Join Date: Aug 2004
Local Time: 08:12 AM
'The Uneven Playing Field': Gender & Youth Sports Injuries
This is the cover story from this week's New York Times Magazine
; I've cut it down extensively (full article here
), mostly by trimming out personal anecdotes.
The Uneven Playing Field
By MICHAEL SOKOLOVE
New York Times Magazine, May 11
By the time Janelle Pierson sprinted onto the field for the start of the Florida high-school soccer playoffs in January, she had competed in hundreds of games since joining her first team at 5. She played soccer year-round—often for two teams at a time when the seasons of her school and club teams overlapped. Like many American children deeply involved in sports, Janelle, a high-school senior, had traveled like a professional athlete since her early teens, routinely flying to out-of-state tournaments. She had given up other sports long ago, quitting basketball and tennis by age 10. There was no time for any of that, and as she put it: “Even if you wanted to keep playing other sports, people would question you. They’d be, like, ‘Why do you want to do that?’”
That she was playing at all on this day, though, was a testament not to her talent but rather to her high threshold for pain, fierce independence and formidable powers of persuasion. Janelle returned to action a little more than five months after having an operation to repair a ruptured anterior cruciate ligament, or A.C.L., in her right knee. And just 20 months before that, she suffered the same injury to her other knee.
The A.C.L. is a small, rubber-band-like fiber, no bigger than a little finger, that attaches to the femur in the upper leg and the tibia in the lower leg and stabilizes the knee. When it ruptures, the reconstructive surgery is complicated and the rehabilitation painful and long. It usually takes six to nine months to return to competition, even for professional athletes. But after her second A.C.L. operation, Janelle refused to wait that long.
...Janelle’s mother broached the subject with her of whether she should continue playing at all. “I’m afraid for her, and for all these girls,” Maria Pierson told me recently. “What’s it going to be like for them at 40 years old? They’re in so much pain now. Knees and backs and hips, and they just keep going. They’ve been going at this so hard for 10, 11, 12 years, and it’s taking a toll. Are they going to look back and regret it?” Janelle’s father was concerned, too, but a bit more philosophical. Title IX, the federal law enacted in 1972 mandating equal opportunity in sports, has helped to shape a couple of generations of girls who believe they are as capable and as tough as any boy. With a mix of resignation and pride, Rich Pierson said to me: “We’ve raised these girls to be headstrong and independent. That’s Janelle.”
Janelle told her parents that she was still determined to play soccer in college—and that she would race through her rehab in order to salvage the end of her senior season in high school. Her physical therapist thought that was a bad idea. Her surgeon was reluctant to write a letter to her school stating that she was medically cleared to resume playing, but Janelle persuaded him.
..By Janelle’s and her mother’s count, her club team, with 18 players, had suffered eight A.C.L. tears—eight—during her high-school years: Janelle’s two, another player’s two and four other girls with one each. A high-school teammate one class above Janelle endured chronic ankle problems and, according to a Miami Herald article, six ankle operations—three in each leg—over the course of her four years on the varsity soccer team. This casualty rate was not due to some random spike in South Florida. It is part of a national trend in the wake of Title IX and the explosion of sports participation among girls and young women. From travel teams up through some of the signature programs in women’s college sports, women are suffering injuries that take them off the field for weeks or seasons at a time, or sometimes forever.
Girls and boys diverge in their physical abilities as they enter puberty and move through adolescence. Higher levels of testosterone allow boys to add muscle and, even without much effort on their part, get stronger. In turn, they become less flexible. Girls, as their estrogen levels increase, tend to add fat rather than muscle. They must train rigorously to get significantly stronger. The influence of estrogen makes girls’ ligaments lax, and they outperform boys in tests of overall body flexibility—a performance advantage in many sports, but also an injury risk when not accompanied by sufficient muscle to keep joints in stable, safe positions. Girls tend to run differently than boys—in a less-flexed, more-upright posture—which may put them at greater risk when changing directions and landing from jumps. Because of their wider hips, they are more likely to be knock-kneed—yet another suspected risk factor. This divergence between the sexes occurs just at the moment when we increasingly ask more of young athletes, especially if they show talent: play longer, play harder, play faster, play for higher stakes. And we ask this of boys and girls equally—unmindful of physical differences. The pressure to concentrate on a “best” sport before even entering middle school—and to play it year-round—is bad for all kids. They wear down the same muscle groups day after day. They have no time to rejuvenate, let alone get stronger. By playing constantly, they multiply their risks and simply give themselves too many opportunities to get hurt.
Comprehensive statistics on total sports injuries are in short supply. The N.C.A.A. compiles the best numbers, but even these are based on just a sampling of colleges and universities. For younger athletes, the numbers are less specific and less reliable. Some studies have measured sports injuries by emergency-room visits, which usually follow traumatic events like broken bones. A.C.L. and other soft-tissue injuries often do not lead to an E.R. visit; the initial examination typically occurs at the office of a pediatrician or an orthopedic surgeon. Studies of U.S. high-school athletics indicate that, when it comes to raw numbers, boys suffer more sports injuries. But the picture is complicated by football and the fact that boys still represent a greater percentage of high-school athletes.
Girls are more likely to suffer chronic knee pain as well as shinsplints and stress fractures. Some research indicates that they are more prone to ankle sprains, as well as hip and back pain. And for all the justifiable attention paid to concussions among football players, females appear to be more prone to them in sports that the sexes play in common. A study last year by researchers at Ohio State University and Nationwide Children’s Hospital in Columbus, Ohio, reported that high-school girls who play basketball suffer concussions at three times the rate of boys, and that the rate for high-school girls who play soccer is about 1.5 times the rate for boys. According to the N.C.A.A. statistics, women who play soccer suffer concussions at nearly identical rates as male football players. (The research indicates that it takes less force to cause a concussion in girls and young women, perhaps because they have smaller heads and weaker necks.)
But among all the sports injuries that afflict girls and young women, A.C.L. tears, for understandable reasons, get the most attention. No other common orthopedic injury is as debilitating and disruptive in the short term—or as likely to involve serious long-term consequences. And no other injury strikes women at such markedly higher rates or terrifies them as much. Rachel Young, a former soccer player at Virginia Tech who had to stop playing after two A.C.L. ruptures and substantial cartilage damage in her right knee, told me that young women she knew feared the injury but rarely talked about it. “A.C.L. is like a curse word,” she said. “You just cringe when you hear it.”
An A.C.L. does not tear so much as it explodes, often during routine athletic maneuvers—landings from jumps, decelerations from sprints—that look innocuous until the athlete crumples to the ground. After the A.C.L. pulls off the femur, it turns into a viscous liquid. The ligament cannot be repaired; it has to be replaced with a graft, which the surgeon usually forms by taking a slice of the patellar tendon below the kneecap or from a hamstring tendon. One reason for the long rehabilitation is that the procedure is really two operations—one at the site of the injury and the other at the donor site, where the tendon is cut.
If girls and young women ruptured their A.C.L.’s at just twice the rate of boys and young men, it would be notable. Three times the rate would be astounding. But some researchers believe that in sports that both sexes play, and with similar rules—soccer, basketball, volleyball—female athletes rupture their A.C.L.’s at rates as high as five times that of males.
...Men also tear their A.C.L.’s, most frequently in football and from direct blows to the leg. But even football players, according to N.C.A.A. statistics, do not rupture their A.C.L.’s during their fall seasons at the rates of women in soccer, basketball and gymnastics. The N.C.A.A.’s Injury Surveillance System tracks injuries suffered by athletes at its member schools, calculating the frequency of certain injuries by the number of occurrences per 1,000 “athletic exposures” practices and games. The rate for women’s soccer is 0.25 per 1000, or 1 in 4000, compared with 0.10 for male soccer players. The rate for women’s basketball is 0.24, more than three times the rate of 0.07 for the men. The A.C.L. injury rate for girls may be higher—perhaps much higher—than it is for college-age women because of a spike that seems to occur as girls hit puberty...Imagine a hypothetical high-school soccer team of 20 girls, a fairly typical roster size, and multiply it by the conservative estimate of 200 exposures a season. The result is 4000 exposures. In a cohort of 20 soccer-playing girls, the statistics predict that 1 each year will experience an A.C.L. injury and go through reconstructive surgery, rehabilitation and the loss of a season—an eternity for a high schooler. Over the course of four years, 4 out of the 20 girls on that team will rupture an A.C.L.
One weekend in the fall of 2007, I watched a soccer match involving two teams of 13-year-old girls in Southern California with Holly Silvers, a physical therapist and the director of research at the Santa Monica Orthopaedic and Sports Medicine Research Foundation...Silvers, along with a Santa Monica orthopedic surgeon, Bert Mandelbaum, designed an A.C.L.-injury-prevention program that has been instituted and studied in the vast Coast Soccer League, a youth program in Southern California. Teams in a control group did their usual warm-ups before practices and games, usually light running and some stretching, if that. The others were enrolled in the foundation’s “PEP program,” a customized warm-up of stretching, strengthening and balancing exercises. An entire team can complete its 19 exercises—including side-to-side shuttle runs, backward runs and walking lunges—in 20 minutes. One goal is to strengthen abdominal muscles, which help set the whole body in protective athletic positions, and to improve balance through a series of plyometric exercises—forward, backward and lateral hops over a cone. Girls are instructed to “land softly,” or “like a spring.”
...The Santa Monica Orthopaedic and Sports Medicine Research Foundation published results of its trial in the American Journal of Sports Medicine. The research was nonrandomized and therefore not the highest order of scientific research. (The coaches of teams doing the exercises made a choice to participate; the control group consisted of those who declined.) Nevertheless, the results were attention-grabbing. The subjects were all between 14 and 18. In the 2000 soccer season, researchers calculated 37,476 athletic exposures for the PEP-trained players and 68,580 for the control group. Two girls in the trained group suffered A.C.L. ruptures that season, a rate of 0.05 per 1,000 exposures. Thirty-two girls in the control group suffered the injury—a rate of 0.47. (That was almost twice the rate for women playing N.C.A.A. soccer.) The foundation compiled numbers in the same league the following season and came up with similar results—a 74% reduction in A.C.L. tears among girls doing the PEP exercises.
The program has direct parallels with the research taking place at the military academies. Both are focused on biomechanics—the way athletes move—in no small part because gait patterns can be modified, unlike anatomical characteristics like wider hips. [UNC injury epidemiologist Steve] Marshall has been encouraged by information taken from the sensors attached to his subjects as they jump. “Women tend to be more erect and upright when they land, and they land harder,” he said. “They bend less through the knees and hips and the rest of their bodies, and they don’t absorb the impact of the landing in the same way that males do. I don’t want to sound horrible about it, but we can make a woman athlete run and jump more like a man.”
Silvers stressed the importance of training girls as young as possible, by their early teens or even younger. “Once something is learned neurally, it is never unlearned,” she said. “It never leaves you. That’s mostly good. It’s why motor skills are retained even after serious injuries. But ways of moving are also ingrained, which makes retraining more difficult with the older athletes. The younger girls are more like blank slates. They’re easier to work with.”
The PEP program, and others like it around the country, are not without their skeptics, who ask how you can try to solve a problem before you are even confident of its cause. Donald Shelbourne, an Indianapolis orthopedic surgeon and researcher, is perhaps the most vehement of the critics. “It’s like me taking antioxidants,” he says. “I don’t have cancer yet, so it’s working, right? These retraining programs play on emotions without data. They’re unproven. Jumping and landing is something that everyone knows how to do, and now we’ve got people saying, ‘We can teach you to do it better.’ I don’t buy it.”
Coaches rarely like to give up precious practice time for injury prevention, and often have to be pushed by parents. As Diane Watanabe, an athletic trainer who is part of the Santa Monica research team, puts it: “Coaches have to see a performance boost. Otherwise, they won’t do it. That’s the only way we can sell them on this program.” The bigger barrier, though, may be political. Advocates for women’s sports have had to keep a laser focus on one thing: making sure they have equal access to high-school and college sports. It’s hard to fight for equal rights while also broadcasting alarm about injuries that might suggest women are too delicate to play certain games or to play them at a high level of intensity. There are parallels in the workplace, where sex differences can easily be perceived as weakness. A woman must have maternity leave. She may ask for a quiet room to nurse her baby or pump breast milk and is the one more likely to press for on-site child care. In high-powered settings like law firms, she may be less likely, over time, to be willing to work 80 hours a week. She does not always conform to the model of the default employee: a man.
Mary Jo Kane, director of the Tucker Center for Research on Girls and Women in Sport at the University of Minnesota, voices that sort of concern. “I’m not in any way suggesting that this topic should not be taken seriously,” she says. “We need to do everything we can do to prevent injuries. But when you look at the stories that get told, that those who cover women’s sports are interested in telling...it does seem that so little coverage focuses on women’s accomplishments, on their mental toughness and physical courage. There is a disproportionate emphasis on things that are problematic or that are presented as signs of women’s biological difference or inferiority.”
Sandra Shultz, an A.C.L. researcher who teaches graduate courses in athletic training and sports medicine at the University of North Carolina at Greensboro, said she was more willing to focus on sex difference. “It depends on what side of the fence you’re on,” she told me recently. “If your job is to encourage inclusion of more women in sport, maybe you are not going to accentuate the negative. You don’t want to paint women in a negative light and tell a girl that if you play sports, your knees, by the time you are 30 or 35, may be in bad shape. But intuitively, people know it. As a researcher and a clinician, I’m willing to talk about these things so we can do something about them.” Shultz and other researchers say that A.C.L. research and the training programs spawned by it may end up protecting women from a range of injuries—all of them stemming from poor form and underdeveloped muscle. “Just because a kid is good at a sport does not mean she has the foundational strength or movement patterns to stand up to constant play,” she says. “What I’d like to be able to say is: ‘Before you engage in a sport, I am going to teach you how to move. And I am going to give you strength.’ ”
Rich and Maria Pierson never had to push Janelle into soccer or to reach for higher-level teams, and they certainly never berated her after bad games. These types do exist, stereotypical “Little League parents,” but it is far more difficult than some imagine to push a reluctant child into sports, especially at a level that demands great commitment. Children may acquiesce for a while, but all but the most passive or abused will eventually rebel and shut down. I found a different syndrome: parents of highly motivated, athletic children who are supportive of their kids’ sports but bewildered by the culture. The children, often as not, are the ones leading the way, and the whole family gets pulled along in ways it never anticipated. “We had no idea what we were getting into,” Rich Pierson said. “You just feel your way as you go. She started playing with a local team, just once or twice a week, then began with the travel team, and after that it just builds on up.”
...In many sports, a youth athlete’s paramount relationship is now with a club rather than a school team. Annual fees and travel to tournaments often run into the thousands of dollars. Parents pay for camps and private sports tutors. The guiding principle is that childhood sport is too important to be left to volunteers and amateurs. The quality of coaching, in terms of skills and tactics, is probably better than in past generations, but it is also narrower. Rather than being coached by educators who see them during the school day and have some holistic sense of them as children, young athletes are now mentored by coaches who cultivate only their athletic side. At what age should a young athlete begin traveling to out-of-town tournaments? How many days a week should she be playing? When should she give up her other sports? The professional coach is usually not equipped to know what’s best, but he wields tremendous influence all the same, sometimes by threat. He makes the schedules and sets the rules, and a child who does not go along risks losing her place on the team.
“Parents’ hearts are usually in the right place,” says Colleen Hacker, a sports-psychology consultant who has worked with athletes from the preadolescent up through the college, Olympic and professional ranks. “I don’t think anybody’s saying, ‘Honey, how do we screw them up tomorrow?’ But the attention, judgment and objectivity that parents bring to their work lives and other spheres of importance, they don’t bring to their kids’ sports.”
The club structure is the driving force behind the trend toward early specialization in one sport—and, by extension, a primary cause of injuries. To play multiple sports is, in the best sense, childlike. It’s fun. You move on from one good thing to the next. But to specialize conveys a seriousness of purpose. It seems to be leading somewhere—even if, in fact, the real destination is burnout or injury.
Janelle's high school, St. Thomas Aquinas, is the alma mater of the tennis immortal Chris Evert and the former football star Michael Irvin. It places a high value on attracting and developing young athletes, and on keeping them healthy enough to go on and play in college. “I get more compliance from the boys,” the school’s athletic trainer, Dwayne Owens, told me. “Boys are actually willing to sit if that’s what I tell them. The girls want to get back out there. They want me to tape them up and let them play.” I repeatedly heard similar sentiments from doctors, coaches and others: Girls are more likely to put themselves at risk. If they’ve played through a lot of pain in the past, they may be inured to it.
There is a fascinating parallel in research on injury rates in U.S. Army basic training, a two-month regimen that pushes recruits to their physical limits. In numerous studies going back more than two decades, women are shown to suffer injuries at substantially higher rates than men, with stress fractures to the lower legs a particular problem. But one large study also suggests that the women are both more frequently injured and tougher. It takes a bigger injury to knock them out of the service. The men, by comparison, are wimps; they leave with more minor ailments. In sports, just as in the military, women are relative newcomers. In both venues, there may be an element of “toughing it out” to prove they belong. “From the earliest levels in girls’ sports, up through the elite and Olympic level, how one plays the sport, how one comports oneself, is talked about in specific ways that transcend technical or tactical expertise,” Colleen Hacker says. “It is more overt with the girls than the boys. Character counts. Physical toughness, mental toughness and handling adversity count.”
Michael Sokolove is a contributing writer for the magazine. This article is adapted from Warrior Girls: Protecting Our Daughters Against the Injury Epidemic in Women’s Sports, which will be published in June.
Not entirely sure where I wanted to go with this discussion-wise...I'm partly assuming the topic will naturally be of interest to some of the parents, and current and former athletes, around here.
The research into biomechanics, and the possibility of customized training programs drawing on that research to make sports safer (and in particular, to reduce A.C.L. injuries in girls), sounds fascinating, and one can only hope the initial reported results reliably hint at better prospects to come. Of course it also sounds as though better data on comparative injury rates at various ages, and for various sports, is needed. The passage about how the organization (and perceived stakes) of youth sports have changed over the past few decades also seemed reminiscent of things I've seen some posters here say before, concerning their own youth athletics experiences.