USC’s JuJu Watkins Tears ACL. Why Women Suffer This Injury More Often

This was a bad twist in USC’s hopes to win the NCAA women’s basketball championship. Just five minutes into the Trojans’ 96-59 win over Mississippi State in the second-round of March Madness, their star shooting guard JuJu Watkins went down with a tear of her right anterior cruciate ligament that will require surgical reconstruction and months of rehabilitation before she can return to the court.

It’s an injury that’s unfortunately all too familiar among female basketball players. In fact, a study published in 1999 found that female college basketball players were 3.5 times more likely than their male counterparts to suffer ACL tears. There are theories as to why this is the case, with an emphasis on the word “theories.” That’s because — surprise, surprise — researchers haven’t studied ACL injuries in women athletes at the same rate of men.

Watkins’ ACL Injury Is A Blow To The Trojans’ Championship Aspirations

Through her first two collegiate seasons, Watkins scored 1,709 points, the second most ever behind only Ohio State’s Kelsey Mitchell, who tallied 1,762 from 2014 to 2016. Watkins’ averages of 24.6 points, 7.0 rebounds and 3.5 assists this season had earned her Associated Press All-American honors and front-runner status for national player of the year. It also helped the Trojans earn the fourth No. 1 seed in this year’s NCAA tournament after going 30-3. But the Trojans’ chances of winning the whole ball of wax took a big knee to the gut when Watkins’ right knee buckled during a fast break drive to the basket.

The ACL plays a critical role in stabilizing the knee. A ligament is a band of fibrous tissue that runs from one bone to another in a joint. Your knee joint typically has four such ligaments connecting your upper leg bone, the femur, with your bigger lower leg bone, the tibia. These are the ACL, posterior cruciate ligament, medial collateral ligament and lateral collateral ligament. The ACL and PCL have the word “cruciate” in them because these ligaments criss cross to form an X. You could also say both are quite crucial in keeping your knee joint from going a-rocking.

The ACL Tear And Surgery Will Keep Watkins Out For Months

You may be able to get away without surgery after a complete ACL tear if the muscles around your knee are strong enough to compensate and most of the cutting that you do is limited to scissors. But when you regularly play basketball, soccer or other sports that involve a lot of cutting, jumping and pivoting, chances are you’ll need to get your no-longer-connected ACL replaced and reconstructed via surgery. The surgeon may want a piece of you, meaning a piece of your patella or hamstring tendons to serve as a replacement ACL. Alternatively, the surgeon may use an ACL from a cadaver, but such grafts may not be as durable and your body could end up rejecting them, as I have detailed in Forbes previously.

The actual operation is just chapter one of a long journey. Afterwards, you’ll have to build your muscles back along with strength, balance and a bunch of other things that you can lose distressingly quickly. As you may know, it’s always easier to break things than build them back up, and your knee is no exception. It can take up to six months of physical therapy before a return to the court is possible.

Differing Anatomy May Put Women At Higher Risk for ACL Tears

You could fill several All-Star games with star women’s basketball players who have gone through ACL tears. The rosters would include Sue Bird, Tamika Catchings, Candace Parker, Cameron Brink, Paige Bueckers, Azzi Fudd and now Watkins. Although star men’s basketball players such as Derrick Rose and Kyrie Irving have gone down to such injuries as well, the overall percentage doesn’t seem quite as high. Available studies and numbers do bear such differences out, suggesting that women are somewhere between two to eight times more likely to suffer an ACL injury than men.

It isn’t completely clear what’s causing that difference, though. One possibility is anatomical differences. Females tend to have wider pelvises, which could change the mechanics of how different parts of the lower extremities move around during rapid changes in direction. You only have to observe a bunch of men struggling to do a split to understand the differences in hip structures. The result of such differences in theory could be that women experience more stress on the supporting tissue like the ligaments when engaging in certain movements like running, jumping and pivoting. But these anatomical differences and the resulting impact haven’t been studied enough yet for all of this to be more than a theory.

So what can you do if your pelvis is indeed wider? Although Shakira may have sang that your hips don’t lie, they also don’t readily change their structure. Plus, different hip structures have different advantages in different settings. Maybe in the future researchers and trainers could be more hip to what these differences may be and how to better tailor strengthening and training methods accordingly. This could include changing the way you run, jump and pivot and focusing on developing different muscles, which are the protectors of your joints.

Differing Muscle Mass Could Play A Role In ACL Tears

This brings up another possible reason why women may be prone to get ACL tears: differences in the mass and strength of muscles supporting the knee. Your knee joints aren’t supposed to work in isolation from the rest of your body. It would be kind of weird if they did and a reason to contact your doctor. When you run, jump, cut and pivot, the quadricep muscles in the front of your thigh and the hamstring muscles in the back of your thigh should be bearing a decent amount of the force. But when such muscles are underdeveloped and not trained to contract at the right times, they can be like those members of your project group who don’t do whole lot, shifting most of the load and stress on to just a few — in this case, the ligaments of your knee.

Therefore, it’s not surprising that a big part of rehabilitation after ACL surgery is building up and strengthening your quadriceps and hamstrings. This not only can help you get back to your former kickus assus self, it can also prevent tears of your ACL graft or your other ACL.

On average, women tend to have less muscle mass around their knees than men. Women are also often “quad dominant” with stronger quadriceps muscles than hamstring muscles. Less muscle mass and an imbalance between the front and backs of the thighs could put the knee ligaments at greater risk.

Now, unlike bone structure, muscles are things that you have a bit more control over. Exercises like squats, lunges and step-ups can strengthen your quads. It’s easy, though, to neglect your hamstrings since you can’t see them as readily in mirrors and selfies. Plus, a lot of movements like running, jumping and cycling can be quad heavy if you aren’t conscious of your hamstrings. Therefore, be conscious about working into your work-outs more hamstring-active exercises like hamstring curls, lunges, glute bridges and deadlifts.

Hormones May Be A Factor In ACL Tears

The differences in the average muscle mass seen in women versus men can be due in significant part to differences in testosterone levels. Testosterone can help build muscle density. And women typically have comparatively lower testosterone levels.

At the same time, women tend to have significantly higher estrogen levels than men, although estrogen levels do fluctuate throughout the menstrual cycle. Evidence suggests that estrogen may contribute to looser tendons and ligaments that in turn could make your joints looser. That could allow you to be more flexible and able to do things like the aforementioned splits. But more lax joints can move in different directions more readily and thus leave your ligaments more prone to damage.

This doesn’t mean that you should start taking testosterone and trying to lower your estrogen levels just to protect your knee ligaments. Messing around with your hormone levels could mess around with a whole lot of other stuff. Plus, there are other evidence-based ways to protect ACL such as the aforementioned hamstring exercises.

Differing Jumping And Pivoting Styles Could Contribute To ACL Tears

This is one situation where style may matter as much as substance. If it’s your style to bend you knees and hips less when landing from a jump, you will land more straight-legged and flat-footed. This will end up putting more force through your knees and therefore more strain on your knee ligaments. Observation has shown that more women may utilize this jumping style, which may put them at greater risk for ACL tears.

Naturally, jumping styles are not necessarily inborn, immutable traits. This isn’t a “why bother without a Y chromosome” situation. It could be that females at earlier ages don’t get the training or socialization to jump and move in the same ways as males. But even if you are older and find yourself landing too flat-footed and hard after you jump, don’t despair. Physical therapists and other training professionals can help your muscles, nervous system and the rest of your body learn new jumping styles.

This brings up the possibility that female athletes are moving in other ways that may be making them more prone to ACL tears. This could include subtle ways of placing your feet when pivoting or anticipating where someone else will be moving. Females may not have access to the same training and coaching that many males do. Even though an athlete may finally get access to good training and coaching when reaching the elite level, some of those not-so-great habits learned in earlier years could end up persisting.

Again it’s still not clear how many ACL injuries among female athletes over the years could have been prevented and how. The trouble is not enough research has been done in these areas to support the growing numbers of girls and women playing sports. Whenever a star athlete like Watkins goes down with a serious injury, there’s one possible positive twist at least. It could bring more attention to the injury and finding new ways to prevent it.