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A knee problem

Study raises questions regarding factors and prevention

Posted: April 25, 2009 10:05 p.m.
Updated: April 26, 2009 4:55 a.m.
It is every athlete’s greatest fear.

Cal State Bakersfield guard Kelley Tarver said it sounded like the crunching of a “bag of potato chips.”

Cal Poly Pomona forward Megan Ford said the rehabilitation process was like “Chinese water torture.”

Both called the pain “indescribable.”

If severe enough, and without the proper treatment, an injury to an athlete’s knee can be career-ending.

Scarier still, it could happen to any high school athlete.

According to a study published in the American Journal of Sports Medicine conducted by the American Orthopaedic Society of Sports Medicine from 2005-07 on high school athletes, 44.6 percent of all sports-related surgeries are knee-related.

Football (58.0 percent) ranked at the top of sports with most knee injuries, while baseball (3.5) demonstrated the lowest injury rate.

What does not make the situation better is that unlike other states, California does not require a certified athletic trainer be present at any events.

In fact, the CIF-Southern Section only denotes requirements for medical supervision for football in its official rule book, leaving all other sports unspecified.

Logic tells us that as the competitive level increases, the potential for injury does as well.

Players diving one way, sliding another and running headlong toward a loose ball; the risks increase.

But one wonders if there are other contributing factors, especially looking at the case of Valencia junior soccer player Nicollette Smith.

Last season, she tore the anterior cruciate ligament in her knee in a college showcase game in San Diego on March 30, 2008.

This season, Smith says she folded the meniscus in her other knee over itself on Jan. 30 at Valencia High.

Both injuries required surgery and rehabilitation, and they cost Smith the season.

When Smith tore her ACL, she says she got her heel stuck in a divot in the field and “the ligament just popped” — Factor No. 1 — playing conditions.

In her meniscus injury, she said it was the direct result of player contact — Factor No. 2 — competition.

And with the competition level comes two more things to be considered — Factors No. 3 and No. 4 — the importance of strength and conditioning and medical supervision.

Dr. David R. McAllister, chief of sports medicine in orthopaedic surgery at the UCLA Medical Center noted that the simple fact that the frequency of knee injuries comes as no surprise.

“There is a lot of stress put on the knee,” McAllister said. “It is the most commonly injured joint, so that is not surprising that they are finding in kids the high rate of injury.”

However, there are many things that can be done to reduce those numbers.

Several local college athletic trainers offered some suggestions based on what they have seen from incoming freshman.

When it comes to playing conditions, there is a lot that needs to be taken into consideration.

First, what is the playing surface?

According to The Master’s College head certified athletic trainer Dave Larsen, the number of injuries has decreased at the school since the school switched from a natural to an artificial turf field.

Like Smith’s injury, many of his athletes’ injuries were the result of torn-up fields.

And while the use of FieldTurf worked for the Mustangs, Larsen warned that the injury rate can hinge on equipment.

“Probably the No. 1 thing is that athletes wear the correct cleats,” he said. “With the ACL tears that I’ve seen in the last 12 years, it has been that they are wearing 3/4-inch cleats, we call them mud cleats. Fast stop, knee twists and there goes the ACL.”

In football, Canyon High has a turf field, which is also where Golden Valley plays.

Valencia also plays on turf, meaning West Ranch does as well.

The College of the Canyons has turf, which is where Hart and Saugus football each call home.

Even Santa Clarita Christian plays on turf when they have home games at Harry Welch Stadium.

McAllister agrees that the quality of the product has improved dramatically over the years since the first stages of AstroTurf, and with the current versions of FieldTurf, the injury potential has gone down.

In an odd twist, it remains the natural surfaces that could provide the most harm to the athlete if the field is not properly maintained.

Sprinkler heads, divots, or any uneven surfaces could cause injury.

But like most kids, Smith just wanted to get back on the field, no matter the surface and start playing.

“As soon as I woke up from having the surgery, I started doing exercises,” Smith said.

But is the pressure to compete too high? In McAllister’s opinion, yes.

“What we are seeing now is that kids playing at a younger age, and (they) are playing year-round,” he said. “There is a school team and a club team. Kids never really get a break. They are putting a lot more time into these sports, which increases the risk of injury.”

Soccer is a perfect example of this concept, and a sport in which girls experienced 56.4 percent of their injuries, according to the study.

From club play to the high school season and back to club play, athletes – and parents – are making a yearly commitment.

But with the pressure to make it to the next level, some kids may be trying to do too much to their bodies too soon.

“We know that kids, before they are mature, can’t withstand as much,” McAllister said. “They get more injuries, they have more areas of soreness. They can’t take the number of repetitions and the amount of training that the college or pro athlete can take. That is a known fact. More is not always better. That is contrary to what the coaches may say.”

But to Smith, like many others, she wouldn’t want it any other way.

“It is really aggressive because everyone is fighting for that main title,” she said. “There is a lot more publicity that people are trying to win, so it is going to be a lot more aggressive. But, I don’t find it as fun as when everyone is not playing hard and showing their desire to play and win the game.”

This season, Valencia girls soccer shared the Foothill League crown with Canyon.

Unfortunately, Smith was in her first appointment to repair the folded meniscus during the game.

For some athletes, the pressure to get back on the field may be too great, and they try to do too much too soon.

Both Sarah Ehrsam and Chad Peters, certified athletic trainers at College of the Canyons, agree that other injuries can play into an athlete’s risk of hurting their knee.

Noting that ankle injuries are the most common, knee injuries can be some of the most severe, and when trying to play through pain, Ehrsam and Peters noted that the athlete can tend to favor the existing injury at the expense of doing damage elsewhere.

They also noted that there is the mental aspect of coming back.

There can be hesitancy for a player to put his or her full force on the injured leg.

Even that can potentially lead to further injury — again through favoring — but also as other athletes continue to maintain their aggressive style of play.

Therefore strength and conditioning is essential, moreover, the proper strength and conditioning.

“They are just not in shape,” said Peters of the incoming freshman. “(Most injuries occur) at the beginning of the season as they get into shape.”

Everyone spoken to agreed that it is critical that proper actions be taken to strengthen the joints and associated muscles.

Robert dos Remedios, the strength and conditioning coach at the College of the Canyons, has a stellar record of success when it comes to combating knee injuries.

With over 20 years in strength training, and co-authoring the book — Men’s Health Power Training: Build Bigger, Stronger Muscles through Performance-based Conditioning — he touts only four ACL injuries on his watch over the last 12 years.

“Teach your kids how to land, body position and awareness,” dos Remedios said. “Of course you want to build a strong base. We get kids that don’t have a lot of body awareness, especially our girls, so we have to retrain them.”

Dos Remedios said the most common misconception is that you need extensive weights and exercise equipment in order to have a successful training program.

In reality, he said the emphasis should be on body weight and resistance training.

Velocity Sports Performance is one such local location that subscribes to the practice of focusing on landing as well.

It specializes in helping athletes improve in many different areas, including post-rehab strength training.

“We train athletes of all ages and skill levels, helping improve speed, power and agility,” said Adam Johnson, director of sports performance at Velocity’s Santa Clarita location.

Former Canyon running back J.J. DiLuigi, former Saugus lineman Shane Watterson and former Valencia basketball player Chelsey Hastigan have all gone to Velocity Sports Performance, as have various sports programs from Hart and Valencia.

As good as strength and conditioning is for the young athlete, it is equally important to realize that simply doing a workout is not good enough.

McAllister warns that the athlete must get a proper balance of activity, do the correct types of workouts and prevent overtraining.

Because of this, Larsen says many programs in the area ranging from high schools to club sports have gone to the PEP Program (Prevent injury, Enhance Performance), specific to ACL-injury prevention.

Developed by the Santa Monica ACL Prevention Project, the program is a 15-minute warm-up replacement described on the Santa Monica Orthopaedic and Sports Medicine Group's Web site as follows: “This prevention program consists of a warm-up, stretching, strengthening, plyometrics, and sport specific agilities to address potential deficits in the strength and coordination of the stabilizing muscles around the knee joint.”

Even the program may not be enough, and not every school is taking part.

Other needs arise, such as medical supervision.

What about practice?

Nearly half of the injuries reported in the study occurred during practice.

“There is no question that it would be highly desirable to have a staff athletic trainer,” McAllister said. “They are not a coach. They are paramedical personnel. Just having that person there and in the loop and being on the front line.”

That means there is staff on site with knowledge of the athlete, his or her injury, the ability to monitor the treatment and recovery process and with preventative skills.

“The reason we are here is for the welfare of the student athlete,” Ehrsam said.

One thing done at The Master’s College is that the athletic training staff puts each of its athletes under a pre-screening for potential injury predictors such as muscle weakness, tightness and imbalances, Larsen said.

Therefore, injury management is largely left to the coaching staff.

Though trained in first aid and CPR, not every coach has the background necessary to adequately diagnose an injury on the field, nor tell if an athlete is fit to go back in the game.

“We know the competition in the Santa Clarita Valley and that could cloud judgement,” Larsen said.

He also noted that the direct result could mean that mild injuries turn into moderate and moderate to severe.

It is also a notion that Ehrsam and Peters share.

“It is a conflict of interest for the coach to manage the injuries,” Ehrsam said. “Do they want to win? They may have to take them off (the field) because of the welfare of their injury.”

There are so many things to consider.

And add this to the list of questions.

Whether looking at the playing conditions, equipment or strength and conditioning practices, McAllister said it boils down to one thing.


“There is a lot more pressure on kids to excel at an early age,” McAllister said. “But my sense of it is yes, yes it is too competitive. The kids are playing too many hours, and the hours in which the kids are playing in club is increasing.

“(For) a lot of parents and kids alike, there is a real desire to succeed and be competitive, and there is no end in sight in terms of what they are willing to do to be the best they can be.”

If there is going to be so much emphasis in high school athletics, even more questions circulate regarding personnel.

Therefore, McAllister’s solution is a simple one.

“By far the most important thing is that kids need rest,” he said. “More is not always better, and playing year-round is discouraged. They need time off.”


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