Anterior Cruciate Ligament Injuries

Elizabeth A. Arendt, MD

Address
University of Minnesota, Department of Orthopedics, Box 492,
420 Delaware Street SE, Minneapolis, MN 55455, USA.
E-mail: arend001@umn.edu
Current Womens Health Reports. 2001, 1:211217
Current Science Inc. ISSN 15345874
Copyright 2001 by Current Science Inc.

Increasingly, epidemiological data has shown differences

in the total number of injuries and in the incidence of
serious knee injuries among males and females in jumping
and pivoting activities. Particularly, strong epidemiological
data support increased incidence of non-contact anterior
cruciate ligament injuries in females. Despite more than a
decade of vigorous debate and intense study on this topic,
research has yet to clearly link gender as an individual
risk factor for this injury. Risk factors can be divided into
intrinsic or extrinsic factors; for this review they are
divided into anatomic, hormonal, and neuromuscular
categories. The most intriguing of these deals with neuromuscular control of the limb. In particular, neuromuscular
issues involving hip and trunk position and its muscular
control have been increasingly implicated in this injury
etiology. Gender differences have been found in motion
patterns, positions, and muscular forces generated with
various lower extremity coordinated activities. Thus, many
clinicians currently advocate a strengthening program that
emphasizes proximal hip control mediated through gluteus
and proximal hamstring activation in a close chain fashion.
This, combined with skill training in landing and pivoting
maneuvers, is thought to help prevent injury. We must
encourage continued, structured, and focused research
in this area. However, until specific predictive and
protective factors are identified, training and prevention
programs should continue to be implemented,
assessed, and improved.

participating in sports [3]. For example, the National

Collegiate Athletic Association (NCAA) participation rate
increased 69% for females versus 13% for males in a 15-year
period (academic year 1982 through 1987) [4]. Title IX led
to an increase in female participation in organized sports
at both high school and college levels. This paralleled an
increase in exercise and physical activity for females through
recreational and non-organized physical activity also. Studies
of the first female military cadets, done between 1977 and
1980, helped establish a females physiological capabilities
in conditioned and non-conditioned states [58]. These
studies suggested that many performance variables differed
due to improper conditioning for young women. With
proper conditioning, the injury rate became less disparate
when compared with the male cadets. Whiteside [9] and
Clarke and Buckley [10] independently concluded that there
was a greater difference between sports than between men
and women in the same sport regarding injury.
During the next two decades, increasing epidemiological
data emerged to support differences in the total number of
injuries [1113] and the incidence of serious knee injuries
[1417] among males and females who participate in
jumping and pivoting activities. In particular, epidemiological data supports an increase incidence of non-contact
anterior cruciate ligament (ACL) injuries in females
[1518,19,20]. An excellent review article concerns the
epidemiology of knee ligament injuries [21].The risk factors
associated with female sports injuries, in particular the risk
factor for increased rate of non-contact anterior cruciate ligaments, is currently a topic of vigorous debate and intense
study in the field of sports medicine and musculoskeletal
health. Research has yet to clearly link gender as an individual risk factor to this injury etiology. Possible reasons for
this gender-specific injury have been reviewed elsewhere
[19,22,2325]. This review attempts to focus on a few
of the risk factors that continue to be most debated.
They will be divided into anatomic, hormonal, and neuromuscular risk factors.

Introduction
Early literature regarding athletic injury supported the sportsspecific nature of an injury. Sports injuries sustained by
female athletes were no different than those of male athletes,
and the type of injury one obtained was more related to the
sport played [1,2]. The passage of Title IX Educational Assistant Act of 1972 required institutions that received federal
funds to provide equal access and funding to males and
females in all curricular and extracurricular activities. This
resulted in a dramatic increase in the number of females

Anatomic Risk Factors

Though much discussion and focused research has
been given to the role of laxity as a risk factor, there is no
consensus on its being a predictor of ACL injury. Laxity
is generally divided into generalized hypermobility and
specific joint (knee) laxity. The theory is that by the time
a laxed person senses the knee getting into a dangerous
position, it may be at a point of no return, thus leading to
injury. Interest in this theory began in 1970, when Nicholas

212

Sports Medicine and Orthopedics

reported a strong correlation between hyperlaxity and knee

injury rate [26]. However, subsequent studies in the late 70s
and early 80s dispelled this [27,28]. More recently, Decoster
et al [29] found no significant difference in overall injury
patterns between hypermobile athletes compared with nonhypermobile athletes. However, there has been found to be
an association between hypermobility and musculoskeletal
complaints (which include overuse type injuries) in a study
on military personnel [30].
The second way to discuss laxity is by examining anterior
posterior (AP) translation of the knee. There is continued
debate concerning the following: 1) if increase in AP translation of a non-injured knee is a risk factor for ACL injuries;
and 2) whether there is a difference between males and
females AP translation. Current literature supports varying
results [3134]. Therefore, no consensus can be made on
whether there are significant differences in AP translation
between males and females or whether an increase in AP
translation of the knee is a predictor of ACL injury.
One of the more intriguing anatomic features that has
come under recent review is tibial slope. The theory is that
in the quads active mechanism of ACL injury, those with
a greater posterior tibial slope would be more susceptible
to injury (ie, the greater the posterior slope, the easier it
is for the femur to slide down the slope when the tibia
is subjected to a quadriceps active force). DeJour and
Bonnin [35] and their French colleagues have been strong
advocates for discussing the role of tibial slope in pathologic knee motion. They demonstrated that for every 10
increase in posterior tibial slope, there is a 6 mm increase
in anterior tibial translation. However, Meister et al. [36]
conducted a case-controlled study of 50 ACL-deficient
knees and compared them to 50 age-matched knees with
patellofemoral pain and found no difference in tibial slope
between two groups. Jackowski et al. [32] demonstrated
no difference in tibial slope as measured on computed
tomography (CT) scan between male and female varsity
athletes. However, the role of tibial slope is an intriguing
risk factor that has come under recent review and merits
further thoughtful investigation.
An anatomic risk factor that has been extensively
debated in the literature is the size of the intercondylar
notch. The theory is that notch stenosis results in impingement and therefore tears the ACL. However, a recent
thorough review of intercondylar notch [37] was undertaken as part of a consensus conference in 1999. At
that time, the 15 published studies in English literature
were reviewed. Nine of them addressed gender differences.
Though there is much literature implicating the role of
the femoral notch size in ACL injury, inconclusive
results prevail concerning gender and notch dimensions.
The main problem is that studies use different methods to
measure notch size. It was thought that there was
difficulty in obtaining valid and reliable measurements. In
particular, there was no control for leg rotation. Rotation
of the leg is most important to control when plain

radiographs are used to measure the notch. Only one study

stated that leg rotation was controlled. The conference
attendees concluded that consensus on the role of the
notch in gender-specific ACL injuries cannot be made at
this time [38]. Table 1 presents findings of the conference
published by Griffin et al. [23].However, there is increasing discussion regarding the role of the ligament size of
the ACL inside the notch, rather than the variable of notch
dimensions. Two earlier studies reported a significant difference between males and females regarding the width of
the anterior cruciate ligament [39,40]. These studies did
not control for height and weight. Researchers of more
recent reports examined the cross-sectional area of the
ACL in female versus male varsity athletes, controlling for
height and weight. They found that the cross-sectional area
of the ACL in the female was significantly smaller than that
of the male [32,41]. One case control study used magnetic
resonance imaging (MRI) to evaluate the ACL in the noninjured knee of 20 females with a unilateral ACL-deficient
knee. The authors compared this to gender, age, and
activity-matched controls, The ACL-deficient group had
significantly smaller cross-sectional areas of the ACL
ligament than controls [42]. In a recent cadaveric study,
the width of male and female ACLs were found to be
statistically different, as was the relationship between the
width of the ACL and the femoral intercondylar notch
width. However, the absolute measurement of the
femoral intercondylar notch width was not found to be
statistically different [43].
Therefore, the debate continues as to the role of the
femoral intercondylar notch and whether a small notch
houses a small ACL and/or whether the ACL is at risk
because it is smaller and thereby weaker.
Hormonal Environment
The females unique hormonal environment is clearly
different than that of her male counterpart. Studies implicating sex-specific hormones in the creation of increased
injury risk in females have generated these three hypotheses: 1) Sex-specific hormones increase tissue laxity [44]
and this increased laxity leads to increased injury potential;
2) sex-specific hormones change the composition and
cellular structure of ligaments [45,46] leading to a weaker,
inferior ligament; and 3) there may be a hormonal influence on the neuromuscular control of extremity function,
in particular coordinated limb motion. This hormonal
influence may be absolute or it may be concomitant
with hormonal changes during a females menstrual cycle
[23,47,48]. This influence may be mediated
through neuromuscular control of the limbs and/or
proprioception. Though estrogen hormones also may play
a role (relaxin, progesterone, and others). Despite heated
debates, significant speculation, and many studies in
the role of sex-specific hormones and the prevalence of
musculoskeletal injuries in females, there continues to be a
lack of agreement in whether this effect is causal [23].

Anterior Cruciate Ligament Injuries Arendt

213

Table 1. Summary of the Hunt Valley Consensus Conference on the prevention of

non-contact ACL injuries.
Recognizing a need to critically examine and summarize existing data on prevention strategies and their implied risk
factors for non-contact ACL injuries, 22 orthopaedists, family physicians, biomechanists, and athletic trainers met
in Hunt Valley, MD, in June 1999. Their goals were to increase awareness in the at-risk population and medical
support personnel about prevention strategies and to stimulate increased efforts in injury prevention research.
After carefully reviewing available data on injury risk factors and their associated prevention strategies, the participants
formulated the following consensus statements:
Environmental risk factors
1. At present there is no evidence that knee braces prevent ACL injuries.
2. Increasing the shoe-surface coefficient of friction may improve performance but also may increase the risk
of injury to the ACL. Because shoe-surface interaction is modifiable, this area merits further investigation.
Anatomic risk factors
1. There is much literature on the role of the femoral notch size and ACL injury, but because of the difficulty
of obtaining valid and reliable measurements, no consensus on the role of the notch in ACL injury has been reached as yet.
2. At present, there are insufficient data on ACL size (absolute or proportional) to support the concept that
ligament size is related to the risk of injury.
3. There are insufficient data to relate lower-extremity anatomic alignment to ACL injury; therefore,
further research is needed.
Hormonal risk factors
1. At present, there is no consensus in the scientific community that sex-specific hormones play a role in
the increased incidence of ACL injury in female athletes, but further research in this area is encouraged.
2. Hormonal intervention for ACL injury prevention cannot be justified.
3. There is no evidence to recommend modification of activity or restriction from sport for females at any time
during the menstrual cycle.
Biomechanical risk factors
1. The knee is only one part of a kinetic chain; therefore, it must be borne in mind that anatomic sites other than
the knee, including the trunk, hip, and ankle, may have a role in ACL injury.
2. Common biomechanical factors involved in many injuries include impact on the foot rather than [on] the toes during
landing or changing directions, awkward dynamic body movements, and biomechanical perturbation [before] the injury.
3. The common at-risk situation for non-contact ACL injuries appears to be deceleration, which occurs when
the athlete cuts, changes direction, or lands from a jump.
4. Neuromuscular factors are important contributors to the increased risk of ACL injuries in females and appear
to be the most important reason for the differing ACL injury rates between males and females.
5. Strong quadriceps activation during eccentric contraction was considered to be a major factor in injury to the ACL.
Prevention strategies
After reviewing the existing neuromuscular training prevention programs, participants agreed on the following
statements regarding prevention strategies:
1. Early data show that specific training programs that enhance body control reduce ACL injury rates in female
athletes and may increase athletic performance.
2. Training and conditioning programs for male and female athletes in the same sport may need to be different.
3. Those involved in the care of athletes should identify sport-specific at-risk motions and positions and
encourage athletes to avoid these situations when possible.
4. Strategies for activating protective neuromuscular responses when at-risk situations are encountered should be identified.
Future research directions
The consensus group emphasized the need to continue to define specific neuromuscular, proprioceptive, and motor control
factors associated with injury. However, until specific predictive and protective factors are definitively identified, training and
prevention programs should continue to be implemented, assessed, and improved. There is a pressing need to improve public
and participant awareness of the risk of ACL injury and the possibilities for prevention.
(Adapted from Griffin et al. [23]; courtesy of the American Academy of Orthopaedic Surgeons.)

Two recent studies that reviewed the mechanical properties of ligaments in a primate model have shown no correlation between material properties of ligaments and estrogen
levels [49,50]. Literature to date supports that if there is a
causal relationship between females hormonal environment
and ligament injury, it is unlikely due to the negative effect of
hormones on the material properties of a particular ligament.
The cyclical environment of a females menstrual cycle
has come under much review. An earlier work by Wojtys

et al. [51] reviewed non-contact female ACL injuries.

Wojtys suggested more injuries than expected in the
ovulatory phase of the menstrual cycle. There was a statistical error reported from the original study and its findings
have been subsequently retracted based on lack of significant results [52]. Other studies have added to the confusion in this area. A Norwegian study reported that fewer
anterior cruciate ligament injuries occurred in mid cycle
[53]. The study used a questionnaire to establish menstrual

214

Sports Medicine and Orthopedics

phase. A more recent presentation by Dr. Slauterbeck

examined hormone levels using saliva samples obtained
within 48 hours of a non-contact anterior cruciate ligament injury. His study reported that ACL injuries occur
more commonly in late luteal and early follicular phase
[54]. Another study used a questionnaire format, to review
the timing of a non-contact ACL injury on menstrual phase
in college varsity female athletes; this study reported no
significant difference between the day of the menstrual
cycle and the timing of ACL injury [55]. A recent study
presented at our summer meeting compared non-contact
anterior cruciate ligament injuries and hormonal levels
judged by urine analysis. This study reported an increase in
anterior cruciate ligament injuries in mid-cycle [56].
Taken collectively, there still continues to be much
debate concerning the relationship between non-contact
anterior cruciate ligament injuries and menstrual cycle
function. However, recent studies show that women who
use oral contraception may be less susceptible to athletic
musculoskeletal injuries compared with non-contraceptive
users [55,57,58].
Neuromuscular Factors
Certainly, the most intriguing modifiable risk factory
regarding acute anterior cruciate ligament injuries in both
males and females deals with neuromuscular control of
the limb. Current discussion focuses on a quads active
injury pattern for anterior cruciate ligament injuries. The
activated quadriceps with the knee in low degrees of
flexion places a measurable strain on the anterior cruciate
ligament [24,59]. Researchers of one study found that
female athletes relied initially on their quadriceps muscle
in response to anterior tibial translation, thus firing their
quadriceps muscle first. Male athletes and female and male
control subjects relied initially on their hamstrings for
further knee stabilization [60]. These authors and others
maintained that female athletes have a quadriceps dominant knee that might be responsible for increased anterior
translation in certain activities, leading to increased ACL
stress and the increased risk of ACL injury.
Exploring neuromuscular issues has lead many investigators to look toward the hip and trunk position and its
muscular control as contributing to knee activities [24].
Gender differences have been found in motion patterns,
positions, and muscular force generated in various lower
extremity coordinated activities [6164]. Females have
been shown to have less hamstring and gluteus medius
activation than males do (WB Kibler, MD, unpublished
data 1999 and LJ Huston, MS, unpublished data 1999).
Hewett and associates [47] studied the effects of a
jump training program and landing mechanics in
high school female athletes. The aim of the program was to
decrease landing forces by teaching neuromuscular control
during landing and to increase vertical jump height. The
6-week program primarily emphasized proper jump technique and plyometric training (Table 2). Key findings

included that knee adduction and abduction moments

decreased an average of 50% with this training program.
These same researchers evaluated this program in a group
of high school female athletes who participated in soccer,
volleyball, and basketball [48]. Collectively, untrained
female athletes had a higher incidence of serious knee injuries (3.6 times) than did trained female athletes. Also,
they had a higher injury incidence than did male athletes
(4.8 times).Therefore, many clinicians currently advocate a
strengthening program that emphasizes proximal hip
control mediated through gluteus and proximal hamstring
activation in a closed chained fashion. This, combined with
skill training and landing and pivoting maneuvers, is
thought to be beneficial in injury prevention [23].
In addition to improving neuromuscular limb control,
avoidance strategies for at-risk situations have been studied
and shown to be helpful in reducing ACL injury risks. This
has been shown in the sport of basketball [65,66]
(Griffis et al., unpublished data, 1989) and alpine skiing
[67]. Additionally, the role of balance training and
proprioception has been highlighted as a modifiable risk
factor, reducing the risk of anterior cruciate ligament
injuries in soccer players [68].

Conclusions
A rational approach to prevent or to decrease the rate of
injury occurrence typically centers on defining risk factors
and injury mechanisms. This results in attempts to reduce
or to eliminate these risk factors. Although research
efforts have yielded much information, they have not
resulted in an elucidation of risk factors of non-contact
ACL injuries (with the possible exception of research
efforts in downhill skiing) [67]. However, there is
compelling information that neuromuscular control and
balance are favorable for injury reduction. In addition,
knowledge of injury mechanisms and avoidance strategies for at-risk situations appear to be prudent factors to
discuss with both developing and elite athletes. Several
prevention programs have been designed to increase neuromuscular control, improve balance, and/or teach avoidance strategies for at-risk situations in the hope that they
will be effective in decreasing injury rates. We have yet to
identify a risk factor with a causal relationship between
the risk factor and the injury occurrence. However, it
seems prudent and reasonable to increase awareness of
what is known and to encourage implementation of
existing neuromuscular prevention programs (or some of
their components) to an individual sport endeavor. We
should encourage continued structured and focused
research in this area and be aware that research has yet
to clearly link gender as an individual risk factor to
this injury occurrence.
Because of the numerous benefits that sports provide to
both females and males, the increased incidence of
ACL injuries in females who play certain sports should not

Anterior Cruciate Ligament Injuries Arendt

215

Table 2. Sportsmetrics* Training Program

Exercise/Activity

Duration/Repetitions

Phase I (Technique)
Wall jumps
Tuck jumps
Broad jumps, stick land
Squat jumps
Double-leg cone jumps, side-to-side/back-to-front
180 jumps
Bounding in place

Week 1
20 sec
20 sec
5 reps
10 sec
30 sec/30 sec
20 sec
20 sec

Week 2
25 sec
25 sec
10 reps
15 sec
30 sec/30 sec
25 sec
25 sec

Phase II (Fundamentals)
Wall jumps
Tuck jumps
Jump, jump, jump, vertical jump
Squat jumps
Bounding for distance
Double-leg cone jumps, side-to-side/back-to-front
Scissor jump
Hop, hop, stick

Week 3
30 sec
30 sec
5 reps
20 sec
1 run
30 sec/30 sec
30 sec
5 reps/leg

Week 4
30 sec
30 sec
8 reps
20 sec
2 runs
30 sec/30 sec
30 sec
5 reps/leg

Phase III (Performance)

Wall jumps
Step, jump up, down, vertical
Mattress jumps, side-to-side/back-to-front
Single-leg jumps for distance
Squat jumps
Jump into bounding
Single-leg hop, hop, stick

Week 5
30 sec
5 reps
30 sec/30 sec
5 reps/leg
25 sec
3 runs
5 reps/leg

Week 6
30 sec
10 reps
30 sec/30 sec
5 reps/leg
25 sec
4 runs
5 reps/leg

*Sportsmetrics; Cincinnati Sportsmedicine Research Foundation, Cincinnati, OH

Adapted from Hewett et al. [47].
Before jumping exercises: stretching, 15--20 minutes; skipping, 2 laps; side shuffle, 2 laps. Each jumping

exercise is followed by a 30--sec rest. Post-training: cool-down walk, 2 min; stretching, 5 min.

These jumps performed on mats.

warrant a change in the way females compete or in the sports

they choose. Rather, it should stimulate research to examine
multiple variables that may contribute to this injury etiology,
thus leading to a safer athletic experience for all participants.

6.
7.
8.
9.

References and Recommended Reading

Papers of particular interest, published recently, have been
highlighted as:

Of importance
Of major importance

10.
11.

12.
1.
2.

3.
4.

5.

Haycock CE, Gillette JV: Susceptibility of women athletes to

injury, myths vs reality. JAMA 1976, 236:163165.
Calvert R: Athletic injuries and deaths in secondary school and
colleges 19751976. (National Center for Education Statistics,
Department of Health, Education and Welfare). Washington, DC:
US Goverment Printing Office, 19751976.
Bodnar LM: Historical role of women in sports. Am J Sports
Med 1980, 8:5455.
The National Collegiate Athletic Association (NCAA):
Participation at a Glance 19831998. Accessible at
http://www.NCAA.org. Accessed August 15, 2001.
Protzman R: Physiologic performance of women compared
to men. Am J Sports Med 1979, 7:191194.

13.

14.

15.
16.

17.

Tomasi LF, Peterson JA, Pettit GP: Women's response to army

training. Phys Sportsmed 1977, 5:3237.
Anderson JL: Women's sports and fitness programs at the
US military academy. Phys Sportsmed 1979, 7:72.
Lenz HW: Women's sports and fitness programs at the
US Navel Academy. Phys Sportsmed 1979, 7:4150.
Whiteside P: Men's and women's injuries in comparable
sports. Phys Sportsmed 1980, 8:130140.
Clarke K, Buckley W: Women's injuries in collegiate sports.
Am J Sports Med 1980, 8:187191.
deLoes M: Epidemiology of sports injuries in the Swiss
organization youth and sports 19871989. Int J Sports Med
1995, 16:134138.
Engstrom B, Johansson C, Tornkvist H: Soccer injuries among
elite female players. Am J Sports Med 1991, 19:37275.
Zillmer DA, Powell JA, Albright JP: Gender-specific injury
patterns in high school varsity basketball. J Womens Health
1991, 1:6976.
Engstrom B, Forssblad M, Johansson C: Does a major knee
injury definitely sideline an elite soccer player? Am J Sports
Med 1990, 18:101105.
Ferretti A, Papandrea P, Conteduca F: Knee ligament injuries
in volleyball players. Am J Sports Med 1992, 20:203207.
Ireland ML, Wall C: Epidemiology and comparison of knee
injuries in elite male and female United States basketball
athletes [Abstract]. Med Sci Sports Exerc 1990, 22:S82.
Lindenfeld TN, Schmitt OJ, Herdy MP: Incidence of injury
in outdoor soccer. Am J Sports Med 1994, 22:364371.

216

Sports Medicine and Orthopedics

18. Arendt E, Dick R: Knee injury patterns among men and

women in collegiate basketball and soccer: NCAA data
and review of literature. Am J Sports Med 1995, 23:694701.
This was one of the early epidemiological reports that used a
large database, which revealed a gender specificity to this
musculoskeletal injury.
19. Arendt EA, Agel J, Dick R: Anterior cruciate ligament injury
patterns among collegiate men and women. Journal of
Athletic Training 1999, 34:8692.
This article reviewed the second five year evaluation (19941998) of
the anterior cruciate ligament injuries in collegiate men and women
soccer and basketball programs using the NCAA injury surveillance
system. A second portion of the study reviewed a profile of the
injured ACL athlete, which was a pilot study.
20. Malone TR, Hardaker WT, Garrett WE: Relationship of gender
to ACL injuries in intercollegiate basketball players.
J South Orthop Assoc 1992, 2:3639.
21. Ohara W, Paxton LW, Fithian DC: Epidemiology of knee ligament injuries. In: Akeson WH, O'Connor JJ, Pedowitz RA, eds.
Daniel's Knee Injuries: Ligament and cartilage structure,
function, injury and repair. Baltimore: Lippincott Williams
& Wilkins, in press.
22. Arendt EA: Anterior cruciate ligament linjuries in women.
Sports Medicine and Arthroscopy Review 1997, 5:149155.
23. Griffin LY, Agel J, Albohm MJ, Arendt EA: Noncontact anterior
cruciate ligament injuries: Risk factors and prevention
strategies. J Am Acad Orthop Surg 2000, 8:141150.
This article contains early data on existing neuromuscular
programs that suggested enhancing body control may decrease
ACL injuries in women
24. Kirkendall DT, Garrett WE: The anterior cruciate ligament
enigma. Clin Orthop Rel Res 2000, 372:6468.
25. Medvecky MJ, Bosco J, Sherman OH: Gender disparity of
anterior cruciate ligament injury: etiological theories in the
female athlete. Bull Hosp Jt Dis 2000, 59:217226.
26. Nicholas JA: Injuries to knee ligaments: Relationship to
looseness and tightness in football players. JAMA 1970,
212:22362239.
27. Mortez JA, Walters R, Smith L: Flexibility as a predictor of
knee injuries in college football players. Phys Sportsmed 1982,
10:9397.
28. Kalenak A, Morehouse CA: Knee stability and knee ligament
injuries. JAMA 1975, 234:11431145.
29. Decoster LC, Vailas JC, Lindsay RH, Williams GR: Prevalence
and features of joint hypermobility among adolescent
athletes. Arch Phys Med Rehab 1997, 151:98992.
30. Acasuso-Diaz M, Collantes-Estavex E, Sanches-Guijo PS:
Joint hyperlaxity and musculo-ligamentous lesions: study
of a population of homogeneous age, sex, and physical
exertion. Br J Rheum 1993, 32:120122.
31. Rozzi SL, Lephart SM, Gear WS, Fu FH: Knee joint laxity and
neuromuscular characteristics of male and female soccer
and basketball players. Am J Sports Med 1999, 27:3212.
32. Jackowski DM, Kirkley A, Speechley M: A prospective cohort study
to determine risk factors for ACL injury in varsity athletes. London,
Ontario Canada: University of Western Ontario; 2001.
33. Weesner CL, Albohm MJ, Ritter MA: A comparison of anterior
and posterior cruciate ligament laxity between female
and male baskeball players. The Physician and Sportsmedicine
1986, 14:149.
34. Daniel D, Malcom L, Losse G: Instrumented measurement
of ACL disruption. Orthop Trans 1983, 7:585586.
35. DeJour H, Bonnin M: Tibial translation after anterior
cruciate ligament rupture. Two radiographic tests compared.
J Bone Joint Surg Br 1994, 76:745749.
36. Meister K, Talley MC, Horodyski MB, et al.: Caudal slope
of the tibia and its relationship to noncontact injuries
to the ACL. Am J Knee Surg 1998, 11:217219.
37. Arendt EA: Relationship between notch width index and
risk of noncontact ACL injury. In: Prevention of noncontact
ACL injuries. Edited by Griffin LY. Rosemont, IL: American
Academy of Orthopaedic Surgeons, 2001:3343.

38.

Griffin LY: Prevention of noncontact ACL injuries. Rosemont,

IL: American Academy of Orthopaedic Surgeons; 2001.
39. Muneta T, Takakuda K, Yamamoto H: Intercondylar notch
width and its relation to the configuration and crosssectional area of the anterior cruciate ligament.
Am J Sports Med 1997, 25:6972.
40. Staeubi HU, Adam O, Becker W, Burghart R: Anterior
cruciate ligament and intercondylar notch in the coronal
oblique plane: anatomy complemented by magnetic
resonance imaging in cruciate ligament-intact knees.
Arthroscopy 1999, 15:349359.
41. Anderson AF, Dome D, Gautam S, Awh MH, Rennirt GW:
Correlation of anthropometric measurements, strength,
anterior cruciate ligament size, and intercondylar notch
characteristics to sex differences in anterior cruciate ligament
tear rates. Am J Sports Med 2001, 29:5866.
42. Willits K, Fowler P, Kirkely A, et al.: MRI analysis of anatomic
variables in the etiology of anterior cruciate ligament
in female athletes. Paper presented at American Orthopaedic
Society for Sports Medicine, Traverse City, MI, 1999.
43. Rizzo M, Holler S, Bassett FH: Comparison of males'
and females' ratios of anterior-cruciate-ligament width
to femoral-intercondylar-notch width: a cadaveric study.
Am J Orthop 2001, 660664.
44. Heitz NA, Eisenman PA, Beck CL, Walker JA: Hormonal
changes throughout the menstrual cycle and increased
anterior cruciate ligament laxity in females. Journal of Athletic
Training 1999, 34:144149.
45. Liu SH, Al-Shaikh R, Panossian V: Primary immunolocalization of estrogen and progesterone target cells
in the human anterior cruciate ligament. J Orthop Res 1996,
14:526533.
46. Slauterbeck JR, Narayan RS, Clevenger C: Effects of estrogen
level on the tensile properties of the rabbit anterior cruciate
ligament (ACL). Trans Orthop Res Soc 1997, 22:76.
47. Hewett TE, Stroupe AL, Nance TA, Noyes FR: Plyometric
training in female athletes. Decreased impact forces
and increased hamstring torques. Am J Sports Med 1996,
24:765773.
This paper contains key findings that knee adduction and abduction
moments decreased by an average of 50% in women who
trained with this program.
48. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR: The effect
of neuromuscular training on the incidence of knee
injury in female athletes: a prospective study. Am J Sport Med
1999, 27:6997705.
This is one of the few studies that shows an injury reduction
secondary to a training program.
49. Arendt EA: The effect of estrogen on material and mechanical
properties of the intra and extra articular knee structures.
27th AOSSM Annual Meeting. Keystone, CO, 2001.
50. Strickland SM, Belknap TW, Levine RE, Turner AS, Write TM,
Hannafin JA: Lack of hormoneal influences on mechanical
properties of sheep knee ligaments. Paper presented
at the 46th Annual Meeting of the Orthopaedic Research
Society. Orlando, Florida, March 1215, 2000.
51. Wojtys EM, Huston LJ, Lindenfeld TN, et al.: Association
between the menstrual cycle and anterior cruciate ligament
injuries in female athletes. Am J Sports Med 1998, 26:614619.
52. Wolman RL: Association between the menstrual cycle and
anterior cruciate ligament in female athletes [letter to the
editor] Am J Sports Med 1999, 27:270271.
53. Myklebust G, Maehlum S, Holm I, Bahr R: A prospective
cohort study of anterior cruciate ligament injuries in
elite Norwegian team handball. Scan J Med Sci Sports 1998,
8:149153.
54. Slauterbeck JR: The effect of hormone levels in female athletes
on the frequency of anterior cruciate ligement injuries. Paper
presented at the National Athletic Trainers Association Annual
Meeting. Los Angeles, CA, 2000.

Anterior Cruciate Ligament Injuries Arendt

55.

56.

57.

58.

59.

60.

61.

62.

Arendt EA, Bershadsky B, Agel JA: Periodicity of non-contact

ACL injuries during the menstrual cycle. J Gend Specif Med
2001, in press.
Wojtys EM, Huston LJ, Boynton MD, et al.: The effect of the
menstrual cycle on ACL injuries in women as determined
by hormone levels. Am J Sports Med 2001, in press.
Moller-Nielson J, Hammer M: Women's soccer injuries in
relation to the menstrual cycle and oral contraceptive
use. Med Sci Sports Exerc 1989, 21:126129.
Lloyd T, Triantafyllou SJ, Baker ER: Women athletes with
menstrual irregularity have increased musculoskeletal
injuries. Med Sci Sports Exerc 1986, 18:37479.
Noonan TJ, Garrett J, Garrett WE Jr: Patellar tendon-tibial shaft
axis angle (PPT-T angle) and its relation to noncontact
injuries of the anterior cruciate ligament. Paper presented
at the American Academy of Orthopaedic Surgeons 63rd Annual
Meeting. Atlanta, GA, 1996.
Huston LJ, Wojtys EM: Neuromuscular performance
characteristics in elite female athletes. Am J Sports Med 1996,
24:427436.
Putnam CA: Sequential motions of body segments in striking
and throwing skills: descriptions and explanations. J Biomech
1993, 26:125135.
van Ingen Schenau GJ, Bobbert MF, Rozendal RH: The unique
action of bioarticular muscles in complex movements.
J Anat 1987, 155:15.

63.

217

Gregoire L, Veeger HE, Huijing PA, van Ingen Schenau GJ:

The role of mono-and biarticular muscles in explosive movements. Int J Sports Med 1984, 5:301305.
64. Bobbert MF, van Zandwijk JP: Dynamics of force and muscle
stimulation in human vertical jumping. Med Sci Sports Exerc
1999, 31:303310.
65. Moore JR, Wade G: Prevention of ACL injuries. J Strength
Cond Res 1989, 11:3540.
66. Griffin LY: The Henning program. In Prevetion of noncontact
ACL injuries. Edited by Griffin LY. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2001:9396.
After a 10-year study of ACL injuries in female basketball programs,
Henning formulated a prevention program based on what he called
the quad cruciate interaction. It was never brought to publication as
a primary article; however, his program is well reviewed in this article.
67. Ettlinger CF, Johnson RJ, Shealy JE: A method to help reduce
the risk of serious knee sprains incurred in alpine skiing.
Am J Sports Med 1995, 25:531537.
This article represents one of the few studies that utilizes a training
program and shows injury reduction.
68. Caraffa A, Cerulli G, Projetti M, et al.: Prevention of anterior
cruciate ligament injuries in soccer: a prospective controlled
study of proprioceptive training. Knee Surg Sports Traumatol
Arthrosc 1996, 4:1921.