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Tuesday, June 3 at Noon ET

High Rates of Injury for Female High School Athletes

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Michael Sokolove
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Tuesday, June 3, 2008; 12:00 PM

Michael Sokolove answers questions about his book, "Warrior Girls," excerpted in today's Health section. The book is an examination of how overtraining and intense competition contribute to higher rates of injury for girls who play high school sports than boys .

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Sokolove was online Tuesday, June 3 at noon ET to take your questions and comments.

A transcript follows.

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Fairfax, Va.: Thank you so much for writing this article! I'm only 23 years old and already I've had three separate ACL reconstructions and 1 meniscus repair for injuries from soccer and skiing. And frankly I was only a recreational sports woman, no Picabo Street - I never played at an intensity or for a time span which would make this amount of injury seem logical. I would absolutely encourage everyone reading this article to take it seriously and do everything possible to protect your knees. Take it from a relatively young woman who has already resigned herself to the elliptical, just can't justify any more high-risk sports. Thanks for raising awareness about this.

Michael Sokolove: Thanks for your comment. It is stories like yours that spurred me to write Warrior Girls. It is sadly easy to find women - young women -- with multipe ACL tears and other major knee injuries, and the longterm impact of such injuries, in terms of lost mobility, is serious. And it's happening increasingly to girls in their mid and even early teens. What I hope is that these younger girls will be led to prevention programs that cut into the injury rates. The other component is that we have to make changes in the youth sports culture and tackle issues of over-play and early specialization, becasue at the moment we're manufacturing injuries.

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Falls Church, Va.: Hi - Appreciate your researching this important topic. Do you discuss in your book the accelerating trend toward recruiting by colleges of female athletes at younger and younger ages and the additional competitiveness and intense training at young ages before the bodies are fully developed as a contributing factor to these injuries? Thank you.

Michael Sokolove: Yes, definitely, I devote a great deal of attention to recruiting and college scholarships -- or I should say the fantasy of college scholarships. Full scholarships go to only the top top sliver of national level athletes, the best of the best. Partial scholarships are nearly as hard to get. Yet we have all these young athletes hoping to land them. The fantasy to a large extent is perpetuated by the youth sports culture, and particularly the sponsors of "college showcase" tournaments, which are the most destructive part of the whole youth sports landscape.

Teenage girls (and boys) play up to five soccer, basketball, lacrosse or whatever games in the course of three days -- which is something we do not ask of college or even pro athletes. It's insane, unjustified and leads directly to injuries. A character in my book suffered her second ACL injury while playing her third out of town tourney in three weekends.

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Baltimore: The article says that the girls with the highest risk are those whose knees "cave inward" when landing. I don't understand what the author means by "cave inward". Which way is the knee moving?

Michael Sokolove: The knees collpase toward ech other -- also known as knock knees or knee valgus of sometimes "kissing knees." Most researchers consider this a telltale sign of a girl who may go on to suffer an ACL rupture, although it's not known for sure if the knee valgus is a primary cause or just a tipoff.

What such knee movment does show, however, is that the athlete has poor running and landing form -- which can usually be modified through a series of strengthening and balancing exercises.

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Bethesda, Md.: I wish they had this type of training when I was playing soccer eons ago! I'm curious though if there are any plans to do long-term follow up of the girls who do end up tearing their ACLs. I'm pushing 20 years since I tore my ACLs playing soccer and it's nearly impossible to find any information about what I should be expecting (arthritis etc.) as I hit my mid 30s and beyond. It's all just anecdotal evidence.

Michael Sokolove: There are definitely studies out there, almost all of them indicating that those who suffer an ACL tear are at substantially higher risk of developing arthritis -- and at at younger ages. The risks go up for multiple ACL tears in the same knee. This is why the ACL prevention programs are so vitally important.

Some of the best studies have been done among female team handball in Denmark, where healthcare is paid for by the state and ACL tears are considered a serious public health issue. One interesting thing is that the better the surgery gets and the quicker women can get back on the field the less seriously they take the injury -- which is unfortunate since the longterm risks do not go down.

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NYC: I have a question regarding woman athletes. I am a cyclist and ride two to three days a week. Usually I ride on the weekend along the Hudson River. I have been noticing that there are significantly more women (3 to 1) then men running. Cycling there are more men but the absolute numbers are smaller. The age of the women running are generally in the 20s but not limited to that demographic. I am struck by this because it seems women are doing more exercise then men. Is there any data on this? Or is this just an specific to NYC?

Michael Sokolove: I believe the data and most anecdotal information shows that adult women are more devoted to exercise than men. One thing in my book I try to do is to distinguish between exercise and competitive sports; they're not the same thing. Competitive sports involves risk, almost always. I think those risks are usually well worth it for the fun and the life skills that we get from competing. I make the case in the book that competitive sports, in many ways, are BETTER for girls than boys -- in that sports do not socialize girls in some of the unfortunate ways that they can for boys. (We have seen no female athletes jailed for engaging in dog-fighting or arrested in strip club shootings.)

The downside of competitive sports for girls is they're getting hurt way too much -- at rates we can cut into. Great as sports are for girls, the intent of Title IX was not to create a generation of adult women who limp around like they played a decade in the NFL.

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Northbrook, Ill.: Concerning high school softball and baseball, there has been an increase in injuries lately. There is speculation that all players in the field should start wearing protective gear. As a second baseman I would find this incredibly uncomfortable and distracting. What is your take on this?

Michael Sokolove: This is a sort of engineering question, and I don't hold musyelf out as an expert on these kind of equipment matters. Generally, though, equipment -- including knee braces -- does not prevent injuries. Ankle braces for girls with chronic ankle sprains lock the ankle in place and may actually put more stress on the knees and hips.

Baseball HELMETS certainly do prevent injury. But some studies have found other "protective" baseball and softball equipment may absorb force and may have the opposite effect.

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Burke, Va.: At what age do you recommend incorporating these warm-ups into a team's practice routine? My 10-year-old daughter just completed her first season of travel soccer and is already suffering from tendonitis just below her left knee. Her team doesn't do any stretching or adequate warming up. Thank You.

Michael Sokolove: Ten years old is not too young to begin proper warmups and specific, gender-based ACL prevention. Holly Silvers, an ACL researcher and physical therapist involved with the PEP program in Santa Monica, told me that she can modify the movement patterns of female athletes of any age -- but she is far more successful with younger girls, before puberty, because they are "blank slates."

The whole idea is to get girls to decelerate, change direction and land from jumps in a less upright -- and more flexed -- position. And to avoid "vulnerable positions" -- upright, legs extended and knees locked. To take a spirited young athlete and instill this early, and repetitively, is the very best hope for injury prevention. The research is still young -- no one is saying all injuries can be prevented -- but these programs are the state of the art.

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tournaments and scholarships: My daughter played soccer from the age of 6, played in the top division of select soccer, varsity all of her HS years of playing, and did get a partial scholarship to college. However, her junior year in HS she tore her ACL (during a club game, not HS) then her meniscus the following year, then the same ACL again her sophmore year of college, ending her playing. She also had to have surgery to fix a screw from the last repair. I'm sure she's got a lot to look forward to with that knee in the coming years. Who knows, a knee replacement by the age of 35? I debate whether it was worth it, because you're right, the schedule of games she played was ridiculous and I certainly share the guilt on that decision - though she loves the game so much that she now coaches a boys team.

Michael Sokolove: Your very sad note is an echo of the main character in my book -- a young woman named Amy Steadman -- who was going to be one of the great US soccer players of her generation. When I met her, she was 20, retired, had undergone five knee surgeries, including four ACL reconstructions, and walked with great pain and difficulty.

She pushed too hard and too quickly to return from her injuries. Like lots of young female athletes, she was incredibly determined and tough. Everyone applauded her her gusto and rooted for her to come back from each injury, and in the span of too few years, she had lost her career and much of her mobility and is headed for a knee replacement, perhaps by age 30. I don't blame her parents at all -- or any parents.

What needs to be fixed is the culture that urges our kids to pick a "best" sports so early on -- play it to excess -- and then show their toughness by coming back from injuries at a faster clip than pro athletes do. (Million dollar pro athletes know what's at stake, as do their teams; they generally take proper time to heal.)

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Maryland: what kind of factor does weight play in this type of injury? I see HS female athletes who, while fit, still carry a bit of extra weight (along with many others in the US, obviously). Does that heighten the potential for this kind of injury?

Michael Sokolove: The short answer is yes, although I don't think weight is a primary cause of knee injuries in women. However, several studies have shown that it increases risks. But this is all quite complicated. Another risk for female athletes, especially runners, is to think that being as skinny as possible will enhance performance -- and to shed weight to the point that they have decreased bone density.

The key point is not weight but strength and MUSCLE. When boys move through puberty, they get stronger, often without much effort of their own. Girls do not. But if htey want to play sports at a high level -- and avoid injury - they absolutely MUST add muscle to hold joints in place. The typical teenage female athlete has flexible joints and too little muscle to keep them in stable positions. that is a primary cause of not only the knee injuries we're talking about -- but ankle, hip, and back pain, as well.

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Arlington, Va.: I'm excited you're doing this chat as I read your article in the NY times on the same subject. Clearly this has also sparked debate about whether female athletes should be pushed as far as males - have you had any insight from those you interviewed for the story on this? Personally I feel like the girls will push themselves just as hard, if not harder, and who's to tell them not to go out and, as Nike says, "Just do it"?

Michael Sokolove: I think we're pushing both boys and girls too hard. The current youth sports culture is insane -- too much play; indefensible early specialization.

It's bad for boys. What my book makes clear is that it's WORSE for girls. So we have to do two things. Fix the culture, which, admittedly, is difficult. There are economic interests at stake. (The tournaments, for instance, where so many injuries occur, fill up hotel rooms and restaurants in host communities. Yes, they're fun for kids, but why are there so many and why do they entail plane travel and hotel stays? There's money to be made.)

The other thing that has to happen is that girls -- impolitic as some may find this -- have to be regarded as girls. They have strengths as athletes that boys do not have. And weaknesses. As long as they are to compete within this culture, they need to be entered, as young as possible, into preventative programs that address their deficiencies.

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Washington, DC: After reading this article as well as the longer one published in the NY Times recently, I was wondering what other topics your book covered beyond ACL injuries and the other limited areas focused on by the newspapers.

Michael Sokolove: In the book, I pay a great deal of attention to the "warrior girl" ethos. Many coaches and trainers I talked to believe that girls are "tougher" than boys. I don't know if that's literally true, but I do strongly believe they will play through more pain -- and are more difficult to convince to leave the field when injured.

There is fascinating research among women in military basic training that parallels this: Women are injured at much higher rates. But it takes a bigger injury to drive them out of the service. By comparison, the men are wimps! It could be that in sports, as in the military, women as comparable newcomers are still trying to prove their bona fides. Or, in sports, girls may feel a greater sense of community -- of bonding to teammates -- and to the duty of sticking it out and playing.

Whatever the reasons, this should be a warning sign for parents: We want our girls to be tough and to play through discomfort, but not through serious injury. Some ofthe girls I interviewed I believe were so used to playing in pain that they were innured to it. They didn't know what it was like to play healthy.

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Washington, D.C.: Can any of this be caused by the fact that some boys get more "training" for lack of a better word in jumping, etc. I know when I was younger I was constantly climbing trees and my friends and I were proud of how high of things we could jump off of. Lord knows my knees don't thank me for it now, but I never had a serious knee injury while I was playing sports. I feel there was much greater danger of that when I was playing in an unorganized setting between 7-14 rather than once I was in competitive sports in high school and college.

Michael Sokolove: I think previous generations of American children, boys and girls, got better training and were better all around athletes. We rode bicycles, waded in streams, played each sport in its season, climbed trees . . we didn't call it cross training but that's what it was. High-end coaches I talked to were consistent in telling me that the athletes they encouter -- even the high-achieving ones -- are often skilled in their sport but surprisingly poor at a basic athletic level.

Great tennis players who cannot hit a baseball. Soccer players who can't play any other sport -- or who, like most American children, are sedentary except for when some coach is on the field putting them through drills. This "one-trick pony" athleticism is an injury risk, and it's a syndrome I pay a great deal of attention to in the book.

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Fairfax, Va.: I have the opportunity to coach younger girls 4th and 5th graders in basketball. Two questions: Can these exercises be used for basketball players and I have heard that a "jump stop" in basketball is very hard on the knees, especially with girls. Is that correct?

Michael Sokolove: There have been movements among some women's basketball proponents to "un-teach" the jump stop. But that particular movement is part of the quick and explosive nature of basketball, and to teach girls to stop more gradually over two or three steps would be like turning the clock back. I think it's a much better idea to condition them in such a way that the jump stop (and other full-throttle athletic moves) do not result in so many injuries.

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Silver Spring, Md.: If ACL injury occurs in spite of preventive measures, what is the best way to reconstruct a torn ACL in order to prevent future ACL injuries and arthritis?

Michael Sokolove: Surgeons have gotten really good at reconstructing ACLS and returning athletes to their previous abilities, or close to it. But the surgery is complicated (it's really two surgeries; one under the kneecap, and another to take a graft from the patellar tendon or hamstring tendon to form a new ACL) and the rehab long and painful.

The best thing to prevent future ACL tears is to rehab well and completely and patiently -- and to find a program to modify movement patterns, as well as to address strength issues to protect the knee. Anyone who tears an ACL more than once should give serious thought to finding a sport that puts the knees at less risk, and there are many of them -- swimming, rowing, cycling . .

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Arlington, Va.: I played Volleyball in college from 1997 - 2000, and my coach was aware of the high rate of ACL injuries in female athletes. I remember hearing somewhere that one of the reasons was that typically our hamstring muscles weren't as strong as our quads compared to men -- the ratio of strength and balance between those muscle groups in the legs needed to be brought closer together. So we focused quite a bit on strengthening our hamstring muscles in all of our weight training programs.

Michael Sokolove: This is correct. Women have more of a tendency to be "quad-dominant" than men, and one theory is that the ACL tears when an athlete lands or decelerates in a straightlegged posture and her quad "over-fires," ripping the ACL from the top. So every prevention program that I'm aware of pays a great deal of attention to strengthening the hamstrings.

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Bethesda, Md.: What type of injuries do girls in gymnastics incur? Do they suffer from ACL injuries or different types? That seems to be a very intense and punishing sport.

Michael Sokolove: Gymnastics is a very difficult sport on young bodies -- as is cheerleading. I must admit, I didn't devote a great deal of space to it in Warrior Girls, as I felt the risks were somewhat self-evident.

What struck me about soccer, basketball, volleyball, lacrosse and some of the others is that parents consider them so wholesome and positive, which they certainly can be, but then you run across these teams -- many of them -- that are just decimated by injuries. Girls hurt from head to toe. Teams of 18 soccer-playing teenage girls -- with eight ACL injuries between them.

This just doens't have to be, and I feel that it can change with more attention given to the problem, more research, and more determination on the part of parents to change a sports culture that manufactures injuries.

Thanks, everyone, for all the great questions. For anyone interested, 'll be talking anxd signing books at Barnes and Noble on Bethesda Ave Thurs nite and the following Tuesday at Borders in Vienna, Va. Thanks!

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