A Critical Analysis of the Factors Contributing to Anterior Cruciate Ligament Injuries in Female Athletes

Abstract

Anterior Cruciate Ligament (ACL) injuries are a prevalent concern in athletic population, particularly among female athletes who are disproportionately affected. The increased incidence of ACL injuries in females is attributed to a combination of anatomical, physiological, and biomechanical factors that influence knee stability. This review comprehensively explores these contributing factors, highlighting gender-specific anatomical differences such as wider pelvis, increased quadriceps (Q) angle, and steeper tibial slopes, all of which predispose females to greater knee valgus during dynamic activities. Furthermore, hormonal influences and greater ligament laxity are discussed as physiological contributors to increased ACL injury risk. Biomechanical factors such as reduced knee flexion, increased knee valgus, and altered muscle activation patterns further amplify the risk of ACL tears in female athletes. Despite extensive research, gaps remain in the understanding of how these factors interact and influence injury susceptibility. This article is focussed on the critical points in the current literature, analyzing key risk factors, and identifying future research directions that can inform more effective prevention strategies. A better understanding of these factors will ultimately contribute to reducing the incidence of ACL injuries among female athletes and improving long-term strength and stability of knee joint.

Keywords: ACL injuries; ACL tear prevention; Anterior Cruciate Ligament; Athletic injury risk; Biomechanical factors; Female athletes; Gender differences in sports injuries; Injury prevention; Knee valgus; Ligament laxity; Q angle; Sports biomechanics.

Figure 1:

Differences in Q angle (N = 224), medial tibial slope and lateral tibial slope (N=74) between females and males. Values are presented as mean ± SD. Data are compiled from the published findings of Mitani et al. [10] and Hashemi et al. [14]. There is a significant difference in the Q angle, medial tibial slope, and lateral tibial slope between the males and females, as shown with the p values.

Figure 2:

Significant Changes in ACL Laxity During Menstrual Cycle Phases in Relation to Estrogen and Progesterone Levels, (N=7). Values are presented as mean ± SD. Data are compiled from the published findings of Heitz et al. [19]. The level of significant difference between the ACL laxity and estrogen or progesterone levels is shown with the p values.

Figure 3:

Comparison of Knee Valgus/Varus Angles Between Men and Women During Single-Leg Drop Landing at Initial Contact and Maximum Knee Flexion, (N=32). Values are presented as mean ± SD. Data are compiled from the published report of Russell et al. [21]. The level of significant difference in the knee Valgus/Varus angles between the males and females is shown with the p values.

Figure 4:

Comparison of Cutting Angles and Knee Flexion Angles Between Men and Women During 90° and 135° Cutting Maneuvers, (N=40). Values are presented as mean ± SD. Data are compiled from the published report of Sheu et al. [26]. The level of significant difference in the knee flexion angles between the males and females is shown with the p values.