The anterior cruciate ligament injury controversy: is “valgus collapse” a sex-specific mechanism?

Abstract

Background Anterior cruciate ligament (ACL) injury is a devastating injury that puts an athlete at high risk of future osteoarthritis. Identification of risk factors and development of ACL prevention programmes likely decrease injury risk. Although studies indicate that sagittal plane biomechanical factors contribute to ACL loading mechanisms, it is unlikely that non-contact ACL injuries occur solely in a sagittal plane. Some authors attempt to ascribe the solely sagittal plane injury mechanism to both female and male ACL injuries and rebuff the concept that knee “valgus” is associated with isolated ACL injury. Prospective studies that utilise coupled biomechanical and epidemiological approaches demonstrated that frontal knee motions and torques are strong predictors of future non-contact ACL injury risk in female athletes. Video analysis studies also indicate a frontal plane “valgus collapse” mechanism of injury in women. As load sharing between knee ligaments is complex, frontal as well as sagittal and transverse plane loading mechanisms likely contribute to non-contact ACL injury. The purpose of this review is to summarise existing evidence regarding ACL injury mechanisms and to propose that sex-specific mechanisms of ACL injury may occur, with women sustaining injuries by a predominantly “valgus collapse” mechanism. Conclusion Prevention programmes and interventions that only target high-risk sagittal plane landing mechanics, especially in the female athlete, are likely to be less effective in ameliorating important frontal and transverse plane contributions to ACL injury mechanisms and could seriously hamper ACL injury prevention efforts. Programmes that target the reduction of high-risk valgus and sagittal plane movements will probably prove to be superior for ACL injury prevention.

The effect of isolated popliteus tendon complex injury on graft force in anterior cruciate ligament reconstructed knees

“…While there is no obvious explanation for the discrepancy observed between these studies and our results, critical factors such as the differences in the loading conditions, sequence of sectioning the PLS and coupled motions under external tibial torque may have contributed. Numerous studies have explored the mechanics of noncontact ACL injuries in athletes to identify the precise kinematics that predispose the ACL to extreme tensile loads leading to its subsequent failure [24][25][26][27][28]. The evidence from these studies has associated excessive tibial combined valgus and external/internal rotations to be the most detrimental motion pattern to the ACL.…”

Ativação muscular do quadril e do joelho em duas aterrissagens realizadas por atletas do sexo masculino

“…According to zebis et al (10) , the excessive activation of the quadriceps over the hamstrings muscles is a possible risk factor for injuries of the anterior cruciate ligament (ACL) in women. Despite the population used in this study, we believe that these mechanisms are true for men, since in vitro studies have demonstrated that the excessive activation of the quadriceps in relation to the hamstrings muscles increases the anterior shear forces of the tibia in relation to the femur and the tension in the referred ligament (11) as well as evidence suggests that this is the main injury mechanism in men (12) . Another aspect little investigated is the difference in the electrical activity in muscles of the lumbopelvic region between different landings in the male population (13) .…”

ECSS Position Statement 2009: Prevention of acute sports injuries

“…This mechanism was demonstrated in a cadaver study (DeMorat, Weinhold, Blackburn, Chudik, & Garrett, 2004), but was criticized for not taking ground reaction forces into consideration. Others argue that knee abduction must be involved in the injury mechanism (Quatman & Hewett, 2009). This theory is partly based on video analyses of ACL-injured athletes where valgus or valgus collapse are frequently reported (Krosshaug et al, 2007a;Krosshaug, Slauterbeck, Engebretsen, & Bahr, 2007b;Olsen et al, 2004).…”