PODCAST: As the Women's World Cup Begins, What's With All the ACL Injuries?

KATIE:  Welcome to On Health with Houston Methodist. I’m Katie McCallum. I’m a former researcher, turned health writer, mostly writing for our blog.

JOHN: I’m John Dabkowski, Creative Services manager at Houston Methodist.

KATIE:  John, welcome back to the podcast. We’ve got you here today because we’re gonna talk about a topic that you and I both enjoy talking about. Quite often, actually.

JOHN: Near and dear to our hearts.

KATIE:  Yep. Today we’re talking about soccer, particularly women’s soccer. Which I always appreciated, John, that you hang with me when I’m talking about women’s soccer. I know sometimes, you know, men’s sports take the lead on stuff, but you’re always really fun and you keep up with women’s sports with me, too.

JOHN: I do, I do my best. I watch a lot of sports. As I age and as I now have a child and things of that nature I have to focus on the sports that I really am allowed to focus on so that my wife doesn’t kill me. Women’s soccer comes and goes but it’s about to come again because the World Cup is coming up.

KATIE:  That’s right. World Cup is right around the corner, Women’s World Cup, I should say. And one of the themes, I think, of this World Cup in particular is the injuries, particularly ACL tears. You know, it’s something that’s always been in the background of women’s soccer but we’re coming into this World Cup with serval top international players out with ACL tears, so it’s kinda hit this forefront.

JOHN: Men’s and women’s injuries are always a thing coming into a World Cup because club seasons are longer than ever and continue to get longer than ever. So, there’s always somebody hurt for some -- for one of the teams, but, like you said, it’s a legitimate theme going into this World Cup, and the list is lengthy.

KATIE:  Yeah, lengthy list. And I remember, probably last winter, you and I were texting, we had run across this Instagram post and it was of a couple of international players going to an award ceremony, it’s like three of them that were gonna be receiving awards at, like, this top awards ceremony, all three of them were on crutches in the photo together because all three had either just torn their ACL or just had their surgery for their torn ACL, and it was kinda that moment of like, “What is going on?”

JOHN: I had the same thought, kinda, throughout the season. I’m an Arsenal fan. The end of our really our entire season got, kinda of, torpedoed, especially in the second half, with some of these injuries. I think three of which were ACLs. And also, are now affecting England going into the World Cup, so I have also been noticing what’s been going on.

KATIE:  Yeah, I mean, I think England and U.S. women’s national team, some really prominent players out. You know, Christen Press tore hers last summer, usually, would probably be able to make it to this World Cup in time. You know, it’s a nine month rehab when things go well, but she’s had a challenging road back. Three surgeries total, you know to repair her ACL and things like that. Catarina Macario, which is a young top player for the U.S. women’s national team, this would have been her debut World Cup, she’s out, tore her’s last summer, challenging road back as well. I know you’re an England fan.

JOHN: Well, you know, now I have to go into spiel that I don’t sound English at all, but I was born there, I promise, and I just moved here. At still an influential age and I don’t sound like one at all. However, yes, typically World Cup time, I’m gonna root for England over anyone else. Who we’re missing: Leah Williamson, we’re missing Beth Mead. Big players that are missing from England and one of the favorites, just like the U.S.

KATIE:  Yeah. You know, they both are still considered the two favorites, the two top favorites. Which is kinda crazy considering that four of the top international players ate out on bo -- between those two teams. But it, -- Yeah, it just comes back to how long the just ACL tear list alone is. You know, you also have Vivian Miedema from Netherlands. She’s probably like the most prolific scorer, I would say, in all of women’s international soccer. And, you know, Netherlands is in our group, actually, U.S. women’s national team group, I should say. So, in some ways, you know, it’s like, “Okay, great, she’s not gonna be there terrorizing us in the group stage.” But she’s one of my favorite players to watch. So, you know, I mean, you -- as a fan you look at the injury list nd you’re like, “Man, this is really gonna change the dynamics of this World Cup.” And then or you and I at a hospital like this, I think you -- we’ve talked about it so many times over the last year, like, what is going on with these tears?

JOHN: It’s interesting, this is always kind of -- It’s always kind of been in the back of my mind that it tends to happen with women more than it does with men, especially when it comes to soccer. A hundred years ago, when I was in college, I took a couple of kinesiology classes and it was a topic that we talked about then and now kind of, again, it’s in the forefront of our minds cause of what’s going on this year.

KATIE:  You watch way more men’s soccer than I do, what’s your perspective on ACL tears in men’s soccer? I mean, like, is it a theme like this in the men’s game?

JOHN: It, obviously happens but there is no -- I've never seen a scenario with the list that I'm looking at right now, where it's like more than ten players all with the same serious injury going into a tournament. Obviously, they happen. You know, I think the latest piece of data I saw was that it's about 2.8 times more likely on the women's side than it is on the men's side. And just anecdotally as a fan that keeps up with both, that sounds about right. And I think again it's kind of just culminated in this fashion going into this World Cup.

KATIE:  Yeah, for sure. And, you know, it's why we're doing today's episode, is to talk about why are ACL tears so common in women's soccer? Sports medicine is a pillar of, you know, any healthcare system, obviously. And we actually talked to a really cool physical therapist today, because her perspective on this is incredibly unique, she's a physical therapist now, she helps people come back from things like ACL tears, she helps with the rehab process, she's also a former professional soccer player so she has seen all of this first-hand, how it's affected teammates careers and other injuries have affected careers. And how training to prevent ACL tears, what that's looked like in the past. So, today we're talking to Jordan Jackson. And I'm really excited for our listeners to hear it.

We're here with Jordan Jackson. Jordan, thanks so much for being here with us today.

JORDAN JACKSON: Thanks for having me.

KATIE:  You have an incredibly unique perspective on what we're talking about today, which is ACL injuries in women's soccer. So, I kind of want to just let you talk about yourself in this context of, you know, you're a former soccer player now you're a physical therapist, talk us through, kind of, your history in this space, from your youth days all the way to today where you're a trained physical therapist.

JORDAN JACKSON: Gosh, it's a lot kind of a long story but we'll hit the highlights. So, yeah, I played soccer for a majority of my life, I'm 32 now and I've been playing soccer since I was three.

KATIE:  Wow.

JORDAN JACKSON: So, it's definitely something that's been a part of my life for a really long time. I think it's interesting comparing youth soccer, like, when I was playing to what it looks like now, it seems different in a lot of ways similar in some. But the premise of that is, like, when you're playing youth soccer, you're playing all the time, especially when you're at a certain level, right? When you're competing with your club team, you also have progressing into high school teams, you're playing year-round and stuff like that. So, that translated for me pretty quickly into, like, high school soccer, getting recruited to play college soccer at the University of Nebraska. And so, I was up there for four and a half years and then drafted to the Dash in 2014, as a part of their expansion team. But I think my exposure to knee injuries was something that was talked about since I was little. Like, you always hear about people getting injured playing soccer and stuff like that. And I think something that was really prevalent that stood out in my youth soccer days that I continued even through my professional days was that I was training, specifically for movement foundations, movement-based training, sport specific training, how to cut, how to land, how to move that type of thing.

KATIE:  Yeah.

JORDAN JACKSON: And, I think, I started that when I was 10.

KATIE:  Is that pretty normal, to start that early?

JORDAN JACKSON: No.

KATIE:  Okay.

JORDAN JACKSON: I don't think it is. Well, and to be fair, I didn't move around a lot as a kid, I grew up in Kansas City and that's kind of where I stayed for -- until I went off to college. But coming from, like, from Kansas and coming into Houston I have not been aware of anything that does that, especially in the soccer realm.

KATIE:  Yeah.

JORDAN JACKSON:  I don't know if soccer is not as common of a sport, right? You hear about Texas football and Texas baseball, like, all, like, those sports right? And so, but it's just not something that, I think, is common enough that it's expected, when it comes to like youth soccer and training and stuff like that, and really up to professional levels.

KATIE:  Yeah, it's interesting is you really, you've spanned the youth sports to club teams, to high school teams, college teams, professional level. I mean, along this way were you -- it sounds, like, maybe you're just kind of always interested in movements and you mentioned, like, you’ve been training for cutting and things like that. So, were you always interested and is that what kind of segued into becoming a physical therapist?

JORDAN JACKSON: A little bit. My original, you know, career aspirations was to be an athletic trainer because I really wanted to be involved in sports, and I think that was something that I always had. But it was never really my first goal to think about what I was gonna do for the rest of my life it was, “Oh, I'm gonna be professional soccer player, and I'm gonna figure it out later.” You know. But yeah, I think I've always had an interest in the best way to move. And I think it just stemmed from being an athlete, like, in knowing that you have the professional aspiration you have to be training in that way and trying to be the best that you can be as the athlete to get to that level. And I think that's where it came from. I also think it's a little bit of luck.

KATIE:  Okay.

JORDAN JACKSON: Because where we started in Kansas City with this movement training program, it started, like, very small probably three times the size of the room that we're in right now and it was over, like, an ice hockey rink in Overland Park.

KATIE:  Oh, interesting.

JORDAN JACKSON: And it expanded to just -- You know what I mean? It was just like, “Oh, this sounds cool.” We found out about through our club coach, who had an older team that was trying it out and he had us do it as, like, the younger team, and just stuck with it.

KATIE:  And that's probably -- You're kind of alluding to, it's unusual for someone your age and in women's soccer to probably get that exposure, I guess.

JORDAN JACKSON: Every time I meet, you know, youth soccer players or interact with their parents, or anything like that, I always ask, like, “Well, what are you doing outside playing soccer? What else is going on?” And I haven't come across really anything that's consistent in terms of, “Oh, we're doing this type of thing.” Or, “We're doing this type of movement training. We're doing this type of strength and conditioning.” It just seems to be more of playing soccer, which is great, right?

KATIE:  Well, we need to do a lot of it to get good at it, right?

JORDAN JACKSON: Yeah, but it doesn't necessarily hit the foundations that you wanna build, especially as a youth athlete, right? And just kind of those motor patterns that can be elicited when you're that age and stick with you as you go. If you're never trained properly then sometimes it doesn't affect you but sometimes it really does.

KATIE:  I didn't play college sports, but I played a lot of high school sports, and so, like, I feel like my body is breaking down a lot younger than I want it to. And I saw a physical therapist, I think, maybe like, five or six years ago -- No, it's probably way more, it's probably 10 or 15. We were just talking about how time flies. I think I was in my mid 20s and he was kind of, like -- he was he was having me do something, I was moving and he was like, “I don't know that you, like, run correctly.” And I was like, “What do you mean? Like, how can you run wrong?” He’s like -- You know, we talked about it. And it's like, yeah, unless you're taught how to do some of these, like, patterns and movements you kind of just go about potentially doing ‘em wrong for a long time.

JORDAN JACKSON: Yeah, I mean, it's really -- that's pretty much hits the nail on the head, you know. And I think in a recreational athlete and kind of, like, your everyday person I think it's okay.

KATIE:  Yeah.

JORDAN JACKSON: Right, it doesn't really have any dire issues that come along with it. But --

KATIE:  Maybe some knee pain here and there but get a foam roller and work on it.

JORDAN JACKSON: Exactly. But when you have someone that is, you know, you go and play these sports on different levels and stuff like that, and now you're putting these movement patterns that when you're running, okay, but now you're cutting, now you're landing, now you're making contact with someone and you're trying to pay attention to a ball, and trying to do something else, read the field, and it just brings all these things into one, and there has to be more than just playing to in order to better be prepared for that. And not only to be a better player but just protect yourself and reduce risk of injury when it comes to that.

KATIE:   Yeah, speaking of that, what's been your experience with injury? If I can ask, what's been your personal experience with injur -- I mean, have you torn an ACL, have you -- I mean, I'm sure you've had teammates that have torn ACLs, so what does that look like for you over the course of this career?

JORDAN JACKSON: Yeah, it's pretty crazy. So, I've been very fortunate, I have not torn an ACL, find some wood. Someone out there listening, knock on some wood for me. But I partially tore my MCL in college. And it was nothing serious, it was a minor tear, no surgery, eight-week rehab, like, it was nothing. I mean, in terms of knee injuries it was bottom of the on the totem pole.

KATIE:   Which to me still sounds like a lot. Because, again, it's just an every day exercise. It's still like, “Okay, wow, an MCL tear.”

JORDAN JACKSON: Yeah, it sounds much worse than it than it is. And it was a contact injury, which kind of is not as prevalent as, like, non-contact ACL stuff and all those stats that that we can talk about but -- So, that was that's my personal experience. But I've had friends and teammates that you know the typical or maybe, like, the atypical that you hear and, “Oh, I tore my ACL, I came back I tore it again, I came back I tore my other.” Like, I've had countless teammates probably at least five that are right on top of my head that have torn their ACL's three plus times.

KATIE:   It's the retearing, too, that just is like -- just goes to show how, like, common this is becoming. And, I mean, from your perspective is it becoming more common or we just hearing about these ACL injuries more because women's sports is kind of getting elevated, I think, in the in the news cycle and stuff like that. What's your take on that?

JORDAN JACKSON: I think it's both. I think that, one, yes, it's be -- like, we're hearing more about female sports and so with that especially on, like, the national stage and the international stage those players bring so much attention. And unfortunately, there's quite a few of them that are injured right now, and so I think that's kind of trickled down into the professional side and into the college game and stuff like that, in terms of being reported or being talked about. But I also think that it hasn't been -- like, it's gone from minimal to exponentially more, I think, it's also the part that more people are talking about it. I went back and looked at my 2014 NWSL schedule, basically, and at that time --

KATIE:  Oh, I like this.

JORDAN JACKSON: Yeah, at that time there were nine teams, Houston was the ninth team, right? And we had 24 games, we played each team twice and then a couple other teams we played them, like, other time and so -- I mean, we didn't have any interseason tournaments, as well either, so it was really that was it. It was about six months, season ended, and then people either went back home to train or went back to their colleges and showed up again for preseason. And that was pretty much it, there wasn't a lot of offseason stuff. But with that being said, now there are twelve teams in the league with a plan to have fourteen teams by next year and what that does is increase the number of games that they're gonna be playing in the same amount of time. I think the season expanded maybe by a month or two, so I think it's over seven months now maybe eight months, if you go all the way through to the postseason, as opposed to six. But between 2022 and 2021 they played eighteen more games.

KATIE:  Wow.

JORDAN JACKSON: And they added the Challenge Cup, which is inter-season tournament. And that's not even talking about international players. Like, you look at the U.S. women or international players that play in NWSL from other countries, as well, that have their duties to their country things, when it comes to World Cup and friendlies, and the She Believes Cup and all these things are going on. And then you look at all of that -- you kind of write all of that down and then you look at the injuries, especially, I feel like there's been a spike in this past year. So, we're talking 18 more games, we're talking more teams, more inter-season tournaments and we have an increased number of knee injuries to not only the U.S. women's players but also the NWSL players. And it's -- there -- it's too big or it's too, kind of, jarring for it to be a coincidence, as from a PT kind of looking at that. I just hope it -- something comes of it. Like, I think this is not a new thing that -- you know and we're talking --

KATIE:   It’s getting the spotlight right now because of the setting. Like, World Cup is just right around the corner, you know, now we've got all these people out.

JORDAN JACKSON: Right, yeah. And we're talking, like, elite athletes. Like, these are professional athletes, NWSL players, these are the top of the best players in the world and they're tearing their ACL and they have the same risk as someone who is a recreational soccer player. Like, it doesn't make sense to me. And I think that it's not only -- I think the biggest thing is to identify where the meaningful change is. And it's not just talking about, “Okay, women have wider hips and sometimes have knee valgus.” And, “Okay, let's move the needle to a different place and try to push the limits when it comes to making meaningful change for all these players.”

KATIE:  I love that. I think that's, like, such a great message. It reminds me too, I was watching the Angel City documentary last night and, you know, they showed Christen Press’ ACL tear from, I think, like, last summer. And I remember when that happened. It was surprising too, because she's, like, notoriously known for, like -- she hadn't really been injured, like at all. Like, you know there's always some players that in any sport, they're, like, “Oh, they're prone to injury.” You know, like, “Oh, such and such is out again. Like, is his health gonna continue to be a thing.” Whereas like a Christen Press, you know, you've never had -- almost never had an injury and then goes out with an ACL tear. But yeah, so, like, even people who have been able to stay injury free still at the top of their game in their club teams are getting injured. It's just -- Something's gotta be there.

JORDAN JACKSON: Right. And I think, like, there's two kind of separate blocks that you can kind of put this in, and one is the prevention. But then the second piece is someone tears their ACL and that only increases their risk more to have a second, or to tear the other side and that kind of thing. So, then it's what is being done that's different than someone who was previously not injured, right, that you're doing to prevent injury, versus, okay, now we have an injury. That can't be the same, you can't approach that the same way. So, what are the differences and how do we ensure that we can reduce the re-tear risk as much as possible, knowing that you're going to get some percentage, just from the fact that you had an injury, you have a more risk to get another one. But how do we take out all the other variables to reduce that as much as possible? And I think that can't be the same as a healthy player that you're doing exercises with, it has to be different and individually tailored for that athlete specifically.

KATIE: So, let's get to some basics here now that we've kind of, like, we've gone to the precipice of this. Like, talk to us about what an ACL tear is in that, you know, why do women seem to tear them more frequently than men.

JORDAN JACKSON: Hmm, yeah. So, ACL is a ligament in your knee and its main purpose is to stop translation of your femur on your tibia, and so you see that a lot in deceleration. So, you think of someone sprinting and trying to slam on the brakes, or you're cutting, and you have that knee bend. The other part of it is that it helps to control some internal rotation of your knee. And so those types of twisting injuries and if you're landing and your knee twists the ACL is meant to help check that.

KATIE: Okay.

JORDAN JACKSON: For how they tear, a lot of times it's a non-contact injury from cutting, landing, stopping quickly, having to go at a different direction, that's a large part of it. Another part of it is a contact injury. So actually making physical contact at the knee or at the ankle, at the hip and stuff like that, and then it puts your knee in a vulnerable position where it could tear.

KATIE: It seems more prevalent in women's soccer than men's, and so, like, that leads me to the question of, is it more common for women to tear their ACLs than men, in the context of soccer, even specifically?

JORDAN JACKSON: Yeah, I think a hundred percent it is, and I think research is really robust in supporting that fact. I think the clarity piece of why that is, is still on this, like, revolving door, of kind of really trying to pinpoint why. I think there's things that us as females cannot change when it comes to the risk of an ACL tear, because of things like bony anatomy, hip angles, angle of your femur, stuff like that. And also, things that relate to hormones and menstrual cycles and how that impacts ligaments and thing like that, can't change those things. But I think where the difference comes outside of anatomical things like that is the neuromuscular control part, the balance part, and that movement training part, where because we're anatomically built different, we move different, compared to male soccer players.

KATIE: I did want to ask you about the menstruation stuff, do you know anything about that research?

JORDAN JACKSON: Yeah, so there's this female, like, athlete triad, essentially, that is at the heart of all of it. And that has to do with, like, eating disorders, it has to do with overtraining, it has to do with bone health, it has to do with menstruation and things like that. And it's something that's been heavily researched, especially in, like, the adolescent female and stuff like that, in how and if they meet some of these criteria it really disposes them for injury when it comes to stress fractures and stuff like that.

KATIE: Yeah.

JORDAN JACKSON: From the ACL side, like, separate from, like, the triad of it specifically the, like, the menses part, there's been some research with ACLs that show an increased risk with pre-menstruation.

KATIE: Okay.

JORDAN JACKSON: Or in the days after you finish your cycle and stuff like that. And I -- it's intertwined with the hormonal changes that your body goes with. Now, I have not done any, like, deep dive into that but I think that's -- it's something that's been talked about, kind of, along with the anatomical differences between males and females that have just contributed to that increased risk. That's not necessarily the bulk of it, I don't think, but it's definitely part of the pie when it comes to risk.

KATIE: Gotcha. Okay.

[Music]

JOHN: Why are ACL injuries more common in soccer than other sports? Jackson says it comes down to the nature of how the game is played. In any sport where you have sudden stopping, cutting, twisting, or landing the risk of ACL injury increases. And soccer doesn't just involve one or two of these motions, all are encountered throughout the course of a game. Putting a soccer ball at a person's feet complicates things even further, since it brings even more attention to the knee. That said, ACL injuries do occur in other sports, too, including basketball, football, gymnastics, even downhill skiing. Up after the break, Jackson and Katie talked about the path forward for reducing ACL injuries in women's soccer, discussing the importance of translating what research has taught us about these injuries into actual meaningful change.

[Music]

JOHN: And now we're back with Jordan Jackson.

KATIE: Is this something where there just needs to be more training around how to move and, you know, you talked about decelerating, and landing from jumps is this things of like, “Okay, let's just -- muscle memory, this is how you should -- eventually we want you -- when you jump we want your leg to do this as it lands, because that's the safest thing for it.” Or, what does that look like?

JORDAN JACKSON: I think it's tough to say if there is, like, an exact blueprint to what it looks like. I do think that, kind of, what we touched on about, you know, neuromuscular training and true movement training and bio mechanics, and strength conditioning that is specific to soccer without actually playing soccer, if that makes sense. I think that's a big missing piece, and I think the sooner that you start that the better. But I also will say that as, in my experience, as I've aged through soccer, that tendency to do that decreases. Which you would think it might be the opposite, as you reach higher levels of soccer and things like that you might be exposed to more resources or, you know, you're labeled as a professional athlete you kind of assume you have access to certain things when it comes to movement training and recovery and strength and conditioning and this stuff. And it almost seems to be a little bit of the opposite, at least in my experience, when I was playing.

KATIE: Yeah.

JORDAN JACKSON: Because it's so much talked about when you're a high school girl playing soccer, “Okay, make sure you're -- like, you know, this is very common, tears in high school, things like that. And then once you get to college it's, if it hasn't happened yet then you're kind of out of your window of things, and I think the emphasis falls away a little bit.

KATIE: Okay.

JORDAN JACKSON: And then even at the professional game it was something I continued on my own, it wasn't necessarily a part of being at the level I was at, it was because I had access to it and already knew about it prior.

KATIE:  Hmm. And so, do you think that's something where, you know, is it a resources problem or, like, a commitment from people supporting players to say, like, “No, you need to be doing this.” Or is it just literally like, “That's not part of the budget, so we just aren't going to prioritize this.”

JORDAN JACKSON: Gosh, it's I think it's both. I think resources for sure, because -- especially, like, athletes, athletes know their bodies, right, and -- But also, athletes are they come -- like, we show up and we play. Our job is show up, we play and we practice, right? We don't -- I mean, I don't wanna blanket statement, I don't know everything there is to know about nutrition, I don't know everything there is to know about optimal muscle recovery or everything there is to know about something else, but if there's people on the medical staff or that are telling me this and advising me on that as a part of a collective, right, for a team then I'm gonna probably follow what they're saying, follow their advice and stuff like that. So, from the resources, if that isn't there then it's either not the principles aren't getting translated or they're just not aware that, “Hey, like, this actually could help with things.”

KATIE: You talked about just more games getting played. You know, do you think about the season and players may be playing in multiple leagues, so you know NWSL in the summer, but then you go overseas and play and, you know, European league in the fall, how much is this, like, an overuse thing or playing too much, or is it lack of recovery? Like, what does that -- Do we know -- How much do we know of that leads into ACL injuries?

JORDAN JACKSON: I think we can probably, pretty, confidently say that it -- the more that you're playing, right, it increases your risk just from an instance standpoint, right? The amount of times you're gonna be put in positions that put your ACL at risk and that kind of thing. But I think the role of fatigue is massive, when it comes to looking at overall load for a season and even all the way down to just overload for a week for an individual game, and that kind of thing. But you put that over a year and it's like, if you're not getting optimal recovery then you're essentially at risk for more as you're more fatigued. Because that's when your injuries are gonna happen as opposed to when you're fresh kind of right at the start of the season.

KATIE:  Yeah. And so that recovery piece, I think, is, like you said it's so critical. And what what's happening in -- like, let's say I don't recover enough, is it just that my muscles aren't ready the next time so they're less, like, strong when I need them to do what I need them to do to decelerate, or what's going on there?

JORDAN JACKSON: Yeah, it's part of it. I think the other thing that comes from it is that you start to see these different compensations, right? So, if you're your body's gonna still do what you're asking it to do.

KATIE: Right.

JORDAN JACKSON: So, if I wanna go into a cut I'm still gonna cut, but maybe instead of using, like, my hip dominant muscles to in order to help that I'm doing -- my knee is taking more load because my hip is fatigued, for example. I mean, that -- and that's pretty isolated example. But just as a general thing it's you get these movement compensations and you just get the muscles that can't handle the repetitive load over 90 minutes, over multiple games a week, multiple weeks for a season, you know. So, it all kind of compounds on each other, I think.

KATIE: I see. And we're talking a lot about the things that could be done to, perhaps, prevent some of these, but, I mean, to some extent, is it -- is tearing an ACL an inevitability of playing, you know, women's soccer? For -- Let's say you have a 36/37-year career, like, is that just inevitable even with all the right resources, to some extent, or is this something we really can -- You know, I think people are saying this is -- “Look, this is a problem we need to talk about it.” Like, what is the next step here?

JORDAN JACKSON: I 100% believe that it is not inevitable. I think that you can have a soccer career and not tear your ACL. I think playing soccer a lot like as in any sport, I think that there's the risk that you will but, I think we -- it shouldn't be what it is. The high percentage that it is and the prevalence that it is, it shouldn't be that way, and I do think that there is so much that we can do. And I think one thing that's come with, like, in the league expanding and women's soccer getting more notoriety and a little bit more resources, right, we're seeing more research when it comes to that, and I think that's fantastic. And I think you need the information in order to make a plan forward, but I think at this point we're starting to get the information and now it's, what are we doing with it? We can see different landing mechanics and different things when you're fatigued or not fatigued, for example, but what are we doing with it?

KATIE: Right.

JORDAN JACKSON: What's coming out of that?  Is there -- Is this a preseason screen that's getting injury prevention to continue through the season? Is it an offseason program that they're following or that players can do based on what their risk is? Because my risk is maybe not the same as someone else’s, or things that could predispose me are different from somebody else's. And I think there isn't a blanket answer, but it needs to be tailored with the information that we're getting, as research is done, and stuff like that.

KATIE: Speaking of research, you and I were talking, you're actually in a pretty interesting research study right now that, I think, would be really cool to hear as we as we talk about next steps. So, talk to us about this research study you're doing, or I think you're just about to wrap up. Because I think it's a really nice, like, dovetail into the next step forward, potentially.

JORDAN JACKSON: Yeah, so the research study we're doing is looking at neuromuscular training programs in pre-adolescent soccer players. So, we're talking, like, 8/9-year-olds to 11.

KATIE: So, pretty young.

JORDAN JACKSON: Yeah, pretty young, for sure.

KATIE: You started at three.

JORDAN JACKSON: Yeah, yeah. I think at three it's more like a -- the herd moving, right, not true soccer. But yeah. So, what we're doing is we brought in a lot -- I think, over 100 girls are a part of this study. So, we brought in all these girls, and we tested them on measures that are common tests for assessing injury risk, assessing for knee injuries and stuff like that. So, we're using hop testing, Y balance testing, strength for quads and hamstrings and some agility measures, as well. And then we're using force plates to determine counter movement jumps, both double leg and single leg. So, that brings in, kind of, the landing piece and stuff like that. And so, what we're doing is -- The control group is continuing with their normal kind of club warm up, whereas the experimental group are completing a neuromuscular training program that they do a few times a week for eight weeks, and then we come back and we retest everything. So, it's really seeing, like, what are the implications of an established neuromuscular training program in this age group.

KATIE: Yeah.

JORDAN JACKSON: Because there's -- The FIFA 11 is what came out initially, and that's kind of geared towards adolescent soccer players and stuff like that. But this is the kid’s version of it.

KATIE: Okay.

JORDAN JACKSON: And so, we're just kind of seeing, like, is it adequate initially, right? And this is -- There's not too many studies that have been done that are looking at this age group but, I think, hopefully if it shows any meaningful changes when it comes to improving balance or hop, or strength measures, all those things have positive correlations to decrease ACL injury risk and lower extremity injury risk in general.

KATIE: Yeah, I mean, it sounds like, too, something they can carry with them through their career, you know. So, these, like, same muscle habits and things, and behaviors can be, kind of like, imprinted almost. That's really cool. I would be excited to see, you know, the study when it comes out. We can reach back out and talk about it.

JORDAN JACKSON: Yeah, I'm excited to see what it has to offer. Hopefully it also lays the ground for some ways that research can continue, and not only in the pre-adolescent group but, I think, definitely in the high school and the college age group, and as you get into those, like, higher levels. I think the research doesn't necessarily gear itself towards that, it is more towards these, like, younger groups and stuff like that, so I think that's great. Let's see what this has to do and then see if we can apply it on a different scale to, you know, Division One college programs, professional programs and stuff like that.

KATIE: Another question I have just based off what you were just saying, you know, these eight or nine year old girls, like, if you could go back -- I mean, you made it injury free through your career, but if you could go back and, like, tell your friends and things like, you know, “Hey, this is what I wish we were all doing, what we all knew.” Like, what would you say to prevent -- you know, to prevent an ACL tear, like, what would you say to them? Like, what are the most important things in your mind?

JORDAN JACKSON: I think, as a youth player something that I would encourage everyone to do, no matter what your sport is, is to play every sport that you can. Because, I think, that is absolutely instrumental in laying down athletic movements that you're not gonna get just from playing soccer all day, every day. But, I think too, kind of from what my experience has been looking back, I think I would, I mean, as, like, ten-year-old as much, like, advocacy as I could do, I would bring in every club in Kansas City that I knew, or any soccer player that I knew, I would just tell them to come and do this or find something that's similar, and just see what it's doing. Because you look back in that facility is still there, it's moved to a different location but it's still there. And there's been people that have gone through from high school all the way up to the professionals. And you look back at those players and -- who's been injured and it's not very many.

KATIE: Yeah. And this is the movement facility you were talking about in Kansas?

JORDAN JACKSON: Yeah.

KATIE: So, yeah pretty, like, unique and it's maybe not so coincidental that everyone who, kind of, moved through it, perhaps, had some better outcomes later.

Yeah. I'm also just really intrigued by, you know, your switch from professional soccer to physical therapy. So, can you talk to us about your path and -- I know you and I were talking a little bit about how you landed at Houston Methodist, and I know you're moving on, but, like, talk to us about, kind of, that career progression and why you got into it, and how it went.

JORDAN JACKSON: My first experience, kind of, into physical therapy was in the offseason and I was gonna get some dry needling done with one of my teammates and they sent us over to Methodist when it was on Timmins, and that's how I met some of the PTs that are -- I still, like, work with today.

KATIE: Oh, cool.

JORDAN JACKSON: And so, that was my first exposure to PT. So, I walk into this clinic and, you know, we go and needle and stuff and I just start asking, like, “What do you -- What do you guys do here?” Because I never been through physical therapy, I didn't --

KATIE: Really?

JORDAN JACKSON: Yeah.

KATIE: Until you're a professional athlete you had not been?

JORDAN JACKSON: No.

KATIE: That's wild to me, I don't know why.

JORDAN JACKSON: Is it?

KATIE: Yeah.

JORDAN JACKSON: It's just, like, I've never been. And, like, even when I got injured in college my athletic trainer -- we did that at Nebraska, she rehabbed me back and that was it. It was never, like, a clinic or anything I was going to. So, come in and I'm just, you know, picking all these guys brains. I’m like, “What do you guys, like do here? Like what's --

KATIE:  Dry needling.

JORDAN JACKSON: “Like, what is this? Like -- And then that turned into saying, like, “Hey, well, you know, in the off season come, like, shadow, you know, see what's it about, see if you like it.” And I was like, “Okay, great.” So, I started shadowing and just kind of hanging out with one of the PTs for a little bit and really liked just the -- the patient care, and especially the treatment of, like athletes when it came to surgery rehabs. Because again, never been through that, so you see these people kind of come in, going through their surgical progressions and stuff. And it was really eye opening, and I was like, “I really like this. This is -- this feels like it could be something I could do or at least look into.” And so, I continued shadowing a little bit while I was playing, and then when I retired, I was like, “Well, what am I going to do now?”

KATIE:  Time to make some decisions.

JORDAN JACKSON: I’m like, “Well, I really like physical therapy.” So, I got a job at a -- just a private clinic that is in River Oaks, and I worked there for almost a year as a tech, just to, like, get -- figure out if I really do like this. “Let me work for second and see if I actually like, you know, the process.” And I really did, so I applied to PT school and got into Texas Women’s, in the medical center. And so, I did that for three years. And then it’s so funny, my -- I think I was just meant to be at Houston Methodist in some way. So, one of my clinical rotations I did at Houston Methodist, and the guys who was my clinical instructor is the same person that had treated me back -- or been part of it, back when I got needled when I was playing. And so, I was like, “Well, this is interesting.”

KATIE: Stars are aligning.

JORDAN JACKSON: Right. And so, I had that rotation with them and found out about their sports residency program that they offered, which I thought was amazing. In PT school it’s very all-inclusive when it comes to things. I mean, you’re getting ortho, neuro, name it, like, you’re learning everything, right? But the sports residency, it gives you extra year of, like, mentorship, experience, everything like that when it comes to sports, across the board. So, knowing I wanted to end up back in soccer on the medical side, I was like, “This is perfect.” So, I applied and was accepted to their residency and finished that up last year.

KATIE:  Yeah, that’s so cool. And just so our listeners know, I mean, you’re here today a physical therapist, but maybe gone tomorrow, pretty soon. But we are so grateful to have had you. I know I would be super excited if I needed PT and it was like a former Dash player that I’d watched play. I’d be like, “Yeah, this is pretty cool.”

JORDAN JACKSON: Yeah, no, it’s been great. I think I’ve really, really enjoyed bringing my personal experience from soccer into the clinic and, kind of, bringing a lot of the principles that I have gained when it comes to training and load management, and just all the things that you don’t really even think about until you’re on the PT side. Like, I was never -- when I was playing, I wasn’t necessarily thinking about warming up and, you know what I mean? And just like --

KATIE:  As an everyday exerciser, I write about this stuff all the time and I still am like, “Ope, I didn’t warm up, I know I should have.” Or, “Ope, I skipped stretching and I know I’m gonna feel -- like it’s gonna hurt tomorrow.”

JORDAN JACKSON: It’s crazy. Like, if I had a kid come in and was like, “Oh, well, I have, you know, knee pain, or something, I’m a soccer player.” I go, “Well, how many games have you played in the last month?” And they tell me they played 20 games, and that to -- as their PT I’m like, “Okay, like let’s see if we can disperse this a little bit, whatever.” But I’m playing -- I was playing 20 games. You know what I mean, you just don’t think about it until you’re on the other side of it. So, it’s been a really interesting and really educational thing for me, as well, to kind of put everything into perspective and try to bring some different viewpoints to the PT side when it comes to soccer players and other athletes.

KATIE:  Yeah, I think -- Like I said, you have such a unique perspective, and, like, we’ve been super glad to have you at Houston Methodist. And excited to see what you do next, and, like, what you can take from what you’ve learned here into the world that you’re gonna move on to. But thank you so much for joining us today, as well, here on the podcast, so. A tiny little microcosm of Houston Methodist. But we really appreciate, like, being able to talk to you and hear, like, your first-hand kind of experience and knowledge, on top of this. It’s been super cool.

JORDAN JACKSON: Yeah, thanks so much. I enjoyed talking with you guys, and always happy to talk about ACL things. It’s definitely a passion, and to bring that tear risk down is, like, my ultimate goal in life, so.

KATIE:  Absolutely, love it. Well, thanks so much.

JORDAN JACKSON: Thanks.

JOHN: So, that was all incredibly interesting. I thought that, maybe, the most interesting part to me, again, as someone who has taken a couple of kinesiology classes in college, almost 20 years ago, even back then really, like, I think the main talking point was, “Yeah, women have more of these injuries and that's kind of just the way it is.” And I think one of the most interesting things that Jordan talked about was, like, that's not the case.

KATIE: Yeah, I mean, I think -- even from my perspective, I probably thought, like, “Okay, it's more common to women, it must be something about the female anatomy or something like that.” And as Jordan said, like, that's going to be a part of it, yes, but it's a part, a small part, and that this does not have to be an inevitability of women's soccer. Which I think is -- from what you were saying of you guys talked about this 20 years ago, and, like, here we are 20 years later, and this is still -- not even just a problem in women's soccer, but, like, at the highest level. Like, it has not been solved yet. And I think her message of finding ways to really make meaningful change is big, because we seem to be talking about this for a long time with doing very little. I thought it was really interesting. And part of that meaningful change -- One of the changes that can be made, at least in youth soccer from the girls’ perspective, is Jordan mentioned the research study that her and another Houston Methodist doctor have been working on, essentially, having young girls do a different training plan that strengthens the knee and things like that. I think those are those early steps towards building these lasting habits that, you know, female players can grow with so that in their 35, maybe even 40-year career and ACL injury doesn't have to be an inevitability. I mean, there's still gonna be tears here and there but it's retearing. You know, she talked about how some people tear their ACL 3/5 times, I mean, that's crazy. And, like, you know, wherever we can start to kind of pull that number back, I think it's gonna make a big impact. And, you know, she talked a lot about the length of the schedule, but I know, John, you know, the men's game has a pretty long schedule too, so I mean  --

JOHN: And I think the condensed nature of the schedule is as big a factor as the length. I mean, these guys play every three days, for the most part, and then in a World Cup year play every three days for four or five weeks of the summer, or four or five weeks of what is usually the offseason as well.

KATIE:  A certain number of games are gonna need to be played, just to fit a, you know, a calendar year and, you know -- So, maybe that's not the thing to touch on but some of those other things we talked about the sense of -- and even just the -- like, the female -- like, the hormonal changes and stuff like that. Like, taking a look at how the hormonal shifts and balances in women is different, and it might be able to be fixed, like, those are just areas that people don't talk about a lot, and, like, research hasn't really probably caught up there. I mean, it's getting better, but then now, like, taking that research and saying, like, “Okay, we know this is what your cycle looks like every month, how should your training plan change?” I think that stuff’s really cool.

JOHN: I'm excited to see kind of how this develops because, like you said, I think we're getting to the point now where it's not just a shoulder shrug and these guys get more of these injuries, and that's the way it is. And, you know, hopefully a couple World Cups from now we're not staring at this long list of folks that are injured with the same injury that are losing 9 to 12 months of their professional careers trying to recover from them.

KATIE: Yeah, totally. And I think too, you know, just as we close out here. I think Jordan’s story and her, kind of, role in some of this moving forward is cool, because, you know, you have this former player who went into physical therapy which is going to be a foundation of how you know the ACL prevention story continues. And so, you know, you have this person, sort of, front and center. You know, she's back -- she's back closer to soccer players now, able to take everything she's learned, you know, from here and other places and really, like, teach players how to protect themselves with the things they can control so that doesn't happen in the future. So, I think this is really -- a really interesting episode, especially heading into the World Cup where, you know, we're gonna be missing a couple players, but I -- To me, I think, there's some light at the end of the tunnel. And so, I'm glad we talked to her today.

Well, that's gonna do it for us today. If you enjoyed our episode, please be sure to share, like and subscribe to On Health with Houston Methodist wherever you get your podcasts. And for more topics like this visit our blog at houstonmethodist.org/blog. In the meantime, stay tuned and stay healthy.

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