hormonal, neuromuscular and anatomical differences to variations in training and landing techniques. The claims after you got injured is what you can get once you get a lawyer to represent your case.

Benincasa’s physical therapist Kyle Stover, owner of Cor Sports Physical Therapy in Armonk, sees roughly 25 girls a year, compared to five boys. In addition to soccer, sports in which girls are most likely to suffer an ACL injury are basketball, and volleyball. “In Westchester County, soccer tends to be a bigger sport, so I see more soccer players. For guys the injury rates are higher in football, soccer, and basketball and they tend to be contact injuries. Lacrosse is a growing sport, so we are seeing a rise in the frequency there as well as skiing.”

The ACL is located deep in the middle of the knee and attaches the femur to the shin bone. The ACL, along with three other ligaments, controls excessive motion of the knee joint and keeps the lower leg from sliding too far forward or rotating. That is why the knee buckles and the leg becomes unstable when it is torn.

When a player is injured, the athletic trainer may run a quick ACL test to determine the severity of the injury, but an MRI is the diagnostic gold standard. Once a complete tear is diagnosed by an orthopedist, and prior to surgery, the patient must go to physical therapy to strengthen the leg muscles and restore normal range of motion. She also has to wait for the swelling in her knee to subside, which can take from a week to two months. Benincasa had surgery less than two weeks after the injury occurred, but Kennedy had to wait two months.

After surgery, the athlete must continue physical therapy for roughly six months before returning to a sport. Six months after surgery, Kennedy could jog slowly, but it was 11 months before she returned to her sport (in a brace) because of the extent of damage in her knee. “I was back in PT within three days of my surgery and went religiously three times a week for the next six months. The goal was to get full range of motion back. Following PT, I worked out at a gym three times a week for the next four months to make sure I was in better shape than before my injury.” Working out at the gym may be why Kennedy only suffered a partial tear of her other ACL and was back on the field (in a brace) in three weeks.

Statistics
ACL reconstruction surgery is the most common orthopedic surgery, accounting for 200,000 surgeries annually in the U.S. The greatest incidence of these surgeries occurs in the 15-25-year-old age group of patients who participate in pivoting sports. ACL injuries costs over 3 billion dollars per year in medical expenses nationwide.
Prevention
ACL injuries are physically and emotionally debilitating to the injured athlete. They also impact the athlete’s team and family, the medical community, insurance companies and society as a whole.  Fortunately, research into prevention has proven effective.

The most widely recognized prevention program in the United States is the PEP (Prevent injury, Enhance Performance), which was developed by The Santa Monica ACL Prevention Project. Its purpose is to decrease the number of ACL injuries incurred by female soccer players. The PEP Program is a 15-minute training session that consists of a warm-up, stretching, strengthening leg and core muscles, plyometrics (jump training), and sport-specific agility training such as pivoting. The Santa Monica group found that this intervention resulted in 88% fewer ACL injuries in their athletes.

Dr. Stephen Nicholas, Founder and Director of NY Orthopedics and Director of the Nicholas Institute for Sports Medicine and Trauma at Lenox Hill Hospital, studied the effect of balance training (using $18 foam boards) on Scarsdale High School athletes who participate in high-risk sports. He found that adding balance training to the normal warm-up routine significantly decreased the number of ACL injuries.

Stover at CorSports reports,  “When teams and /or athletes carryout prevention programs with a well trained professional, there are good results. Unfortunately I do not see enough teams practicing any injury prevention programs. We strongly encourage that these prevention programs be performed two to three times a week.”

The coaches at Rye High School, Rye Country Day School, and Holy Child have all implemented ACL prevention programs based on the PEP program or the FIFA 11+, which is similar and used throughout Europe. Garnets Girls’ Soccer Coach Rich Savage says the prevention programs have helped. “Unfortunately we have had players with ACL injuries over the past several years, but the basic number of injuries has decreased.”

Holy Child athletic trainer Becca Canetti teaches the PEP program to coaches and students once per season, and the coaches are responsible for implementing it.

Rye Country Day Girls’ Soccer coach Alin Andrei stresses the importance of prevention exercises. He tells his players: “Don’t wait until the season starts. Get in shape to play; don’t play to get in shape!” Andrei also encourages his players to rest. “Don’t let a packed schedule leave you so tired that your technique gets sloppy. Adequate sleep, rest days, and alternating hard workouts with easier workouts are all important strategies in reducing your risk of injury and making you a strong, powerful athlete.”

Dr. Nicholas says the key to prevention is reaching kids pre-puberty and having them participate in a prevention program like the PEP for six weeks pre-season. “Every athlete must be taught how to jump, land, cut, and pivot to lower the risk of injury.” He also encourages young athletes to participate in a variety of sports to prevent overuse injuries, wear the correct cleats for grass and turf, and change shoes every six months. His motto, “Work smart, not just hard,” is especially appropriate for teenagers who think they are unstoppable, until life proves differently.

As Kennedy acknowledges, “At Holy Child we do an ACL prevention warm-up before every practice on both my field hockey and basketball team.  But I used to think this could never happen to me. Following my surgery, I preach to the team to take those exercises much more seriously.”