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Scott Webb: Welcome to Check-Up Chat with EvergreenHealth. I'm Scott Webb. And today, we are discussing the anterior cruciate ligament or ACL, and why women are more likely than men to suffer injuries to their ACLs.

And joining me today is Dr. Camille Clinton. She's an orthopedic surgeon at EvergreenHealth Orthopedic and Sports Care. So doctor, thanks so much for your time today. We're talking about the anterior cruciate ligament, better known as ACL. And I think that a lot of us think we know what the ACL is or what it does because of sports injuries, but it's really great to have an expert on to clarify things. So let's just start up front here. What exactly is the ACL?

Camille Clinton: So the ACL or anterior cruciate ligament is one of four ligaments in your knee. And it's in the middle of the knee. The ACL and the PCL are the two cruciate ligaments in the middle of the knee and it has a couple of functions. One is it keeps the tibia or the leg bone from moving too far forward. And then it also, most importantly, helps with rotational stability of the knee. If you don't have an ACL, when you go to step and pivot or twist or turn, the knee will move abnormally, which is painful and can cause other problems with your knee.

Scott Webb: You know, in watching sports, watching basketball, when you see players suffer ACL injuries, it does look incredibly painful. And I guess I'm wondering, because it seems like it's often not a contact injury per se, and sometimes doesn't really seem like there's any warning signs or that the players weren't even really doing all that much. So really, how does injury to the ACL occur?

Camille Clinton: Most of the time, you're right, it is a non-contact injury. So about 70% of the time, it's a player or athlete running. Usually, they pivot and change directions and the ACL tears. It can also happen with landing from a jump. Hyperextension can do it as well. And then there are obviously contact mechanisms too. But most of the time, it's non-contact.

Scott Webb: Are there any warning signs? Does anyone ever really know that their ACL is about to be strained or torn?

Camille Clinton: Not usually. Usually, it's something that just happens kind of out of the blue. Certainly, some people may have had a mild injury before, and so maybe they have some mild looseness to their ACL to start with. But for the vast majority of people, there's not a warning.

Scott Webb: Yeah, because with things like a hamstring or something, you can feel something start to get a little bit tight and you think, "You know what? I better back it down a little bit." But as you say, there's really no warning signs for ACL. And with that in mind, can ACL injuries differ from men and women?

Camille Clinton: Yes, women and girls are more likely to tear their ACL for given sports. Female soccer players are three and a half to four times more likely to tear their ACL than boys or men. And really, across the board, women are predisposed to ACL injuries. And there's a number of reasons for that. Some of which are preventable or can be, I guess, altered, and some can't.

Anatomically, women are more predisposed to having ACL injuries because on average, the female pelvis is wider comparatively to a man's. And so the angle at the knee is slightly different and that increases the strain on an ACL.

Ligamentous laxity or overall looseness of ligaments can also predispose people to ACL injuries. And that's more common in women. There is some evidence that, hormonally, there can be some differences. During the woman's cycle at different times, you can be more predisposed to an ACL injury. So there's some type of hormonal effect as well, probably again affecting ligamentous laxity.

And then women tend to be quad-dominant. So the quads are relatively stronger than the hamstrings and hamstrings are protective for ACL injuries. So that's another factor. And then there's the way women or girls on average do sports. Women and girls, we tend to land flatter footed and also tend to be more upright when cutting, pivoting, changing directions and both of those things predispose to ACL injuries.

Scott Webb: This is really interesting. And as a dad of a 13-year-old daughter who plays basketball and softball, I'm very interested in this topic as I'm sure listeners are. And because ACL tears are more common in women, are they also then more likely tore-tear an ACL?

Camille Clinton: Yes. So especially in younger women or girls, so if you're looking at teenagers, the re-tear rates, if either tearing the same that was repaired or reconstructed or tearing their opposite knee, can be up to 20% to 25% within two years of their first injury. So actually, in a lot of studies, the rate of tearing the second knee is higher than tearing that first knee that was reconstructed, but the rates are really high and likely due to the fact that there are these predisposing factors that haven't been fully addressed.

So one of the goals in an ideal world is to address everything we can before the first ACL injury happens. And as a better mom, if an ACL injury happens, do everything we can to try to prevent another one.

Scott Webb: And so when we talk about maybe not prevention, but how to sort of acknowledge that woman athletes are more predisposed to tearing their ACLs, what can they do? You mentioned that they tend to play more upright and land more flat-footed. So is it just sort of doing the opposite of those things? Or do you have a list here that you can share with female athletes on how to avoid tearing their ACLs?

Camille Clinton: There's actually a number of programs that have been proven to reduce the risk of ACL injuries in female athletes. And they do focus on hamstring strength. Hip strength and core strength are actually really important too, because it's the position of the upper body compared to the lower body that can put more strain on the ACL as well if you're off balance.

So hip and core strengthening, it’s actually going through kind of plyometric type exercises where you practice jump-landing appropriately, when you practice cutting and pivoting, and you practice doing those things appropriately. And adding that in, for athletes, ideally at a pretty young age, can reduce the risk of ACLs moving forward.

Scott Webb: Well, that's good to know. So let's assume then that a female athlete has torn her ACL, how is that injury treated? What is ACL reconstruction?

Camille Clinton: So ACL reconstruction, essentially, we take a piece of soft tissue, generally a tendon, from somewhere else in that patient's body or potentially from a donor and use that to replace the ACL. ACLs traditionally have been thought that they don't heal well if you try to repair them and they in general don't heal on their own.

There has been some renewed interest in repairing ACLs. And in some very specific instances, that can be successful, but the rate of a re-tear is higher after doing that than an ACL reconstruction. So most of the time, it's still a reconstruction at this point. And so essentially, we take a graft and bring it up through the knee in the same position that person's ACL was in and fix it on both sides. And then after rehab process, that graft functions like a normal ACL.

Scott Webb: Yeah/ that's really interesting because, I guess I always thought that they were repaired. So interesting to know that reconstruction is really maybe the gold standard. And when it comes to that and choosing a graft, are there any special considerations when choosing which graft to use.

Camille Clinton: Yes. So for younger patients, using their own tissue is far superior than using allograft or donor tissue. So that's the first consideration that's been shown time and again that the success rates are higher with using your own tissue. As far as using your own tissue, there's three grafts that we use most often, a patellar tendon graft, which is a piece of the kneecap, middle part of the patellar tendon, a little piece of bone from where the patellar tendon inserts on the tibia; a quadriceps tendon graft, which is a piece of the middle of the quadriceps tendon; or a hamstring graft. And there's pros and cons to each of those.

As a gold standard, I would say for athletes, has always been a patellar tendon graft. The biggest downside of it though is that there's a risk of having pain in the front of the knee afterwards. And that's something that's more common in girls and women to start with. Hamstring grafts have a lower risk of having that pain in the front of the knee. But they are starting to be shown as potentially having a higher failure rate, especially in younger patients. And part of that correlates with the size of the hamstring, but women, especially more petite women are more likely to have smaller hamstrings and that then can increase the risk of re-tearing in that graft. The other issue is, as I mentioned before, women's hamstrings are relatively weaker compared to the quadriceps. And so taking a hamstring graft can further weaken the hamstrings.

So quadricep grafts have started to become used more frequently, especially in women and female athletes, because they avoid some of the problems with the other graphs. So you don't have hamstring weakness because you're not doing anything to the hamstrings. And the risk of pain in the front of the knee is lower than it is with the patellar tendon graft. And at least with the relatively couple years studies that we have, the success rates are the same as they are for patellar tendon graft. So we're not seeing higher re-tear rates. So there's become a renewed, I'd say, popularity of using quadriceps grafts for young female athletes.

Scott Webb: And when can patients return, especially women here as we're discussing today, when can they return to sports activities after an ACL reconstruction?

Camille Clinton: So traditionally, a lot of times people would say six months, but the reality is it usually tends to be closer somewhere between the nine to 12-month mark. Returning to sports is more dependent on getting strength back than it is on that graft keeling in. The graft keels in far before we let people return to sports. It's that they have to get their hamstring strength back, their quad strength back, the core strength back, the hip strength back, so that we don't get re-injured again.

Scott Webb: Yeah. And it does seem like when you hear famous athletes, you know, tearing their ACL, that it's always somewhere between nine and 12 months, right? Like it's rare that it's sooner than that. And you give us a sense there of why, because it's not just sort of strengthening the knee and gaining confidence in the knee, but it's everything around the knee, right?

Camille Clinton: Right. Exactly. It's getting all of that back to prevent reinjury.

Scott Webb: Can female athletes ever be fully confident in the original knee that was torn or their other knee? What would be your advice to them as they try to get back into sport activities after an ACL tear and reconstruction?

Camille Clinton: So I would say that absolutely they can be confident in their knee again. There are multiple examples of professional female athletes who've torn ACLs and gone back to play or torn ACLs when they were 16 and now play for the US National Soccer team. So you definitely can be confident of the knee again.

The goal is once there's an ACL reconstruction, someone rehabs it, that at some point, you know, they don't think about it having been torn. Usually, you don't fully forget the whole episode, but that you're not thinking about it as you're playing or doing anything. But the psychological aspect of having an ACL injury is real and important. And it's important for that to be addressed and worked on in the recovery process too.

Scott Webb: And when it comes to Evergreen, is there multidisciplinary or interdisciplinary care available to patients so that you can kind of address the whole self, not just the knee and the reconstruction, but also, as you say, the psychological effects of having torn their ACL?

Camille Clinton: Yes, at Evergreen, we have orthopedic surgeons and primary care sports medicine, physicians, primary care doctors, and a whole team that's there to try to help people through sports injuries and work on the different aspects of that as well as physical therapy.

Scott Webb: I love that team approach. And this has been such an interesting topic. Thank you so much for your time today and you stay well.

Camille Clinton: Thanks. You too.

Scott Webb: And to make an appointment or learn more about services provided, please visit evergreenhealth.com/ortho-sports-medicine. And that wraps up this episode of Check-Up Chat with EvergreenHealth. Head on over to our website at evergreenhealth.com for more information and to get connected with one of our providers.

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