ACL injuries plague the Women’s World Cup. The solution for athletes may need to start much earlier

By Amanda Sealy, CNN

(CNN) — You know it the moment it happens. Sometimes it comes with an audible pop. Other times it’s just enough pain to signal that something isn’t quite right.

When you tear your anterior cruciate ligament or ACL, it’s less about the pain in the moment, but more about the pain of knowing that surgery and a year-long recovery lie ahead.

I know this because I’ve torn mine twice. Both times, the same knee. Both times, playing soccer.

After seeing the headlines of how many of the world’s top players are missing out on this year’s Women’s World Cup — including two from the US team — it’s hard not to think of this injury as an inevitable part of the sport, especially as a woman.

Different studies have found female athletes are two to eight times more likely than their male counterparts to tear their ACLs.

“This issue has been around for a long time, it’s gotten worse and worse,” says Dr. Andrew Pearle, chief of sports medicine at the Hospital for Special Surgery in New York City.

But then why haven’t we done anything about it?

It may be too late for me or the countless others who have already suffered from this injury, but there are things that can and should be done starting with even our youngest players.

Ahead of the Women’s World Cup, CNN Chief Medical Correspondent Dr. Sanjay Gupta and I spoke to trainers, physical therapists and doctors, and it’s clear that there are ways to prevent this, starting with even the youngest players.

Many of these things, I really wish I had known.

Why women?

The people we spoke to say there are many risk factors that can play into injuries, including the level of resources going to players, possibly the type of field, specializing too early in one sport; maybe it’s anatomy or biomechanics.

When it comes to women, I had always heard that we were more likely to tear their ACLs because of their wide hips, but Holly Silvers-Granelli, chair of Major League Soccer’s medical assessment research committee, says it’s more than that.

“When we started looking at this data, literally 23 years ago, back in 2000, we had determined that there’s anatomic risk factors, there’s hormonal risk factors, there’s environmental risk factors,” says Silvers-Granelli, who has a masters in physical therapy.

Let’s start with a quick ACL primer. The ACL is a ligament that runs diagonally from the outside of your femur to the inside of your tibia. “If you slide your hands into your pockets, that’s the direction the ACL runs,” explains Silvers-Granelli.

This ligament is what helps people move laterally, but women’s ACLs tend to be smaller.

Women also have larger Q angles — the ratio of hip width to femur length. This matters because this angle can cause someone to more easily go into a knocked-knee position and that puts more stress on the ACL.

Think of that position like Elvis’ famous dance, says Pearle. “That’s how people pop their ACL. Their knees come together. Twenty-five years ago, when they first discovered it, they were watching films, they’re like, oh, they look like Elvis, because their knees come together, but we call it dynamic valgus.”

These are the risk factors we can’t control, but the good news is, the ones we can control can make a big difference.

Injuries aren’t inevitable

On April 19, Leah Williamson, captain of the England national team, was playing for her club, Arsenal, against Manchester United. As she stepped to intercept the ball, she went down right away.

Silvers-Granelli says she could tell almost immediately what had happened.

“Her foot is outstretched. She’s basically, there’s zero bend to her knee and hip. Her hip is to the side, we call that hip abduction and then she inwardly rotates. It’s a classic mechanism.”

Williamson tore her ACL just three months ahead of the World Cup.

Silvers-Granelli and Pearle say injuries like this can be preventable with neuromuscular training which helps develop muscle memory and body control.

“Every time you squat, every time you change direction, you do so with your body in the appropriate position to absorb the load, and to do it efficiently,” says Pearle.

There are a few key areas to focus on.

First, you have your back chain muscles, what Silvers-Granelli calls the ACL’s best friends. Because women tend to be more quad dominant, strengthening the hamstrings, glutes and calves help act as the reins. When you’re cutting, you need to slow down quickly and these muscles help you decelerate.

Remember that knocked-knee position? That’s where hip muscles come in. Silvers-Granelli calls the hips the steering wheel of the knee.

“When we see that knock-knee position that most ACL collapse into either slightly before or after the rupture has occurred, typically the side muscle groups of the hip have failed you,” she says. “They weren’t able to withstand forces that were going in the other direction, dropping your knee inward.”

Then you want to make sure you’re playing lower in an athletic stance. Silver-Granelli says women also tend to play more upright, which can put them in a more dangerous position.

Silvers-Granelli and other researchers have put all of these concepts into practice by creating several programs including PEP (Prevent Injury, Enhance Performance) and 11+.

They’re designed as dynamic warmups that can be done in 10 to 15 minutes, twice a week. They also require no equipment and are free. There’s also a free app to help guide people through them.

Studies have shown that they don’t just reduce ACL injuries — they can reduce them by a lot.

“If we do the right types of training and engage the right muscle groups and we work on the muscle imbalances and the improper biomechanics that are currently existing in these players, we can’t prevent them all, but we can mitigate risk by about 72% which is incredibly effective,” Silvers-Granelli says.

You’ll never get the risk of injury down to zero, especially when you’re playing a physical contact sport, but considering most ACL injuries happen in a noncontact setting, some of this is in our control.

“They happen with sudden changes of direction, particularly contested, sudden changes of direction,” Pearle says.

Starting early

I was 25 when I tore my ACL the first time, but this is just as serious of an issue for much younger athletes.

Over a 10-year period, Pearle says he saw a 300% increase in ACL injuries in adolescents.

So while the injuries among top professional players have brought this issue into the spotlight, he says the highest incidences are still in high school athletes — and he is seeing increasing numbers in middle school-age athletes.

Pearle says this is why parents need to be aware that these injury prevention programs exist.

“If you got a girl’s soccer team, you’d say to the coach or the sports organization, OK, what’s your neuromuscular training plan? What are you guys doing for it? You know, that should be a question that everybody asks,” Pearle says.

Even if a team doesn’t have one of these programs built in, Brian Maddox, head athletic trainer for the women’s professional soccer team the North Carolina Courage, encourages parents to try to implement these exercises themselves. He says around puberty is a good time to start.

“You can reproduce that as a parent, a club coach who is, who maybe just has a soccer background, you can implement that,” Maddox says.

Maddox says this part of the game is especially important because if you’re only emphasizing winning games and tournaments, you lose focus of the long-term development of the athlete.

“One of the biggest preexisting risks for injury is if you’ve had that injury before and if you can prevent that in the first place at a younger age, you have less likelihood of having that injury again. So I think that’s why the emphasis on trying to prevent this at a younger age, so they are, when they come to us, they are ready to perform at the level we expect them to perform,” Maddox says

Long-term consequences

“You have the knee of a 60-year-old!” This is what my orthopedic surgeon exclaimed while looking at my most recent MRI scans.

This isn’t what anyone wants to hear when they’re just turning 40.

It’s not another ACL tear, but I have to get another knee surgery this year to clean up some scar tissue and get injections that will hopefully take the place of my missing cartilage.

My doctor says I will most likely need a full knee replacement later down the line.

“I’m sick of operating on 16-year-old high school soccer players, knowing what their destiny is with this stuff,” says Pearle.

“You’re looking at being a young, 30-year-old who was a former athlete, and now you’ve got an arthritic knee, and you can’t run on it. You know it sucks. You can’t even play pickleball.”

This is why Silvers-Granelli is trying to get coaches at all levels to take this seriously.

“I think if we expand that job description to include player safety, wellness and longevity, you know, when you have an ACL injury, the risk of osteoarthritis is very significant,” she says.

In sports, you wear all kinds of protective equipment to reduce risk of injury – helmet, pads, shin guards. And that’s exactly how Pearle thinks we need to look at these neuromuscular training programs: “If you’re going to play, you’re going to do these exercises, otherwise you shouldn’t play.”

But these programs have been around for more than a decade and still have been slow to catch on.

“This actually keeps me up at night to be really honest with you,” Silvers-Granelli says.

“We want to let people know is that it’s not an inevitability, it doesn’t need to be.”

This is really what I wish I had known.

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