Barber: ACL tears on the rise among young athletes

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So much of Owen McGarva’s high school experience had been defined by knee injuries that when it was time to buy a varsity letterman’s jacket, he depicted a pair of crossed crutches on the back, beneath his last name. The Jolly Roger of a wounded pirate. A bit of morbid humor in the face of adversity.

The first time McGarva, a senior at Maria Carrillo High School, wore the jacket to a basketball game was on Jan. 2. The Pumas were hosting El Molino High. Sometime during that contest, a teammate missed a shot. McGarva tipped the loose ball, planted his foot and began to pivot his body as he went to grab it. He felt something pop in his left knee.

“I hit the ground, and the first thing I did was make eye contact with my dad in the stands,” McGarva said.

Because he knew. The boy felt almost no pain in the knee. He strode across the court, over to the team bench, and sat down. He walked to his car after the game and drove home. Two days later, on Monday, he went to school. But McGarva had a good idea of where all of this was headed.

“I had a pretty substantial gut feeling I had done it again,” he said. “Even my parents were pretty hopeful for me, but I knew.”

An MRI exam would soon reveal a torn anterior cruciate ligament and torn meniscus, a piece of cartilage described as the shock absorber of the knee. This was a cruel blow to McGarva. A little more than two years earlier, he had torn his left ACL, meniscus and quadriceps muscle. And about 11 months prior to that, he had torn the same ACL and fractured his left tibia — all playing basketball.

McGarva, now 18, has been rebuilding his knee joint for most of the past three years. And when he begins college in the fall, he will probably be on crutches again. He’s scheduled for surgery to the meniscus on March 28, and expects to have the ligament re-attached next November.

McGarva is an extreme case, to be sure. But he is not alone among teen and preteen athletes dealing with the devastation of a shattered knee and what it means for their relationship to sports.

“Oftentimes with these kids, it’s a huge part of their identity,” said Todd Weitzenberg, a doctor of physical medicine and rehabilitation sports medicine at Kaiser Permanente Santa Rosa Medical Center. “Whether or not they’ll return to sport is in question. The ligament can’t be repaired; it must be reconstructed. The recovery takes nine months to a year, so they basically lose a year of their sporting life.”

What troubles a lot of health professionals and coaches is that these injuries appear to be increasing in frequency. ACL tears are the skinned knees of the 21st century.

A study published in Pediatrics, the official journal of the American Academy of Pediatrics, in March 2017 found an increase of 2.3 percent in ACL tears among patients aged 6 to 18 over the previous 20 years. The jump was most noticeable in females 6 to 16 and males 15 to 16. Another study, conducted in the state of New York and written up in the American Journal of Sports Medicine in March 2014, reported an increase in ACL reconstruction surgery among 3- to 20-year-olds from 17.6 per 100,000 in 1990 to 50.9 per 100,000 in 2009.

There is some skepticism about these studies, because their data is based on medical procedures and/or insurance billing. It is possible that it’s not the rate of ACL tears that is rising, but rather the ability of doctors to diagnosis the injury, or the likelihood of parents and young athletes to opt for surgery.

“Twenty or 30 years ago, if you injured your knee as a high school football player, you may have gone to see a pediatrician and they’d say, ‘Yeah, your knee’s busted,’ and might not have looked further,” said Christopher Walter, a doctor of osteopathic medicine (he also has board certification in sports medicine) who works for St. Joseph Health Medical Group and has offices in Santa Rosa and Petaluma. “Maybe there’s no MRI, and your career’s over. I see guys with arthritis every day who grew up in the seventies or eighties. They’ll say, ‘Oh, yeah, I injured my knee playing football.’”

But Walter, like a lot of medical professionals, believes ACL tears are indeed becoming more common among pre-college athletes. It makes sense, for several reasons.

Most data suggest that participation in youth sports increased steadily over the years, peaked around 2008, and has been in decline since then. But the intensity of that participation is revving high. More and more kids are playing sports year-round, supplementing (or replacing) their high school games with club competition and, for some, college ID camps. The adults around them are placing ever more importance on achievement, and at younger ages, with the not-always-realistic promise of college scholarships as subtext.

Walter is fully in favor of neuromuscular training for young athletes, but added: “If you need a neuromuscular program to play youth sports, have we pushed it too far? Because they should be playing to have fun. You shouldn’t be treated as a professional athlete when you’re a 6-year-old lacrosse player.”

And compared to previous generations, more young athletes are focusing on a single sport.

“Maybe by the time they’re in high school you can see becoming focused on one sport,” Weitzenberg said. “Even then, I would encourage them to be multi-sport. But I think it’s an absolute travesty in younger athletes. You see it in 9-, 10-year-olds. I think parents are really doing an injustice to these children.”

None of this push for perfection is ideal for maturing bodies. The knee joint, which bears much of the load in running, cutting, jumping and landing, is particularly vulnerable to repetitive, high-intensity movement. And that’s especially true in girls. As Weitzenberg explained, girls tend to have wider pelvises, which create a different angle in the knee, and, post-puberty, are affected by hormones like relaxin that can loosen ligaments. Compared to boys the same age, they may also have received less training in proper technique.

It would be healthier for all underage athletes to play multiple sports, and to take time off between seasons. That’s not where we’re currently headed.

But there are ways to mitigate. Andrew Ziemer, program director of the SR United soccer club, said an obvious place to start is proper maintenance of playing surfaces. He also subscribes to sports periodization, which emphasizes a year-round schedule that builds in non-competitive training periods. Ralph Montes, director of SR United’s girls teams, said the club requires three days between games — one day of full recovery, another at 60 percent of full effort or less, and one more day of harder practice.

Last fall, Ziemer mailed a videotape and letter to every high school soccer coach in the area, urging a higher priority for conditioning and safety. Over the previous two years, Montes said, there were a total of 13 ACL tears among high school girls during the local soccer season. This year, there was one.

Ligaments will always be vulnerable to one football player crashing into the side of another’s leg. But 70 percent of ACL tears come in non-contact situations. That’s why doctors, trainers and coaches are increasingly focused on exercises to strengthen the knee.

Weitzenberg is at the forefront. Working with two physical therapists from San Jose, he designed a regimen of exercises meant to stabilize the leg by adding strength and flexibility to the muscles around the knee and hips. He put the entire program on the Kaiser Permanente website. It’s free to anyone, and includes videos of all the movements.

Weitzenberg, who grew up in Santa Rosa, regularly visits school and club teams to spread his gospel. He is convinced that all middle schoolers should be doing similar exercises in PE.

“Somewhere around 12 or 13 is the ideal age. As early as sixth grade,” Weitzenberg said. “Their bodies are maturing from child to adult; their athletic activities are going from fun to competitive. That’s really when effort begins to occur. It’s like helmets and seatbelts. If you make it part of a kid’s life early, it’s not a burden.”

It’s a hard sell, though. The exercises don’t offer full benefit unless the athlete does them consistently over time. Weitzenberg’s site recommends that many of the drills be done four times a week for six weeks before the season begins, then three times a week in-season. And there are a lot of them. The doctor empathizes with his target audience.

“They’re teenagers,” Weitzenberg said. “They’re busy. They’re practicing, studying, trying to get into college. And they’re teens. They just don’t want to do it.”

He is trying to develop an app that would remind kids to do the exercises, and ping them in some way when they do. He also has learned to tailor his message, reminding the athletes that his program will help them become better soccer players, not just healthier ones.

“It improves balance and coordination. No matter what sport,” Weitzenberg said. “It improves speed, jumping ability, agility tests. You can market the program to coaches and parents as a safety measure, but to market to athletes, you have to sell it as performance improvement.”

Another reason for optimism: The technology and surgical procedures are getting better. Replacement ligaments must be grafted onto the bone, and the location and fixation techniques of those grafts have improved since Walter finished his residency a decade ago.

“When we reconstruct a 16-year-old’s ACL, I want that to be the last time,” he said. “And that’s a big ask. I want that surgery to last longer than my career.”

The rehabilitation process is evolving, too. Weitzenberg said doctors used to recommend a nine-month rehab. The standard rule of thumb is now a year. And the focus has become more holistic.

“Obviously, there’s a decrease in strength because of muscle atrophy on the affected side,” Weitzenberg said. “Now we’re seeing weakness on the other side, too. And that’s the side they’re relying on. Because of a lack of exercise, they’re blowing out the other side, too.”

McGarva rehabbed for about nine months after his first operation. He was a model patient. But he acknowledges now that he may have returned to basketball too soon.

McGarva loved the game with a passion. A couple weeks before his first ACL injury, a coach informed the boy he’d be playing with the varsity squad as a sophomore. He had realistic dreams of being the star of the team by the time he was a senior. It all vanished. And yet McGarva doesn’t sound at all bitter about his setbacks. He was school president as a junior, and he worked 20 hours a week that year to squirrel away some money. He has taken multiple AP classes and has dabbled in art and choir.

“I loved everything I’ve done,” McGarva said. “Honestly, I’ve had a pretty easy life besides this. It really helped me realize there are other things out there. I always sort of knew I wouldn’t play much past high school. So this has been great for me. The only thing I kind of regret is I wish I took it a little slower after that first recovery. Long-term, I don’t know what the repercussions will be.”

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