Eleven-year-old Josie Berg-Hammond was running sideways in gym class when her right knee popped and buckled. She had torn a ligament, but surgery was delayed for two years because she was still growing.
As the preteen waited for the operation on her anterior cruciate ligament, or ACL, she was encouraged to remain active. But her unstable knee kept giving out. Now, more than a decade after surgery, Berg-Hammond says she has constant pain in her knee.
"It hurts to walk and to do any sort of physical activity," said Berg-Hammond, 24, of Chicago, who never dreamed her childhood mishap might have lifelong consequences.
Once considered an adult injury, ACL tears are occurring more often in the legs of elementary and middle school-age children, orthopedic specialists report. The increase, which stems in part from better diagnostic tools and a dramatic increase in children playing competitive, organized sports, has created a vexing problem: What's the best way to fix it?
For years doctors have advised delaying surgery until the bones are done growing, usually around age 14 for girls and 16 for boys. In the meantime, children were prescribed physical therapy and encouraged to remain active while using a knee brace, with the exception of cutting, pivoting and contact sports.
But postponing surgery hasn't worked very well, in part because it's difficult to keep children from further damaging the knee while they wait — in some cases for years. Athletic youngsters often must stop playing sports they love, a loss that can lead to depression and affect a child's identity and friendships.
"It's very difficult to have a condition where there isn't a clear, favored treatment," said Dr. Mininder Kocher, associate director of the division of sports medicine at Boston Children's Hospital and one of the country's busiest pediatric ACL surgeons. "The kids who tear them young are good athletes; they were strong enough or had good enough technique to generate that force in the knee."
Kocher, also a professor of orthopedic surgery at Harvard Medical School, has helped pioneer novel surgeries for children that bypass the growing areas of the leg bones or are designed to minimize damage to the area. Though Kocher's published data show low failure rates among his young patients, nobody knows what the long-term outcomes will be.
The ACL, which connects the thigh bones and shinbones inside the knee joint, is a crucial stabilizer during sports like basketball, football, soccer and lacrosse. Its job is to protect the knee from shifting, rotating and hyperextending as an athlete runs, jumps or lands. An easy way to tear the ligament involves simultaneously decelerating and twisting.
In adults, surgery isn't always necessary, especially for those with sedentary lifestyles. Though skiing and soccer might be out, it's possible to walk, run and even play tennis with a fully torn ACL.
Risks are higher for children because it's hard to get them to modify their activity. A study published last year in The American Journal of Sports Medicine found that young athletes who delay surgery five months or more have a higher chance of suffering a secondary knee injury. Waiting can lead to progressive damage to other parts of the knee, including the meniscus and cartilage, multiple studies show.
"It's almost like having a ticking time bomb in the child's knee," Kocher said. "The damage can happen in free play or recess, not just travel soccer."
When 12-year-old Hugh Besl of Cincinnati suffered an ACL tear during a lacrosse game in April, multiple doctors recommended intense rehab with the hope of stabilizing the knee. If that didn't work, then surgery might be an option, the family was told.
As time went on, however, and Hugh's knee remained unstable, the Besls opted for surgery at Boston Children's Hospital with Kocher, who operated Aug. 9. The decision was based on what might be best for Hugh in the long run, said his mother, Anne.
"At first you think, wow, he can't play sports," she said. "Then you think, wow, he's 12 and already hurt something major. What will he be like when he's 30?"
Added Hugh, who loves soccer, baseball, lacrosse, snowboarding and basketball: "I really just want to be able to play outside with my friends."
Though official statistics are scarce, orthopedic specialists estimate that thousands of children and teens are tearing their ACLs each year. Researchers at Children's Hospital of Philadelphia found a 400 percent increase in youth ACL injuries over the last decade, according to findings presented at the American Academy of Pediatrics 2011 annual meeting. Girls have up to eight times the risk of an ACL tear as boys, though no one knows exactly why.
Traditional surgery on the ACL requires tunneling into parts of the leg bone. In children, these areas are still growing; the drilling can risk stunting development or creating deformities that are difficult to correct.
As a result, some physicians still tell parents it's better to wait. Orthopedic surgeon Victor Romano of West Suburban Medical Center in Oak Park encourages children to be as active as possible between the injury and surgery, as long as the sports don't require pivoting and cutting.
"I give them a brace, and if the knee feels safe and doesn't give out, I'll let them play," said Romano, the team doctor for Fenwick High School and Dominican University.
Romano, who did Berg-Hammond's operation, said earlier surgery may be warranted if the knee does give out repeatedly, which could damage the cushioning in the joint and lead to arthritis.
In some cases, like a partial ACL tear, nonsurgical treatment is a painstaking but viable option. But a fully torn ACL won't heal on its own even with rest and rehabilitation. It must be re-created using a graft, or a tendon from another part of the body, like the hamstring. In a traditional surgery, the graft is placed into a tunnel drilled inside the bone to act as scaffolding for a new ligament to grow on.
The shift toward earlier surgery has been fueled by new and modified techniques that minimize the potential damage to growing bones. With one such procedure, used mainly in children younger than 9, surgeons reroute a ligament around the shinbone using a tissue graft taken from the outside of the thigh.
"We're bringing the tendon around the back of the knee, through the knee and around the front of the knee," said Kocher, who averages one to three of the surgeries a week.
One of Kocher's former patients, Lindsay Truesdale of Wauconda, was just 6 when she tore the ACL in her right knee after a minor collision with another child in kindergarten. The surgeons they consulted all said the same thing: Wait until after puberty to have surgery. Until then, she could wear a brace and avoid athletic activity.
Instead the family flew to Boston, where Kocher rerouted the tendon. Now 14 and a freshman at Carmel Catholic High School in Mundelein/, Truesdale has been able to play soccer and volleyball and to ski. She wears a brace when she plays sports that require pivoting, and the knee sometimes feels achy when the weather changes.
"I'm really glad they went through with the decision to have surgery," said Truesdale, who estimates her knee is about 90 percent. "It was difficult for me even to think about not running with my friends. Soccer was my thing."
Children who are slightly older may have a different surgery that involves drilling holes in the part of the bone that has already finished growing. One or two of the patient's hamstring tendons are typically used to reconstruct the ACL.
"It's a little more technically demanding," said Dr. Craig Finlayson, an assistant professor of orthopedic surgery at Northwestern University's Feinberg School of Medicine. "It better reproduces the natural anatomy of the ACL and is good for transitional patients who are closer to puberty."
Still, it's not certain how any of these procedures will hold up 20 years down the road. And all types of ACL surgeries have drawbacks, including recovery time of up to a year even with intense rehabilitation. Later other issues may develop, such as osteoarthritis.
Training, even with pre-pubescent children, can help prevent injury, Kocher said. But he also advocates bringing back free play. Hopscotch, jumping rope and tree climbing all involve jumping, landing, core strength and balance.
With so many children playing organized sports, "they are losing the skills that would have been helpful to prevent the injury," Kocher said.
Over the last decade, Berg-Hammond has seen countless chiropractors, acupuncturists and massage therapists, as well as trying an anti-inflammatory diet in search of relief from knee, ankle and now back pain. One doctor suggested regular steroid injections. Her left hip is more than an inch higher than her right, which makes her wonder whether she was still growing at the time of surgery.
"It has had an immense, unforeseeable impact on my life," said Berg-Hammond. "Beyond 'painful,' the best word for my situation is 'frustrating.'"
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