Women are at much higher risk of sustaining season-ending knee injuries like ACL tears compared to men due to a combination of anatomical and athletic risk factors. Anatomically, women more often have risk factors like valgus alignment, joint laxity, narrow ACL notches, and smaller ACLs relative to their size. Athletically, women tend to land with straighter legs and increased dynamic valgus, placing greater stress on the ACL. This combination of risks leads to women having 2-8 times higher rates of ACL injuries in cutting, jumping and twisting sports compared to men. Prevention strategies focus on improving landing mechanics to reduce valgus moments and straight leg impacts.

1. Women & Sports
Injuries
William I. Sterett, M.D.
Vail Summit Orthopaedics
970-569-3240
Emma Kellner, PT, DPT, SCS
Howard Head Sports Medicine
970-262-0179

2. Or . . .The Things I Think I
Know
After Almost 20 Years with the Women’s US
Ski Team

3. William I. Sterett, M.D.
USOC Team Physician
2014, 2010, 2006 and 2002 Winter Olympics
Head Physician, US Women’s Alpine Ski Team
Medical Director, VVSC
Vail Summit Orthopaedics

4. What We Will
Talk About Today
u Do Women Really Have A
Higher Injury Rate In All
Sports?
u Anatomical Factors Leading
To Higher Injury Rates
u Performance Factors
Leading To Higher Injury
Rates
u Differing Treatment Plans
Based On Risk Factors

5. What We Will
Talk About Today
u Lots To Possibly Talk
About In a Future
Series
u Concussions
u Dehydration
u Female Athlete Triad

6. For Example
Concussions Among
Alpine and Freestyle Skiers
u 2080 injuries reported in 7
World Cup Seasons
u 12% were injuries to the
head and face
u Concussions - 82% of
these hand and face
injuries
u 24% were Severe
u Alpine vs Freestyle
u Twice as likely to sustain a
Concussion in Freestyle
u Snowboard in between
Freestyle and Alpine
u Freestyle >
Snowboard>Alpine
u Concussion Risk
u Women had a Higher
Concussion Incidence than
Men
u 1.5x higher
u Across all 3 disciplines
Br J Sports Med 2014

7. What We Will
Talk About Today
u Today We Want To
Focus On
u Knee Injuries That
Are Season Ending
u Prevention
Strategies

8. DEPENDING ON THE
SPORT, WOMEN ARE AT
MUCH HIGHER RISK TO
SUSTAIN A SEASON
ENDING INJURY

9. Lets Use ACL Tears as an Example
Typically Season Ending
Sport Males Females
Basketball 1 3.5
Volleyball 1 3
Soccer 1 4
Recreational Skiing 1 6
World Cup Skiing 1 1

10. Time-Loss Injuries on
the World Cup Circuit
All Injuries

11. Injuries Among World Cup Ski
And Snowboard Athletes
Alpine Skiing
u 30% have a time-loss
injury per season
u 11% have severe injuries
u >28 days off
Snowboarding
u 38% have a time-loss
injury per season
u 14% have severe
injuries
u >28 days off
Scand J Med Sci Sports 2012

12. ACL Injuries on French Alpine Ski Team
397 Racers 191 Men, 188 Women
u Overall ACL Injury Rate
u 28% of Men and 27% of Women Sustained AT LEAST
One ACL Tear
u ACL Injured Racers Had A 39% Risk Of Sustaining
Another ACL Tear During Their Career.
u Men And Women Racers Had Similar Injury Rates
u World Cup Ski Racing Is About The Only Sport With
Similar ACL Injury Rates In Females And Males
Pujol et al, AJSM 2007

13. 379 Skiers on French Alpine Ski Team
u 19% Incidence Of Re-rupturing The Same Knee
u >30% Incidence Of Tearing The ACL On The
Opposite Knee
u Mean Number Of Surgeries After ACL Injured
u 2.4
u Higher ACL Injury Rate, Re-injury And Bilateral
Injury Rate In Racers Ranked In The Top 30 In The
World
Pujol et al, AJSM 2007

14. Competitive Female Athletes
This is the World I’ve Been Living In

15. LETS TALK
RISK FACTORS

16. ANATOMICAL RISK FACTORS
BULLET POINTS, NOT COMPREHENSIVE
u Valgus Or “Knock
Kneed” Alignment
More Common In
Females
u Hyperlaxity Much More
Common In Females
u Loose Jointed
u Congenittal

17. ANATOMICAL RISK FACTORS
BULLET POINTS, NOT COMPREHENSIVE
u Other
u Narrow Notch
u Smaller ACL Than Men
u Size Of ACL Relative
To Size Of Athlete
u Menstrual Cycle
u 3x Higher ACL Injury
Rate During Competition
In The Pre-ovulatory
Phase

18. Valgus or Knock Kneed

19. Women are Typically 40 More Valgus
than Men

20. Is Valgus Bad?
u Women Have A Wider
Pelvis (Relatively) And
Therefore Need To Have
Their Knee In More Valgus
To Balance Out
u Knock Kneed Athletes Live
With Their ACL On
“Stretch”
u Valgus Knees Are At Much
Higher Risk Of Sustaining
An Injury To The ACL

21. Hyperlaxity

22. Congenitally Loose Jointed
There’s actually Criteria For This

23. Hyperlaxity
u Women Have A
Much Higher
Incidence Of
Congenital
Hyperlaxity In The
General Population
Than Men
u Shoulders That
Dislocate
u Knee Caps That
Dislocate

24. Loose Jointed Athletes
u Much Higher Risk Of
Sustaining An ACL
Tear
u Much Higher Risk Of
Re-tearing A
Reconstructed Knee

25. Loose Jointed Athletes
u Athletes With A Torn ACL
Were 4.5 X More Likely To
Meet The Criteria For Being
Loose Jointed Than
Athletes That Had Not Torn
Their ACL
u Good News – Much Lower
Risk Of Developing
Arthritis Down The Line In
Patients With Hyperlaxity

26. Hyperlaxity
This Is What We Look For

27. NEXT RISK FACTOR
FOR WOMEN

28. Anatomic Risk Factors
Narrow Notch

29. Anatomic Risk Factors
Narrow Notch

30. Here’s Why a
Narrow Notch
is a Big Deal
The Bone of the
Notch Will Pinch the
ACL During Twisting
or Hyperextension

32. Other Anatomic Risk Factors
u ACL Size
u The Male ACL Is Roughly 30%
Larger Than The Female ACL
u Female Athletes Are Often
Similar In Size To Their Male
Counterparts
u Especially In High School
Sports
u The Forces The Knee Sees Due To
Twisting Injury May Be Equal In
Men And Women
u Smaller ACL Must Be A Risk

33. Other Anatomic Risk Factors
u Menstrual Cycle
1. Menstrual Phase
2. Pre-Ovulatory Phase
3. Ovulatory Phase
4. Post Ovulatory
Phase

34. Other Anatomic Risk Factors
u Menstrual Cycle
1. Menstrual Phase
1. 3-5 days
2. Pre-Ovulatory Phase
3. Ovulatory Phase
1. Mid-Cycle
2. Roughly two days
4. Post Ovulatory Phase
1. Progesterone Increases

35. Pre-Ovulatory Phase
u 3x Higher ACL Injury Rate In
Female Athletes During the
Pre-Ovulatory Phase
u Ligaments Often More Lax In
General During Pre-ovulatory
Phase
u Evidence Is Weak But May Be
Multi-factorial
u Hormonal Ligamentous
Laxity
u Energy-fatigue
u Relative Anemia

36. Now On To Athletic
Factors Pre-disposing
Women To Season
Ending Injuries

37. Athletic Factors
2 Biggies
1. Landing
“Strategies”
2. “Dynamic”Valgus

38. Athletic Factors
2 Biggies
uLanding
“Strategies”
u Looking at you from
the side
u Women
u Tend to Land More
Straight Legged
u Men
u Land With More of a
Flexed Knee

39. Athletic Factors
2 Biggies
u Straight Knee
u May “Pinch” The
ACL Against The
Notch
u Narrow Notch
u Hyper-extension
u Flexed Knee
u More Protective
Of The ACL

40. Athletic Factors
2 Biggies
u“Dynamic”valgus
u Looking At You From
The Front
u Knee Caves In During
Landing

41. Athletic Factors
2 Biggies
u “Dynamic”valgus
u May Be Due To Weak
Glutes
u Knee Cap Needs To Go
Over The Second Toe
During Landing
u Can Pinch The ACL
u Narrow Notch
u ACL May Already Be On
Stretch From Being Born
Knock Kneed

44. CAN WE START
PUTTING THIS ALL
TOGETHER??

45. THE INCREASE IN ACL INJURIES IN
WOMEN IS MULTIFACTORIAL

51. ANATOMICAL
RISKS
Combined With

52. ATHLETIC RISKS
u STRAIGHT LEG LANDING
u KNEE “DIVES” IN
u FOOT EVERTS OR
PRONATES

54. Leads To 2-8 X Higher
Season Ending ACL
Injury Rates In Female
Athletes

55. Bottom Line
u Loose Jointed
u Knock Kneed
u Poor Landing Mechanics
u SUPER HIGH RISK WITH CUTTING, JUMPING TWISITING
SPORTS
u MALE OR FEMALE

56. EMMA IS GOING TO
TEACH US SOME
PREVENTION
STRATEGIES

57. BUT FIRST JUST A
COUPLE OF SLIDES ON
DIFFERING TREATMENT
STRATEGIES FOR WOMEN
ATHLETES

58. THE TREATMENT PROBLEM
u Women Tear Their ACL
More Frequently Than Men
u Women That Are Knock
Kneed Or Hyper Lax Are At
Much Higher Risk Of Re-
tearing Anything We
Reconstruct
u Look at the French Ski
Team

59. Working on the Problem
u Cadaver Grafts For The ACL
Have An Unacceptably High
Re-rupture Rate In Young
Athletic Women
u Patellar Tendon Grafts
u Lower Re-rupture Rate
u But…. Ski Racers And
Jumping Athletetes Are
Very Hesitant Because Of
The Risk Of Developing
Patellar Tendonitis
u Hamstring Grafts Are Loved
By Ski Racers
u Higher Re-rupture Rate In
Hyperlax Females
Unfortunately
u May Even Contribute To
Increased Hyper-
extension

60. Working on the Problem
u Quadriceps Tendon
Graft To Replace The
ACL
u I Tend To Use This As My
Graft Of Choice In The
Hyper-extenders, And
Revision Situations
u More Successful Graft in
Patients with
Generalized
Ligamentous Laxity
Kim et al 2010

62. With More Women
Playing Sports,
Maybe This is All Just
Evolution

63. Evolution of Man

64. The Evolution of Women

65. THANK YOU!!!
WE NEED TO THINK OF, AND TREAT,
OUR FEMALE ATHLETES DIFFERENT
THAN WE TREAT OUR MEN