Alexis Garcia made a routine move, attempting to pass the soccer ball to a teammate.
Suddenly, her right knee locked. It twisted awkwardly.
She heard a “crunch” as she crumbled to the field.
The pain, she said, was excruciating.
Then the tears came. Not from the physical agony, but a feeling of dejection waft over the New Paltz High School senior. She knew what her injury likely was, and what it meant for her soccer career.
Garcia, 17, had suffered a torn ACL in her right knee. In fact, she had joined a growing number of athletes who have sustained that injury in both knees.
That “crunch” or “pop” many athletes describe hearing has become a familiar sound on athletic fields. Often accompanying the sharp pain is a jarring diagnosis and season-ending surgery soon after. That also signals a grueling, months-long rehab process without assurance of ever returning to form.
The rate of knee injuries among adolescents has steadily increased by about 2.3 percent each year in the last decade, according to a study presented in 2015 by the American Academy of Pediatrics.
And Garcia is far from the only athlete locally, or nationally, who has been a part of that statistic.
About 1.35 million youngsters, ages 6 to 19, are rushed to emergency rooms each year with sports-related injuries, according to a 2013 study done by Safe Kids Worldwide, an international advocacy group for the prevention of childhood injuries. Close to 200,000 of those injuries are to the knee. In a 2008 study in the American Journal of Sports Medicine, knee injuries accounted for 60 percent of all high school sport-related surgeries observed.
Andres Blanco, a former running back for the Spackenkill High School football team, tore the meniscus in his left knee last October. Weeks later, his friend and schoolmate, Eileen Fiore, tore her right ACL during a soccer game. She said that several teammates on her East Fishkill Power travel soccer team also suffered knee injuries in recent years, including Arlington High School senior Stephanie Seefeldt.
Theories and reasons for this trend vary. Some coaches attribute the spike to an increase in physicality among athletes. A number of medical experts believe the modern prevalence of sports specialization has contributed to the rise in joint injuries among teens, and suggested that proper physical conditioning can help reduce risks.
Along with the physical strain of recovering from an injury that requires surgery, young athletes often struggle mentally and emotionally to deal with being cut off from their teams, and feeling vulnerable.
“I was a healthy and active person,” said Garcia, who had surgery on Sept. 16. “As a teenager, you kind of feel invincible. Then you get hurt, and suddenly that’s gone.”
The anterior cruciate is one of four ligaments in the knee that stabilize the joint, holding the knee in place and restricting excessive movement. The meniscus is a piece of cartilage in the knee that cushions the joint and provides shock absorption between the thigh bone and shin.
Garcia suffered her latest injury on Aug. 31, during the first game of the season for the New Paltz girls soccer team. She had missed the previous season after suffering a torn ACL in her left knee as a junior, then spent a year rehabilitating in hopes of a triumphant return.
But within minutes, it was gone. All the progress of the past year, undone in one move.
Close to 30 percent of athletes who have had ACL surgery suffered a similar injury that required an operation within two years, with 20.5 percent of them sustaining an injury to the other knee, according to a study conducted by the American Orthopedic Society for Sports Medicine in 2013.
“When I tore my left ACL last year, my doctor (David Yasgur at Caremount Medical in Katonah) told me it’s common to tear the other one,” Garcia said. “During recovery, you get so used to putting all the pressure on the good knee and overcompensate. Your mechanics are thrown off and it puts extra strain on the healthy leg.”
As it becomes more common for athletes to compete rigorously all year, putting additional strain on their joints, the chances of injury increase exponentially, medical experts said.
“Many of us (in the medical field) think the rash of injuries is caused by the increased exposure to repetitive stress,” said Dr. Lonnie Davis, an orthopedic surgeon based in Fairfax, Virginia, who performed the operation to repair Blanco’s meniscus. “A lot of athletes are playing one sport year-round and it puts repetitive stress on the same joints. They tend to outperform their age-match peers of years past, but it’s coming at a cost.”
According to the American Academy of Pediatrics, the most common major knee injuries among teens are tears in the medial collateral ligament, followed by the ACL and the meniscus. Female athletes, particularly soccer players, are up to eight times more likely than boys to suffer these injuries, according to a 2008 study done by the National Institutes of Health Medicine Plus.
Rehabilitation varies by injury, sport
The rehabilitation process for major knee operations typically requires months of physical therapy and it often takes an emotional toll, even more so among youngsters, Davis said.
Once the patient has recuperated enough to put pressure on the knee and regained some mobility, the objective shifts to strengthening the joint and the muscles around it for a return to normal activity.
Two months after their respective surgeries, Blanco and Fiore began going to physical therapy three times per week. Blanco’s routine included body squats, lunges, leg presses and elliptical training. Fiore worked extensively on a StairMaster and stationary bike, then ran a mile each day.
As the patient progresses, the workouts intensify. And, eventually, the sessions become geared toward a return to their sport. The goal for Blanco, in addition to recovering from the torn meniscus, was conditioning his legs for the rigors of football and the sudden, short-distance bursts the sport requires.
Fiore’s two-hour sessions keyed more on cardio, in preparation for soccer. There was a focus on lateral quickness and, later, workouts with a soccer ball — dribbling around cones in zig-zagging patterns, and redeveloping footwork and regaining kicking power.
The recovery process for a torn ACL typically requires 6-12 months, depending on the severity of the tear. And perhaps longer before an athlete is totally able to regain their form.
“I think it’s as much of a mental comeback as it is physical,” Garcia said. “It’s a year before you’re back on the field, but probably another year after that before you truly feel OK and not hesitant and worried about it.”
And, Garcia’s fears that two knee operations would dissuade college suitors were eased last month. She received an offer from the SUNY Plattsburgh women’s soccer team and made a verbal commitment to play there next fall.
“I always hoped for a happy ending,” she said.
Searching for answers
The obvious question is, can anything be done to slow the epidemic?
Some coaches suggest that the evolution of the athlete and increased physicality in sports contribute to the rise in injuries.
“When I played, soccer wasn’t this physical,” said Joanne Metzger, the New Paltz High School girls soccer coach, who also played at Siena College. “With technology, the footwear and balls being better designed, the pace of the game is much faster. The skill level is higher and it’s more competitive than it was 20 years ago. To contend with speed, you have to get physical.”
There are a number of theories on the cause of this uptick in knee injuries as well as preventative measures. Many experts believe the root is overuse of the joint without adequate conditioning. Attrition can wear on the ligaments.
“Kids are being pushed so hard in the number of practices and games, and then they’ve got other commitments,” said Michael Mejia, a sports science specialist who runs B.A.S.E. Sports Conditioning in Nassau County. “You’ve got athletes running all over the field for an hour, using their quads, hip flexors and hamstrings like crazy and making them contract. Then they stop, and soon after, they’re sitting in a car to head home for homework.”
Over time, Mejia said, that routine can cause a diminished range of motion in the youngster’s muscles and joints. The cumulative effect can make them more susceptible to serious injury.
Sports specialization — the demands of travel teams, showcases and children playing one sport all year — contribute to that, Davis said, adding that he has a 9-year-old daughter who plays travel soccer. For the athlete, there is incentive in skills development and in hopes of the additional exposure helping to garner college interest.
“There are pressures from the parents, coaches, other kids,” said Davis, who played football and ran track at Cornell University. “If other kids are playing all year and it’s getting them an edge in skills, you don’t want to fall behind.”
Mejia and Davis suggest athletes would benefit from proper rest — the recommended eight hours of sleep each night — and not focusing on one sport. Granted, Fiore is a three-sport athlete, Garcia also plays lacrosse and Blanco used to run track in the spring.
Stretching modernized to combat injuries
The harsh reality is that no surefire method exists to prevent awkward twists during physical activity.
But Mejia pointed to a 2009 study done in Sweden that tracked 2,500 soccer players, ages 12 to 17, for seven months. Introduced to the athletes was a 15-minute neuromuscular warmup. The study found that the pre-game exercises helped decrease the ACL injury rate by 64 percent.
Those routines generally feature extensive stretching, one-legged squats, lateral shuffling, balance training and plyometric jumping exercises to strengthen the legs. Mejia also recommended a post-game regimen of at-home stretching, including the use of a foam roller.
Garcia said Metzger incorporates some of those principles during New Paltz’s 25-minute warmup. This year, Metzger said, she added yoga to the routine.
Davis agreed that a “post-activity stretch” can be helpful. Early neuromuscular training can also be beneficial, he said.
“Especially in the scholastic athlete, we’ll find that technique issues are a big factor,” Davis said. “We can decrease the rate of ligament injuries by teaching them proper techniques for jumping and landing, cutting, turning.”
Unfortunately, Mejia said, it’s after a serious injury has been sustained that people become most receptive to preventative measures. He recommends a proactive approach for parents and coaches, teaching kids as young as 10 about the importance of conditioning.
“Knee injuries in sports will never be completely alleviated,” Davis said. “Every time an athlete steps on the field, that’s an understood risk, especially in contact sports. But as there are advancements in medicine, we can better diagnose and treat the injuries, and going forward, we can try to reduce the risk. That’s the best we can do.”
Stephen Haynes: firstname.lastname@example.org, 845-437-4826, Twitter: @StephenHaynes4