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Girls Nine Times More Likely To Suffer Sports-Related Knee Injuries

When it comes to basketball and soccer, girls and boys are not created equally. Differences in anatomy, biomechanics and hormones make girls up to nine times more likely to injure the anterior cruciate ligament (ACL) in their knees than their male counterparts when playing these sports.

CHOC pediatric orthopedic surgeon Afshin Aminian, M.D., says prevention is always the best approach when it comes to knee injuries. He recommends young female athletes begin a neuromuscular training program as early as age 11. Ideally, girls should start training six weeks before the season starts. Coaches should also teach injury avoidance techniques and provide adequate warm-up exercises and stretching before a game.

"We see a higher incidence of ACL injuries in girls related to basketball and soccer because of the differences in the way girls land, run and cut in these popular sports," Dr. Aminian says.

"Knee braces have not been shown to be effective in preventing these injuries. However, neuromuscular training, which includes weight training, patterning drills for sports-specific movements and warm-up exercises, have demonstrated a dramatic effect. A biomechanical analysis of the player's movements, with constant feedback from the instructor to the athlete, is also necessary to develop safer playing techniques. In one recent study, these preventive measures reduced ACL injuries in female athletes by 88 percent."


The ACL is the strong, elastic tissue connecting the femur, the upper thigh bone, to the top of the tibia, the larger of the two bones in the lower leg. It stabilizes the knee joint, and keeps it from moving from forward to back.

There are several reasons why girls are more vulnerable to ACL injuries. For starters, the ACL is thinner in girls. The diameter of a girl's ACL is about roughly half that of a boy the same age.

There's also the wider design of the female pelvis. As a result, when girls jump up to make a play, they tend to land stiffly in a straightlegged, knock-kneed position. In contrast, boys land with their knees slightly bent and bounce a little, cushioning the impact on the knee joints.

That little bounce makes a lot of difference in terms of biomechanics. Girls typically do not have the same level of muscular control in their quadriceps and hamstrings as boys do. As a result, they have less stability in the knees when landing from jumping and cutting activities. The stiffer landing increases the stress on the ACL, making it more likely to rupture. "If you watch a men's basketball game, you'll hear a lot of squeaking sounds from their shoes on the wooden floors because they bounce when they land," Dr. Aminian says.

"When you watch a women's basketball game, you don't hear the squeaking because they don't bounce, they stay in place."

During certain times of the month, hormonal factors come into play. Although researchers do not yet know why, studies indicate female athletes are more prone to injury during ovulation, when estrogen levels are highest. Female hormones apparently affect the composition and mechanical properties of the ACL.

"Supervised neuromuscular training, stretching, improved balance and injury avoidance strategies when running, jumping and landing can help girls narrow the gender gap in ACL injuries," Dr. Aminian says. "These preventive strategies clearly work, but they have to start early."

Dr. Aminian's office is located at 1310W. Stewart Drive, in Suite 508, in Orange. For more information about pediatric and adolescent sports medicine, please contact him at (714) 633-2111.


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