When JoAnna Coffey tore her left ACL ski racing at age 12, she met with more than four different surgeons in and around her hometown of Aspen.

“At the time, many doctors were very hesitant to operate on me, as I was young and still growing,” Coffey says.

Finally, someone recommended Dr. Bill Sterett, Head Physician for the US Women’s Alpine Ski Team and managing partner at Vail-Summit Orthopaedics & Neurosurgery.

Due to Coffey’s young age, Sterett used a cadaver ligament to replace her ACL. He cautioned her that this may only last about 4 years as cadaver ligaments have a much higher retear rate in athletes under age 20. Coffey was racing at a very high level, yet this ligament lasted for 12 years.

“I had a lot of hard falls and crashes and a lot of damage over time, so I’m surprised it lasted that long,” she said. “When I retore my ACL in 2016, I had no doubts that I wanted Dr. Sterett and his team to repair my knee again.”

This time, he suggested employing her quadricep tendon to repair the torn ACL.

“After following Dr. Sterett’s recovery and rehab plan, I came back very strong and have had zero issues with my left knee,” she said.

While many surgeons still use the patellar tendon to replace the torn ACL, Sterett and his team began moving away from this technique almost 20 years ago. He found that most ski racers were unhappy with the graft site pain associated with this technique and up to 12% of patients had to miss an additional year of competition due to chronic patellar tendonitis.

“Utilizing the quadriceps tendon for ACL reconstruction has become the go-to graft choice in my practice,” he said. “Since transitioning to this, I noticed a decrease in chronic patellar tendonitis combined with a very low re-rupture rate in my patients.”

Hamstring tendons are also successfully used in ACL reconstruction, in the right patient.

“Ski racers all love hamstring grafts to replace the ACL,” said Sterett. “We are hesitant to use hamstring tendons in female athletes that are ‘loose-jointed,’ or hyper lax, because the technique may contribute to even more hyperextension, a known contributor to ACL tears.” Patients with congenital hyperlaxity have a four times higher rate of tearing an ACL replaced with a hamstring tendon than with a patellar tendon, even in the first year.

Women are much more likely to be born with loose joints than males. Because Sterett works so closely with female racers on the World Cup circuit, many of his athletic patients meet the criteria for being hyper lax.

THE FEMALE FACTOR

For over 20 years, Sterett has been the US Women’s Alpine Ski Team’s head team doctor. He manages all kinds of injuries, from sprains to concussions. He regularly receives calls at 4 a.m. (which is midday in Europe, where most athletes spend a good portion of time racing) to help determine whether it’s safe for an athlete to compete after an injury. He describes his work with the team as a “fascinating, life-long journey that’s been a lot of fun,” but it’s also one that has made him an expert in the field of female injuries, prevention and recovery.

As recreational skiers, women are six times more likely to suffer an ACL tear than men. In most sports, female athletes are three to four times more likely to tear their ACL than their male counterparts. This statistic includes everything from snowboarding to basketball, volleyball, field hockey and soccer players. (World Cup racing is about the only sport with similar ACL injuries in females and males.)

The increased risk stems from a combination of anatomical and performance factors. 

Anatomically, women are more likely to have been born “knock-kneed” and loose-jointed. Knock-kneed athletes put the ACL “on stretch” and are more likely to tear their ACL than “bow-legged” athletes. Secondarily, when athletes jump and land, if their knee caves inward during landing, they are putting the ACL at extreme risk. Women’s ACLs are typically 30% smaller than men’s, for the same height and weight, which also increases risk of tear.

However, the biggest risk factor involves loose joints, which affects 8% to 10% of the population. Athletes with a torn ACL were 4.5 times more likely to be loose-jointed than athletes who had not torn their ACL. Interestingly, in Sterett’s experience, professional athletes have a higher incidence of hypermobility. In one season, 15 of 17 athletes on the World Cup circuit met the criteria for hyperlaxity, which is tested through five simple flexibility exercises called a Beighton Score.

“Hyperlaxity may help athletes to reach the next level,” Sterett said. “Unfortunately that also puts them at higher risk for these season ending injuries.”

In addition to anatomical risk factors, women experience performance factors.

From a performance standpoint, ACL injuries can be lessened by landing with a flexed knee rather than in an extended position. Secondly, as the load is absorbed, making sure the athlete’s knee doesn’t cave inwards, which puts the ACL at extreme risk.

THE FUTURE OF RECOVERY

Along with educating his patients on recovery and injury prevention, Sterett continues to explore cutting-edge medicine. His latest hope lies in biologics, such as stem cell and Platelet-Rich-Plasma (PRP) treatments. He has been using biologics in surgeries for three years and has seen success, though not enough research exists to specifically quantify improvements. However, Sterett predicts that in three to five years, he will be able to tell patients exactly what benefits—and the percentages—they can expect with stem cells or PRP as a surgical adjunct.

Meanwhile, Coffey has relied on Sterett to keep her going. Though she has stopped racing, Coffey is a sponsored extreme backcountry skier. Last January, she tore her right ACL and suffered a severe meniscus tear. After a successful quadriceps tendon ACL reconstruction (with the addition of stem cells and PRP treatments), she has been cleared by Sterett to surf in Maui.

“I’m thankful to have known Dr. Sterett for 16 years and counting, and he is the only surgeon I trust and want to work on my knees,” Coffey said. “My family and I chose Dr. Sterett for his professional, yet friendly, demeanor and expertise on repairing young athletes’ torn ACLs. He’s super friendly and answers all your questions and speaks to you in regular terms, not doctor terms. When I go to see him, it’s like seeing an old friend.”