Anterior cruciate ligament injuries in female athletes

Abstract

The anterior cruciate ligament (ACL) is frequently injured in elite athletes, with females up to eight times more likely to suffer an ACL tear than males. Biomechanical and hormonal factors have been thoroughly investigated; however, there remain unknown factors that need investigation. The mechanism of injury differs between males and females, and anatomical differences contribute significantly to the increased risk in females. Hormonal factors, both endogenous and exogenous, play a role in ACL laxity and may modify the risk of injury. However, data are still limited, and research involving oral contraceptives is potentially associated with methodological and ethical problems. Such characteristics can also influence the outcome after ACL reconstruction, with higher failure rates in females linked to a smaller diameter of the graft, especially in athletes aged < 21 years. The addition of a lateral extra-articular tenodesis can improve the outcomes after ACL reconstruction and reduce the risk of failure, and it should be routinely considered in young elite athletes. Sex-specific environmental differences can also contribute to the increased risk of injury, with more limited access to and availablility of advanced training facilities for female athletes. In addition, football kits are designed for male players, and increased attention should be focused on improving the quality of pitches, as female leagues usually play the day after male leagues. The kit, including boots, the length of studs, and the footballs themselves, should be tailored to the needs and body shapes of female athletes. Specific physiotherapy programmes and training protocols have yielded remarkable results in reducing the risk of injury, and these should be extended to school-age athletes. Finally, psychological factors should not be overlooked, with females’ greater fear of re-injury and lack of confidence in their knee compromising their return to sport after ACL injury. Both intrinsic and extrinsic factors should be recognized and addressed to optimize the training programmes which are designed to prevent injury, and improve our understanding of these injuries.Cite this article: Bone Joint J 2023;105-B(10):1033–1037.

Increased risk for early revision with quadriceps graft compared with patellar tendon graft in primary ACL reconstructions

“…Although the literature describes female sex as a risk factor for ACL injury [38,44], it appears not to affect the outcomes after reconstructive surgery [25,51].…”

Decreased sagittal slope of the medial tibial spine and deep concavity of the lateral tibial spine are risk factors for noncontact anterior cruciate ligament injury

“…Tibial eminence had a potential role in inhibiting tibiofemoral translations when a compressive load was transmitted from the distal femur to the tibial plateau. Anterior translation, internal rotation and medial displacement of the tibia relative to the femur, either considered in isolation or in combination, have been proposed as mechanisms involved in ACL strain and injury [7, 12,18]. Previous studies demonstrated that a smaller tibial spine area, a decreased medial tibial spine volume and a narrower eminence width provided less restraint to tibial translation and rotation relative to the femur, thereby increasing the risk of ACL injury [11,27,28].…”

“…Additionally, a noticeable concavity exists in the lateral tibial spine, and the depth of this concavity in the sagittal plane might serve as a risk factor associated with ACL injuries. Moreover, it is noteworthy that sex, particularly female sex, has been identified as an independent risk factor for ACL injury [18]. However, discrepancies exist regarding whether specific geometric knee measurements are associated with ACL rupture risk among males and females [3,17,23,31].…”

Satisfactory 5‐year functional outcomes following primary ACL reconstructions from the UK National Ligament Registry

“…In 2022, 6% of primary ACLR patients had an associated LET surgery. This may reflect the growing evidence for the role of additional LET procedures in improving rotation stability and reducing the risk of Rezansoff ACL graft failure in high-risk patients [17][18][19][20][21][22][23].…”