Essence Carson, forward for the WNBA’s New York Liberty, hammers out a set of box jumps at The Hospital For Special Surgery on Manhattan’s Upper East Side. In a fluid sequence, she leaps to the top of the box, lands, then steps back down to the ground. The box is tall, nearly reaching the waist of her 6-foot, 165-pound frame. It’s tall enough that everyone in the gym—athletes, trainers and normal folks just looking to shore their bum knees—pause and crane their necks to watch Carson soar back up.
Dressed in a navy blue “Garden of Dreams” t-shirt, mesh shorts and a pair of Nike Air Maxes with her WBNA-logo socks pulled high, Carson is in a “dry run” of her rehab program, performing exercises with low weights for low reps to illustrate what she’s been doing in her physical therapy sessions. The box jumps look difficult, but in truth Carson is bouncing onto the platform with relative ease. It’s a long way from where she was in June 2013.
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“It was a fast break,” Carson recounts. “The point guard from Atlanta was chasing me down, and I saw her coming. I was like, ‘She is going to try and strip me, but she’s little. She’s not going to block me.’ So I’m just going to Euro-step and finish on the other side of the basket. I never got the chance to do that. As soon as I stopped to jump, my left knee just snapped. I couldn’t’ even push off, and I crumpled to the floor.”
Carson suffered a torn ACL, a serious, possibly career-threatening knee injury, best known for affecting high-profile male athletes like Adrian Peterson and Robert Griffin III. But some reports suggest that women can be up to 10 times more likely than their male peers to suffer the injury. Tears are especially prevalent among basketball players of both genders, but female ballers seem to be at an increased risk. “As a female basketball player, you know these injuries happen a lot,” Carson says. “I’ve seen them in high school, in college, and even at the pro level.”
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As a woman gets older, the likelihood that she will suffer an ACL injury seems to drop. But that’s mostly due to declining participation in sports over time.
“Whether you’re in high school or [in your] early 20’s, that [gender] disparity is still there, in that a female is between two and six times more likely to suffer an ACL injury,” says Tim Hewett, Ph.D. and Director of Research at Ohio State University Sports Medicine. “That doesn’t change. What changes is the number of athletes participating. What you’ll see in your clinic from high school, you’ll see all these young girls coming in with ACL reconstructions. Then, later on, you see a relative 1:1 [ratio of women to men coming in]. As males and females age and get into their mid- to late-20’s, a lot more guys play recreational sports. Therefore, there’s a lot more ACL injuries among males.”
Hewett believes the increased risk of ACL injury among women is due mostly to the disparity in neuromotor control between men and women. Both men and women have growth spurts during puberty, but men also get what Hewett refers to as a “neuromotor spurt”—they develop a greater ability to control their larger frames. Women don’t get that spurt, so they have what he calls a “machine motor mismatch,” meaning women grow but don’t develop the same level of neuromotor body control to go with their bigger frames the way men do. “[This machine motor mismatch] leads to compensatory patterns that put women at risk,” Hewett says. The four compensatory patterns are: ligament dominance, leg dominance, trunk dominance and quadriceps dominance.
Women, who tend to be ligament dominant, seem to use their joints and ligaments to dissipate force, instead of their muscles, which is what men do. “[Women] allow the ligament and the joint to absorb force [subconsciously],” Hewett says. “Muscles, in the sagittal and flexion plane, are designed to absorb and dissipate force. Ligaments are not, and they rupture.”
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Besides that, women tend to be more asymmetrical with their musculature. They have a mismatch between the muscularity of their upper bodies and their lower bodies, with their lower bodies being stronger. This disparity tends to lead to a higher risk for injury. “We’ve studied entire county school systems of girls and boys,” Hewett says. “Every soccer, volleyball and basketball player in the county comes into the lab, gets screened and then they go out and play their sport and we track them with high fidelity over time, [seeing] who goes on to [suffer an] injury. Those athletes that have the greatest asymmetries have significantly greater risk.”
Another thing that adds risk for female athletes: their torsos. The changes in a woman’s torso are far more drastic and rapid than what happens to men during puberty. “If you watch a woman play basketball or soccer relative to a male, you’ll see a lot more total range of motion and movement in the trunk,” Hewett says. “It’s more out of control. The problem with that is it creates torques around the knee joint that end up in the ligament.”
The final reason Hewett cites for the disparity between men and women in injury susceptibility is that women tend to use their quads to decelerate, instead of the muscles of their posterior chain, like men do. “When girls land on one leg, that’s when ACL injuries happen, because girls way under-activate the glute, and they instead use their quads,” Hewett explains. “The quadriceps is a big, strong muscle, but there are a lot of problems with being quad-dominant. Even though it does compress your knee together, that’s not really good. If you think about the geometry of the knee, that causes the knee to go into an inward position and causes the tibia to actually come forward and rotate internally. That’s basically the mechanism of how you tear your ACL.”
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Internal rotation while attempting to quickly decelerate is exactly how Carson injured her ACL. “It seemed like her knee collapsed inward when she did [injure her knee],” says Theresea Chiaia, Carson’s physical therapist. “It looks like she hurt it on a jump stop. I watched the film numerous times, and it seemed like a move she did hundreds of times, but in that instant her knee collapsed in and she blew out her ACL.”
The Road Back
Carson’s rehab started immediately after her injury. In the three weeks between the event and her surgery, she worked with Chiaia to regain a normal range of motion in her leg. “[When she went into surgery], she was walking normally without crutches,” Chiaia wrote in an email. “Her knee was quiet. It had recovered from the trauma of her injury and was ready to be fixed.”
Following surgery, the first order of business was to ensure Carson was able to stand with her brace and crutches. That happened in the hospital.
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The next day, they arrived at the physical therapy center, where Chiaia had essentially to rebuild Carson from the ground up.
“She had to walk, then stand on one leg, then run, [and] jump,” Chiaia says. To do that, Chiaia worked Carson through progressions of movements on a table to rebuild the strength in her leg.
Their first step at the physical therapy center was to “control the pain and swelling, quadriceps function and the range of motion,” according to Chiaia. The two met between three and four times each week and achieved their goals through cryotherapy (cold therapy), electrical stimulation to get the quadriceps firing and range of motion exercises.
Chiaia had to teach Carson to walk normally. That started with her standing—she simply learned to put weight on her left leg and balance while doing it. Chiaia started challenging the Liberty guard on one leg. “[She was] squatting on one leg, stepping down from a box on one leg, lunging on one leg, and doing Single-Leg Deadlifts,” Chiaia says.
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Carson had to apply all of her strength and balance gains to a basketball movement—running. She started running on an Alter-G machine, which allows an athlete to run naturally but without the full challenge of supporting her body weight. That went on for two weeks, during which they gradually decreased the amount of weight being supported by the machine. Then Carson started to run on a treadmill.
Carson’s rehab evolved into moves you recognize at your gym—things like Box Jumps and Jumping Rope. “Plyometric training was introduced so we could start working on Essence’s ability to jump, land, decelerate and change direction,” Chiaia says.
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That led to (you guessed it) on-court basketball drills. “Essence took what she practiced in physical therapy and applied it to her basketball skills—things like shooting, defense and changing direction,” Chiaia says.
Nine months after the injury, when we saw her working out on the Upper East Side, Carson was leaping, twisting and stopping as quickly and effectively as you would expect from a professional athlete.
Carson, who has already been playing with the Liberty in the pre-season, will take the court Saturday, May 17, for her first regular season game since her injury. She said the hard work she put in during rehab has paid more than just physical dividends.
“[This injury showed me] how strong I am mentally,” Carson says. “It was a battle the entire way. And you just have to stay positive through it the entire time. You have down days, but overall you want to make sure that you are positive because that’s what’s going to help motivate you to get better.”
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Physically, Carson should be heading into this season stronger than ever. Both legs, which she defined as “sticks” before her injury, have beefed up significantly. “Once I am done here, I am going to be a lot stronger,” she says. “Hopefully that means I jump higher, because then maybe I could just touch the top of the backboard [laughs].”
Carson could have fallen into a deep depression as a result of her injury, but she was nothing but positive as she wrapped up her physical therapy session. “Everything happens for a reason,” she says. “Maybe the rest of my body needed to rest. Maybe I needed a break. I play basketball year round and I hadn’t had a summer off since I can’t even remember, maybe when I was a teenager or pre-teen. So maybe it was just time for a break, a mental break and a physical break, too. It sucks that it had to be an ACL injury that caused it, but I’ll come back and I’ll be stronger.”
Carson’s Rehab Exercises
At the direction of her physical therapist, Carson incorporated the following exercises into her rehab, to help return her to the court in better shape than ever.
Squats: for shooting, jumping and defense
Single-Leg Squats: for strength in deceleration and cutting
Jumping: for power
Cone touches and ball drills: for balance and control at her knee
Boxing: for transfer of weight, core control and endurance
Single-Leg Deadlifts: for hamstring strength and balance
Lawn Mowers: for buttocks strength, and balance
Clocks: for hip stability (very basketball-specific)
Forward Step-Downs: for eccentric quadriceps control
Isokinetic Training: to isolate her quadriceps muscles