Girls, ACLs, and Myths

The NY Times has an article about girls and ACL tears titled “The Uneven Playing Field,” while Vern Gambetta offers his thoughts in a post titled, “Perpetuating Myths.”

Unfortunately, the stories fail to educate the masses. At the beginning, the warning signs are clear: too much competition, too soon:

She had competed in hundreds of games since joining her first team at 5. She played soccer year-round — often for two teams at a time when the seasons of her school and club teams overlapped…She had given up other sports long ago, quitting basketball and tennis by age 10.

Gambetta attacks the overcompetition in his post:

This whole article overlooks several key factors, not the least of which is the fact that in long term athlete development process the female athlete is victimized by a system that throws them into competition and skill development before they have the physical base of preparation. They over compete and under train and are coached by coaches that have no formal training as coaches and do not understand the needs of the female athlete. The system or lack thereof rewards the more aggressive girls who develop earlier and does not take into account the girl who not as aggressive. In addition there is an incessant search for athletic scholarships that causes the girls to over compete to showcase their talents.

His critique mirrors Cross Over: The New Model of Youth Basketball Development: no long term athlete development, compete too early and too often, no athletic base, coaches without training, and too much emphasis on showcasing abilities for scholarships without training to improve.

Unfortunately, rather than warning female athletes, athletes, parents and coaches now prepare for an injury rather than train to prevent one.

PARENTS OF TEENAGE GIRLS who play sports have grown accustomed to what seems like entire teams battling injuries — and seeing those who do make it onto the field wrapped in Ace bandages or wearing braces on various body parts.

I first investigated ACL injuries because I met four girls from a San Diego-area high school at a camp and all had injured their ACL within the year. If so many girls in one program were getting hurt, maybe something about the training or lack thereof contributed to the high injury rate, and I wanted to ensure that I avoided the problem with the athletes I train or coach.

In the meat of the article, Sokolove explains the difference between injuries in boys and girls by addressing hormonal and biomechanical issues:

Girls and boys diverge in their physical abilities as they enter puberty and move through adolescence. Higher levels of testosterone allow boys to add muscle and, even without much effort on their part, get stronger. In turn, they become less flexible. Girls, as their estrogen levels increase, tend to add fat rather than muscle. They must train rigorously to get significantly stronger. The influence of estrogen makes girls’ ligaments lax, and they outperform boys in tests of overall body flexibility — a performance advantage in many sports, but also an injury risk when not accompanied by sufficient muscle to keep joints in stable, safe positions. Girls tend to run differently than boys — in a less-flexed, more-upright posture — which may put them at greater risk when changing directions and landing from jumps. Because of their wider hips, they are more likely to be knock-kneed — yet another suspected risk factor.

However, his next comment contradicts his opening paragraph:

This divergence between the sexes occurs just at the moment when we increasingly ask more of young athletes, especially if they show talent: play longer, play harder, play faster, play for higher stakes.

As the opening paragraph illustrated, for many athletes, this occurs long before puberty, with many athletes specializing in one sport and competing year-round by 10-years-old.

Gambetta disagrees with the hormonal and biomechanical angle:

Sure there are physical differences, but the more we accentuate them the bigger they will be. Today the young female is severely short changed because of the constant stream of information like that presented in this article. Unfortunately this is what the parents, coaches and the girls themselves read and believe.

Why am I upset? Because once again we totally miss the point. Don’t set the bar lower because they are girls. Set the same expectation for training as the boys. Girls do respond to training.

During the NCAA Final Four, the ESPN analysts made a big deal out of UConn’s Geno Auriemma no longer teaching the jump stop for fear of ACL injuries. Stanford’s Tara Vanderveer told me the same thing several years ago. Like Gambetta’s points, this approach misses the point completely. It’s not jump stops that cause ACL injuries. Stopping, in general, along with changes of direction are the sites where the injuries occur. However, it is the inability to decelerate properly and handle one’s body weight at game speeds which cause ACL injuries. Therefore, the cause is not the jump stop, but the inability to jump stop correctly. Gambetta argues that this is not a technical deficiency, but a strength deficiency:

All the BS about different landing and running mechanics is just that, pure bull shitake. Poor landing and running mechanics 99% of the time are due to lack of strength, the ability to handle their own bodyweight. You can blame lack of core strength, whatever that is, but it is really a lack of strength throughout the entire kinetic chain. There must be a daily investment in strength training as part of warm-up that includes exercises that are mindful and proprioceptively demanding.

I agree that strength is the underlying factor in many injuries. I am embarassed for high school girls when I ask them to do a push-up and they cannot. I find it even worse when their excuse is that they are a girl. That’s not a reason why you cannot do a push-up. Why do coaches allow athletes to get away with such behavior?

I see athletes – boys and girls – every day who simply cannot bend properly. Now, some of it is a strength issue and some is bad habit or poor teaching. For instance, coaches often ask players to sit into a low stance with a straight back, meaning a back which is perpindicular to the floor. This is nearly impossible. To train this position, coaches have players do wall sits. However, why do you need to use the wall to sit in that position? Because there is no way that one can stay balanced with a straight back and a low stance. The instruction creates poor movement. Rather than sitting into a proper squat, players bend forward with their knees to keep their back straight and their weight balanced. However, this position puts strain on the knees and it is impossible to move from this position. So, while strength is an issue, for many it is poor habits which contribute to the problems. Since players start so early, before they have a base of strength, they develop habits before they develop the athletic base. When they add the strength, they have to fix their habits.

Sokolove recounts an experience watching a game with a physical therapist who identifies players who are at-risk and those who move well.

She pointed out another girl with possibly even worse form. She was one of the better players on the field, but Silvers said her advanced skills masked serious physical flaws. I asked her if she could fix the girl, given the opportunity. “Yes, I could,” she said. “In four to six weeks I could improve her a lot. In three months, I could get the job done. I would educate the muscles, educate the nerves. She could build strength and change her patterns.”

I see players who are labeled “athletic” because they look tall and fast running down the court, but they have terrible athletic skills when you look closely. They cannot stop, lack core strength, upper body strength and more. I coached an “athletic” 11-year-old who could not even hold himself in a push-up position, let alone do a push-up.

When I worked Cal’s Elite Basketball Camp several years ago, I sat with the athletic trainer as they played a dumb camp game called land-see-air. As the girls played, the trainer pointed to girls who were at-risk. I asked why she didn’t do anything. She said she asked the staff, but was told there was not enough time. So, the staff valued a game of land-see-air over a frank discussion or presentation on movement skills and injury prevention.

It is this attitude which hurts youth sports the most. As the article states:

Coaches rarely like to give up precious practice time for injury prevention, and often have to be pushed by parents.

Injury prevention is also performance enhancement. When a player can change directions quicker, and more safely, he or she is going to be better at skills that involve changing directions.

“Just because a kid is good at a sport does not mean she has the foundational strength or movement patterns to stand up to constant play,” she says. “What I’d like to be able to say is: ‘Before you engage in a sport, I am going to teach you how to move. And I am going to give you strength.’ “

When I did a coaching clinic recently, I was asked what I would do with five and six-year-olds. I said that I’d tell them to do martial arts. I’m serious. And, this is one reason. By starting in martial arts or gymnastics, kids learn to move, learn body awareness and develop general strength before playing a team sport. These are all positives, especially since few youth coaches stop practice to train general skills. If players start basketball at five and only play basketball, they will have a very shallow foundation of athletic skills. Playing other sports and especially starting with some type of martial arts or gymnastics develops athletic skills which all sports incorporate and give players a head start toward performance and injury prevention.