The anterior cruciate ligament injury controversy: is "valgus collapse" a sex-specific mechanism?

Abstract

Background: Anterior cruciate ligament (ACL) injury is a devastating injury that puts an athlete at high risk of future osteoarthritis. Identification of risk factors and development of ACL prevention programmes likely decrease injury risk. Although studies indicate that sagittal plane biomechanical factors contribute to ACL loading mechanisms, it is unlikely that non-contact ACL injuries occur solely in a sagittal plane. Some authors attempt to ascribe the solely sagittal plane injury mechanism to both female and male ACL injuries and rebuff the concept that knee "valgus" is associated with isolated ACL injury. Prospective studies that utilise coupled biomechanical and epidemiological approaches demonstrated that frontal knee motions and torques are strong predictors of future non-contact ACL injury risk in female athletes. Video analysis studies also indicate a frontal plane "valgus collapse" mechanism of injury in women. As load sharing between knee ligaments is complex, frontal as well as sagittal and transverse plane loading mechanisms likely contribute to non-contact ACL injury. The purpose of this review is to summarise existing evidence regarding ACL injury mechanisms and to propose that sex-specific mechanisms of ACL injury may occur, with women sustaining injuries by a predominantly "valgus collapse" mechanism.

Conclusion: Prevention programmes and interventions that only target high-risk sagittal plane landing mechanics, especially in the female athlete, are likely to be less effective in ameliorating important frontal and transverse plane contributions to ACL injury mechanisms and could seriously hamper ACL injury prevention efforts. Programmes that target the reduction of high-risk valgus and sagittal plane movements will probably prove to be superior for ACL injury prevention.

Figure 1

Multiplanar loading mechanism in women.

Figure 2

More sagittal plane-oriented loading mechanism in men?

Figure 3

The pivot shift test is performed with the patient lying supine with their hip passively flexed to 30°. Approximately 20° of internal rotation is applied to the tibia and the knee is placed in full extension. A valgus force is applied to the knee as it is slowly flexed. An anterior cruciate ligament-deficient knee will remain reduced in full extension but will sublux around 20–30° of knee flexion and then will reduce again in deeper flexion.

Figure 4

(A) Magnetic resonance imaging of bone bruise pattern (lateral femoral condyle and posterolateral tibial plateau) associated with acute anterior cruciate ligament (ACL) injury. (B) Femoral and tibial articulation pressure distribution during simulated ACL injury mechanism as a result of combined valgus and anterior tibial translation. (C) Posterolateral tibial plateau and (D), (E) lateral femoral condyle articular pressure distribution patterns. The sections for the tibia and femur are divided into anterior lateral (AL), middle lateral (ML), posterior lateral (PL), anterior medial (AM), middle medial (MM) and posterior medial (PM).