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Using a mobile device? Click here to see a graphic explain four reasons girls are more likely to suffer ACL injuries than boys

Lyndsey Duty knew it right away. The former Kennard-Dale girls' lacrosse star had seen it before.

It was April 2014, a home game against YAIAA rival York Catholic. Duty corralled the ball, made a move, and dropped to the field. More than a year later, she recalls that moment.

"I remember where I was, where my teammates were standing next to me. I took the ball in and literally felt the entire thing happen," she said. "It was instant pain, and my immediate thought was, 'ACL.'"

Duty's self diagnosis proved to be correct. Her left anterior cruciate ligament, one of two main ligaments that control the motion of the knee, was torn.

Sarah Shearer, a 2013 West York grad who now plays basketball at York College, has a similar recollection from a hoops game during her senior year.

"The ball was being passed to me, as I jumped up I came back down and landed funny. I knew right away. There was a bunch of popping, and it was very painful," she said.

Shearer tried to go back in the game but didn't last long. Her season was over.

In July 2014, before his senior year at Delone Catholic, Jake Wiles was at an AAU basketball practice when he stepped awkwardly and felt intense pain. By the time he made it home, he could barely walk.

Those athletes are a part of a growing trend, as torn ACL injuries have become more prevalent, especially in younger athletes. Their cases are typical. Most ACL tears are not caused by a blow to the knee. Yet the most surprising statistic may be the rate in which female athletes are experiencing the injury compared to males in many of the same sports.

Cause difficult to pinpoint

Recently, the American Academy of Pediatrics reported a steady increase in the number of ACL tears among athletes younger than 18 during the past two decades. In more than 70 percent of occurrences, they are non-contact injuries.

Typically, a doctor will use an MRI to diagnose the injury. Many YAIAA athletes end up in one of the OSS Health offices, with a likely consult with orthopaedic surgeon Brian Bixler, who is known as a knee specialist in regard to sports medicine.

In fact, Bixler estimates that 95 percent of his surgical business is ACL reconstruction in high school — and middle school — athletes. In 2014, Bixler performed more than 100 reconstructions, nearly all in athletes 13 to 18 years old.

Despite the increase in occurrence, Bixler said it's difficult to determine the cause because there can be so many factors, including anatomy, balance, muscle strength, genetics, amount of use and technique.

"All those things play a part," he said. "We don't even know what's happening, which makes targeting and intervention a difficult challenge. A lot of the efforts at preventing them have been on hold a little bit until we can prove what is causing them."

The problem also appears to be affecting athletes younger than middle school. Recently, Bixler has seen a 9-year-old girl and an 11-year-old boy with torn ACLs.

"One theory with these kids is they are playing year-round at a very young age. It's a combination of a young age before they've gotten their core strength developed and year-round play," he said. "One thing we can do is start as young as you can with core-strengthening quad muscles, hip muscles, core strength."

There are conflicting opinions on sports specialization. Some suggest that a young athlete playing only one sport is at a greater risk to tear an ACL, because of the repetitive movements and the potential for joint and muscle atrophy. Bixler said his findings differ.

"I personally don't think so because I see kids that are mostly soccer players that someone will convince them to play volleyball, and they will tear their ACL playing volleyball," he said. "I see that as much as I see the year-round, single-sport athletes."

The American Academy of Orthopaedic Surgeons reported there are more than 200,000 ACL tears annually in the United States, most affecting athletes, most of which require reconstruction.

Trying to prevent ACL tears is not as easy as one might think. At Dover Area High School, athletic trainer Dave App has an exercise regimen designed to improve core strength, and the school's weight room has equipment designed for that purpose.

In addition to improving core strength and balance, there are studies that suggest proper footwear and more advanced coaching of jumping, landing and pivoting techniques can help.

But changing an athlete's technique is not easy.

"You run and land the way you are going to run and land based on your anatomy," Bixler said. "I am not sure we can teach someone to jump and land better. But I know we can increase their core strength. That's where I would put my prevention dollar."

Genetics, anatomy play a role

Some of the blame can be placed on family genetics. Lyndsey Duty's sister, Maddie, tore both of her ACLs. Wiles said his sister, 2010 South Western grad Sarah Wiles, suffered the same injury playing basketball as a high school senior.

Haley Still will miss her upcoming junior basketball season at New Oxford after tearing her left ACL in a powder puff football game in May. The injury came almost two years after she tore the right one playing basketball. Her father, Jim Still, tore his ACL 25 years ago while wrestling for the Colonials.

Haley Still, 16, sits on the exam table at the OSS Urgent Care and Orthopaedic Office in Mechanicsburg Tuesday, June 9, 2015. Still, 16, was in for a follow up appointment after ACL surgery on her left knee. She had surgery on her right knee in 2013. (Kate Penn - GameTimePA.com)

While genetics are a factor, the fact remains that torn ACL injuries are much more common in females than in males.

"It's at least 2-to-1. In some sports it's 4-to-1, and in soccer it's as high as 8-to-1," Bixler said of the gender imbalance.

Anatomy is a major factor. According to Bixler, from the skeletal standpoint, a female's knee is more misaligned compared to that of a male. Her pelvis structure tends to be wider, and her knees are more narrow, causing a natural valgus alignment, or bow-legs, which can cause a difference in balance.

While core strength can play a part in the equation, it is most likely a physiological difference that leads to those statistics. In addition, studies have shown hormones to be a factor. The Journal of Athletic Trainers released research stating that females might be more susceptible to the injury during their menstrual cycles.

Knees rebuilt with 'spare parts'

Regardless of what causes ACL tears, during the past decade, arthroscopic reconstruction has become the norm. Bixler said what used to be accomplished with a wide slice around the knee can now be done with a much smaller incision.

There are typically three options for reconstruction: using a cadaver ligament, a patellar tendon or a piece of the hamstring.

Bixler said he takes a part of the hamstring and turns it into a new ACL using the same incision, roughly 2 inches in length.

"I use two of your smaller hamstring tendons. That's the only way I do it," he said. "I think they were put there as a spare part, but I can't prove it.

"First was the development of arthroscopy, we can look inside the knee and see what's happening. You can see better by making the small incision outside the knee than we could making the open incision."

For Sarah Wiles, Bixler used the hamstring. Jake Wiles' surgery was performed by Dr. James Dreese, who is one of the orthopedic surgeons for the Baltimore Ravens. Dreese used Jake's patellar tendon, which attaches the bottom of the kneecap to the top of the tibia.

No substitute for hard work

No matter the procedure, the tough part comes later, including a long rehab process, typically lasting at least nine months.

"It involves a lot of tears," Lyndsey Duty said. "Physical therapy was the worst. At some points, I didn't want to be there, and I was like, 'I am never going to get better.' I could tell my muscle had deteriorated so much. It was so noticeable, and I was like, 'How am I supposed to rebuild this?'"

Wiles had a rehab partner in friend and former Squires' hoops teammate Devon Moore, who is recovering from his own torn ACL.

"We work out together a lot, and having someone you can talk to helps," Wiles said. "It's a good feeling to have someone support you and someone who knows what you are battling through."

Haley Still entered her rehab less than two weeks after her May 29 surgery. Since it's her second time around, she knew what to expect.

Haley Still, 16, of New Oxford, has x-rays taken of her knee at the OSS Urgent Care and Orthopaedic Office in Mechanicsburg Tuesday, June 9, 2015. Still, 16, was in for a follow up appointment after ACL surgery. (Kate Penn â ” GameTimePA.com)

"It's helped me to expect that there is worse to come and what's best to come," she said. "I've been waiting for the worst stuff to happen, but it's not as bad as my other leg. The worst is a lot of pain and not being able to do as much."

Shearer had to make two adjustments when she was cleared to play. She had to get used to both the knee and the faster speed of the college game compared to high school. It was difficult, as was the mental battle to stay motivated.

"It was definitely a challenge. Tearing my ACL made me a lot slower," she said. "I had to work on my lateral speed, overall quickness and agility. I had to train a lot harder in the summer so I would be up to par with the college game."

Much of the recovery process depends upon the athletes themselves. There is no substitute for hard work.

Bixler added that even when someone follows rehab procedure correctly, he still needs to see two things before he deems an athlete ready to go.

"One is you have to get the quadriceps muscle back, strength and conditioning, so your body has to respond," he said. "Another thing is the ACL is not just replacing a part. We are putting a new part in there, the body has to remodel it and give it blood supply before it can take stress."

Athletes take hit to psyche

Some athletes are caught off guard when they find out how long they will be sidelined. But they are not alone.

"I really thought, 'Do the surgery, and you are right back at it.' I didn't think it would take nine months to fully heal," said Kennard-Dale's Katelyn Golden, who hurt her knee following through on a pitch for the Rams' JV softball team.

"I was sent for an MRI April 6. They called on April 7 and had my parents break the news to me. I cried for about two hours," said Golden, who'll be a sophomore in the fall. "I went in for therapy, and there were four girls in the physical therapy office, all from different sports, all different stages, all with a torn ACL. That made me realize it's not just me."

It can test the mental well-being of any recovering competitor.

Molly Cowan is a licensed psychologist with Pressley Ridge in Harrisburg. She has worked with athletes at various levels, including at James Madison University. A former athlete herself, Cowan understands the trauma an injury can cause to a person's psyche.

"ACL tears are no joke," she said. "For somebody on a high school team, a college level team and above, your identity is so wrapped up in sports. The self-image takes a hit."

Kennard-Dale's Lyndsey Duty helps teammate Morgan Day stretch during halftime of the District 3 third place game against Susquehannock at Lower Dauphin Middle School in Hummelstown on May 21. Duty tore her ACL during the lacrosse season last year, and came back towards the end of this year's basketball season. (Kate Penn â ” GameTimePA.com)

Cowan added that there can be the normal questions of, "What if I am not as good? What if I can't play in college? What if this happens again?" She said it's important to set goals for rehab — much like setting goals for athletics — and stay involved with the process.

"Some can do well on their own. For others, that's where somebody like me comes in," she said. "When you get hurt, learn about it. Don't just depend on Mom and Dad. Keep those negative thoughts at bay, and turn them around."

Cowan recommends keeping a routine and staying involved with the team, but for some athletes, simply being on the sidelines can be quite a challenge.

"There were times, maybe I didn't show anybody, but I struggled with it. Your mind wants to go 100 percent, but your body won't," said Wiles, who is slated to play basketball at Susquehanna University.

Unlike the others, Wiles had no idea how badly his knee was hurt. Also unlike the others, he consulted with several doctors and not only delayed surgery, but played in all 11 of the Squires' football games in the fall.

Wiles said he was limited as far as the movements he could make while playing quarterback. However, it was worth it to have a final year of playing for his father, Steve Wiles, who coached at Delone for seven seasons, before taking the Susquehannock job for the upcoming season.

"Being a senior was a big part of it," Jake Wiles said. "I looked at it as if I had surgery right away, I probably wouldn't have been able to play anything. I looked at it as there's not much I can lose. There was a lot of long nights deciding what to do."

Duty, a three-sport athlete, was cleared to play during the 2014-15 basketball season, but with a lacrosse scholarship to Old Dominion University secured, she didn't want to push it. She made a couple of late-season appearances on the Rams' hardwood and even scored a basket at the end of the season.

"It was really hard for me to sit on the sideline and watch. Being on the bench with the girls is one thing, being on the field or floor is another," she said.

No rushing back

The good news is that modern medicine has led to great success in getting athletes back on the field, pitch or court. But Bixler warns ACL patients they have an increased risk of tearing up the other knee, or re-injuring the same one, particularly during the first three years.

During a recent follow-up appointment, Haley Still nodded while Bixler said there is a 20 percent chance of it happening again.

It's a speech he has given before.

"All I am doing is replacing a part. I am putting a new ACL in the same femur, the same tibia, the same leg alignment. You tore the best one you've had, you can tear the one I made for you," Bixler said, then lightly added: "Odds are you are not going to tear it— so don't do it again."

The doctor also warned Still not to overdo it, despite the fact that during her first rehab appointment a week after surgery she was able to move her damaged knee an impressive 111 degrees.

"You are supposed to be 90 degrees two weeks out," Bixler said, congratulating Still, before adding: "That doesn't mean you can go faster than the protocol."

Until she can play again, Still is looking ahead to becoming an extra coach when the basketball season rolls around.

"Since this was supposed to be my year to put myself out there for colleges it's kind of depressing," she said. "(But) I have my senior year, which is good. I am just going to have a positive attitude, be the heart of the team, give the girls advice and help them out whenever they need it."

Reach Steve Navaroli at 771-2060.

ACL injury prevention

Dover Area School District is trying to help athletes improve their core strength in an effort to avoid ACL injuries.

Dover athletic trainer Dave App, who has dealt with his own torn ACL, helped develop an extensive exercise program with the sole purpose of building core strength. To further the prevention, Eagles girls' soccer coach Brett Altimore worked with the school to get weight room equipment that also builds core strength.

App said he hopes to limit the number of times he witnesses athletes going down in an all too familiar way.

"When we see a kid go down holding his knee a certain way, we kind of know," App said. "You've seen the things so many times and you know the mechanisms of this injury, especially in (non-contact) sports like soccer and basketball."

Costs of ACL repair

$11,500: Typical starting cost of ACL reconstruction surgery, according to the American Academy of Orthopaedic Surgeons

$20,000: ACL reconstruction surgery figures rise more when factoring rehabilitation, Cost Helper Health estimates

$50,000: Average lifetime societal benefit of reconstruction surgery, per patient, according to a study titled "Societal and Economic Impact of Anterior Cruciate Ligament Tears." The savings occur as patients return to more functional, pain-free lifestyles with less chance to develop osteoarthritis later in life.

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