In her 18 years as a physical therapist, Deborah Marotta has seen hundreds of blown-out female knees. Half of the women she sees have knee issues. That’s because serious knee injuries occur six to eight times more often in women than men.
Girls and women suffer from several types of knee injures, most commonly tears of their anterior cruciate ligaments (ACL). That’s because they have three strikes against them where knees are concerned — structure, biomechanics and hormones. Women’s knees have a smaller femoral notch than men’s, their larger hips create an additional angle of stress on the knee and changes in hormonal activity before menstruation create more laxity in their ligaments.
Marotta has found ways to work around those problems. But the founder and owner of Start to Finish Fitness in Cleveland Heights is concerned about a fourth problem, also correctable, that’s been largely ignored: improper coaching for female athletes.
“We’re at the point now that coaches know the girls are different, but what they haven’t put together yet is how to train them differently,” she says. “Girls are getting coached the same as the guys.”
Coaches have a responsibility to coach and train girls and women differently, she says. They should concentrate on strengthening proper muscle groups and respecting hormonal issues.
Marotta’s bottom line — “A stronger hip provides for a more stable knee” — isn’t particularly sexy, but it’s very sensible. She says strengthening two small muscle groups — the hip abductor muscles, which stabilize the pelvis, and the hip rotator muscles, which stabilize the femur — could help prevent many female knee problems.
“Those two muscle groups in the hips are small, but they’re critical, and they are often forgotten in training,” Marotta says.
Another common training mistake, she says, involves the muscle groups on the front of the thigh (quadriceps) and back of it (hamstrings).
“Coaches are really good at training quadriceps because they’re easy,” she says. “Hamstrings are not as fun or as easy to train.” The resulting muscle imbalance increases risk of injury.
Correct training under proper supervision is critical. Women’s “red zone” groups are hip abductors, hip rotators and hamstrings.
Identifying the hormonal component in women’s knee injuries could be helpful with prevention. In the three-to-five day window before the onset of menstruation, it is critical to train differently, Marotta says. She suggests having a team captain report to coaches when the players, more than likely already on similar cycles, are in that most susceptible time period.
“Those are days when you have to be more careful with your players,” she says. Hard, heavy workouts, explosive squat jumps or agility drills that involve cutting are all bad choices for those days. “Coaches need to understand that they have to wait until next week to hit it hard.”
Instead, during those days when players are most at risk, coaches can stress strategy, walk-throughs or conditioning without explosive movement. Or when players are performing in games during this time, players can wear knee braces.
“This is true of any woman, training in any way,” Marotta says. A competitive cyclist and marathoner, Marotta has noticed the difference in her own training: She feels “off” on those days, unsteady on her bike.
Doctors and therapists know much more than they used to about how women can best recover from a torn ACL. Thanks to improved surgical and rehabilitation techniques, what used to be 12 to 18 months of recovery has now become as little as four to six months.
But be careful: Damage isn’t always limited to the ligament. If you have suffered an ACL injury, Marotta suggests asking your doctor about subchondral (bone) bruising. If subchondral bruising is not properly addressed in recovery, it will likely show up as early-onset arthritis later.
“If you’ve got a 14-year-old with a blown ACL and you don’t rehab her properly, in 15 years, she’s going to feel like she needs a new knee,” she says. “You have to be very careful. Six more months now might mean a world of difference 20 years down the road.”