The weakest link? ACL spells trouble for girls athletes

Jessica Archie leaped to deliver yet another kill in the fourth match of the season last month, just as she has done countless times in her life.

This time, though, the 5-foot-7 junior outside hitter at Escondido High joined thousands of other female athletes across the country who have suffered a ruptured anterior cruciate ligament.

Archie didn't bump into anyone during that Sept. 9 leap.

She didn't hit the floor awkwardly.

She didn't land on anyone's foot.

She just landed on one leg, and that was enough to send her to the floor in excruciating pain.

She had torn the ACL, a crossing ligament in the center of the knee that prevents one of the lower leg bones (tibia) from coming forward to the thigh bone (femur) and keeps the thigh bone from rotating abnormally when the foot is planted and causes the leg to twist too much.

Archie also tore the meniscus cartilage and stretched the medial collateral ligament in her left knee.

The ACL is one of four ligaments in the knee, along with the lateral collateral ligament, medial collateral ligament and posterior cruciate ligament.

Archie won't play volleyball again until next fall. The normal time to rehabilitate the injury is six to eight months, and there's no guarantee of she will return athletically to where she was before the injury.

"I was hoping it was just a sprain, but I don't think sprains hurt like that," said Archie, 16. "My head told me it was an ACL.

"We had studied the ACL during an athletic training class last year, so I knew what it meant when the doctors finally told me my ACL was gone."

What Archie and many others are realizing is that, according to The Physician and Sports Medicine, an internet reference journal for physicians, girls suffer this injury much more often than boys.

And girls are more likely to sustain the injury in a noncontact situation, as Archie did, while ACL injuries in boys usually occur in contact situations, like football.

In an NCAA survey of 25 women's volleyball programs, outside hitters and middle blockers -- the ones doing most of the jumping -- accounted for 88.5 percent of the ACL tears.

The American Academy of Orthopaedic Surgeons reports that girls are twice as likely as boys to sustain a non-contact ACL injury in basketball. The numbers are almost four times more likely in soccer, where pivoting on the knee can cause the ACL to rupture just as landing on one foot did for Archie.

A painful path

Archie's noncontact injury marks the fourth time Cougars volleyball coach Lori Becker has had a player suffer the injury in her coaching career that began more than two decades ago. Archie joined Kiersten Grove, who did it while playing basketball for Becker in 1991; Mariee Mena, who tore her ACL during warmups for the 1999 CIF San Diego Section Division II girls volleyball championship match; and Kim Trout, who was hurt while playing volleyball in '97.

Each of those injuries was strikingly similar. There was no warning, no soreness and no pain in the knee before the injury. The knee just gave out, resulting immediately in major pain. And it sent each of the athletes to the sidelines for the better part of the next year.

"If a girl is playing and she gets a pop, pain and swelling in the knee, it's an ACL tear until proven otherwise," said Dr. Laura Alberton, an orthopedic surgeon at Scripps Clinic. "The pop usually means it's an all-in-one thing, meaning it was not a degenerative thing.

"It's like a broken bone. It doesn't hurt until it breaks. Same with the ACL. It goes at once, usually on the landing."

Archie, much like Mena and Tri-City Christian's Jen Michaelson, who ruptured her ACL during the CIF San Diego Section Division V volleyball finals in 2003, said she heard a pop and then felt immediate pain from the ligament rupture.

When the pressure on the ACL becomes too great, the ligament ruptures. Only a few ACL injuries are partial tears. Though partial tears are less severe, they still almost never heal on their own.

In most cases, the ligament is totally gone and must be reconstructed.

That point was driven home to Archie when she watched the video of her one-hour operation, which was performed Sept. 20 by Dr. David Chao at the Oasis Medical Services Organization.

"It looked like a bomb exploded in my knee," she said. "There were parts of the ACL all over the place."

Chao used a piece of the patella tendon from her knee to create a new ACL.

A portion of a hamstring tendon can also be employed for the repair.

"It's a misnomer to say you had your ACL repaired," said Chao, who has been the team doctor for the Chargers for the past 10 years. "You don't take the same piece of wood and nail it back together. That piece of wood is shattered. You need to find a new 2-by-4."

Looking for reasons

What factors make girls more likely to rupture an ACL than boys?

Chao and Alberton both noted a girl's hips are wider than a boy's hips. More girls tend to jump from a knock-kneed position, and the notch inside the knee that the ACL sits in may be smaller in girls.

Alberton said there is some speculation that estrogen receptors on the ACL, which are present but at differing levels in both boys and girls, may result in laxity or looseness of the tissue during a girl's menstrual cycle, making the ACL more susceptible to rupturing.

Genetics, she added, could figure into the equation.

"Knee injuries tend to run in families in some cases," Alberton said. "Right now we don't have the definitive reason for this injury. It could be a combination of all of those factors."

Those factors all contribute to putting much more pressure on a girl's knee, a level of pressure that boys don't have to deal with as often.

"There are so many things working against girls," said Archie, who began her rehab work the day after her operation. "You wonder if you didn't work hard enough, or wasn't strong enough or there was a real reason why this happened to me and not someone else. That would be easier to accept.

"But to know it happened because of a bunch of things I can't control is hard to accept."

One factor that doesn't appear to figure into the equation is height, according to Alberton. Alexis Tate, a basketball player at Rancho Bernardo, and Lina Fanene, a basketball player from Carlsbad, both injured their ACLs while going in for a layup with no one around them during a game in the summer of 2000. They are 6-footers.

Unlike the taller basketball players, Archie stands just 5-7, like Mena.

Fanene actually tore the same ACL twice. She returned from her first surgery in time for track season and tore the new ligament. In her second operation, doctors obtained her replacement ACL from a cadaver.

Chao and Alberton said muscle strength could also contribute to the injury, saying muscle strength is not the same in both the quadriceps and the hamstrings for girls as it is in boys.

"I used to think my legs were always strong," said Mena, who gave up volleyball after leaving Escondido and now plays first base for the University of Oklahoma softball team. "But I guess they weren't strong enough to prevent this.

"After my first operation I made sure my legs were ripped. They have to be strong because you can't strengthen the ACL."

Road to recovery

Mena has undergone three additional surgeries on ligaments in her other knee since her ACL reconstruction.

Counting her ACL surgery, Michaelson has had six knee operations in the past three years.

"In my hands," said Chao, "you're more likely to tear the other knee than the one you originally hurt. We see that more than retearing the same ACL."

Just as Mena continued her athletic career despite more knee operations, Michaelson hopes to return to the volleyball court next year at Point Loma Nazarene.

"I thought about giving it up, but I have such a passion for the game I can't give it up," Michaelson said. "I don't expect anyone to understand that. My passion overrides my mind, but I'm so tired of the cost of playing.

"Whenever I hear someone tore their ACL, I get the heebie-geebies because I still remember the pain."

No matter how well the surgery and the rehabilitation goes, Chao and Alberton agree the knee will never return to what it was before the injury.

It will be good enough to return to competition, but at somewhat reduced strength.

"I can fix the problem," said Chao, "but it won't be a new car."

Said Alberton: "Whenever you reconstruct an ACL, it's never going to be normal. You're functionally normal for everyday life. Once you have an ACL go out, you're never 100 percent in that knee."

- Contact staff writer Terry Monahan at (760) 739-6648 or . Comment at