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Sunday, March 25, 2001

By Lori Shontz, Post-Gazette Sports Writer

The injury is as innocuous as it is devastating.

	Connecticut guard Shea Ralph, right, and teammate Svetlana Abrosimova watch practice from the sidelines at the Mellon Arena. Ralph is out with a knee injury, Abrosimova with a foot injury. (Robin Rombach, Post-Gazette)

Louisiana Tech forward Caterina Frierson was driving for a layup, the same thing she had done for years, when suddenly her leg buckled and her knee hurt. She was out for the season, the victim of a torn anterior cruciate ligament.

Connecticut guard Shea Ralph knows the drill. Twice in a five-month span in 1997, at the end of her freshman year and beginning of her sophomore year, the ACL in Ralph's right knee was torn. She missed a season but returned to the lineup and became a star.

Then her collegiate career ended a month early. In the championship game of the Big East tournament, Ralph was running the fastbreak when she went down again, this time with a torn left ACL.

When she discusses her history of injuries, she does so with a sense of inevitability. "The way I play the game and my body type just clash," Ralph said. "I'm surprised I haven't torn more."

The torn ACL has become epidemic in women's collegiate basketball. This season, 94 Division I players sustained ACL tears. The list includes two of the five players on last season's first-team Associated Press All-America team: Tamika Catchings of Tennessee and Ralph.

The trend became apparent in the early 1990s, when surgeons noticed that more high school girls and college women needed ACL reconstruction, and the NCAA, which tracks injuries in its member schools, noticed a similar spike.

Which begged the question: Why?

"I don't think we're ever going to be able to say it's related exclusively to one thing," said Dr. Scott Lephart, director of the Neuromuscular Research Laboratory at UPMC Center for Sports Medicine and associate professor in the School of Health and Rehabilitation Sciences and Department of Orthopaedic Surgery.

That said, Lephart is one of many researchers working to try to reduce the risk for women athletes.

Since the mid-1990s, study after study has shown that female athletes have more torn ACLs than male athletes. Lephart's numbers show that the ratio in college basketball is 8 to 1, nearly double the difference at the high school level, which still shows a large difference between girls and boys.

The opposite situation, which is also unexplained, occurs in women's soccer: the ratio decreases from a ratio in high school of 6 to 1 to a ratio in college of 3 to 1.

	Graphic: ACL injuries in women

Everyone agrees that the drastic improvement in the quality of play has something to do with it. But that doesn't explain why male athletes, who have played at that level for a longer period, haven't had the problem in such huge numbers.

The knee is kept stable by its ligaments. Among them is the ACL, which is located at the front of the knee and connects the femur (the big bone in the thigh) to the tibia (the shin). Lephart believes the muscles around the knee can also keep the joint stable by helping to absorb some of the force -- if they are strong enough.

The problem seems to be that most women, even highly trained athletes, do not have proportionally the same strength as men in their quadriceps and hamstring muscles. That strength imbalance means that women plant their feet differently when they cut and land differently when they jump.

Lephart has plenty of film to prove his point.

In sequence after sequence, male athletes land with their knees lined up perfectly over their feet, with their feet pointing straight ahead. Female athletes land with their knee pointed in, which is obvious because their feet are out to the side. "It's not conscious," Lephart said. "It's just what they develop."

Also, on the landing, men tend to flex their knees about 30 percent more than women, who tend to land rather stiff-legged. (Which could be because women aren't strong enough to flex so deeply.) Flexing the knee makes the quadriceps longer, which in turn helps more of the force to be absorbed by the muscle.

"If you land still, the force has to be absorbed elsewhere," Lephart said. "By the skeletal system, which is what the ligaments support."

Female athletes also have a bigger tendency to break down at the hip, which makes them wobble. This brings up another problem in the area of proprioception, which is the link between the ligament and the muscle. In the knee, proprioception enables the ligament to sense when the knee is out of position and trigger muscles to stabilize it.

A combination of these factors -- and others -- seems to put the female ACL in what doctors call "a position of vulnerability."

Some researchers have suggested the cause is environmental -- a problem inherent in shoes or playing surfaces. Others say the problem might be anatomical -- maybe a woman's ACL isn't as big or strong, proportionally, as a man's or perhaps a woman's wider hips and the resulting position of the knee put additional stress on the ACL. Lephart said neither has been proved, and a workshop he attended recently decided the data does not support either theory.

Another intriguing theory is that female hormones exacerbate the problem. The hormone relaxin, which is released in the third phase of the menstrual cycle, might cause the ACL to relax more and therefore be more susceptible to injury. The data on this theory is conflicting, Lephart said, and the workshop participants deemed it worthy of further study.

Only one theory passed muster at the workshop, and that's where Lephart has been concentrating his research. He believes that neuromuscular and biomechanical variables are responsible for at least some of the tears.

More important, he believes a specific training program can minimize those differences -- and therefore the risk of injury.

"The answer is not that we're going to prevent every injury," he said. "What we want to do is bridge the gap of the disproportionate rate."

The disproportionate rate disappears after rehabilitation. Men and women have about the same rate of recurrence, 5 to 8 percent. Women and men go through the same rehabilitation after surgery, suggesting to Lephart that the program strengthens the leg in a way that prevents further problems.

So why not strengthen before the tear happens, as a preventative measure?

Lephart is about to begin the phase of his study in which female college and high school athletes will be taught exercises to strengthen their hips and thighs. In addition, they will learn better techniques for landing (foot positioned forward, knee bent) and cutting (more round than sharp) and stopping (stutter step rather than coming to a quick halt).

If, as Lephart suspects, the results will show that preventative measures can help, the next step will be to sell coaches on the idea.

"My father's a coach, so I can say this,: The coaching mentality is such that once you are ingrained in a teaching or training method and you have success, you don't want to change it for anything," Lephart said. "Coaches don't want their athletes to be injured. But if you don't somehow convince the coach that the injury prevention program will also enhance their performance, they are not going to buy into it for strictly injury prevention."

That goes for the players, too. Even Ralph, who has become somewhat of a poster child for the ACL tear, admits that she has rarely spent any time doing her ACL rehab exercises when she's healthy.

For the time being, when Lephart watches women's basketball games, he observes how the players move. He pays particular attention to lateral movement, and he sees some players -- Connecticut point guard Sue Bird, Notre Dame point guard Niele Ivey -- who move more like male players.

"The thing that's encouraging to me is that I can see a difference," Lephart said. "So I know it can be done."