Alex Doukas was moving behind the net. A Bronxville girls lacrosse teammate threw her a pass. It was high. Doukas jumped for the ball. So did the John Jay-Cross River defensive player. In the air, they collided, the girl smashing into the outside of Doukas’ right knee.
Doukas landed with that knee still positioned inward, then caught her cleat in a mended piece of turf. She went down, her face writhing more with anguish than pain.
“I knew right away. I heard it and felt it. I was heartbroken,” said Doukas, whose high school lacrosse career ended in that May 6, 2020 game with her third ACL tear.
ACL stands for anterior cruciate ligament and tears are common among high school athletes.
It’s a devastating injury that, short-term, can keep an athlete sidelined for a year. Long-term, it often leads to arthritis at an early age.
Some sports, including football, soccer, volleyball and lacrosse, pose a higher risk for the injury. And girls are more prone to the tears.
Anatomy and perhaps hormones are thought to be contributing factors in that.
“It’s very rare to have a group of girls here and not have one who has had an ACL (tear),” noted Cassie Reilly-Boccia, co-founder of Athletes Warehouse, a physical conditioning and baseball/softball practice and instruction gym in Pleasantville.
Reilly-Boccia, whose clients include those working out in part to prevent tears and those trying to return to play after ACL injuries, noted the rate of ACL tears among female athletes exceeds that of their male counterparts. Besides wider hips contributing to riskier landings after jumps, some recent studies suggest female hormones increase joint elasticity, possibly increasing the likelihood of ACL tears.
“Everyone wants one answer, but we really might never get it,” she added of the cause.
“The medical community knows more but the rate is still going up. People are still getting hurt,” Reilly-Boccia said. “I really do think it’s not necessarily one thing but a combination.”
The building in which her facility is located also houses SPEAR Physical Therapy.
“We get at least two or three a season, if not more,” physical therapist Sarah Lloyd said of patients recovering from ACL tears. “It’s just a huge issue.”
To put in perspective how widespread the problem is, Lloyd, a former Princeton lacrosse star who has been a physical therapist for three years, said, “One of the reasons I ended up a physical therapist is I had a lot of friends and fellow teammates who tore their ACL.”
This isn’t a simple injury. Surgery is the prescribed course of treatment, followed by many months of rehab.
It’s an epidemic
The New York State Public High School Athletic Association, which oversees high school athletics in the state, doesn’t keep data on ACL injuries.
Various studies place the number of ACL tears yearly in the U.S. at anywhere from 100,000 to 300,000. That’s a huge range, but both numbers signify a major problem.
Dr. Andrew Pearle, a Rye resident and orthopedic surgeon at Manhattan’s Hospital for Special Surgeries, goes a step further than “major.”
He says ACL tears amount to a “kind of epidemic.”
“It’s absolutely a worsening problem,” he said. “It’s like the concussion story. It’s an incredible story.”
Pearle cited a study showing a 300% increase in ACL tears over a 10-year period, 2000-2010, and said the problem has risen significantly since then.
“In New York state, there’s been an explosion the last 10 years with the highest rate in 15- to 18-year-olds … and it’s continuing to go up,” said Pearle.
“It’s an incredibly horrible thing that’s going on. If an adolescent tears an ACL, they’re pretty much destined to have a disability in early adulthood,” Pearle said, referring to the “downstream affect” of arthritis in the damaged knee.
In fact, there’s a better than 50% chance those who’ve had an ACL tear will get arthritis within 10 to 20 years, he said.
Some are so severe that if patients were older, they’d be candidates for partial or full knee replacement. But physicians prefer to wait on that kind of surgery until people are at least in their 40s.
Pearle noted he has replaced the knees of those in their early 40s with the vast majority having previously suffered an ACL tear.
Pearle performs about 150 actual ACL surgical repairs a year. On a Wednesday earlier this summer, he did four. Three were on teenagers.
He knows he may see some of those kids again.
For boys and girls, the chances of tearing a repaired ACL are 8%, Pearle said, and those who tear one ACL are 12% more likely to tear the same ligament on the other knee, due in part to an athlete compensating with that leg.
And if an ACL is repaired twice, the odds of it tearing again zoom to 25%, he said.
About 70% of ACL tears are non-contact injuries, Pearle added. Of those, he said probably half are preventable.
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Athletes’ stories
Since several older high school and club teammates had suffered ACL tears, Doukas knew about them before tearing her left ACL for the first time in eighth grade while playing in a lacrosse game.
Her first and second tears occurred while she was running and planting her foot.
The second tear of left ACL was different from her other tears. She could run and didn’t initially realize she’d re-torn it. In fact, with her ACL torn, the then-freshman scored Bronxville’s winning overtime goal against Putnam Valley to capture the 2018 Section 1 Class D championship.
She calls her latest ACL tear a “freak accident.”
How much the field’s surface played a role in Doukas’ and other athletes’ injuries will never be known.
But while area high schools are rushing to install more turf, multiple medical studies conclude natural grass is safer, since it provides more give when planting, landing and turning.
Doukas can’t guess the number of people she has known through club and Section 1 play with an ACL injury, saying, “Unfortunately, many athletes.”
Doukas had surgery July 21 and is doing strength and conditioning training. She’s committed to playing lacrosse for Fairfield University, but her projected recovery time means that won’t happen this school year.
Surgery and rehab amounts to a familiar road for her, one North Rockland boys tennis player Joel Manoj started down last spring.
Tennis is not considered a high-risk sport for ACL tears, but Manoj, who’s now a senior, tore his during an on-court drill in late April.
Manoj, who’d been expected to battle for a top singles spot on varsity after being No. 1 singles on the junior varsity, jumped backward for a teammate’s lob and lost his balance.
He tore both his ACL and meniscus and had surgery May 26.
“I didn’t think it was that severe at the moment,” said Manoj, although he couldn’t walk on his leg immediately after the injury.
He’s now continuing physical therapy and hopes to be able to do indoor track this winter, then spring tennis, although he won’t “force” his return.
Former John Jay-Cross River football and lacrosse player Dean Ford, who now plays lacrosse for Fairfield University, tore his left ACL during a football game against Fox Lane after receiving a pass from his twin brother, Bryce, early in the 2018 season.
Three Foxes were in pursuit, but no one touched him.
“It felt like my knee caught. It felt like someone shot me. I blacked out for like 15 seconds. It felt like it popped out,” said Ford, a junior at Fairfield.
After surgery, Ford missed the rest of the football season and all of the basketball season but was able to play in about two-thirds of John Jay’s spring lacrosse games.
Before his first game back, he briefly worried about re-injury.
“It was for maybe five seconds. Then I (thought of) all the work I’d had done in physical therapy and I blocked everything out and there was more of an adrenaline rush and I kind of completely forgot about it,” Ford said.
Ford, who’s one of two players on his college squad to have suffered a torn ACL, noted he was one of several at John Jay who’d endured that injury. He said one girl tore hers two or three times and one guy tore his twice.
“There’s still lingering stuff,” he said, noting the outside of his knee gets tight and starts to swell sometimes if he goes for a run or hasn’t stretched enough.
But he seems confident of staying healthy, noting in part Fairfield’s workout routines include lunges, squats, deadlifts – “everything legs.”
Former Horace Greeley field hockey and lacrosse player Jessica Rosendorf, who plays club lacrosse now at Tufts, sprained her MCL (another knee ligament) and tore an ACL the final day of two weeks of four-hour daily preseason field hockey training sessions as a Greeley sophomore in 2015. This occurred during a full-field scrimmage when a girl she was defending turned and cut back and she cut to stay on her.
She had ACL surgery several weeks later.
Rosendorf’s mother also tore her ACL perhaps 20 years ago, so Rosendorf was familiar with the injury.
In fact, so many people she has known have had a tear that she said, “I don’t even know if I could come up with a number.”
Knowing so many is a large reason why, she said, she’s interested in going into biomechanics and sports injury prevention
Rosendorf, who trains at Athletes Warehouse and includes exercises designed to strengthen muscles to avoid another ACL tear, noted she was out of sports for close to a year.
Pearle indicated that’s normal with nine to 12 months being the average for returning to play.
Causes: Muscle imbalance and more
Cutting and jumping sports pose a greater risk to torn ACLs than other sports.
Causes are debated and likely numerous.
“Everybody has their theory but no one really knows,” said Sharon Robinson, the Bronxville girls lacrosse coach and former Yale player, who cited unforgiving artificial turf – particularly older, stiffer playing surfaces – as one possible cause and, with some girls, wider hips that result in uneven, off-balance landings.
She noted Bronxville players pay for a physical therapist to come in at least twice a week during winter to work on preventative exercises, including drills designed to promote more balanced landings.
Doukas had spent much time doing the right things, but she still got hurt.
Reilly-Boccia, who characterized instances of second ACL tears as “through the roof,” believes very much in preventative training. But she knows there are no guarantees. Reilly-Boccia pointed to parents paying for pre- or post-injury prevention training, as well as, in many instances, physical therapy sessions after insurance expires on them.
But sometimes ACLs still tear or re-tear.
“I feel so sorry for the parents. They can do everything and their kids still are getting hurt,” Reilly-Boccia said.
“I think strength training makes a difference (in prevention),” Rosendorf said. “But there are so many factors – field conditions, (lack of) hydration, fatigue. You can only do so much. I’ll probably never know (what caused my knee to tear). I was definitely not fresh. I’m sure that played a part.”
Year-round play a problem
Although this wasn’t the case with Rosendorf, both Pearle and Rob Fay, who owns Armonk Physical Training and Sports Training and has been a physical therapist for 25 years, blame the ACL problem in part on athletes specializing and playing one sport year-round. Fay noted a “movement pattern” is repeated over and over.
“Sports are crazy. It’s totally out of hand,” Pearle said.
He cited year-round soccer as particularly problematic.
“Girls have a 1.1% risk of tearing their ACL every soccer season. So, if a female athlete plays soccer all season long (for four seasons) every year of high school, the risk is 4.1% per year times four years. (That equals) 16.4% over a high school career,” Pearle said. “For lacrosse, the risk for a female is 0.5% per season. The risk for a female playing softball is 0.2% per season, so you can see if you vary the sport or take seasons off, you can mitigate risk.”
Both he and Fay endorse regular exercise to lower risk. Some exercises are geared toward helping to correct muscle imbalance and others to changing athlete movement, including landings.
Of muscle imbalance, Fay said, “If a quad is stronger than the hamstring, it pulls on the ACL and can cause a tear. You also see glutes shut down and then the overuse of the quad (results).”
Reliance on the quad can cause the knee to have a “wrong movement pattern,” increasing the likelihood of a tear.
“A lot of kids are very, very quad-dominant,” Fay said. “Probably 80% have this imbalance. … Almost every (torn) ACL we see there’s an imbalance. … It’s amazing how many kids have it.”
Sitting in class all day, then playing a sport can lead to problems.
“You see these assessments with high school and middle school kids. Probably 90% of girls have shut-down glutes and use their quads. That puts a lot of stress on the ACL. With boys, it’s probably 70%.”
Fay noted his practice focuses a lot on correcting muscle imbalance and movement patterns, although fatigue can cause a poor movement pattern to return.
Some schools try to incorporate ACL-geared exercise into pre-practice warmups. But Pearle, who at one point coached football, noted practice time is “pretty sacred.” He doubts whether the exercises are always regularly done and, for that matter, done correctly.
Working with his hospital, he’s developing a seven-minute app prevention workout program for coaches to share with athletes. It will include feedback, so coaches can see whether an athlete does the daily program that will include things like air squats, lunges, planks and single-leg jumps. The app’s expected to launch in January.
Pearle has his middle and high school-aged sons do the workout before they sit down for dinner each night.
Both boys play lacrosse and, despite the precautions, Pearle said, “Certainly, I worry about (their ACLs) – every time they play, basically.”
He noted with ACL tears running rampant in female members of his family, he had his then-eighth-grade daughter give up field hockey after she hyperextended a knee playing.
Fortunately, field hockey wasn’t that important to her, but Pearle said of walking away from an athletic activity, “It’s tough because there’s a lot to gain from sports.”
Continuing to play
The fact is, though, “not everybody gets back,” said Pearle, who estimates only 70-75% of those who’ve torn an ACL return to play the sport in which they were injured.
Sometimes parents simply say no.
Jon Atkeson, whose son, Timothy, graduated in June from Bronxville High, noted his son tore an ACL in lacrosse in March of eighth grade. He had surgery and was able to run cross-country in the fall and play freshman basketball in the winter.
But the first day of lacrosse tryouts a year after he was injured, he again tore his ACL.
Atkeson was happy with his son’s surgery, performed at Columbia-Presbyterian, but contacted Pearle for an opinion on his son’s lacrosse future.
Pearle, who hopes that a decade from now MRIs are widely taken of high school athletes to see who’s at risk, so “people are armed with information to decide whether to take the chance,” concluded Timothy’s “physical mechanics were not conducive to playing lacrosse,” Atkeson said.
He noted his son didn’t fit any hereditary profile (three siblings and 20 first cousins have had no ACL problems) and he was a multi-sport athlete, so he used different muscle groups.
“I told him, ‘You can’t do it again. You’re not going pro in lacrosse,’” Atekson said, noting Timothy then pursued cross-country, crew and track.
Doukas said her parents have been supportive and have left the decision of whether to continue playing up to her and “what’s in my mind and heart.”
A final decision won’t be made until she sees how she ultimately recovers.
But Doukas said she’s “hoping for the best,” and her desire to play, despite the risks, is clear.
“It took me awhile to reflect, think, speak to my family, coaches and people I trust. In the end, it’s what’s in my heart that drives me — a fire to compete and live my life fully, to never look back and wish I should have or could have,” Doukas said. “Fear can’t be the driving force, following my dreams should be. … What I can’t live with is throwing in the towel and wondering what could have been.”
Nancy Haggerty covers cross-country, track & field, field hockey, skiing, ice hockey, girls lacrosse and other sporting events for The Journal News/lohud. Follow her on Twitter at both @HaggertyNancy and at @LoHudHockey.
