Brittany Richardson

Treating Knee Injuries in Female Athletes with Brittany Richardson, DPT, MTC

Originally published in the Williamson Source

Women are potentially more susceptible to knee injuries from the ages of 12-25 years due to changes in their bodies during their formative years. Because of that, the team at Bone and Joint Institute of Tennessee frequently sees female athletes in this age range suffering from knee injuries.

Brittany Richardson, DPT, MTC – a physical therapist with Bone and Joint Institute at the Thompson’s Station location in Tollgate Medical Plaza – draws on her experience caring for patients to share her perspective on what makes young women more susceptible to these injuries, how to avoid them and what treatment options are available if an athlete does suffer an injury.

Why Are Females More Prone to Knee Injuries?

The most common age for female athletes to suffer knee injuries is ages 12-25, but especially ages 18 and under. While there are several contributing factors to why, one of the largest factors are the anatomical changes females undergo due to differences in hormones as compared to male counterparts of the same age. 

During puberty, female bone growth rates tend to be higher than the growth rates for their tendons and ligaments. So essentially, when a woman gains height in a long bone, the ligaments and tendons of the surrounding muscles ultimately haven’t had a chance to catch up. This creates an imbalance in flexibility and strength of the surrounding musculature, ultimately leading to increased instability often seen in the knee.

Additionally, research shows that women develop wider pelvises in preparation for child-bearing years. Subsequently, this affects the angles of the developing hip joints, femurs and knee joints and results in women generally having a wider Q-angle or quadriceps angle than men. This will affect the alignment of forces that translate through the quadriceps muscle group and the patellofemoral joint at the knee during repetitive motions, such as squatting, running, cutting and jumping.

Women tend to also have more flexibility and joint laxity, which can predispose them to injury. As hormone levels change throughout puberty and menstrual cycles, joint laxity can ebb and flow. Several research studies show that increased hyperextension at the knee paired with joint laxity places women at a higher risk of Anterior Cruciate Ligament (ACL) injuries than men. 

Another factor is the size difference between men and women. Men typically are longer and taller in their lower extremities while females are generally shorter in stature. For some sports, that’s good for females, such as in gymnastics where being shorter lowers the center of gravity. However, men have an increased rate of growth for muscle mass during puberty due to different hormones, such as increased levels of testosterone. This results in increased strength, power and stability for joints in comparison to women. 

Even when changes to anatomy are not the issue, there can be overload or overtraining issues. The Bone and Joint Institute team will first look at a patient’s baseline of conditioning and coordination for their sport to evaluate the best course of action to heal an injury and avoid risk of re-injury.

Are There Specific Knee Injuries that Are More Common for Women?

Knee injuries can vary greatly in severity. Acute trauma injuries can happen during contact sports to any of the structures that comprise the knee joint. However, overuse or overload injuries are also commonly seen. These include non-contact injuries to most commonly the ACL or Medial Collateral Ligament (MCL) in females, as well as meniscus tears, patellofemoral pain syndrome, patella tendonitis, Iliotibial band friction syndrome (ITBFS) and stress fractures.

ACL injuries often happen during deceleration or jumping activities when there is a sudden stop or quick cut. Likewise, MCL injuries can happen with a quick lateral cutting motion or in an acute trauma situation, from a direct contact force to the lateral aspect of the knee when the foot is planted. Similarly, meniscus tears can occur as a result of direct trauma or an overload of repetitive stresses placed on the knee. 

Patellofemoral pain syndrome (PFPS) is commonly described as anterior knee pain. Prevalence of PFPS in females is 20% in comparison to the male counterpart at 7.4%. This is believed to be related to contributions of structural lower extremity and patellofemoral malalignments, muscle imbalances or weakness of the quadriceps, and physical overload of the joint.These injuries are usually seen with repetitive motions at the knee such as running, swimming or jumping. 

Jumpers can also suffer more specifically patellar tendonitis, which results in anterior knee pain. Runners also commonly face Iliotibial band (ITB) friction syndrome resulting in lateral knee pain, hip pain, or both. These injuries are resultants of repetitive- or overload-type stresses that increase inflammation at the site of the tendon attachments. 

Many high-level female athletes can also suffer from stress fractures at the knee. This is usually resulting from what is known as the female athlete triad. This syndrome takes into consideration psychological conditions that can manifest into physical injuries. The female athlete triad is the combination of psychological eating disorders and malnutrition leading to low energy levels, which affects menstruation and decreases the amount of estrogen levels. This ultimately results in decreased bone mineral density making stress fracture more prevalent during levels of higher impact and activity. 

Are There Specific Sports that Typically Cause Knee Injuries in Females?

Each sport presents its own physical challenges; therefore, depending on the physical demands of the sport, the types of injuries will vary. This can also be greatly affected by many other factors, including foundational strength, baseline conditioning, hormonal changes, anatomical differences and overtraining. Some sport and injury correlations Bone and Joint Institute sees include the following:

• ACL Injuries: women are two times more likely to suffer an ACL injury than men. The most common sports women suffer this injury from include basketball, soccer, lacrosse and skiing.

• Meniscus Tears: the damage to these cartilage pieces can happen during a variety of sports or recreational activities.They are commonly seen in sports like soccer, basketball, lacrosse, wrestling and gymnastics where the knee undergoes increased torsion when the foot is planted.

• Patellofemoral Pain Syndrome: this could occur playing just about any sport or activity where the knee undergoes a lot of knee flexion to extension stresses, including running/sprinting, jumping and biking.

Are There Ways to Prevent Knee Injuries in Females?

The best prevention is to screen young female athletes to ensure they are getting what they need with regard to proper training, nutrition, and mental readiness for play. Building a good foundation of flexibility, range of motion, strength, balance and neuromuscular training during offseason or preseason and during the season when they are completing more sports-specific training is key to reducing the risk of injury. 

Bone and Joint Institute experts work with patients to provide education and neuromuscular training to rehabilitate athletes from current injuries, as well as prevention from future injuries.

Neuromuscular training is a combination of strength and fitness that will combine fundamental and sports-specific movements including resistance, core, balance and agility training. When athletes work on neuromuscular training during offseason or preseason workouts to improve proximal joint strength and control (i.e. the hip and core), they are less likely to suffer injuries at the knee going into their sport-specific training and competitive season. There are several good prevention programs that coaches and trainers can be trained in to provide skilled progression of an athlete during offseason or preseason workouts, including FIFA 11, Sportsmetrics, or Harmoknee, just to name a few. 

Ensuring athletes know what overtraining looks like can also help protect them from injuries. Athletes that transition from sport to sport without an offseason or preseason can be at an elevated risk of injury due to lack of proper rest time for a growing and changing body.

What Are Typical Knee Injury Treatments?

If an athlete is dealing with a non-contact overload or overuse injury such as PFPS, patella tendonitis or ITBFS, the first goal is to calm down the injured tissue and take the load off the knee joint using rest. During this time, medical professionals can maximize the benefit of sessions by focusing on flexibility and strength of the proximal and distal joints of the knee (i.e. the hip and ankle or foot). If these types of injuries are occuring at the knee joint, that generally means there is dysfunction or muscle imbalance at the hip, such as a tightness or a strength issue. This contributes to abnormal forces placed through the knee during activity that can result in tissue injury. The same is true with noted dysfunction at the foot and ankle. 

Once the acute pain is treated and the tissues at the knee have calmed down, the athlete can start to rebuild strength and slowly increase the load on the muscles as tolerated. With a strong foundation built back up, they can then progress back into sport-specific training to return to play.

If an athlete sustains a ligament tear or meniscus injury, the athlete may need surgical intervention to repair or debride the damaged tissue. The benefit of seeing the Bone and Joint Institute team is the patient can transfer from physical therapy for pre-surgical rehabilitation right to the surgical team seamlessly and then return to physical therapy to achieve full recovery back to sport.

Post-operative physical therapy starts at a very low level and low load to rebuild flexibility, range of motion and strength from the ground up. The best way to think of it is like a pyramid. The patient must have a good foundation of flexibility, range of motion and strength before they can work their way up to higher level agility and plyometric training for return to sport. If the athletes don’t have a proper foundational base, then returning to higher level sport-specific activities too quickly will result in an increased risk of re-injury or tissue failure.

Athletes looking to set up their seasons for success and avoid injuries can make an appointment with a sports medicine expert at Bone and Joint Institute to ensure there are no potential issues. To schedule an appointment today, click on the blue button at the top of the page, click here, or call the clinic at (615) 791-2630.

Brittany Richardson, DPT, MTC is a licensed physical therapist with Bone and Joint Institute of Tennessee. She received her Bachelor of Science degree from Auburn University Montgomery in 2010 and her Doctorate of Physical Therapy degree from the University of St. Augustine for Health Sciences in 2016. She has spent her professional career working in outpatient orthopaedic care. Brittany is a certified Manual Therapist and she also has certification in Integrative Dry Needling and training in pain neuroscience.