It was just another normal game day for 16-year-old defender Sammy Kleedtke. She pulled on her Michigan Hawks soccer jersey, laced up her cleats and slid in her shin guards before taking the field to play the game she loved.
It was the spring season of club soccer in her junior year of high school. Kleedtke was a staple of her team’s defense and during her sophomore year had committed to play at UW-Madison.
At one point in the game, Kleedtke was defending against a player who was dribbling the ball down the sideline toward the goal. Suddenly, her opponent cut inside to go to the goal, and Kleedtke turned with her, as any good defender should. As she turned inside, Kleedtke felt her knee crack, and she landed strangely on the ground.
It was still cold out, as it was only April in Michigan, and Kleedtke later realized the crack was really a pop — a telltale sign of a tear of the anterior cruciate ligament, better known as the ACL.
Kleedtke’s story is like those of many other young female soccer players. Compared with their male counterparts, female athletes are 2 to 9 times more likely to tear their ACLs, according to a study published in the U.S. National Institutes of Health’s National Library of Medicine in 2013. Not only that, but involvement in high-risk activities, especially volleyball, basketball and soccer, increase the chances for a woman to tear her ACL.
At the time Kleedtke tore her ACL, she was the first person on her team to do so. Now, she plays Division I soccer at UW-Madison, where a number of her current teammates have also torn their ACLs and gone through the same process as she has.
The ACL is one of four ligaments located in the knee, and it’s responsible for stopping the shin bone, or the tibia, from sliding out from beneath the thigh bone, or the femur. For athletes, the ACL is crucial to movements such as stopping, pivoting, jumping and landing — all critical to the sport of soccer.
While people of all ages are able to tear their ACL, people in high school and college are more likely to injure it simply because there are more of them doing high-risk activities, namely athletics, during this time in their lives.
There are a few reasons for why women are more likely to tear their ACLs, says Joseph Puccinelli, an orthopedic surgeon who works at Beaver Dam Community Hospital in southeast Wisconsin. Women tend to be more elastic than men, and the angle of their hips to their knees is greater, which makes the ACL more likely to rupture.
Puccinelli adds, “And you can take this with a grain of salt … I’m just telling you what the literature says — men tend to be more physically stronger. In other words, they have more defined muscle mass in their legs.”
When looking at ACL tears in sports, soccer is a standout. Puccinelli believes this is due to soccer players wearing cleats and playing on turf, which makes the foot relatively fixed to the ground, allowing the knee to hyperextend. Not only that, but the intense play at full speed increases the chance for player-to-player contact.
Because of the increase of ACL tears in soccer, female players are attuned to the signs and symptoms, namely a pop felt in the knee, followed by immediate pain and weakness in the knee.
Lindsey Brinza, an athletic trainer for women’s soccer at UW-Madison, says players know when they have torn their ACLs.
“A lot of times I’ll run up to them, and they’ll be like, ‘I know what I did,’” Brinza says. “And then they just break down. It’s one of those injuries that you hear so much about in the sport, that they know what it is when it happens.”
In the spring of 2015, Claire Shea, now a junior midfielder on the UW-Madison women’s soccer team, tore her ACL in a high school game. She vividly remembers the injury.
“I knew, but everyone else kept saying, ‘You don’t know, wait until you get the MRI,” Shea says. “And I was just like I know, I know. I know my body. I know the sport. I know what it is.”
Coaches have also have become accustomed to the signs of an ACL tear in women’s soccer. Often the player will go down hard and remain on the ground holding their knee.
Don Arnold, the varsity high school coach for men and women’s soccer at Grafton High School, located 30 minutes north of Milwaukee, says it’s never good to see a player go down and immediately cling to her knee. But, what happens next is critical from a coach’s perspective.
Arnold makes a point to discuss the future with his players and asks pointed questions.
“If this is something that you want to get back to…it’s going to take hard work. It’s nothing that you can just throw some ice on and be fine in two weeks,” Arnold says. “What is the plan to get back to wherever you need to be? Whether it’s being a soccer player again, just being athletic, or just being able to walk without having any pain.”
For many players like Kleedtke and Shea, the answers to Arnold’s questions are surgery and rehab.
While an athletic trainer may perform the Lachman test, commonly known to athletes as the ACL test, on the field to test for a tear, players must go see an orthopedic surgeon in the days following the injury to have the test confirmed with X-rays and potentially an MRI. Then, the orthopedic surgeon works with the athlete to determine which type of ACL reconstruction surgery is the best option.
“A lot of times in orthopedics, we do what is called implant matching, where there is no right answer. We’re designing custom surgeries based on the person’s lifestyle needs, their health and a whole other list of facts,” Puccinelli says.
For Puccinelli, the preferred ACL reconstruction option for young athletes is to take a graft from their own body, rather than using a cadaver or synthetic graft, as it has a much higher healing rate. Grafts can be taken from the hamstring, the Achilles tendon or the patellar tendon, which connects the kneecap to the shinbone — with the patellar tendon being the most common option.
After surgery, the nine- to 12-month journey of rehabilitation begins. Directly following surgery, most athletes are on crutches, keeping weight off their knee and simply working to manage the swelling and pain. Once off crutches, UW-Madison athletic trainer Brinza says the first thing they focus on is walking normally, as their walking pattern may change after surgery. Strength training of the quadriceps, hamstrings, calf, gluteal and abdominal muscles follows. Next, functional work such as step-ups, lunges and squats are integrated, followed by more sports-related exercises. For female soccer players, this includes running with a ball, cutting through cones and jumping correctly.
Kleedtke and Shea recall how physically and mentally tough the rehab process was. Loneliness and isolation are common feelings during the course of the rehab period, as it is often done one on one with a physical therapist or athletic trainer.
“I’m not a person to show my emotions very much, and during those first couple months, I cried so much,” Kleedtke says. “It’s probably the saddest I’ve ever been.”
While players like Kleedtke and Shea know they will come back to play, the process is still a long and hard one. Arnold suggests that one of the best ways to stay motivated is to continue coming to practice and doing exercises while the team plays, but sitting on the sidelines is never fun.
“It’s hard for the athletes to always say how mentally taxing it is on them,” Brinza says. “You’re not playing but still have to put in an hour to two hours a day of rehab, strength training and functional work.”
The passion for the sport and the desire to play are the primary motivations for many players. Shea notes that while the team and coaches can be sources of encouragement to get back, the dominant motivators are a personal love of the game and craving to play again. Those around you can cheer you on during the rehab process, but Shea believes you have to want it for yourself.
As the rehabilitation process wraps up, the athletes begin to experience a mix of emotions, namely excitement and nervousness, as they anticipate the first game back.
“I was really excited, definitely a lot of nerves, but definitely more excited than anything to be back out there because it had been so long since I had played a game,” Kleedtke says. “I was a little scared at first, going into tackles for sure … [but] I wasn’t too afraid to play.”
From a coach’s perspective, Arnold says he always sees some hesitancy in that first game back. He adds that this hesitancy and fear usually continues until the player gets knocked down for the first time. Once they get back up and realize they’re OK, those feelings disappear.
Even after coming back, fears of reinjuring the ACL, or the other ACL for that matter, still remain. Athletes are encouraged to lift weights to strengthen their muscles, specifically their quadriceps and hamstrings. The UW-Madison women’s team regularly incorporates a dynamic warm-up into their routine to loosen up their muscles before hitting the field, which serves as a form of preventive training.
While work like this is being done at the Division I college level, Kleedtke wishes that more emphasis had been placed on preventative ACL tear training when she was younger. With so many young female soccer players tearing their ACLs, combined with their changing bodies and predisposition for ACL tears, Kleedtke feels that simple preventative exercises at a young age is a no-brainer.
Apart from coaching men and women’s varsity soccer at Grafton High School, Arnold also coaches a U-11 girls’ team for the local soccer club. With those players, Arnold uses some simple exercises to strengthen the hips and muscles that keep the knee from bending in during practices.
“It’s inevitable that you’re going to have an injury — it’s athletics. You never know when it’s going to be your last time playing,” Arnold says. “But you know, if you can do something, even so small for five minutes at practice, it may benefit one of them some day.”
Despite playing a high-risk sport like soccer, combined with a high susceptibility to injuring the ACL, female soccer players continue to play the game they love, regardless of the threat of injury.
“You really can’t control whether or not it happens, so trying not to worry about it is honestly the best chance you have of not being nervous,” Shea says. “There’s a lot you can do for preventative work, but at some point, you just have to play the game.”