ACL Injuries and the Fitness Competitor
by Carla Sanchez, C.S.C.S. and IFBB Pro

Watching a fitness competition it becomes evident the high level of training these athletes commit to year round. Their bodies are super lean, athletic, and sculpted with shapely, powerful muscle. In addition to physique training, fitness competitors must also focus on performance routine training. For the fitness routine round, the competitor is expected to execute strength skills with precision, effortlessly transition from one move to the next, perform powerful tumbling passes and dazzle the judges with high-energy, creativity and charisma!

Fitness competitors are consistently working on improving their fitness routine performance by adding more technical strength skills, entertaining dance moves, impressive gymnastics skills, and improved flexibility. So, considering the intense training it takes to become a top notch fitness competitor, a serious knee injury would be devastating.

Unfortunately, however, you all probably know a female athlete who has injured her anterior cruciate ligament (ACL) of the knee. In the fitness industry alone, there are many who have sustained this injury, including myself. As a matter of fact, I have had the unfortunate experience of tearing mine three times and subsequently have undergone four knee surgeries.

My first ACL injury was before my very first IFBB Pro Fitness competition. I competed throughout my pro fitness career battling knee injuries which was challenging and painful.  But with a few modifications to my routine and with creative training, I was able to continue performing and competing. Call me stubborn, but despite the pain and training restrictions, I simply didn’t feel like quitting! I stuck with it and just four months after tearing my ACL the third time, I won the 2-minute round at the 2002 Pittsburgh Pro Fitness Championships!

After the third tear, I began wearing a knee brace and chose not to have surgery again to repair it. It’s very uncommon to injure it as many times as I have, but it is common for female athletes to have more ACL injuries than males with gymnasts leading the injury list.

So why are female athletes more susceptible to an ACL injury? I never imagined the possibility of injuring my ACL! Just like you probably haven’t either! I was always a healthy athlete, even played college basketball, and had never experienced a serious injury until that first ACL tear. At the time of injury I considered myself strong, flexible and agile. I didn’t know that female athletes were more susceptible to an ACL injury so I never considered followed a training prevention plan. In hindsight, if I had followed a training prevention plan, perhaps it would have saved me from several painful surgeries and months of rehabilitation! Remember, an injury can happen to anyone, at anytime. Do what you can to stay healthy and protect your knees!

Pop Goes the ACL

The ACL connects the femur to the tibia at the center of the knee. It is responsible for limiting rotation and forward motion of the tibia, a very important function for a fitness competitor! For the most part, torn ACLs are considered “non contact” injuries. They usually occur during:

1) Planting and cutting moves

2) Straight leg landing from jumps

3) Pivoting with hyperextension

Planting and cutting moves, jumps, and pivots are quite common while performing a fitness routine. If the ACL is injured, the athlete will usually hear a loud “pop” and experience significant swelling within the knee, thus making immediate medical care imperative. It is known in the medical literature that ACL deficient knees or reconstructed ACLs have 105 times greater chance of developing osteoarthritis.

The surgery requires reconstructing the ACL with either a patellar tendon, hamstring tendon or allograft tissue. The surgery is costly and the recovery period is generally six to nine months long, with the first month being the most painful; physically and emotionally. In addition, the loss of muscle tone and sport-specific training, puts a fitness competitor at least a year away from competing again. Given the financial, physical and emotional stress that an ACL injury can incur on a competitor, prevention is crucial.

Why Are Female Athletes More Prone to ACL Tears?

Why does gender make a difference? According to the medical statistics, if you’re a female, you are more susceptible to an ACL injury. Several studies clearly show that in sports that place a significant demand on the ACL such as; basketball, soccer, cheerleading and gymnastics, ACL injuries are up to ten times more common in women than in men. There are many hypotheses as to why women are more prone to ACL injuries than men. They include:

1) “Q” Angle of knee: The Q angle refers to the quadriceps angle or the angle between the hip and the knee. Women’s hips are wider so the femur [upper leg bone] comes down to the knee at a sharper angle, placing additional stress on the ACL.

2) Anatomy of the notch inside the knee: On average, women have a slightly smaller ACL and the place where the ACL passes through the knee joint, the intercondylar notch, is slightly smaller. These anatomic differences may account for a greater susceptibility to ACL injury.

3) Hormonal variations: Ligaments, like many other tissues, are affected by hormone levels in the body. Estrogen makes ligaments looser. One small study found a higher rate of ACL tears around mid-cycle
(days 10-14) when estrogen levels peak. Women on oral contraceptives are thought to have a lower rate of ACL injuries than women not taking oral contraceptives.

4) Loose ligaments: In general, women have looser ligaments, possibly increasing ACL injury.

5) Pivoting Tactics: Women turn and pivot in a more erect position. Bending at the knee and hip reduces ACL stress.

6) Jump Landing Tactics: Women do not bend their knees as much as men when landing from a jump. This increases knee joint pressure.

7) Weaker hamstrings: This is the most probable theory leading to a higher incidence of ACL injury in women. Together the quads and hamstrings help stabilize the knee. The quad muscles are an ACL antagonist, placing stress on the ACL when contracting. The hamstrings are an ACL agonist, removing ACL stress when contracting. If the hamstrings are excessively weak or inflexible, they may not adequately protect the ACL during a strong quad contraction.

Also, if the quads are excessively strong relative to the hamstrings, the ACL may be torn due to a lack of hamstring protection. Women tend to use their quads more then their hamstrings when landing and changing direction which can lead to an ACL tear. It’s very important to realize that anyone, whether you’re male or female, whose quadriceps are significantly stronger than their hamstrings may be highly susceptible to ACL injury!

Training Prevention Plan

Fitness competitors should routinely work with a Strength and Conditioning Specialist and/or a Pilates instructor to be analyzed for any body misalignments and/or muscular imbalances. Together with your trainer create a training prevention plan with the following tips in mind:

Train Hamstrings: Hip extensions, straight leg deadlifts, seated, lying and kneeling leg curls should be incorporated to strengthen the hamstrings.

Avoid the Leg Extension Machine: This machine, which is an open chain exercise (feet not in contact with the floor), can apply shearing forces to the knee, making it more susceptible to knee injuries.

Integrate Strength Training With Balance: Incorporate the stability ball, wobble board, dyna disc, and BOSU ball.

Practice “Closed Chain” Exercise: Exercises such as squats and the leg press are examples of closed chain exercises. These types of exercises keep your foot in a closed position, i.e., in contact with the floor. This incorporates the use of more muscle groups while lessening the forces on the knee present in open chain exercises such as the leg extension.

Practice Plyometrics: Plyometrics teach proper jump landing mechanisms and are an excellent way to achieve sufficient hamstring strength.

Occasionally Train Barefoot: Training barefoot enhances proprioception, which helps prevent injuries.

As a fitness competitor, fitness routine conditioning should be a year-round event. However, even a highly conditioned competitor is not necessarily protected from an ACL injury if the training technique is insufficient or the training environment is inadequate. You can be a superior fitness competitor but if you are practicing your routine at the end of the day when most sport injuries occur, you may still be injured. In addition, if you’re regularly tumbling or practicing fitness skills on a hardwood floor, you may be putting yourself at a higher risk of injury.

In the event that you do tear your ACL, most athletes opt for surgery. Post-operative therapy will initially focus on obtaining full range of motion, followed by a rigorous strengthening program. Typically the athlete is allowed to run in a straight line at three months post-operatively, while pivoting and cutting exercises are usually not allowed until six months after surgery. Always get your physicians approval prior to returning to fitness routine training.

ACL injuries are a serious problem for a fitness competitor but can be prevented! Don’t take your health for granted and follow the recommended measures to insure the health of your knees and in turn you’ll have a successful and fulfilling fitness career!