Changes in Lower Limb Biomechanics Across Various Stages of Maturation and Implications for ACL Injury Risk in Female Athletes: a Systematic Review

Abstract

Background: Female athletes are four to six times more likely to sustain an anterior cruciate ligament (ACL) injury than male athletes. Jump-landing biomechanics are influenced by maturation, with post-pubertal female athletes at a heightened risk of ACL injuries.

Objective: The aim of our systematic review was to identify and summarise the current evidence regarding the changes in kinematic and kinetic risk factors associated with ACL injuries during jump-landing tasks in female athletes at various stages of maturity.

Methods: A systematic search was conducted in PubMed, CINAHL, Web of Science, SPORTDiscus, EMBASE and Scopus. Articles were included if they: (1) conducted the research on uninjured female athletes with no restriction on playing level/experience; (2) provided information regarding the stage of the maturity and the scale used for estimating the maturity status of the participants; and (3) reported a biomechanical risk factor associated with ACL injuries during jump-landing tasks across at least two different maturity groups (e.g. pre-pubertal vs post-pubertal).

Results: Sixteen articles involving 2323 female athletes were included in our review. A total of 12 kinematic and 8 kinetic variables were identified across these studies. Of the 12 kinematic variables reported in our review, we found strong evidence for higher peak knee abduction angle in post-pubertal female individuals compared with pre-pubertal girls (p < 0.05). With regard to the 8 kinetic variables, we found strong evidence for lower relative peak vertical ground reaction force, higher external knee abduction moment and internal rotation moment in post-pubertal compared with pre-pubertal athletes. The strength of evidence for the remaining kinematic and kinetic variables ranged from conflicting to moderate and, in some instances, could not be determined.

Conclusions: Our study provides an overview of the changes in biomechanical risk factors in female athletes during jump-landing tasks at various stages of maturity. We found moderate-to-limited evidence for most kinematic and kinetic variables, highlighting the need for further research.

Fig. 1

Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) flowchart describing the study selection process. ACL anterior cruciate ligament

Fig. 2

Summary of the strength of evidence for the kinematic and kinetic variables across various stages of maturity. IC initial contact, vGRF ground reaction force, ↑ indicates higher kinematic or kinetic values as female athletes progress to the next stage of maturity, ↓ indicates lower kinematic or kinetic values as female athletes progress to the next stage of maturity, ↔ indicates similar kinematic and kinetic values as female athletes progress to the next stage of maturity, ↑↓ indicates conflicting evidence

Fig. 3

Summary of kinematic and kinetic variables in the A sagittal and B frontal plane for meaningful changes from pre-pubertal (red skeletons) to post-pubertal (white skeleton) female individuals. This figure has been adapted from the study published by Galloway et al. [82] with permission from the publisher (License Number: 5746521199753). vGRF vertical ground reaction force