Random Thoughts from a Restless Mind

Dear Coaches and Parents,

For more than 30 years I have had the good fortune to be a volunteer assistant coach for boys and young men playing football, basketball, and lacrosse, sports I played in high school and/or college. In this capacity I became very familiar with the particular dangers of concussions suffered while playing these contact sports. Indeed, one of my sons suffered a severe concussion as a high school lacrosse player, effectively ending his competitive career. I applaud the recent efforts being made at all levels of competition, especially in the area of gratuitous headshots in football, lacrosse, and hockey.

As a fitness coach for the last 10 years or so I’ve learned of another, all too common injury in sports, one that is disproportionally concentrated in the younger athletes: ACL tears in girls and young women. There is a veritable epidemic of ACL injuries in soccer, basketball, and volleyball. Girls are 4-6X more likely to tear their ACL playing these sports than boys. The numbers are quite simply appalling, and yet I hear not a word about this from any media source. Girls are being felled by this injury in droves but it seems no one is talking about how to prevent it.

Can anyone tell me why that is?

It’s not like this is a new phenomenon. A brief Google search turns up academic articles published in 1999. It’s also not as if these injuries are only of historical importance. The daughter of a friend was the third girl playing the same position for the same U17 soccer team for the same coach to suffer a non-contact ACL tear in 2015. Nor were they the only girls on that team so afflicted. When asked what changes had been made by the team or the coach in response to these injuries my friend shook his head. Crickets.

Can anyone tell me how this is OK?

The answer, of course, is that it is not OK. Not even a little bit. The causes underlying the increased risk to suffer an ACL tear in which a female athlete does not come into contact with another player are relatively well known. Studies have been done examining the way girls jump and land. As it turns out, girls tend to change direction and land with an outstretched, straight leg. Boys, on the other hand, do so with a flexed leg, reducing tension on the ACL.

If you watch girls running you can’t help but be struck by the valgus position of the knee when their foot lands on the ground; the knee is markedly inside the foot.  Girls tend to have stronger anterior muscles and therefore tend to be quad-dominant runners. They pull their upper leg forward through the contraction of the thigh muscles. Boys, on the other hand, are posterior chain-dominant runners, pulling their legs up through the contraction of their glutes and hamstrings. Without a strong posterior chain to counteract the effect of the quadriceps, the ACL is again under increased tension, magnifying the risk caused by knee position.

We know why the injuries occur, and as it turns out we also know how to prevent them, or at least reduce their frequency: teach young female athletes safer movement patterns, and put them in strength and conditioning programs that specifically train their posterior chain. If you see this type of training you will recognize it immediately: it’s how we train boys.

Can anyone explain to me why this is not occurring with young female athletes right now?

Even at the highest level of women’s sports we still see non-contact ACL injuries. For example, in 2011, 6 of the 21 members of the U.S. Women’s National Soccer Team had suffered an ACL tear at one point in their careers. However, in more recent years there has been a decrease in these injuries at the professional level because teams are training their female athletes in better neuromuscular recruitment patterns, which creates sounder movement. Athletes are doing strength and conditioning programs that emphasize strengthening their glutes and hamstrings. Hence, we are seeing dramatically fewer ACL tears at the highest levels of women’s sports. There is no way to justify not doing the same thing for girls early in their careers.

Proven templates already exist to do just this. Simply utilizing the off-the-shelf PEP program of stretching and plyometrics has demonstrated meaningful decreases in the incidence of ACL tears. Rather than use such a basic program when it comes to high quality movement patterns, why not look to someone like San Francisco’s Dr. Kelly Starrett? The founder of Mobility WOD and author of “The Supple Leopard”, Dr. Starrett is a consultant to dozens of collegiate athletic departments. He recently took over training for an elite 150-member girls volleyball program with the specific aim of reducing ACL injuries in those athletes. His teachings on proper movement mechanics are peerless, as a quick perusal of his book will attest. Perhaps we should be looking at what he is doing.

Jeff and Mikki Martin have been training kids in Southern California, the epicenter of youth soccer, for well over a decade. Their protocols include meticulous attention to the type of mechanics taught by Kelly Starrett and emphasize the importance of strengthening the posterior chain beginning around age 10. As the developers of the original CrossFit Kids program and more recently founders of The Brand X Method™, they have trained hundreds of young girls who play soccer without a single one of their athletes suffering an ACL injury while under their care. They arguably have the longest track record of successfully and safely training youngsters. Perhaps we should be looking at what they are doing.

One thing is for sure: it is not OK to continue with the status quo. Simply doing what you have always done is nothing less than condemning a high percentage of your girls and young women to suffering an ACL tear and all that goes along with it. The nature of the sports in which we see an epidemic of concussions is such that the only way to prevent them is not to play those sports. This is not the case with non-contact ACL tears in soccer, basketball, volleyball and other sports played by girls. Prevention is possible through the institution of training programs that emphasize the teaching of new, safer movement patterns, as well as strengthening the muscles of the posterior chain.

I’d like to propose a 3-part solution to this problem. First, we would like to offer training to coaches in how to teach better basic movement patterns. One of the most fundamental goals for those of us who utilize The Brand X Method ™ to train kids and teens is to create a cadre of coaches who can do this. We hope that this can become a core part of in-season team training. Secondly, we wish to make available our coaches, and coaches who share our concerns and philosophy, to train your athletes to have a stronger posterior chain. The data supporting the inclusion of weighted squats, deadlifts, and power cleans both in season and out of season is compelling. Our coaches are experts in teaching the proper mechanics involved, and our athletes progress in a safe and measured fashion.

Lastly, the data supporting the inclusion of full-body functional movements executed at relatively high intensity is equally compelling when it comes to not only injury prevention, but also in developing stronger, faster, more durable athletes. The Brand X Method ™ is a proven program that emphasizes proper mechanics and safety. It is the latest version of a program that has been creating highly athletic youngsters and teens for more than 10 years. This type of physical fitness directly translates to more capable and confident athletes in all of the sports mentioned. At CrossFit Bingo our Alpha X Youth Athletics program is available to train your athletes all year round, either individually or in team settings.

It’s time we all start talking about these non-contact ACL injuries in girls’ sports, just like we have been talking about concussions in boys’ sports. Parents should be asking what is being done on behalf of their daughters. Coaches should be committed to stopping the epidemic of non-contact ACL injuries in their female athletes.

We can help.

Darrell E. White, M.D.

Co-Founder, CrossFit Bingo

Co-Founder, Alpha X Youth Athletics

Among the many things that I have called over the course of my lifetime, none has been more meaningful than “Coach”. I spent time on the sidelines and on the bench for about 10 years coaching junior high school sports.  When my own children moved on to high school sports I retired to the committee rooms and the grandstands where adults who don’t coach play their role in youth sports.

There are three roles that adults can and should play in youth sports. First and foremost, all adults who are involved in youth sports should have as their primary goal the safety of the children playing the games. Secondly, kids who play sports should be guided by the adults around those games, taught by their elders not only about the games but also taught the life lessons that one can glean from playing sports. Finally, we ARE talking about kids here; the last important role that adults have in youth sports is to make them FUN!

Let’s start by talking about safety.

I suppose we should probably define youth, huh? There’s not much to debate the inclusion of grade school or junior high school kids. Sure, reasonable people can disagree about the importance of playing time and, when to start cutting kids and when to start playing to win, but through eighth grade there is simply no question that these kids would be considered in the “youth” category. In some quarters it might be a little more dicey with high school athletics, but when it comes to safety I don’t see how you can separate high school kids from their younger brothers and sisters. Protecting ALL of these kids is job number one for every adult involved in youth sports.

A quick word about college sports: the brightest, clearest dividing line between youth sports and sports as commerce, or job, is clearly the line that separates college and other athletic programs aimed at very young adults, and professional sports. But even here that line might be a little fuzzy. There are reasonable people who would say that Division I athletes on scholarship are de facto professional athletes. I suppose I’d feel a little more comfortable with this if a larger percentage of these young men and women went on to earn a living from their sport after college. Certainly we can agree that divisions II and III in the NCAA would still constitute youth sports, don’t you think? For my mind only the most cynical among us would draw a line between divisions I and II when thinking about the safety of the athletes.

So, how do we ensure the safety of our children when they are playing sports? It starts at the very top with league commissioners and athletic directors. Every organization that sponsors athletic competition with youth participants, be it a league or a school or some other organization needs to be clear from the outset that job number one is keeping children safe. Commissioners need to set clear guidelines, rules that will be enforced that put safety first. No spearing in football. Elbows in on the basketball court. No head shots–not a SINGLE headshot–in hockey or lacrosse.

Each one of these directives needs to be clearly communicated to the athletic directors or program directors responsible for individual schools or teams. These men and women in turn need to hire or appoint coaches who will make it their primary mission to teach the children in their charge how to play the game safely. Not only must the coaches do this on the practice field, but as they roam the sidelines and pace in front of the bench they must bring this to the games as well. How many times have you been in the stands and cringed when a defensive coordinator screamed at his players, exhorting them to “take someone’s head off?” I can’t count the number of times I’ve been sick to my stomach watching a coach dance with glee as a long pole defenseman stands over the attackman he cross-checked in the back of the head. No amount of teaching in practice can withstand this type of “coaching”.

During games coaches need to look first to the well-being of their players; only after assuring that they are okay can winning and losing enter the equation. I’m certainly not proud to admit this, but I remember one clear instance where I probably should have kept a star athlete on the sidelines during a football game. I actually had my very favorite coaching job–I was the assistant to the assistant to the assistant backfield coach, responsible only for catching the kids doing something right and praising them for when they did. But I was the quasi-team doctor as well, and when our star halfback limped off the field with a sprained ankle, I really probably should have overruled the head coach, the offense coordinator, and the young man’s father and kept him on the sidelines, at least a little bit longer. Coaches need to allow themselves to be trumped by trainers and doctors.

The ultimate arbiters of safety, however, are the officials on the field. Whether it’s grade school, junior high school, high school, or even college sports, the officials who enforce the rules must make the safety of the participants their primary concern. Oh, I know, I know, the officials are supposed to be invisible, doing everything they can possibly do not to impose themselves on the game, not to affect the outcome of the game. The players should win or lose; the officials should not take a role. Blah, blah, balh. All well and good, until the retaliation for the retaliation for the initial hard tackle from behind results in a three ligament knee tear for that girl who was just about to get that shot off in soccer. All well and good, until they’re wheeling the center off on a stretcher, unconscious from the elbow he took to the jaw as he skated through mid-ice. All well and good, because the officials lost control of the game, allowing dangerous plays earlier for fear that they might “affect the outcome.”

Bullshit.

As far as I’m concerned the greatest responsibility for protecting our children on the various courts and fields of play lies with the officials. The referees and umpires who are right there in the middle of the game MUST protect the children playing the games. Dangerous play just cannot be allowed. Officials have lots of latitude, and every sport has rules, penalties for dangerous behavior. Blow the whistle! Throw the flag! Pull out that red card! Set the tone early and let it be known that dangerous play will not be tolerated.

My youngest child, in ways too many to count an athletic clone of his father, finished his high school lacrosse career sitting on a bucket on the sidelines, sobbing as he vomited. He was vomiting because he had just suffered a concussion, his third, this one the result of a vicious crosscheck to the back of his head. The play occurred just feet from the sidelines, yards from the referee looking directly at the play. Unbelievably, he hesitated. He HESITATED! He actually gave thought to not even pulling his flag. Eventually, out came the flag and the verdict was rendered: one minute for unnecessary roughness. Almost the smallest infraction in the game of lacrosse. One minute for a blatant headshot, right in front of the referee, right in front of Randy’s coach.

The trainer on duty, a lovely young woman, very empathetic… very concerned, hovered over him. Was he crying because his head hurt so much, she asked? No, he sobbed, he was crying because he knew he had a concussion, and he knew that that his playing role in youth sports was now over, his days as a lacrosse player now officially done because it was no longer safe for him to play. How many more, I asked.  How many more children would be hurt before that referee said enough? How many more, I asked him out loud in a silent stadium, my voice the only sound, clearly heard by every ear in the stadium. Everyone turned to look at the father escorting his injured child off the field. Everyone, that is, save one, the coward who couldn’t look at the child he had just failed to protect.

Officials, indeed any adult, who will not protect the children who are playing have NO role in youth sports.