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. 2025 Aug;41(8):3214-3222.
doi: 10.1016/j.arthro.2024.10.051. Epub 2024 Nov 12.

Female Athletes Are Underrepresented in Anterior Cruciate Ligament Reconstruction Rehabilitation Studies: A Systematic Review

Gabrielle Crowell  1 , Jacob Adams  2 , Ian Harmon  3 , Tucker Morey  2 , Rachel Long  3 , Lisa Vopat  3 , Bryan Vopat  3 , Ashley Herda  4
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Free article

Female Athletes Are Underrepresented in Anterior Cruciate Ligament Reconstruction Rehabilitation Studies: A Systematic Review

Gabrielle Crowell et al. Arthroscopy. 2025 Aug.
Free article

Abstract

Purpose: To systematically review the representation of female athletes in the current primary literature available on rehabilitation after anterior cruciate ligament reconstruction (ACLR).

Methods: A systematic review was conducted using PubMed to provide a comprehensive analysis of female representation in ACLR postoperative rehabilitation protocols. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. Studies were analyzed based on nine factors: study population, athletic caliber, menstrual status, research theme, journal impact factor, sample size of male and female participants, time to return to sport, and graft failure rate. Population categories included males-only, females-only, mixed-sex, and male vs. female comparisons. Athletic caliber had 6 tiers. Menstrual status was categorized as natural, hormonal contraception, irregularities, mixed, or unclassified. Research themes were health-focused, performance-focused, or combined. Study impact was assessed via journal impact factor.

Results: Thirty-three studies were included. Females comprised 3031/6798 (44.6%) of ACLR participants. No female-only studies were found; male-only studies accounted for 3 of 33 (9%), mixed-sex for 25 of 33 (69.7%), male versus female subanalysis for 3 of 33 (9%), and male versus female features for 2 of 33 (6%). No studies investigated outcomes for the highest athletic levels. Menstrual status was not considered. No studies focused on performance outcomes; 25 of 33 (69.7%) had a health research focus. Female athletes were under-represented in studies evaluating return to sport timeline and graft failure rate.

Conclusions: Female athletes face a 2 to 8 times greater risk of ACL injury but are under-represented in ACLR postop rehabilitation studies, with only 44.6% participation compared with 55.4% for male athletes. In 9 studies, female athletes comprised 30% or less of participants. Even studies including female athletes at near-equal rates failed to address menstrual status or sex hormones on injury and rehabilitation.

Level of evidence: Level IV, systematic review of Level I-IV studies.

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Conflict of interest statement

Disclosures The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: B.V. reports consulting or advisory with Artelon, Stryker Orthopaedics; equity or stocks with Carbon 22, Spinal Simplicity, and Altior; and board membership with the American Orthopaedic Foot and Ankle Society. A.H. reports consulting or advisory with The University of Kansas Health System. All other authors (G.C., J.A., I.H., T.M., R.L., L.V.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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