THE ACL IN THE FEMALE ATHLETE

Many  studies have shown that young active women sustain anterior cruciate ligament(ACL) injuries more frequently than men.  This is important for many reasons.  Shortterm,  these injuries result in alteration of activity level and sports participation.  Longterm,   women already develop osteoarthritis more frequently than men and this will be compounded in young women who participate in sports and sustain an ACL injury.  Therefore, understanding the reasons for the different injury rates between males and females is critical in formulating a plan to prevent such injuries and still encourage active participation in sports.

The reason for the higher rate of injury is thought to be multifactorial.  Studies have been done to look at hormonal, biomechanical and anatomical influences.  Anatomically, women tend to have a wider pelvis which alters the mechanics at the hip and knee.  The actual ACL and the femoral notch are smaller in women even when adjusted for height and weight.  Biomechanically, women differ from men in their jumping and landing.  Smaller hip and knee flexion angles when landing result in higher ground reactive forces.  This can place increased stress on ACL.  Valgus knee(knock knee) position also results in greater strain.  Women have a quadriceps dominant pattern when resisting anterior tibial translation(leg going forward).  This unbalanced force can also place more stress on the ACL. Finally, ligaments have been shown to be more lax in women which is also influenced by hormonal patterns.

Many factors need to be considered when deciding on treatment of the ACL-injured female patient.  Age of patient, level of competition and future plans of participation need to be considered.   Patient and family need to be involved in the decision on the best treatment for the individual.  Risks, benefits and expectations of nonsurgical and surgical options need to be understood.  High demand athletes and those that have instability issues tend to be good candidates for surgical reconstruction.  Outcomes for women undergoing ACL reconstruction are very good and are similar to men.

Overall, prevention of these ACL injuries should be the focus of researchers, training programs, coaches, physical therapists and orthopedic physicians.  Training programs have emphasized training female athletes in neuromuscular control to alter leg positioning and muscle activation patterns to reduce ground reactive forces and valgus moments when landing.  Increasing and balancing quadriceps and hamstring strength is critical in decreasing strain on ACL during sports.  These programs have resulted in decreasing rates of injury.  More studies need to be done on the reasons for the higher rate of noncontact ACL injuries in women as well as  these training programs.  Implementation, after developing these programs, is the key to improving women’s health now and into the future.        Ignatius Komninakas, M.D.