Review

Artículo original

Anterior cruciate ligament injury in the female athlete: risk and

prevention

África D. Lluna Llorens, Bárbara Sánchez Sabater, Isabel Medrano Morte, Elena M. García García, Sara Sánchez López,
Juan F. Abellán Guillén
Hospital General Universitario Morales Meseguer, Murcia.

Received: 23.01.2017 Summary

Accepted: 23.05.2017
Background: The anterior cruciate ligament (ACL) injury of the knee is the second most common sports injury after the
ankle sprain. It causes knee instability and impacts sport performance. Knowing what predisposes this injury is important to
prevent it, specially in women, where the rate is higher. This paper presents the ACL injury epidemiology, making reference to
the underlying risk factors and its preventive programmes. The aim of this study was to show the risk factors that predispose
to a higher incidence of anterior cruciate ligament injury, as well as to present the effectiveness of the prevention programs.
Methods: A literature review through PubMEd, Cochrane and UpToDate has been performed including the meta-analysis or
clinical trials published over the past 10 years.
Results: The injury incidence rate is three times higher in women than in men. It specially develops in sports like football and
basketball, i.e., sports where pivoting, sharp running direction changes or abruptly stopping exercises are more common. The
risk factors are multifactorial; and the only adjustable ones are the biomechanical risk factors. Prevention programmes are
focused in these factors, trying to enhance strength and biomechanical propioception.
Key words: Conclusions: After the review we can conclude that ACL injuries are more frequent in women. Prevention programmes focus
Anterior cruciate on neuromuscular training (strengthening exercises, proximal control and plyometric exercises) and they reduces significantly
ligament. Prevention. the injury for football and handball players, but not for basketball ones. The programmes focus on strengthening exercises,
Athlete. Risk factors. proximal control and plyometric exercises.

Rotura del ligamento cruzado anterior en la mujer deportista: factores

de riesgo y programas de prevención

Resumen

Objetivo: La lesión del ligamento cruzado anterior de la rodilla (LCA) es la segunda lesión deportiva más frecuente tras el
esguince de tobillo. Provoca inestabilidad de la rodilla y afecta al rendimiento deportivo, por lo que es importante saber qué
lo favorece y cómo lo podemos evitar. En este trabajo se expone la epidemiología de la lesión del LCA haciendo referencia a
los factores de riesgo predisponentes y a los programas preventivos de la misma. El objetivo de este trabajo ha sido mostrar
los factores de riesgo que predisponen a una mayor incidencia de lesión del ligamento cruzado anterior, así como presentar
la efectividad de los programas de prevención de la misma.
Método: Se ha realizado una revisión de la literatura a través de PubMEd, Cochrane y UpToDate incluyendo los metanálisis
o ensayos clínicos publicados en los últimos 10 años.
Resultados: La incidencia de lesión es mayor en la mujer que en el hombre con una relación 3:1, y sobre todo se produce en
deportes como el fútbol y el baloncesto, donde se realizan ejercicios como pivotar, cambio brusco de dirección en la carrera
o frenar de forma brusca. Los factores de riesgo son multifactoriales, entre ellos los únicos modificables son los factores de
Palabras clave: riesgo biomecánicos y es en ellos donde se centran los programas de prevención.
Ligamento cruzado Conclusiones: Las mujeres tienen una mayor incidencia de lesión de LCA. Los programas de prevención se centran en fac-
anterior. Prevención. tores de riesgo modificable, principalmente en el entrenamiento neuromuscular y disminuyen de forma estadísticamente
Deportistas. significativa tanto en el fútbol como en el balonmano, pero no en el baloncesto. Estos programas se centran en ejercicios de
Factores de riesgo fortalecimiento, control proximal y ejercicios pliométricos.

Correspondence: África Dakota Lluna Llorens

E-mail: [email protected]

288 Arch Med Deporte 2017;34(5):288-292

 Anterior cruciate ligament injury in the female athlete: risk and prevention

Introduction Anatomical factors

The anatomical difference between men and women could be a
The anterior cruciate ligament of the knee (ACL) injury rate varies factor that contributes to a heightened ACL injury rate. However, these
depending on gender, sport, and prevention programmes1. It is higher in factors cannot be modified, therefore preventive measures cannot be
women than in men, and a higher rate is seen in sports such as football applied to them.
and basketball1. ACL injury is the second most frequent sporting injury −− The breadth of the intercondylar notch in women is smaller than
after ankle sprain2, which is why it is important to establish the risk factors, in men, however no differences in the risk of ACL injury have been
paying attention to those that can be modified, as this is the main focus revealed3.
of prevention programmes. −− The cross-sectional area of the ACL is greater in men3, which
suggests that a smaller diameter of the ACL in women could be
Epidemiology of ACL injury a tearing risk factor.
−− The Q angle, whose normal value is from 8 to 17º, is greater in
Rate women. This increase is because generally the female pelvis is
The anterior cruciate injury rate varies in the different studies pu- wider and the femur is shorter3 or that a high Q angle increases
blished, possibly due to the different physical activity performed by the the medial stress on the ligaments of the knee3.
study participants. It is essential to highlight that the data published is −− The angle between the patellar tendon and the tibia affects the
heterogeneous, and that the injury rate depends to a great extent on shearing force applied.
sporting performance1,2 and therefore on neuromuscular control, which
should be considered upon analysing the results. Biomechanical factors
The female:male ratio of ACL injuries has recently generated con- The quadriceps muscle displays its greatest muscular activity during
siderable attention. In the study by Prodromos et al.1, the ACL tearing knee flexion exercises, whilst the hamstrings tend to relax; moreover,
rate (female:male) by sport was: basketball, 3.5:1; football, 2.67:1; hockey, when inducing muscle fatigue and performing sporting manoeuvres
1.18:1. According to the level of female athletes: in secondary school in female athletes such as landing on just one leg or changing running
it was 0.09, whilst in men it was 0.02, and the female:male ratio was direction, a reduction in the hip flex occurs, as well as an increase in the
4.5:1. At university, the rate was 0.29 for women and 0.08 for men, with internal rotation of the hip, an increase in knee valgus and an external
a female:male ratio of 3.63:1, and on a professional level it was 0.20 for rotation of the tibia, which leads to less stability in the knee joint3.
women and 0.21 for men, with a female:male ratio of 0.95:1. According In men, all of this is less frequent because they have greater muscle
to this data, as female athletes become more elite, the injury rate reduces control. The lack of this control in women, especially in adolescence,
to almost the same as the rate for males. causes a greater predisposition to slipping of the femur over the tibia
and greater stress on the ACL.
Risk factors Biomechanical risk factors are the only ones considered to be
modifiable, and this is why prevention programmes focus on this area.
To understand why this injury is more frequent among women and
Greater neuromuscular control leads to a reduced risk of ACL injury,
as a means of preventing it, it is important to identify the risk factors. The
which explains why as the sporting level increases and training de-
cause of the increase in ACL injury is multifactorial, and the risk factors
mands are higher, female:male injury ratios are nearly 1:1
have been categorised into: environmental, anatomical, hormonal and
biomechanical3.
Prevention programmes
Environmental factors Biomechanical and biomuscular components are the only mo-
Surface temperatures, friction between materials, and the design difiable elements. Recent studies reveal that certain risk factors such
of footwear soles can be a risk factor in ACL injury3. These factors affect as an increase in knee valgus, limited hip flex or the internal rotation
both men and women equally, which is why there is not a higher rate of the hip predispose the individual to a greater risk of ACL tearing4,5.
among women. The magnitude of these movements can be controlled by increasing
supporting muscle and by alternating this with sporting technique, all
Hormonal factors through the use of preventive neuromuscular training programmes
Proof of the effect of sex hormone effects on connective tissue is (PNMT). A recent meta-analysis assessed the overall effectiveness of
limited and the results of some studies are inconsistent. However, the PNMT and revealed that these programmes reduce ACL injuries in
synthesis of collagen could be reduced up to 40% due to physiological young women4.
oestrogen levels, and up to 50% induced by pharmacological oestrogen Training promotes muscle development, improves movement
levels3. patterns and protects from ACL injury; however, it is not clear which

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África D. Lluna Llorens, et al.

kind of exercises are the most effective in preventing this injury. Upon review published by Michaelidis et al9 in which 12 PNMT are proposed,
assessing the different studies, in which the groups included are not which despite their differences, focus their training plan on neuromus-
homogeneous6-8, it is vital to establish which kind of exercises included cular development and include the types of exercises that have revealed
in PNMT significantly reduce ACL injury. statistically significant reductions in ACL injury.
A meta-analysis published by Sugimoto et al. 4 aimed to establish
the exercises that had the greatest prophylactic effect on reducing ACL Training programmes
injury. They examined four exercise categories: balance, plyometric exer- Different prevention programmes have been proposed with the
cises, strength training and proximal control. The results revealed a sta- aim of reducing the ACL injury rate in female athletes. The characte-
tistically significant lower number of ACL injuries (p = 0.001) with PNMT ristics and exercises of each of these programmes are summarised in
that focused on strength, proximal control and plyometric exercises. Table 1. To establish whether or not they are effective, they have been
Neuromuscular risk factors can be modified through training, assessed using studies with a control group. Below are the main studies
leading to better sporting performance. Furthermore, given that the used to assess these programmes.
majority of ACL injuries occur in non-contact situations, it is necessary
to consider the different biomechanical demands of the different sports, Sportsmetrics
as well as to work on the sporting motion depending on the sport. A prospective study to assess the effect of PNMT on the knee
Different training programmes have been described that reduce injury rate of female athletes. They compared athletes following the
the ACL injury rate9-10. The most important are included in the systematic

Table 1. ACL injury prevention programmes in female athletes.

Programme Sport Characteristics

SPORTSMETRICS Football - Session: 60-90 min

Volleyball - Frequency: 3 days/week
Basketball - Total time: 6 weeks (only pre-season)
FATP Football - Session: 75 min
- Frequency: 3 days/week
- Total time: 7 months
PEP Football - Session: 20 min
- Frequency: 2-3 days/week
- Total time: 12 weeks
KLIP Football - Session: 20 min
- Frequency: 2 days/week
- Total time: 4-5 months
FIFA 11 Football - Session: 15 min
- Frequency: 1 day/week
- Total time: 7.5 months
SÖDERMAN Football -Session: 10-15 min
-Frequency: 3 days/week
-Time: 6 months
MYKLEBUST Handball - Session: 15 min
- Frequency: 1 day/week
- Total time: 5 months
OLSEN Handball - Session: 15-20 min
- Frequency: 1 day/week
- Total time: 5 months
PETERSEN Handball - Session: 10 min
- Frequency: 1 day/week
- Total time: 8 weeks
PASANEN Hockey - Session: 20-30 min
- Frequency: 2-3 days/week (intense) alternated with 1 day/week (maintenance)
- Total time: 6 months
WALDEN Football - Session: 15 min
- Frequency: 2 days/week
- Total time: 7 months
HTP Football - Session: 20-25 min
- Frequency: 2 days/weeks (pre-season) / 1 day/week (season)
- Total time: 9 months

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 Anterior cruciate ligament injury in the female athlete: risk and prevention

programme to those without a specific training programme, as well could reduce lower limb injuries in female footballers compared to
as to a group of male athletes with no training in the different sports those that did not follow the programme. It was established that there
(football, volleyball and basketball). The injury rate in the female athletes were no differences in the study groups, either in terms of the injury
was not significantly lower than in untrained male athletes; however, a rate or the type of injury16.
significant difference was observed in the reduction of the ACL injury
Myklebust
rate in women to which a PNMT was applied compared to those that
A prospective study that assessed the application of a training pro-
did not follow a training programme. This prospective study revealed
gramme in which the balance exercises used focused on neuromuscular
a lower knee injury rate in women after following a specific plyometric
control and landing abilities. Upon finishing the study, a reduction was
training programme11.
seen in the injury rate in elite female athletes that had completed the
Frappier Acceleration Training Programme (FATP) programme compared to those that had not followed it. It was con-
The aim of the study by Heidt et al.12 was to establish the effect cluded that it is possible to prevent ACL injury with the right PNTM17.
achieved with a training programme in the pre-season among female
football players compared to those that did not follow a programme. Olsen
This study led to the conclusion that in this demographic, injuries were A randomised controlled clinical trial, which assessed the efficiency
more frequent in the lower limbs and that the trained group had a of a warm-up programme in reducing the rate of knee and ankle injuries
statistically significant lower injury rate. Despite a statistically significant in female handball players. The warm-up programme aimed to improve
conclusion not being observed, they concluded that the trained group the landing technique, neuromuscular control, strength and balance. It
had a lower ACL injury rate. For all of the above, they concluded that was observed that it prevented injuries and therefore it was established
physical conditioning entails a reduction in the injury rate of female that it should be introduced as part of the PNMT18.
football players.
Petersen
Prevent Injury and Enhance Performance programme (PEP) A retrospective study that assessed the effects of PNMT on ankle and
A clinical trial was carried out in which female football players were knee injury rates, applied to female handball players. It was concluded
randomly separated into a study group and a control group. The aim that neuromuscular training is appropriate and effective in preventing
was to identify the PNMT that reduced non-contact ACL injury rates. knee and ankle injuries in female handball players19.
The conclusion reached was that with the PEP programme, the ACL
injury rate was lower, including among athletes that had a previous Pasanen
history of ACL injury13. A PNMT that aimed to improve motor skills, body control, as well
as to prepare and activate the neuromuscular system. The aim was to
Knee Ligament Injury Prevention (KLIP) prevent non-contact knee injuries, applying the study to female hockey
A prospective study carried out over two years to assess the effects
players. After performing the study, the conclusion was reached that
of preventive programmes on female footballers, basketball players
the preventive programme is effective and can be recommended in
and volleyball players at secondary school. The results suggested that
the weekly training routines of these athletes20.
a programme focusing on plyometric exercises in which the jump
landing mechanism and rapid deceleration were assessed does not Walden
reduced the injury rate in female athletes if it is carried out twice a
A randomised clinical trial that assessed a preventive programme
week for 20 minutes14.
focusing on proximal control exercises, balance and the correct alig-
nment of the knee in football players. It concluded that the warm-up
FIFA 11 Injury Prevention Programme
programme statistically significantly reduced the ACL injury rate21.
The aim of this randomised controlled clinical trial was to research
the effect of the combination of plyometric, strength, balance and
“Harmoknee” training programme (HTP)
proximal control exercises on the risk of injury in adolescent female
A clinical trial was carried out on a multifaceted preventive pro-
footballers. No difference was found in the general injury rate between
gramme in football players. It was concluded that the knee injury rate
the intervention and control group, or in the rate of any kind of injury.
The outcome of the study, in which no effect was found upon applying among young football players was reduced with physical exercise, if this
the exercises, could be due to the poor fulfilment of the prevention was applied alongside an appropriate sporting education22.
programme by the study group15. Furthermore, in a study recently published by Zebis et al.23, the
reduction of the ACL injury rate was assessed upon performing rapid
Söderman direction changes, by applying preventive programmes. A clinical trial
Prospective study based on balance exercises. The aim was to was performed with a sample group of 40 female basketball or handball
establish whether performing these kinds of exercises within a PNMT players, aged between 15-16 years, in which 20 were randomly assigned

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África D. Lluna Llorens, et al.

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