When Michelle Pullano saw her daughter sink to the field during Wahconah High School's soccer game against Mount Anthony in late September, she released her anxiety by pulling on the hair of Stefanie Curry.
Michelle looked at Karen Tonelli, who knew exactly how Michelle felt, having watched her daughter's season end the year before. A little farther down was a Mount Anthony parent, who had met Pullano while their daughters underwent surgery just one earlier.
All four of their children had their 2008 seasons ended by torn anterior cruciate ligaments. Elaina Pullano, currently a junior, had just suffered her second ACL tear, a knee injury that is more common among females.
"I think it was just too much bad energy in one place," her mother said.
Elaina had formed a bond with Jill Tonelli and Aliah Curry during rehab the year before.
Tonelli was a senior captain, forced to sit out the end of her career. Curry and Pullano were sophomores looking to make their way back. The three Wahconah teammates dubbed themselves ACL Nation and wore matching T-shirts as they sweated through rehab sessions.
It was a reminder that they weren't alone.
Before doing research on their injuries, the trio had no idea how big the nation was.
According to the Centers for Disease Control and Prevention, 30,000 U.S. females under age 19 tore their anterior cruciate ligaments in 2006, while a 2008 study by Dr.
"Compared to injuries like sprains, they're not as common, but it's one of the most serious injuries that we see a significant number of," said Dr. Irene Davis, the director of research at Drayer Physical Therapy Institute, a group of 40 physical therapy centers across the country.
Take a look around, and it's not hard to believe.
When Elaina Pullano was at Berkshire Medical Center getting prepared for surgery this past October, the anesthesiologist said his sister, a gymnast, had torn both of her ACLs. Another doctor, a skier, had done the same to each of hers.
"They're a statistic," said Stefanie Curry, Aliah's mother. "It's an awful thing to say, but it's true."
The ACL is one of the four major ligaments in the knee. It connects the tibia (shinbone) to the femur (thighbone) and provides stability to the knee. The ACL's main purpose is to limit excessive twisting of the knee joint.
The ligament isn't stressed when running straight ahead -- only when an athlete pivots, twists and turns. It can be injured either by direct contact or when an athlete twists the knee with too much force.
Dr. Mark Sprague, a surgeon with Berkshire Orthopedic Associates Inc. in Pittsfield, said most studies indicate that female athletes are between two and eight times more likely than males to tear their ACLs. He tells his patients the likelihood is four times as great. Meanwhile, some studies say a female's likelihood can be 10 times greater.
If there are different opinions on the numbers, there are even more possible reasons.
Davis listed four factors -- hormonal, neurological, structural and bio-mechanical (body mechanics).
Some studies have linked the greater frequency of ACL injuries to a woman's menstruation, while others have measured slightly slower reflexes in girls than in boys.
Most, however, have focused on the difference in physiques.
Doctors have noted that the ACL can be narrower in females and that the notch between the femur and tibia is slimmer, which causes more stress on female ACLs.
Women also have wider hips and less muscle strength there -- often creating a knock-kneed effect that can put constant strain on the ACL -- and they're more flexible, resulting in loose ligaments. They also have less strength in their hamstrings, a muscle that greatly reduces the strain on ligaments.
Since Title IX was enacted in 1972, granting women equal rights in the sports world, the level of play has skyrocketed. So have the injuries.
Brian Duquette, a physical therapist at Berkshire Physical Therapy and Wellness in Pittsfield and Dalton, said he blames the year-round sports cycle for part of the increase.
Pullano played soccer for her high school and for a club team and also competed in track. Her mom estimated she's played in 500 soccer games during her lifetime.
Curry, meanwhile, plays high school soccer and basketball, and competes on the club circuit in basketball.
"You look at the club soccer, and you're talking five or six games in a weekend," Duquette said. "Do you really think they're stretching, warming up, cooling down between all of them?"
Dr. James Parkinson, an orthopedic surgeon and the director of sports medicine at Williams College, said he thinks much of the difference lies in muscle.
Calling muscle the first line of defense against injuries, Parkinson said males tend to have more muscle, both because of physical differences and social ones.
Males produce more testosterone and bulk up naturally. They also traditionally spend more time lifting weights and begin resistance training at an earlier age.
While strapping men often are considered the epitome of sex appeal, in women, slender often is seen as more attractive. Female athletes may be well-conditioned, but their muscles tend to be smaller.
"Most women don't want to bulk up and look like Schwarzenegger," Parkinson said. "Since Title IX, women have escalated their spirit. They compete just as hard as the men. They have the same drive. The sports are just as strenuous. But the strength has lagged behind."
Sprague agreed that there's a societal reasons for the difference as well as anatomical ones.
Because boys are brought up to play sports more regularly, he said, they learn how to control their bodies better, allowing them to land more softly and instinctively have a better idea of body position.
"We're in a society where girls, at the age of 4, get dolls and boys get soccer balls," Sprague said. "The good thing is, with Title IX, we should eventually catch up."
Sprague said his belief stems from studies that indicate females can reduce the threat of an ACL injury by training their bodies.
It's an effort that is beginning to catch on with physical therapists such as Duquette. He served in that capacity for four Wahconah students -- all females -- who tore their ACLs in a three-month span last year. He said that in his nine years of performing physical therapy, he's seen about 100 ACL tears.
"If I'm overestimating that number, it's because there were times it felt like that's all that I did," Duquette said
The injuries sparked his development of an ACL Injury Prevention Camp that he ran last summer in Dalton, focusing on training the body to jump and land properly, increasing hamstring strength, and recovering from awkward positions.
Duquette, however, quickly got a reminder that there's no full-proof way to avoid the injuries. Two of his campers are back after reinjuring their ACLs.
The silver lining is that the local surgeons believe the difference will begin to even out.
As women's sports become more competitive and more popular, girls likely will start playing at an earlier age. In order to make teams, weight training won't be optional. As society begins to value the female athlete as much as the male, putting athletic equipment in a girl's crib will become more commonplace. And as trainers learn more about how female bodies react to heavy athletic schedules, they'll aim to improve methods of injury avoidance, as well as recovery.
Davis, however, said it's important that athletes be taught proper techniques before the injuries occur. At the youth level, coaches should be teaching injury fundamentals as well as athletic ones.
"We need coaches to get educated on proper mechanics," Davis said. "We need coaches to teach athletes the proper way to land, how to land lightly and in control, how to land with your knees in the proper position, and how to control their bodies. We should be doing it early on in their development, as soon as they start to play. With training, we can change the recent pattern."
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