journal of orthopaedics 13 (2016) a1–a4

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Editorial

The female ACL: Why is it more prone to injury?

Female athletes tear their anterior cruciate ligaments (ACL) at maneuver. Anatomic risk factors of the femoral notch and
an alarmingly higher rate in certain sports including basket- lower extremity alignment were discussed. Although there is
ball, team handball, and soccer. The participation in sports by much literature on the role of the femoral notch size in ACL
girls has increased dramatically, in recent times.1 The rapidly injury, no consensus on the notch's role in ACL injury can be
increasing numbers of females participating impacts the reached at this time. Identifying sports-specific at-risk
number of injuries. However, the rates of ACL injuries in motions and positions and encouraging athletes to avoid
comparable sports of basketball and soccer have remained these at-risk situations when possible seems promising.
alarmingly high with change in male-to-female ratios over the Further, strategies for activating protective neuromuscular
last 10 years.2 The incidence of female to male is 3.5 times responses when at-risk situations are encountered is also a
greater in basketball and 2.8 times greater in soccer.3 The possible prevention strategy. There is a need to improve public
typical mechanism of injury is a rapid but awkward stop and and participant awareness for risk of ACL injury and the
anticipation of lateral movements.4 The ACL tears in 70 ms. possibilities for prevention. We need to continue to define the
Dynamic movement patterns are very important factors specific neuromuscular, proprioceptive, and motor control
contributing to ACL injury.5 The extrinsic or changeable factors associated with ACL injury. Although specific predic-
factors are controlled by the player and coaches. The intrinsic tive and protective factors are determined, training and
differences between male and female athletes that would prevention programs should continue to be implemented,
explain why women tear the ACL two to eight times more assessed, and improved. From this consensus conference, a
frequently than men. monograph of prevention strategies has been published.5

1. Consensus statement 2. Hormonal

A consensus conference was held in Hunt Valley, Maryland, on Sex hormones have effects on numerous end organs, as
June 10, 1999, sponsored by the American Orthopaedic Society evidenced by changes during menarche and menopause.
for Sports Medicine (AOSSM), National Athletic Trainers' Estrogen, progesterone, relaxin, and other sex hormones have
Association (NATA), National Collegiate Athletic Association cyclic effects. There is no consensus of the scientific
(NCAA), and Orthopedic Research arid Education Foundation community that sex hormones play a role in the increased
(OREF). The goal of the conference was to discuss anatomic, incidence of ACL injury in female athletes.6 One must
environmental, hormonal, and biomechanical risk factors for understand the hormonal activities during the cycle and the
noncontact ACL injuries; specifically, what we know from the hormonal effects during the cycle. In 1998, Wojtys et al.7
written information, areas for further research, and preven- reported on a series of 28 women, who were found to have
tion strategies. From the written information and presentation more ACL injuries than expected during the ovulatory phase
of the twelve physicians and nine basic researchers at this and fewer injuries during the follicular phase at a p-value of
retreat, a prevention booklet was published.5,6 The categories 0.03. However, reevaluation of these data led to the discovery
of risk factors were anatomic, environmental, hormonal, and that the results were not statistically significant but only
biomechanical. Neuromuscular factors appear to be the most showed a trend.8 More recently, Wojtys et al.9 have reported,
important reason for the higher rate of ACL injuries in females on 69 females with acute ACL injuries studied within 24 h at
compared to males.6 The at-risk situations for noncontact ACL four centers by menstrual cycle details and urinary hormonal
injuries appear to be deceleration, cutting or changing levels. These results supported a significantly greater than
directions, and landing.5 Prior to the injury, an awkward expected percentage of ACL injuries during midcycle (ovula-
dynamic body movement and a perturbation event are usually tory phase) and less than expected during the luteal or
observed. With this, quadriceps activation during eccentric follicular phase.9 Wojtys et al.9 reported that oral contra-
contraction is a major factor in ACL injury during the at risk ceptives reduce the rate of ACL tear in the ovulatory phase.
A2 journal of orthopaedics 13 (2016) a1–a4

However, no recommendations are being made to modify  0.044.18,19 Sheiboume et al.20 reported on the relationship
practices, activity level, or place females on oral contraceptive of the intercondylar width of the femur and ACL tears
pills in the face of these results.6 In the follicular stage, ACL prospectively There was no statistically significant difference
injuries have been reported to be less by Wojtys. Myklebust10 in notch width between height groups for men and women.20
reported higher rates of ACL injury 1 week before menses and Women were found to have significantly narrower notches
just after menses. Slauter Beck and Hardy also found higher than men, with height and weight as co-variants. After ACL
ACL rates before and after menses.11 reconstruction with 10 mm autografts, there was no difference
in graft tear pattern between the groups, men or women.
Regardless of gender, individuals who possess smaller notch
3. Anatomic differences
dimensions appear to be, at greater risk for injury than
individuals with larger notches.21 A template to position the
The lower extremity static alignment and measurements have knee during acquisition of notch views was suggested to
not been predictive of ACL injuries.1,12 Authors frequently slate reduce the variability. Analysis of the intercondylar notch has
that the female has a wider pelvis than the male. However, also been recorded by computed tomography22 and by
females have a narrower pelvis. Horton and Hall, found that magnetic resonance imaging.15 Magnetic resonance imaging
males had a greater hip width by 3 cm and longer femoral length scans have been analyzed for notch size and ACL volume. The
by 5 cm.12,13 The ratios of hip width to femoral length were about ACL volume was also significantly smaller in females and
equal – 0.73 in males and 0.77 in females. Ratios appear to be a there was indeed a significant correlation between femoral
more important measurement than absolute width. notch volume and ACL volume, that is, smaller notches
housed smaller ACLs. There are conflicting data about whether
femoral intercondylar notch stenosis is a predisposing factor
4. Femoral notch
for an acute ACL tear and whether there are significant
topographic differences between men and women. Most
The ACL size and orientation determine width and shape of authors have found a statistically significant smaller notch
the femoral notch. Regardless of gender, smaller notches have width index (NWI) in patients with bilateral or unilateral ACL
been associated with increased rate of ACL injury. Most ruptures when compared with normal knees.14,15
authors report that a smaller ligament is housed in a smaller
notch. However, Muneta et al.14 used measurements from
5. Neuromuscular
Japanese knee cadavers to determine ACL cross-sectional area
as it relates to notch dimensions.14 The small notch knees did
not have a thinner ACL in them. Anderson et al. by magnetic Gender differences in neuromuscular activation patterns have
resonance imaging, notch width index between the sexes were been reported to contribute, to ACL injury. Compared to males,
not statistically significant. With adjustments for body weight, females have been found to be less effective in stiffening their
the size of the ACL in girls was found to be statistically smaller knee.23 Maximum contraction of the knee musculature
than in boys.15 The question remains whether or not a smaller significantly decreased the anterior tibial translation in men
ligament is more apt to fail. It remains unknown whether a and women comparing relaxed to contracted states. However,
bigger ligament is stronger. the percent increase in knee stiffness was significantly greater
There are conflicting data about significant NWI differences at the p = 0.003 level, with male percentages of 473% and
between men-and women. Some studies have demonstrated females 217%.23 Wojtys et al. have done excellent work on the
that there are no gender-related differences in NWI,14 whereas comparison of neuromuscular performance in elite male
other studies have shown that there is a difference between athletes, female athletes, and nonathletic females.24 Results
male and female subjects.15,16 The reason for the increased of these tests revealed that the female athlete and controls
injury rate in women remains unclear; it is probably caused by demonstrated more anterior tibial laxity by arthrometry than
a complex interplay between multiple variables.17 Other male counterparts and less muscle strength and endurance.
studies suggest that the NWI and other morphologic param- The female athletes take significantly longer to generate
eters of the osseous intercondylar fossa may not be critical maximum hamstring torque during isokinetic testing than
etiologic factors in the patient with a unilateral or bilateral ACL males. The muscle recruitment order in some female athletes
tear. Muneta et al.14 suggested that if a narrow intercondylar was markedly different, and the quadriceps was recruited
notch contains a smaller ACL, this may explain why people initially in response to anterior tibia translation instead of the
with narrow notches have a higher incidence of ACL injuries hamstrings for initial knee stabilization.24
but no significant correlation was found after dissecting
cadaveric knee joints. Anderson et al.15 evaluated 100 high
6. Core stability
school basketball players by MR imaging. They found no
correlation between ACL and notch size; this suggested that
the size of the ACL cannot be predicted from the size of the It has long been understood that lack of control contributes to
intercondylar notch. These data indicated that narrower ACL an individual getting into a position that allows for an ACL
width might be indicative of reduced ACL strength, which rupture. In recent years, the realization of proximal control
could be more susceptible to injury. dictating distal function has become increasingly apparent.
The femoral notch-to-width ratio was 0.189 for noncontact One concept that has been closely linked to this has been the
injuries and 0.233 for contact. The normal was 0.231 idea of ‘‘core stability’’. The ‘‘core’’ may be operationally
 journal of orthopaedics 13 (2016) a1–a4 A3

defined as the abdominal, back extensor, and hip musculature straight-leg landings. Therefore, prospective analysis is likely
strength/function that contribute to stability of the lumbo- to be received more warmly by the athletes if the program is
pelvic-hip region complex where a person's center of gravity is presented with an emphasis on performance improvement
located and all movement begins.25 Richardson et al.26 showed rather than injury prevention. With increased participation in
that the abdominal musculature role as a primary stabilizer of these programs, multiple-center analysis will have the power
the internal and external obliques are the primary stabilizers necessary to determine which factors significantly predispose
of the trunk, and the transverses abdominus promotes athletes to ACL injury. The future for injury prevention is
lumbopelvic region stability of utmost importance for func- bright. We must rise to the challenge.
tion. A study by Cresswell et al.27 gave evidence that
transverses abdominus is critically important to spine
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