                             THE VIRGINIAN-PILOT 
              Copyright (c) 1996, Landmark Communications, Inc.

DATE: Sunday, April 7, 1996                  TAG: 9604080209
SECTION: SPORTS                   PAGE: C1   EDITION: FINAL 
SOURCE: BY DEBRA GORDON, STAFF WRITER 
                                             LENGTH: Long  :  315 lines

AILING KNEES TRIP FEMALE ATHLETES THEORIES ABOUND ON WHY WOMEN'S LIGAMENTS ARE MORE LIKELY TO TEAR.

A stuffed bear she'd had as a child propped against her chest, Ashley Stanley lies on an operating table straining to see over the sheet that separates her head from the rest of her body.

``Cool,'' the 18-year-old from Virginia Beach says, as she catches a glimpse of her right knee.

The knee, with a 3-inch incision in it and several hollow stainless-steel tubes sticking out of it, resembles some gruesome dissection. Actually, this is the midpoint of one of the most common operations performed on female athletes - an anterior cruciate ligament, or ACL, replacement.

The ACL is the part of the knee that connects the thighbone and shinbone.

Tear it and you can still walk. Ride a bike. Swim. But if you want to play basketball, soccer or any other sport that involves twisting the knee, you're going to need an operation.

Statistics on outpatient surgeries are hard to come by, but based on cases they see, doctors and coaches say the ACL injuries are unusual in sports medicine. Curiously, they occur commonly with women and girls, but are less frequent with men and boys.

A recent National Collegiate Athletic Association study showed that female basketball players are four times more likely than men to experience an ACL injury; women soccer players are nearly three times more likely.

``It's a devastating and fairly frequent injury for women basketball players,'' Old Dominion University women's basketball coach Wendy Larry says.

Theories for the gender differences abound in orthopedic medicine. Some experts say it's related to women's physiology. Women's bodies tend to slope in at the knees because they have wider hips. Also, the ``femoral notch,'' the space at the bottom of the thighbone through which the ACL runs, tends to be narrower in women, sometimes pinching and tearing the ACL.

In a paper published in the American Journal of Sports Medicine last year investigating gender differences in ACL injuries, the authors hypothesized that more women may be novices at sports than men. The nearly 50 percent increase in women's soccer programs in the past six years ``may introduce players less experienced in the rigors of collegiate soccer. As a result, these new participants may be more susceptible to ACL injuries.''

But local orthopedic surgeon John Schaffer, who treats many Hampton Roads athletes and who repaired ODU basketball center Odell Hodge's ACL injury last year, doesn't buy the argument that women aren't in good shape.

``When you get to the intercollegiate level, sometimes women are pushed as hard or harder as the men,'' he says.

But he does think fatigued muscles could play a role in the injury. So the stronger you are, the lower your chances of an injury.

ODU head athletic trainer Marty Bradley agrees. He tries to keep his athletes' legs as strong as possible, so they can withstand ``all the torques and forces that occur in athletics.''

Other than that, he says, ``wear the proper equipment and shoes for the sport and keep your fingers crossed.''

It didn't work for Stanley.

The ODU freshman has been involved in sports for years. She played field hockey through junior high and high school, is an avid runner and began learning martial arts last year.

This is the first injury that's ever sidelined her, and it came not during a breaking run up the field, but during a karate class.

She was practicing her self-defense moves one day in January when her partner executed a ``foot sweep,'' coming up behind her and trying to knock her foot out from under her.

Stanley felt a searing pain in her right leg and dropped to the floor. She stood up and tried several more moves before falling again. One more try on her feet, this time with some front kicks, one more fall to the mat, and she knew something was seriously wrong. She left the gym that day in an ambulance.

The injury has been frustrating for this tall, healthy-looking woman.

``I'm just not used to not being able to run. And I'm starting to miss it. Then I see my friends in class and know they're going higher in the karate rankings, and I can't.''

And, she knows, even after the surgery, she'll have at least six months of intensive rehabilitation.

The good news: She can expect to go back to sports with undiminished ability.

Even a decade ago, Stanley probably would have had to say goodbye to sports forever, says Dr. Patrick W. O'Connell, an orthopedic surgeon with Virginia Beach Orthopaedic Associates. Not now.

Katie Etter, a senior at Cox High School, is testament to the surgery's success. Etter, now 17, was 16 when her ACL tore during a recreational soccer game.

She had put her right leg out to tackle another player, planted her left leg, twisted and felt the same burning pain Stanley described.

Her surgery a few weeks later went well, but seven months later, while playing in only her second game after the injury, she tore the ACL in the other leg.

``That was heartbreaking,'' she remembers.

Only now is she finally getting back into sports, playing soccer again, practicing basketball. She refuses to worry about reinjuring the knee.

``I think if I worry about it, I would be more susceptible to injuries. They say that after the surgery the knees are stronger than before; so I go with that.''

In Operating Room 1 at Virginia Beach General Hospital, O'Connell and his surgical team are ready for Stanley's ACL reconstruction. Thanks to an epidural anesthetic, Stanley is numb from the waist down, so she can watch the procedure on the small television set by her head.

First, O'Connell has to create a new ligament from existing tendon and bone in Stanley's knee. After opening an incision just below her kneecap, he gently scrapes off the white tendon from part of her tibia, the bone just below the knee. Then he uses a drill, saw, chisel and hammer to carve out a knob of bone at each end of the tendon.

This 2 3/4-inch strip of soft tissue and bone, looking like some weirdly shaped chicken leg, gets unceremoniously dumped in a container of liquid, where surgical assistant Ron Sisson will clean and measure it.

The rest of the surgery occurs arthroscopically, through small holes punched in Stanley's knee. Into these holes, O'Connell inserts the arthroscope, a straight, tube-like instrument with a tiny light and camera on the bottom.

Immediately, a picture of the inside of Stanley's knee appears on the television screen. O'Connell watches the screen as he guides the scope around the knee, where it resembles a silver snake wending its way through a cave.

The good news is that the rest of the ligaments in Stanley's knee look fine. A couple of nicks and scrapes here and there, but no major damage.

But the ACL is just a poor shadow of its former self, literally a stump.

Before he can remove the stump and replace the ligament, O'Connell has some housekeeping to do. Using another instrument that acts like a tiny vacuum cleaner, he sucks up the excess fat and tissue from around the ACL and kneecap. Then, with the equivalent of a minuscule electric sander, he carefully shaves and smooths the ``notch,'' the bone through which the ACL passes. By enlarging the notch, O'Connell reduces the chance that the ACL will get torn or caught in it again.

Then he drills a hole through Stanley's shinbone, into which he'll anchor the graft.

O'Connell inserts the graft, which is suspended by green sutures resembling sewing thread, into the portion of the knee still open from earlier in the operation. He threads one suture through a hollow tube that exits the midpoint of Stanley's thigh and tugs tightly until the graft fits snugly into the hole he's drilled for it.

O'Connell then taps the bone more firmly into place with a chisel and hammer and drills a screw into the small space above the graft, wedging it into the small tunnel even tighter.

The same procedure, performed at the lower end of the graft, another screw - ``It's not enough metal to set off a metal detector,'' promises O'Connell - and the operation is nearly finished.

Sisson flexes Stanley's knee 30 times, a precursor of the intense physical therapy she'll begin in a few days, to make sure the notch isn't impinging on the new graft.

Everything works fine, and O'Connell begins suturing up the knee.

For Stanley, the surgery is just the beginning. She faces months of physical therapy - beginning with simple joint movements, then moving on to strengthening and toning the leg and knee.

Eventually, she knows, she'll be back on the mat. Good as new.