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The injury was painful, but the recovery was excruciating - physically and mentally.
"Before surgery, it hurt really bad but, even after surgery, I'd go to physical therapy and I was crying every time because it hurt so much," 15-year-old Ashlee Pratt said. "And the whole summer, I couldn't really do anything. I was going mad, stuck in my house."
Pratt, who underwent anterior cruciate ligament replacement surgery in June 2013, is one of an ever-increasing number of young female athletes who sustain an ACL injury each year. According to a new clinical report from the American Academy of Pediatrics Council on Sports Medicine and Fitness, the ACL injury risk increases significantly among girls 12-13 years old, and the largest number of ACL injuries is among female athletes 15 to 20.
Among high school and college athletes, females have a two to six times higher ACL injury rate than male athletes in the same or similar sports. While such injuries are common among soccer players, basketball, lacrosse, field hockey and volleyball players also sustain ACL injuries.
"We are seeing increasing numbers of ACL injuries every year," said Dr. Jeffrey Mikutis, a board certified pediatric orthopedic surgeon and chair of the department of surgery at Dayton Children's. "And for a number of reasons, girls are more susceptible than guys to such injuries."
According to the American Academy of Orthopaedic Surgeons (AAOS), between 100,000 and 300,000 total ACL injuries occur each year in the United States. The treatment costs exceed $1 billion annually in female varsity athletics alone. Since 2010, Dayton Children's has treated more than 300 females with ACL tears.
And while, according to the AAP study, girls are more likely to have surgery, they are less likely to return to sports after an ACL injury, cutting short their athletic career.
What makes females more susceptible to such injuries and what can be done to prevent them?
The ACL runs diagonally in the middle of the knee and is one of the four major ligaments that stabilize the knee joint.
According to the AAOS, most ACL injuries - whether in male or female athletes
- occur by noncontact mechanisms, often during landing from a jump or making a lateral pivot while running. Pratt's injury, in fact, occurred while she was on a trampoline.
"You see these injuries most often in sports when you have a lot of start and stop," said Ann Smith, physical therapist with the Dayton Children's Orthopaedic Center for Spinal and Pediatric Care.
There may be considerable swelling and instability after an ACL injury. Some patients, like Pratt, describe hearing a loud pop.
"My leg felt like it was spaghetti," she said. "And the pain was horrible."
In the genes
Biomechanic, neuromuscular and hormonal factors may all contribute to the increased incidence of knee injuries in female athletes.
"There are anatomical and physiological differences that play a part as well as hormonal differences," Mikutis said.
From different pelvic structures to looser ligaments, there are many physical differences that contribute to the higher risk in females. According to the Mayo Clinic, women tend to have a strength imbalance, with the muscles at the front of the thigh (quadriceps) being stronger than the muscles at the back of the thigh (hamstrings). The hamstrings help prevent the shinbone from moving too far forward during activities so, when landing from a jump, women might land in a position that increases stress on their ACL.
The fluctuation of hormones such as estrogen and relaxin might also play a part in contributing to the increased occurrence of ACL injuries in females.
Beyond gender, other factors can contribute to an increased likelihood of sustaining a knee injury.
"Year-round sports have changed the dynamics of everything," Mikutis said. "Kids max themselves out, they have no downtime and really set themselves up for injury."
With the increase in club teams, most sports are rarely confined to a single high school season. And athletes are spending an increasing number of hours on the court, on the field or in the gym.
"I ask kids how many hours they are playing or practicing and they tell me 20 hours or more in a week," Smith said. "It's fatiguing them."
Beyond teen years
Growing up does not mean outgrowing ACL injuries or related problems.
Even years after an ACL injury, mobility can be impacted. Studies have found that 10 to 20 years after an ACL injury - regardless of whether it was surgically repaired - the rates for degenerative knee osteoarthritis are greater than 50 percent. That means teens with ACL injuries might be facing osteoarthritis as early as their 30s.
And ACL injuries aren't limited to teenage female athletes. Just ask Ashlee's mom Carey Lightner, of New Carlisle, who skates with the Gem City Roller Girls, and recently tore her ACL.
"It was me not listening to my body," Lightner said. "That is one of the lessons I learned."
While gender plays a major role in the prevalence of ACL injuries, girls are not destined to fall prey to the painful diagnosis.
"Being in the best possible condition is helpful, but there are sports acceleration and ACL injury prevention programs that can significantly reduce the risk," Mikutis said.
The AAP report highlights the importance of neuromuscular training programs that teach athletes to "preprogram" safer movement patterns that can reduce injury risk during activities. The exercises are most valuable for female athletes 14-18 years old and studies have shown a relative risk reduction rate between 52-100 percent for non-contact ACL injuries.
"An ACL injury can be life-altering," Smith said. "But, in many cases, it can be prevented."
Dayton Children's Sports Medicine offers a variety of services and programs to meet young athletes' needs. For information, visit childrensdayton.org.
Sportsmetrics is an ACL prevention program designed to help athletes avoid non-contact ACL injuries and improve overall performance. Sports-metrics trainers are available nationwide, including locally at Good Samaritan North Health Center and Upper Valley Medical Center. Their 20-minute Warm Up for Injury Prevention & Performance (WIPP) is available online. For information, visit www.sportsmetrics.org.
The Santa Monica Sports Medicine Research Foundation PEP Program: Prevent Injury and Enhance Performance and the Lurie Children's Institute for Sports Medicine Knee Injury Prevention Program (KIPP), are also designed to reduce the risk of ACL injuries.
Mikutis is a proponent of taking time off from sports or playing multiple sports to reduce fatigue and overuse injuries.
A year after her surgery, Pratt is eagerly awaiting the all-clear from her doctor, but her mom knows she may never be the same carefree girl.
"This may change how she looks at things and might cause her to hold back a little," Lightner said.
Recovery times vary for ACL injuries, but it is not unusual for it to take a year before athletes are fully cleared to return to play. Pratt has some advice for others who have to undergo similar surgery.
"Even if the pain is unbearable - and it will be - fight through it and do your physical therapy," she said. "At one point, I wanted to give up but, now, I'm really thankful that I stayed strong."