Women & Sports Injuries
William I. Sterett, M.D.Vail Summit Orthopaedics
970-569-3240
Emma Kellner, PT, DPT, SCSHoward Head Sports Medicine
970-262-0179
Or . . .The Things I Think I Know
After Almost 20 Years with the Women’s US Ski Team
William I. Sterett, M.D.USOC Team Physician
2014, 2010, 2006 and 2002 Winter OlympicsHead Physician, US Women’s Alpine Ski Team
Medical Director, VVSCVail Summit Orthopaedics
What We WillTalk About Today
u Do Women Really Have A Higher Injury Rate In All Sports?
u Anatomical Factors Leading To Higher Injury Rates
u Performance Factors Leading To Higher Injury Rates
u Differing Treatment Plans Based On Risk Factors
What We WillTalk About Today
u Lots To Possibly Talk About In a Future Seriesu Concussionsu Dehydrationu Female Athlete Triad
For ExampleConcussions Among
Alpine and Freestyle Skiers
u 2080 injuries reported in 7 World Cup Seasonsu 12% were injuries to the
head and face
u Concussions - 82% of these hand and face injuries
u 24% were Severe
u Alpine vs Freestyleu Twice as likely to sustain a
Concussion in Freestyle
u Snowboard in between Freestyle and Alpine
u Freestyle > Snowboard>Alpineu Concussion Risk
u Women had a Higher Concussion Incidence than Men
u 1.5x higher
u Across all 3 disciplines
Br J Sports Med 2014
What We WillTalk About Today
u Today We Want To Focus Onu Knee Injuries That
Are Season Ending
u Prevention Strategies
DEPENDING ON THE SPORT, WOMEN ARE AT MUCH HIGHER RISK TO
SUSTAIN A SEASON ENDING INJURY
Lets Use ACL Tears as an ExampleTypically Season Ending
Sport Males Females
Basketball 1 3.5
Volleyball 1 3
Soccer 1 4
Recreational Skiing 1 6
World Cup Skiing 1 1
Time-Loss Injuries on the World Cup Circuit
All Injuries
Injuries Among World Cup Ski And Snowboard Athletes
Alpine Skiing
u 30% have a time-loss injury per seasonu 11% have severe injuries
u >28 days off
Snowboarding
u 38% have a time-loss injury per seasonu 14% have severe
injuries
u >28 days off
Scand J Med Sci Sports 2012
ACL Injuries on French Alpine Ski Team 397 Racers 191 Men, 188 Women
u Overall ACL Injury Rateu 28% of Men and 27% of Women Sustained AT LEAST
One ACL Tearu ACL Injured Racers Had A 39% Risk Of Sustaining
Another ACL Tear During Their Career.u Men And Women Racers Had Similar Injury Ratesu World Cup Ski Racing Is About The Only Sport With
Similar ACL Injury Rates In Females And Males
Pujol et al, AJSM 2007
379 Skiers on French Alpine Ski Team
u 19% Incidence Of Re-rupturing The Same Kneeu >30% Incidence Of Tearing The ACL On The
Opposite Kneeu Mean Number Of Surgeries After ACL Injured
u 2.4
u Higher ACL Injury Rate, Re-injury And Bilateral Injury Rate In Racers Ranked In The Top 30 In The World
Pujol et al, AJSM 2007
Competitive Female AthletesThis is the World I’ve Been Living In
LETS TALK
RISK FACTORS
ANATOMICAL RISK FACTORSBULLET POINTS, NOT COMPREHENSIVE
u Valgus Or “Knock Kneed” Alignment More Common In Females
u Hyperlaxity Much More Common In Femalesu Loose Jointed
u Congenittal
ANATOMICAL RISK FACTORSBULLET POINTS, NOT COMPREHENSIVE
u Otheru Narrow Notch
u Smaller ACL Than Men
u Size Of ACL Relative To Size Of Athlete
u Menstrual Cycleu 3x Higher ACL Injury
Rate During Competition In The Pre-ovulatory Phase
Valgus or Knock Kneed
Women are Typically 40 More Valgus than Men
Is Valgus Bad?u Women Have A Wider
Pelvis (Relatively) And Therefore Need To Have Their Knee In More Valgus To Balance Out
u Knock Kneed Athletes Live With Their ACL On “Stretch”
u Valgus Knees Are At Much Higher Risk Of Sustaining An Injury To The ACL
Hyperlaxity
Congenitally Loose JointedThere’s actually Criteria For This
Hyperlaxityu Women Have A
Much Higher Incidence Of Congenital Hyperlaxity In The General Population Than Menu Shoulders That
Dislocate
u Knee Caps That Dislocate
Loose Jointed Athletesu Much Higher Risk Of
Sustaining An ACL Tear
u Much Higher Risk Of Re-tearing A Reconstructed Knee
Loose Jointed Athletesu Athletes With A Torn ACL
Were 4.5 X More Likely To Meet The Criteria For Being Loose Jointed Than Athletes That Had Not Torn Their ACL
u Good News – Much Lower Risk Of Developing Arthritis Down The Line In Patients With Hyperlaxity
HyperlaxityThis Is What We Look For
NEXT RISK FACTOR FOR WOMEN
Anatomic Risk FactorsNarrow Notch
Anatomic Risk FactorsNarrow Notch
Here’s Why a Narrow Notch is a Big Deal
The Bone of the Notch Will Pinch the ACL During Twisting or Hyperextension
Other Anatomic Risk Factorsu ACL Size
u The Male ACL Is Roughly 30% Larger Than The Female ACL
u Female Athletes Are Often Similar In Size To Their Male Counterparts
u Especially In High School Sports
u The Forces The Knee Sees Due To Twisting Injury May Be Equal In Men And Women
u Smaller ACL Must Be A Risk
Other Anatomic Risk Factors
uMenstrual Cycle1. Menstrual Phase2. Pre-Ovulatory Phase3. Ovulatory Phase4. Post Ovulatory
Phase
Other Anatomic Risk Factorsu Menstrual Cycle
1. Menstrual Phase
1. 3-5 days
2. Pre-Ovulatory Phase
3. Ovulatory Phase
1. Mid-Cycle
2. Roughly two days
4. Post Ovulatory Phase
1. Progesterone Increases
Pre-Ovulatory Phaseu 3x Higher ACL Injury Rate In
Female Athletes During the Pre-Ovulatory Phase
u Ligaments Often More Lax In General During Pre-ovulatory Phase
u Evidence Is Weak But May Be Multi-factorialu Hormonal Ligamentous
Laxity
u Energy-fatigue
u Relative Anemia
Now On To Athletic Factors Pre-disposing
Women To Season Ending Injuries
Athletic Factors2 Biggies
1. Landing “Strategies”
2. “Dynamic”Valgus
Athletic Factors2 Biggies
uLanding “Strategies”u Looking at you from
the side
uWomenu Tend to Land More
Straight Legged
uMenu Land With More of a
Flexed Knee
Athletic Factors2 Biggies
u Straight Kneeu May “Pinch” The
ACL Against The Notch
u Narrow Notch
u Hyper-extension
u Flexed Kneeu More Protective
Of The ACL
Athletic Factors2 Biggies
u“Dynamic”valgusu Looking At You From
The Front
u Knee Caves In During Landing
Athletic Factors2 Biggies
u “Dynamic”valgusu May Be Due To Weak
Glutesu Knee Cap Needs To Go
Over The Second Toe During Landing
u Can Pinch The ACLu Narrow Notchu ACL May Already Be On
Stretch From Being Born Knock Kneed
CAN WE START PUTTING THIS ALL
TOGETHER??
THE INCREASE IN ACL INJURIES IN WOMEN IS MULTIFACTORIAL
ANATOMICAL RISKS
Combined With
ATHLETIC RISKS
u STRAIGHT LEG LANDING
u KNEE “DIVES” IN
u FOOT EVERTS OR PRONATES
Leads To 2-8 X Higher Season Ending ACL
Injury Rates In Female Athletes
Bottom Lineu Loose Jointed
uKnock Kneed
uPoor Landing Mechanicsu SUPER HIGH RISK WITH CUTTING, JUMPING TWISITING
SPORTS
u MALE OR FEMALE
EMMA IS GOING TO TEACH US SOME
PREVENTION STRATEGIES
BUT FIRST JUST A COUPLE OF SLIDES ON DIFFERING TREATMENT
STRATEGIES FOR WOMEN ATHLETES
THE TREATMENT PROBLEMu Women Tear Their ACL
More Frequently Than Men
u Women That Are Knock Kneed Or Hyper Lax Are At Much Higher Risk Of Re-tearing Anything We Reconstruct
u Look at the French Ski Team
Working on the Problemu Cadaver Grafts For The ACL
Have An Unacceptably High Re-rupture Rate In Young Athletic Women
u Patellar Tendon Grafts
u Lower Re-rupture Rate
u But…. Ski Racers And Jumping Athletetes Are Very Hesitant Because Of The Risk Of Developing Patellar Tendonitis
u Hamstring Grafts Are Loved By Ski Racers
u Higher Re-rupture Rate In Hyperlax Females Unfortunately
u May Even Contribute To Increased Hyper-extension
Working on the Problem
u Quadriceps Tendon Graft To Replace The ACLu I Tend To Use This As My
Graft Of Choice In The Hyper-extenders, And Revision Situations
u More Successful Graft in Patients with Generalized Ligamentous Laxity
Kim et al 2010
With More Women Playing Sports,
Maybe This is All Just Evolution
Evolution of Man
The Evolution of Women
THANK YOU!!!WE NEED TO THINK OF, AND TREAT, OUR FEMALE ATHLETES DIFFERENT
THAN WE TREAT OUR MEN