Torn ACLs more common in high school girls' sports, but experts say prevention is possible

NINA MOINI: The Minnesota girls' high school basketball tournament started a few hours ago. It's the latest round of state high school championships to come through the Twin Cities. And in recent years, youth sports have grown in participation and competition. There's evidence of another trend. More high schoolers appear to be tearing their ACLs, especially in girls' sports. It's a common injury in sports, but a serious one.

The ACL is a ligament that helps hold the knee in place. A torn one usually means the end of an athlete's season, and it can require surgery. For young athletes, it can also have particular social, emotional, and economic impacts. Joining me to help explain all this is Jill Monson. She's lead physical therapist for the Complex Knee Injury Clinic at Twin Cities Orthopedics, based in Eagan. Thanks so much for being with us, Jill.

JILL MONSON: Thanks for having me, Nina.

NINA MOINI: Have you observed this personally in your work, this rise in ACL tears among high school athletes, in particular in your work?

JILL MONSON: Well, absolutely. I mean, unfortunately, it's been a steady trend throughout my career. We're talking about it more now, but this risk of ACL injuries among female athletes in particular has been present for many years.

NINA MOINI: So a study I'm reading here by the National ACL Injury Coalition looked at these injuries, like you said, over 15 years. So between 2007 and 2022, it found an increase of 32% in girls' sports-- wow-- compared to about 15% in boys sports. Other research has suggested women are more likely to tear their ACLs than men. I mean, is there an agreement in your field about what could be causing the disproportionate rates?

JILL MONSON: Well, agreement-- we're still seeking answers. There's a lot of things that we don't fully understand. There's great emerging research, but it's been a conundrum for quite a while, both in terms of injury prevention but also managing things post-injury. But with female athletes, there's differences from male athletes. Kids are playing sports younger. They're playing more hours of sport per week at a younger age.

Arguably, they're playing a higher level sport at an earlier age than what they used to. So what that means is there's just more exposure happening at a younger age. And developmentally, females and males are different in terms of the impact of puberty on perhaps laxity and the stretchiness of the ligament, which could be a risk factor for females.

There's not a clear understanding of the exact mechanism behind that difference that we see, but there's a lot of different thoughts based on anatomy of the joint, landing patterns, and different mechanical things about how a female athlete moves compared to a male athlete. Like I said, developmentally, females go through puberty earlier than boys, and so there's some risk, perhaps, during those critical phases of development in a young girl.

NINA MOINI: And this might be more anecdotal, but I do wonder if there have been more diagnoses or more people going to the doctor over the years. A lot of people have said-- I don't know if this is true in every case-- but that people used to maybe tough it out more in the past. And I don't even like to use that expression. But you what I'm talking about, right? This idea that going to the doctor is somehow not OK or weak. But the ACL sounds like the type of injury that you really know you need to go to the doctor.

JILL MONSON: Correct. It's typically quite traumatic. The athlete will have a moment where their knee will give way. They'll usually fall down. There's a pretty much immediate onset of swelling. Oftentimes, it's painful, especially if additional structures are injured. And so it's often not something that people are inclined to just ignore and walk off.

You'll have kids who will have other injuries where they might swell a little, but not noticeably. But typically, an ACL is a very large effusion or swelling at the joint. And so typically, people are coming in and seeking medical consult for it fairly early. There's a lot of orthopedic urgent cares in the Twin Cities, so people can go in that evening right after they get hurt.

And the diagnosis is pretty straightforward. It's pretty obvious when a kid has torn their ACL. Oftentimes, the athletic trainer right there at the school or the high school or the university can do an on field or on court assessment as well. So these are usually picked up, and the treatment that is usually pursued is a surgical reconstruction of the ligament.

NINA MOINI: What are some of the short and long term impacts of this type of an injury, particularly on these younger athletes?

JILL MONSON: It's significant impact. Of course, it pulls them out of their sport for a very long period of time. We're not recommending that athletes go back to competition any sooner than 9 or 10 months after a reconstruction, so they're missing an entire season. So you have to look at it in the scope of what their goals are athletically and where they're at in their timelines. But the short term impact is just coming to grips with the fact that, oh my gosh. This is a serious injury. I'm out. What is my next 6 to 12 months going to look like?

And certainly, it's different than what they were hoping for. And so that creates a lot of psychological distress. You withdraw kids from their usual environments. Kids who do sports, those are their friends. Those are the kids that they're always spending so much time with every week. And so we really encourage them to find ways to stay engaged with their team in a different role than what they're used to.

We talk to them about creating other opportunities at school for things that they might not typically have time for that they might have time for now, but a lot of their time is going to be devoted to rehab so that they can recover, especially for the kids who do want to get back out and return to their sport.

NINA MOINI: Are there long term physical impacts? Is this something people usually 100% recover from, or is it something that some people are dealing with throughout adulthood?

JILL MONSON: That's an excellent question. I think we have a lot of optimistic language that we use about this, where everybody returns to sport, when in reality, not everybody does return to sport. 65% of athletes might return to sport, but that leaves that other percentage not, and they might not return at the prior level that they were used to competing at.

So you do see some kids not returning to sport for a number of different reasons. You do see a high risk, sometimes, of a recurrent injury, either at the same knee or at the other knee, which is a concern. When kids are recovering from this-- first of all, when you tear your ACL, you are at a higher likelihood of developing osteoarthritis at your knee, which means those changes to the cartilage within the joint.

And a reconstruction doesn't save us from that. We still are going to see a higher prevalence of osteoarthritis in people who have sustained this injury and had the surgery, which, of course, has long term consequences in terms of function and health. And so that's part of the reason why we really want to be thorough in our rehabilitation is so that we educate patients first and foremost, but we also take care of everything we can to minimize that potential negative impact of future arthritis.

Bone density is also lost, which, again, in young women who are trying to gain bone density leading into their low 20s so they can have it for the rest of their lives, this injury and offloading of the limb that goes along with it has a negative impact on bone mineral density, which is a concern, particularly for women.

NINA MOINI: What do you want folks to about prevention for an ACL injury? What are some of the best ways to prevent this from happening, besides just not moving or not playing sports?

[LAUGHTER]

Which is what I did.

JILL MONSON: Yeah, that's not a good option.

[LAUGHTER]

The answer is not to get on a bike, but the answer really is, we do have excellent injury prevention programs, and very good evidence shows that they work, and they work really well. But the catch is you have to do them consistently. So you can't dabble in injury prevention for a couple of weeks here or there or one day out of the week. If you do a 15 to 20 minute warm up, dynamic warm up, which is well-documented. FIFA 11 Plus is a good example.

And there's a lot of collaboration with the International Olympic Committee, the IOC, on an injury prevention warm up. You think about athletes. They're always doing a warm up before a practice or a game. Why not employ a warm up that is evidence-based in terms of a significant reduction in not only ACL injuries, but other lower body injuries that take an athlete out of sport?

And so if they're complying with these routines, 15 to 20 minutes, two to three times per week, significant reductions in injury risks are observed. You just have to be consistent with the programming. And that's the push of the messaging recently is hey, it works, but you have to do it. You have to have investment from coaches and from the athletic medicine staff getting touches with those teams.

NINA MOINI: All right. So helpful. Thank you so much for educating us all, Jill. Appreciate your time.

JILL MONSON: Thank you for having me.

NINA MOINI: Jill Monson is a physical therapist and orthopedic clinical specialist based in Eagan.