Learn about ACL Injuries
Dr. David Marshall discusses why girls have more acl injuries than boys and how they can prevent acl injuries with proper training and conditioning.
Casey Bass: Today on ClubHouse Gas, another reason that girls have to be tougher than boys.
It is our honor to be joined once again by friend of the show and Director of Sports Medicine here at Children's Healthcare of Atlanta, Dr. David Marshall. Thanks for joining us.
Dr. David Marshall: It's my pleasure. Thanks for having me back.
Casey Bass: You recently wrote a blog for us at clubhousegas.com about ACL injuries and we all hear a lot about ACL injuries and most sport fans know about them because if an ACL injury happens to their favorite player, they know they are done for the year. Your take on it was a little different. You're saying that far and away more girls have ACL injuries than boys.
Dr. David Marshall: That's true.
Casey Bass: What are the statistics and why is that?
Dr. David Marshall: Well, first of all ACL is the Anterior Cruciate Ligament, that's the main ligament inside the knee that protects against rotational torque on the knee, and girls seem to that number of boys, really 5 to 7 to 1 depending on what study you need.
Casey Bass: So it's like a close.
Dr. David Marshall: It's like what?
Casey Bass: It's not even close.
Dr. David Marshall: It's not even close, no, it's not close even it's 5 to 1 at least, some say 7 to 1.
Casey Bass: So there has to be some pretty concrete serious reasons for that statistics to be so big.
Dr. David Marshall: Yeah, there are.
Casey Bass: What do you attribute?
Dr. David Marshall: Well, there is basically biomechanical reason. The boys are structured different than girls. I had people say that, well, that just proves that boys are better athletes than girls, but we know that's not true, that's gets us into big trouble. But there is clearly some definable biomechanical differences that girls have from boys. We can look at all of the joints and the little extremities starting at the hips, going down to knees even to the ankles and feet that make a big difference.
And the first one really is the hips, that we know if you watch a girl jump, if you watch a girl land, when they land, their knees tend to go inwards. We call that valgus collapse. So that kind of take on knock knee configuration when they land, or if you watch a male or a boy jump, we really don't. When we land, we tend to keep our knees on top of our feet, and that keeps the knee joint functioning as a hinge joint, it doesn't allow to start torquing sideways to become a ball on a socket joint. So just that torquing inward with landing or loading, puts the ACL at risk in females.
Casey Bass: And what causes the torquing inward?
Dr. David Marshall: I think it's the core, the core strengthening, core stability seems to be a pretty hot topic in physical therapy or sports medicine and more specifically with the females, it's the gluteus medius. It's the main external rotators of the hip if you will. And that's been shown biomechanically in the lab, that in males when we land, that muscle probably starts to fire even before we land. It actually anticipates the landing so our body has learned through, I guess evolution, had to protect itself. Where in females when they land, that muscle remains idle throughout the landing cycle.
Casey Bass: So girls have wider hips which puts them in different angle, the muscles on the outside of their hip fire at a different timing rate?
Dr. David Marshall: Well, in girls usually they don't fire at all. That muscle remains idle throughout the landing cycle. So what we try to do is teach that muscle how to fire not just with landing but maybe before landing. If we didn't teach that female athlete how to anticipate landing through gluteal muscle firing, then we can maybe make their hips torque the same way or not torque the same way for that matter, as boys.
Casey Bass: I have done a lot of coaching and been around a lot of coaches in my life but I have never seen the gluteal firing drill, and I am sure most guys watching the video have no idea how to do that. How do you coach, or how do you teach that?
Dr. David Marshall: Well, it takes time because basically what we are doing is we are teaching girls how to fire their muscles in a different fashion. So it takes their repetitive training through biofeedback, through repetition based muscle memory is what we are trying to do. And there is ACL Prevention program that seem to be popping up all over the country that are targeted towards young female athletes.
They use to target the college or the NCAA athletes but we have found that it was too late. They are have already touring their ACLs and then they took it down to the high school athlete, again it might be too late.
So really it's the middle school-age female athlete that we are targeting and then the sports that seem to be the higher risk ACL sports are soccer and basketball, those are ones that involved a lot of repetitive cutting, pivoting, sudden change of directions with acceleration and deceleration.
Casey Bass: With ACLs, it's lateral movement, mostly that has the benefactor or is it any kind of rotational movement?
Dr. David Marshall: Well it's a sudden change of movements. For example, like we said earlier that the knee joint was designed to function as a hinge joint. It's suppose to bend and straight in the frontal plane and when it does that, the ACL which is that ligament is in stress. It's when they start to plant and then torque or rotate inward for reasons that we have talked about, when they torque inwards, now that lateral motion or that ball and socket function of the knee, now that puts that ACL at risk.
So it just takes a plan and a sudden shifting inwards that cause that ACL to become stress and probably tear. Most ACL injuries in female athletes nowadays are non-contact, it's not like Gale Sayers or the Ray Nitschke's where they take somebody else to blow into the side of their knee and have that whole thing explode inside, it's a sudden plan, change of directions and that cause the ACL to pop.
Casey Bass: This is why we have you on repeatedly, anytime I am going to get a Ray Nitschke drop in on ClubHouse Gas wearing good shade.
Dr. David Marshall: I could have Dick Butkus in there, do you like a Dick Butkus guy.
Casey Bass: I am a Nitschke guy, I wear 66 because of Nitschke. What about the hamstring? You talked in the blog about the differences in the quad muscles and the hamstring.
Dr. David Marshall: Right. Yeah, the hamstring muscles actually protect the ACL where the quadriceps muscles in the front actually work against the ACL. In other words, if you look at the knee model, if I pull the chin bone or the tibia forward, then that stresses the ACL and that's what the quadriceps do. The quadriceps are the largest and strongest muscle we have in our body, as they come down they grab under the chin bone.
So when the quadriceps muscles contract, they pull the chin upward, just naturally through biomechanics, the chin bone or tibia wants to come forward and that stress the ACL.
On the other hand, the hamstring muscles in the back, attach back here, so they help try to keep the chin bone from coming forward. So really the hamstrings are protective of the ACL, the quadriceps work against it and that's another difference that we find males versus females.
In males, we tend to fire our hamstrings a split second before the quadriceps muscle. So the hamstring is engaged to try to hold that tibia in place, so when the quads contract, that knee joint is going to be remained stable where in female, that's just the opposite. They tend to fire their quads a split second before their hamstrings which gives that chin bone moving forward which already puts the ACL out stress. So that chin coming forward and then that rotational torque that we talked about, that's often times enough to tear the ACL.
Casey Bass: Is that something like what the glut muscle that coaches can work on the girls firing?
Dr. David Marshall: Exactly, through this training program, they address all those issues. They address the gluteus medius or the external rotator firing, the core strength and then firing and strengthening of the hamstring muscles to try to wake them up earlier in that landing, cutting, pivoting cycle.
Casey Bass: Why do strength trainers and weight coaches at high schools not focus more on the hamstring? Why do we see kids not doing hamstring?
Dr. David Marshall: I think it's basically new information that we have known all along that back -- since when we were kids back in the 20s, playing sports we have known all long, that your quadriceps muscles, your thigh muscles, they are the one that gives you power. That's how you drive the opponent off the ball, the hamstring muscle is really -- we didn't really think about that as being helpful.
Also I like to use the term the mirror muscles, that when the kids like to work out, they look at themselves in the mirror and they think about the muscles they can see which are the quadriceps muscles. You don't really see the muscles in the back, you don't really think about them as improving your physique.
Casey Bass: Well Dr. Marshall we appreciate it. A lot of great information there. Any more questions, you can ask Dr. Marshall yourself. Just go up to our blogs tab, click there, read the ACL Comments or the ACL Blog and leave a question for Dr. Marshall. He will come right in there and answer it for you. That's going to do it for us today, we look forward to seeing you, right back here next time, for another great edition of ClubHouse Gas.
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