Anterior Cruciate Ligament TearsWhy Females Face a Greater Risk

Gabrielle OBrien
Mrs. Bagley
Intern Mentor G/T-Period 1
January 17, 2017
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She sprints down the field, soccer ball at her feet. She is gaining on the goal; just

one more defender to beat, and she will have a clear shot. She dribbles straight ahead,

waits until the last possible second when the defender is a foot away, and then makes a

sharp fake to the left. Pop!

She falls to the ground, her right knee throbbing in pain. She tries to get up again,

only to feel her knee immediately give out and thud to the ground once again. She

clutches her leg, gasping for breath and fighting back tears.

Every year, in the United States alone, approximately 200,000 individuals endure

a similar situation. Medically speaking, this experience describes an injury sustained to

the anterior cruciate ligament, more commonly known as the ACL. The anterior cruciate

ligament is one of four ligaments in the knee and is located posterior to the patella,

connecting the tibia and the femur. The ACL provides stability, allows for dynamic

motion, and contributes to proprioception. There are many causes of anterior cruciate

ligament injuries, including rapid changes of direction, sudden stops, and improper

landings from a jump. The severity of the injury differs from patient to patient, ranging

from grade one to three sprains to complete tears. The recovery process of an ACL tear is

extensive and expensive, with reconstruction surgery alone costing thousands of dollars

and necessitating months of physical therapy. As a female soccer player, I have seen four

teammates tear their anterior cruciate ligament in just the past two years. In general,

female athletes are two to eight times more likely to sustain an injury to their

anterior cruciate ligament than their male counterparts due to anatomical,

biomechanical, and hormonal differences.

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There are several anatomical characteristics unique to females that put them at a

greater risk for anterior cruciate ligament injures. For example, on average, females have

a wider pelvis. The correlation between pelvis width and ACL injuries was investigated in

research conducted by Dr. Anh-Dung Nguyen at the Applied Neuromechanics Research

Laboratory, in which two hundred eighteen participants (one hundred and two males and

one hundred and sixteen females) were studied. Using eight clinical measures of static

alignment, it was found that the alignment of the lower extremities (such as the hip,

pelvis, knee, and foot) contributes to the magnitude of the quadriceps angle. Specifically,

a wider pelvis results in a greater quadriceps angle, or Q angle. The Q angle is the line of

force of the quadriceps made by connecting the anterior superior iliac spine (a point at the

base of the pelvis) to the mid-point of the patella. The average Q angle for females is

seventeen degrees, while the average Q angle for males is fourteen degrees. A greater Q

angle can cause an increase in the compression of the lateral patella and decrease

neuromuscular and quadriceps reflex response time (Hafeez). This is significant to

anterior cruciate ligament injuries because these factors place more stress on the ACL and

decrease the ability of the quadriceps muscle to support the ligament. The Q angle is also

associated with the tibiofemoral angle, an angle formed between the femur and the tibia.

In Dr. Nguyens experiment, females tended to have a greater tibiofemoral angle as well.

Another anatomical feature that makes females more likely to sustain an ACL

injury is the intercondylar notch. The intercondylar notch is the deep groove between the

condyles (rounded ends) of the femur bone. Women tend to have a narrower

intercondylar notch, which restricts the movement of the ligament. Restricting the
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movement of the ACL makes it more likely to strain or tear when the knee is subjected to

a twisting motion (DeVries).

There are also biomechanical characteristics unique to females that make them

more prone to anterior cruciate ligament injuries. The biomechanics, or way that

organisms move, differs greatly between females and males. For instance, females are

more prone to femoral anteversion. Femoral anteversion is when the femur rotates

inward, causing the knee to point inward as well. Dr. Massaki Kaneko at the National

Institute of Health investigated the relationship between femoral anteversion and anterior

cruciate ligament injury by studying sixteen female subjects. The subjects were divided

into low and high groups based on femoral anteversion using Craigs test and were

analyzed using certain tests while jumping on one leg. It was found that the subjects in

the high group had a lower hip flexion angle, a higher knee flexion and valgus angles,

and greater rectus femoris muscle activity. This led to anterior tibial displacement when

landing from a single-leg jump. This means that when females land from a jump,

ultimately because of higher femoral anteversion, they land in a way that is more likely to

injure the anterior cruciate ligament (Kaneko).

Females are also more prone to hyperextension, which occurs when the knee

joint is forced to extend beyond its normal range of motion, thus placing stress on the

ACL (Colio). Knee hyperextension occurs most frequently when the anterior of the knee

experiences force, thus pushing the joint backwards. Hyperextension is more common in

females because females are generally more flexible than males and thus have the ability

to extend their knee beyond its normal range. Another biomechanical factor is that

females tend to activate their hamstring less when decelerating than males, which places
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more stress on the anterior cruciate ligament. In addition, females generally have a higher

quadriceps-to-hamstring strength ratio, meaning females quadriceps is far stronger than

their hamstrings. This increased ratio creates more tension in the ACL because the force

of impact when landing is not absorbed by the surrounding muscles (McDaniel).

Research indicates that hormonal factors influence the risk for anterior cruciate

ligament injuries as well. In particular, the levels of estrogen and progesterone seem to

play a role. As the levels of estrogen and progesterone fluctuate throughout the menstrual

cycle, females seem to be at the greatest risk during the preovulatory phase, when

estrogen and progesterone levels are rising. Evidence for this correlation was discovered

in 2002 when a study followed sixty-nine female athletes who had sustained an ACL

injury. Urine samples from the participants were collected within twenty-four hours of

the injury to analyze estrogen, progesterone, and luteinizing hormone metabolites levels.

The results showed that women had a significantly higher chance of injuring their ACL

during the preovulatory phase as opposed to during the luteal, or postovulatory, phase

(Wojyts).

Another study required thirty-seven female participants to report their menstrual

cycle and provide salvia for sex-hormone testing within seventy two hours of injuring

their anterior cruciate ligament. It was found that twenty-six out of the thirty-seven

participants tore their ACL during the preovulatory phase of their menstrual cycle

(McDaniel). The reason that higher hormone levels put females at a greater risk for ACL

injury is that the hormones, estrogen especially, loosens the ligament and negatively

impacts the functioning of the nerves and muscles (Osborne).

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While it is widely accepted that females are at a higher risk for anterior cruciate

ligament tears than males, there are different theories as to the exact causes for this

discrepancy. Specifically, some believe that hormonal differences do not put females at a

higher risk. Some theorists claim that hormone levels vary too much from individual to

individual to allow for concrete evidence to be gathered to support the idea that females

are more susceptible to ACL injury at a specific time in their menstrual cycle. However,

multiple studies have consistently shown that females are in fact more likely to tear their

anterior cruciate ligament during the preovulatory phase of their menstrual cycle.

Additionally, research has proven that hormones impact nerve function, which would put

females at a higher risk for injury as it would decrease neuromuscular control. In light of

the controversy, it is certain that more research remains to be done regarding anterior

cruciate ligament tears. As stated in a report published in the British Journal of Sports

Medicine, research to date suggests that [hormones] alone are probably not responsible

for changes in the structure, metabolism and mechanical properties of the ACL [] the

role of other sex hormones (eg, relaxin, progesterone, testosterone) in the biology and

pathology of the ACL are poorly understood. A push for further research is vital because

the more information that can be discovered regarding the cause of anterior cruciate

ligament injuries, the faster effective injury prevention techniques can be developed so

that hundreds of thousands of patients can be spared thousands of dollars and months of

pain.

Females are far more likely to injure their anterior cruciate ligament due to

anatomical, biomechanical, and hormonal differences. The anatomical variations that

make females more susceptible are having a wider pelvis, a greater Q angle, and a
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narrower intercondylar notch. The biomechanical disparities are females natural

tendency to activate their hamstring less than males when decelerating, to hyperextend

their knees, to engage in femoral anteversion, and to have weaker hamstrings. While the

exact role that hormones play in making females more likely to injure their ACL is

controversial, it is certain that hormonal differences do make females more susceptible to

injure this ligament, particularly during the preovulatory phase of the menstrual cycle. It

is due to these anatomical, biomechanical, and hormonal differences that females face a

far greater risk than their male counterparts when it comes to anterior cruciate ligament

injuries.
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Works Cited

Colio, Sean. "Understanding Knee Hyperextension." Sports-Health, 6 Nov. 2015.

Accessed 9 Jan. 2017.

DeVries, Carrie. "Why Are Women at Greater Risk for ACL Injuries?"

Sports-health, 7 May 2015. Accessed 10 Jan. 2017.

Galland, Mark. "Preventing ACL Tears - Why Are ACL Tears More Common In Female

Athletes?" Orthopaedic Specialists of NC. Accessed 20 Oct. 2016.

Hafeez, Andeela, et al. "'Q' Angle." Edited by Venus Pagare. Physiopedia.

Accessed 27 Oct. 2016.

Kaneko, Massaki, and Keishoku Sakuraba. "Association between Femoral Anteversion

and Lower Extremity Posture upon Single-leg Landing: Implications for

Anterior Cruciate Ligament Injury." Journal of Physical Therapy Science.

National Institute of Health. Accessed 9 Jan. 2017.

McDaniel, Larry W., et al. "Reducing The Risk Of ACL Injury In Female Athletes."

Contemporary Issues In Education Research, vol. 3, no. 3, Mar. 2010, pp.

15-20.

Nguyen, Anh-Dung, et al. "Relationships Between Lower Extremity Alignment and

the Quadriceps Angle." PubMed Central, 7 June 2010. National Center for

Biotechnology Information. Accessed 26 Oct. 2016.

"Non-Contact ACL Injuries in Female Athletes: an International Olympic Committee

Current Concepts Statement." British Journal of Sports Medicine.

National Institutes of Health.

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Osborne, Maria. "Why Do Females Injure Their Knees Four to Six Times More Than

MenAnd What Can You Do About It?" Women's Integrated Services in

Health, July-Aug. 2012, pp. 1-6.

Wojtys, EM, and LJ Huston. "The Effect of the Menstrual Cycle on Anterior

Cruciate Ligament Injuries in Women as Determined by Hormone Levels."

PubMed. National Institutes of Health. Accessed 10 Jan. 2017.