Knee Injuries Take a Toll on Many Female Athletes


By JERE LONGMAN

Five minutes before halftime, Shea Ralph planted her feet to bound
for a layup, only to have her left knee buckle in the final of the
Big East Conference women's basketball tournament early this month.
She screamed in pain and pounded the floor, knowing immediately
what had happened. As soon as her coach reached her on the court,
Ralph said, "I tore it."

 For the third time in her career at the University of Connecticut
- twice in her right leg, once in her left - Ralph had ruptured the
anterior cruciate ligament, which stabilizes the knee and controls
its pivoting. She will be on the bench at the women's Final Four,
beginning tomorrow in St. Louis, but only to cheer on her
teammates.

 The Final Four will provide a sobering glimpse of the
pervasiveness of knee injuries in women's basketball. UConn will
have to defend its national championship without Ralph, an
all-American swing player. Purdue, the 1999 national champion, will
be without point guard Erika Valek, who shredded her anterior
cruciate ligament last Saturday.

 The most dominant team in the sport, Tennessee, will be absent
entirely, largely because forward Tamika Catchings, the national
player of the year last season, tore an anterior cruciate ligament
in January.

 Since the mid-1990's, studies have shown repeatedly that women are
two to eight times more likely to tear the ligament than men who
play the same jumping and pivoting sports, like basketball, soccer
and volleyball. This season alone, at least 95 women playing
basketball in Division I colleges have been so injured, an informal
survey showed.

 But even though almost everyone in women's basketball acknowledges
that torn knee ligaments have reached epidemic levels in high
schools and colleges, doctors, coaches, trainers and players are
struggling over how to respond. Some universities are taking
elaborate steps to try to reduce A.C.L. injuries, while others say
they do not know what to do. Even the most aggressive measures have
not guaranteed healthy knees.

 Medical research in the past two years has suggested that the risk
of a torn ligament can be diminished if women strengthen the
muscles that support the knee and retrain themselves to cut, jump
and land in more stable positions. But it may take another
generation before significant headway is made in reducing the
disproportionate number of injuries, according to interviews with
two dozen doctors, women's coaches, trainers, strength coaches and
players.

 While encouraging, the latest research is preliminary and subject
to a lag between the lab and the basketball court. Researchers say
many coaches prefer traditional conditioning methods. Others are
uninformed about the latest neuromuscular training or confused
about which innovative techniques to use.

 Even some athletes have been reluctant to embrace preventive
measures fully in the belief that they will not get hurt while
spending as much time as possible developing the particular skills
of their sport.

 "No one is on the same page," said Dr. Timothy E. Hewett, director
of applied research at the Cincinnati Sportsmedicine Research and
Education Foundation. "We have good, strong data to suggest you can
do something about this. But everyone has his own opinion. It's not
just coaches, but we all get set in a certain way of thinking, and
it's very difficult to change those opinions until something
shocking happens.

 "I talk to people all the time, and there's always a percentage I
can tell who don't believe what I have to say. Strength coaches,
head coaches, athletes, they're thinking: `I don't believe all the
research hullabaloo. It's not worth my time. It's not going to
happen to me.' "

 The National Collegiate Athletic Association does not compile
exact data on anterior cruciate ligament injuries, but it has
estimated that a female athlete can be expected to tear the
ligament once with every 300 participations in practice or games.
Several reporters who cover women's basketball regularly have
compiled a list of at least 95 women who sustained a torn A.C.L.
this season among the 318 schools in Division I. That amounts to
about 1 of every 40 players.

 Over all, about 1 in 10 female varsity collegiate athletes has
some type of season-ending knee injury each year, including
approximately 3,000 who tear an anterior cruciate ligament, Hewett
said.

 "It seems like this has to be the roughest year of all," said Leon
Barmore, coach of two national championship teams at Louisiana Tech
University, which lost a top player to a torn A.C.L. last
September.

 After Ralph was hurt earlier in her career, she had surgery and
rehabilitated her knee exhaustively, lifting weights and balancing
on a wobble board and a mini-trampoline while people tossed balls
at her. And yet she got hurt a third time.

 "You think that nothing is going to happen to you if you do what
they tell you to do," Ralph said. "If you spend the right amount of
time in the weight room, the right amount of time on your game,
everything will come full circle for you. That's obviously not the
way it happens."

Looking for a Reason

 Geno Auriemma coached women's basketball from 1985 until 1997 at
the University of Connecticut without any anterior cruciate
ligament injuries on his team. Now Ralph has had three such
injuries, and point guard Sue Bird has had another. UConn's only
recruit thus far for next season, Ashley Valley of Colchester, Vt.,
tore the ligament before her senior season of high school.

 "It's the luck of the draw, a crapshoot," Auriemma said. "I don't
know what the answer is. I really don't."

 Many coaches share his sense of resignation. Cindy Stein of
Missouri said coaches are reluctant to talk about ligament injuries
the way race car drivers are reluctant to talk about crashes. Dawn
Staley, a two-time Olympian who is now the women's coach at Temple,
said: "I don't know if you can guard against an A.C.L. injury. If
it happens, it happens."

 Barmore said his Louisiana Tech team did nothing beyond standard
training. "I'm sure if you research it, you'll find you're supposed
to do certain things," he said. "We do the weights; we jump rope a
lot. As far as certain techniques of exercise, I'm not smart enough
for that. If somebody presents it to me, I'd consider it."

 Schools that fail to adopt preventive techniques as part of a
strength and conditioning program, however, run the risk that
disproportionate injury rates will continue, said Dr. Scott
Lephart, director of the Neuromuscular Research Laboratory at the
Center for Sports Medicine at the University of Pittsburgh.

 "If there isn't an intervention, there's no reason to suggest
anything will be different," Lephart said.

 Yet even at schools like the University of Tennessee that have
intervened aggressively to prevent torn knee ligaments, athletes
continue to get them.

 Much remains perplexing about an injury that has become prevalent
as women run faster, jump higher and submit their bodies to more
extreme forces. Seventy percent of A.C.L. injuries in female
athletes occur without a collision with another player, many after
a sudden stop or a landing on one leg.

 There is no clear understanding of the causes of these types of
noncontact injuries, doctors said. A number of risk factors have
been identified in women: wider hips, hormonal changes at certain
times of the menstrual cycle that may lead to laxity in ligaments,
the smaller size of the ligament and of the notch through which it
connects to the femur in the upper leg.

 The frictional contact between basketball shoes and the wooden
court could be a factor in ligament tears. So could the fact that
women tend to begin playing sports at a later age and often without
the same kind of strength training as men.

 Medical researchers say that in athletic activities, women tend to
land in a more upright position than men, their knees turn inward,
and there is a greater disparity in strength and coordination
between their dominant and weaker legs. When jumping and cutting,
women depend more on the quadriceps muscle, which pulls the
shinbone forward and tightens the anterior cruciate ligament, while
men rely more on the hamstring, which provides an opposing force.
Women also tend to have a greater imbalance than men in the
comparative strength between the hamstring and quadriceps in the
thigh, doctors said.

 "We know how the A.C.L. is injured," Lephart said. "We can predict
when it's going to be torn. The thing we don't know is why women
are tending to get into that position so much more than men are. I
don't think in the next 15 or 20 years we'll have a definitive
answer."

 While athletic opportunities for women have increased
exponentially over the last three decades, women appear not to have
been trained properly to take advantage, said Dr. Edward Wojtys, a
professor of surgery at the University of Michigan medical school
and a leading researcher into A.C.L. injuries.

 Wojtys recently completed a study of 52 varsity athletes that
indicated that women who play jumping and twisting sports like
basketball and soccer actually had less control of the rotational
forces of the knee than did women who were swimmers and rowers. The
opposite was true for men, he said.

 "There is probably something drastically wrong with training and
conditioning," Wojtys said. This preliminary evidence indicates
that the traditional training method of running and weight lifting
may not be helping, but rather "appears to be hurting women, making
them more prone to injury," he said. "That's really scary."

 Other medical researchers said they would hesitate to draw the
same conclusion based on such a limited study. But a number of them
said it was time to consider alternative training methods for
women. This was not to suggest that women were lesser or deficient
athletes, they said.

 "We coach like men coach, we condition the same way, we do agility
the same way, but what if some of it could be harmful to us?" said
Kay Yow, the women's basketball coach at North Carolina State and
the 1988 American Olympic women's coach. "I don't know what to do.
I'm afraid to do anything that isn't based on research."

Special Training Might Help

 Some universities, including
Minnesota and Purdue, use parts of a neuromuscular training program
devised by Hewett and two other doctors, Frank Noyes and Thomas
Lindenfeld of the Cincinnati Sports Medicine and Orthopedic Center.
The program, which evolved from a 1999 study of high school
athletes that suggested that many anterior cruciate ligament
injuries might be preventable, is designed to be used for six weeks
in the preseason and several times a week during the season.

 The training involves exercises like stretching, one-legged
balancing drills, bounding maneuvers into a deep crouch, tuck
jumps, twisting jumps, and proper landing techniques. The goal is
to get athletes to flex their knees and hips, stimulating the use
of the hamstring muscle, stabilizing the knee and shielding the
anterior cruciate ligament.

 The hopes are that the exercises will make proper movement
automatic during competition and that the thigh muscles, not the
knee ligaments, will absorb the forces of impact.

 Some doctors and trainers suggest that such programs be started as
early as elementary school. "It's easier to change bad habits when
they're younger than when they get to college," said Sara Wiley,
conditioning coach for women at the University of Minnesota.
"There's something wrong with 16-year-old girls having multiple
A.C.L. injuries."

 For 10 minutes before practice, Wiley said, Minnesota players do
exercises like balancing on uneven surfaces to stabilize the knee.
Players also attend a kind of jumping school, where they learn to
land on the balls of their feet and rock back toward the heel
instead of landing flat-footed. The University of Pittsburgh
videotapes female athletes to screen for biomechanical problems.

 The University of Virginia, which has not seen an anterior
cruciate ligament tear since Debbie Ryan became the women's
basketball coach 24 years ago, uses exercises derived from studies
on preventing basketball and soccer injuries. Jeff Kawaguchi, the
team trainer, said Ryan stressed bent-knee positioning on defense
and jumping and landing on two feet, and also graded players on the
biomechanics of their shooting form.

 At Colorado College, a Division III school, the trainer, Bruce
Kola, uses everything from skateboarding to jumping on water beds
and pogo sticks to build strength in a female athlete's trunk and
pelvis and to practice the simultaneous use of the hamstrings and
quadriceps. Kola said no women on the college's teams had torn an
A.C.L. in six years.

 Tennessee also employs extensive methods in an attempt to prevent
knee injuries, which have hit the university hard in recent years.
Jenny Moshak, assistant athletic director for athletic medicine,
helps tweak the design of the players' shoes.

 To strengthen and induce flexing of the hips and knees, the Lady
Volunteers sometimes train while wearing thick tubing connected at
the ankles. To improve balance in different positions, they play a
form of Twister, train on rocker boards and even stand on one leg
in their hotel beds while on the road.

 All this drilling, though, did not prevent Catchings, the top
player in the country a season ago, from tearing the ligament on
Jan. 15, ending her season.

 "A lot of us scratch our heads and think we did everything we
could and you still get five A.C.L.'s in one year," Moshak said.
"That's the crazy thing."

 Only five universities have separate training and conditioning
departments for women, Moshak said. Coaches are restricted to 20
hours a week with players during the season, and when asked to give
up time for exercises that may or may not prevent ligament
injuries, "they panic," she said.

 Doctors, coaches, trainers and players agree that much more
spending on research is needed to address the problem. The N.C.A.A.
spends only $60,000 to $70,000 a year on sports science research.

 Randall Dick, the N.C.A.A.'s assistant director for health and
safety, was an author of a seminal study in 1994 pointing out the
higher rate of knee ligament injuries for female basketball and
soccer players. He noted that the N.C.A.A. is not a medical
organization and said it was doing what it could to work
collaboratively with scientists. Some coaches and doctors, however,
wondered whether ligament injuries received less attention because
they affected women in greater proportion.

 "If it was killing the men's game like it was hurting ours, I feel
like they would say, `We've got to find an answer to that,' " Yow
of North Carolina State said.

The Athlete's Perspective

 When she crumbled with her third anterior cruciate ligament tear
in the recent Big East tournament, Ralph said it felt for five
minutes like "somebody taking a knife and going to town on my knee,
like they're ripping stuff out of there."

 Because her hips are wide and her feet are pigeon-toed, Ralph said
she considered herself to be at high risk of knee ligament injury.

 "Like a time bomb waiting to happen," Auriemma said, even if there
is no scientific certainty of this.

 Ralph and other UConn players jump explosively onto and off boxes,
learning to land with knees flexed and with feet in the proper
position. Auriemma reminds them to play on the balls of their feet.
The Huskies also perform exercises to work the ankles, knees and
hips and weight- room drills to strengthen the hamstrings. But
Ralph and Bird also said they only did some of the balancing drills
that some other schools use as a preventive measure when they were
in rehabilitation.

 "An athlete isn't going to have the mind-set of, `I'm going to
prevent an injury if I do this,' " Ralph said, "because they don't
believe they're going to get injured in the first place."

 Although she wonders whether women's bodies were built to
withstand the forces of contemporary basketball, Ralph also said
she plans to play next season in the Women's National Basketball
Association. She believes that, after surgery and rehabilitation,
her knee will be strong again. Always honest, though, she remains
somewhat skeptical about the ability of medical science to prevent
ligament injuries.

 "I did what they told me to do, what I was supposed to do, and I
still tore it," Ralph said.   
Copyright 2001 The New York Times Company