Howe: Injuries haven't stopped her game. Photo: Jon Gardiner
The sound of women's sports is all too frequently the sound of the ACL (anterior cruciate ligament) tear: a quick, loud pop that silences crowds and stops play and echoes in the heads of injured players. "I can still hear it. I remember thinking, Yep, that's it," says Caitlin Howe, a guard on the Duke women's basketball team. "And then I fell on the floor." Howe, a junior, has heard the sound more than most. She has repeatedly torn the ACL in her right knee--three times in four years--and repeatedly come back to play on it.
"I know way too much about knees," says Howe. She describes her third and biggest surgery. "They took three different pieces of tissue--some of my patella, some hamstring, and a cadaver ligament--and braided them all together. So I basically have three where I use to have one." Howe plans to play this season, having rehabbed since March. "I've never even considered stopping."
Howe's attitude is a sign of the times. These days, of the 250,000 or so people who tear their ACLs every year, many can expect to return to their previous level of play. But it wasn't so long ago, says Allison Toth M.D. '94, an orthopedic surgeon and head of Duke's Women's Sports Medicine Program, that a loud pop on the field or the court was almost always the sound of a career ending.
"Twenty years ago, odds were you didn't come back from an ACL tear. The surgeries weren't even performed until the late Seventies." A former player herself, a guard on Yale's women's team, Toth remembers when teammates went down and never came back. "I had one teammate who was one of the best players to come out of Kentucky, and she had torn her ACL her senior year of high school. She'd had it reconstructed--at that time, they would do an extra-articular reconstruction, essentially just tightening up tissues outside the knee, and hoping that was enough. Frequently, it wasn't. She tried to play, but it kept hurting her. So she had to quit. It was discouraging to watch that."
Now, for the majority of athletes Toth treats, she doesn't have to. The surgery has come a long way in twenty years. "When I was playing in the mid-Eighties, the techniques were a bit less sound. They would make these huge incisions on the knee. And they didn't know how to position the graft anatomically. But now we have better instruments, and we know much more than we used to. The re-tear rate is down to between 3 and 8 percent."
According to the American Association of Orthopedic Surgeons, female athletes are seven times more likely than males to injure the ACL. The causes and the best methods of prevention aren't completely understood. Theories abound--a hamstring-quadriceps strength imbalance and a weakening in the ligaments during menstruation, among others--and an athlete like Howe, who rehabbed for months only to re-tear the ligament in her first game back, would have good reason to doubt the efficacy of prescribed regimens. "The second time was the hardest for me," she recalls. Two minutes into the first game of her senior year, Howe had just scored the 2,000th point of her high-school career. "They stopped the game and everyone came out to give me a hug. And then on the next play, I was driving to the basket, and it just gave out. I cried and cursed and was slapping the floor. Not from the pain--it didn't hurt that bad. But it was like, 'What is wrong with my knee that this keeps happening? I really, really want to figure this out.' "
Toth does, too. That's one reason she became an orthopedic surgeon. In 2001, fresh out of a residency at the New York Hospital for Special Surgery, where she assisted trainers working with the New York Giants, she was named director of Duke's newly created Women's Sports Medicine Program, only the second of its kind in the country.
That year, Toth put together a study to test whether training female high-school athletes to jump safely would decrease their rate of injury. "It did significantly," she says. "Women tend to avoid bending their knees and hips when they land, so they land very stiff, and that puts a lot of stress on the ACL, whereas men really cushion the landing. And, actually, girls jump well in pre-adolescence. So it's probably some anatomical change at puberty that influences those biomechanics. They probably land stiffly to compensate for the way their pelvis is tilted. But you can train that out. A lot of our women's teams at Duke are using this program now. Just twenty minutes a day, three times a week."
Toth acknowledges, though, that despite the findings, there is no sure fix. "Lacrosse is as faithful to the training program as any team. And still, they had four tears in one season. I think it probably has a lot to do with the surface they play on, the turf. But it doesn't mean we're not going to keep trying."