Maturation and biomechanical risk factors associated with anterior cruciate ligament injury: Is there a link? A systematic review

Objective

To establish the potential link between sex-specific maturation and biomechanical factors associated with ACL injury during dynamic tasks.

Design

Systematic review.

Literature search

Five databases (CINHAL®, Cochrane Library, PubMed®, Scopus®, and SPORTDiscus) were searched and monitored until 27 May 2024.

Study selection criteria

Cross-sectional, cohort, case-control, or interventional studies reporting one or more biomechanical variable linked with ACL injury and which assessed participants across two or more maturation phases were considered eligible.

Data synthesis

Studies were assessed for risk of bias using a modified version of the Newcastle Ottawa Scale and overall quality of evidence was rated using GRADE. Metrics and effect sizes were presented where available.

Results

Eighteen included studies examined 400 males, 1377 females, and 315 participants of undefined sex across various maturation phases. The methodological quality of most studies (n = 16) was considered good, and satisfactory for two. Knee abduction angle, knee abduction moment, knee flexion angle, and ground reaction forces were most commonly reported. Knee abduction angles and moments and knee flexion angles were greater in late and post-pubertal females than males and pre-pubertal females during both landing and cutting tasks. When normalised for body mass, ground reaction forces were generally greater in males compared to females overall and for less mature participants for both sexes. Overall quality of evidence was low or medium across the four biomechanical measures.

Conclusion

Sex-specific maturation considerations are important in the targeted development and implementation of ACL injury risk identification and prevention strategies.