First-time anterior cruciate ligament injury in adolescent female elite athletes: a prospective cohort study to identify modifiable risk factors

M K Zebis; P Aagaard; L L Andersen; P Hölmich; M B Clausen; M Brandt; R S Husted; H B Lauridsen; D J Curtis; J Bencke

doi:10.1007/s00167-021-06595-8

First-time anterior cruciate ligament injury in adolescent female elite athletes: a prospective cohort study to identify modifiable risk factors

Knee Surg Sports Traumatol Arthrosc. 2022 Apr;30(4):1341-1351. doi: 10.1007/s00167-021-06595-8. Epub 2021 May 7.

Authors

M K Zebis¹, P Aagaard², L L Andersen^{3

4}, P Hölmich⁵, M B Clausen⁶, M Brandt³, R S Husted^{7

8}, H B Lauridsen⁹, D J Curtis¹⁰, J Bencke¹¹

Affiliations

¹ Department of Physiotherapy, Faculty of Health, University College Copenhagen, Sigurdsgade 26, 2200, Copenhagen, Denmark. mzeb@kp.dk.
² Department of Sports Sciences and Clinical Biomechanics, Muscle Physiology and Biomechanics Research Unit, University of Southern Denmark, Odense, Denmark.
³ National Research Centre for the Working Environment, Copenhagen, Denmark.
⁴ Department of Health Science and Technology, Sport Sciences, Aalborg University, Aalborg, Denmark.
⁵ Department of Orthopaedic Surgery, Sports Orthopedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark.
⁶ Department of Physiotherapy, Faculty of Health, University College Copenhagen, Sigurdsgade 26, 2200, Copenhagen, Denmark.
⁷ Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C); Department of Physical and Occupational Therapy; Department of Clinical Research; Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
⁸ Department of Clinical Research, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark.
⁹ Team Danmark, The Elite Sport Organization of Denmark, Brondby, Denmark.
¹⁰ RUBRIC (Research Unit on Brain Injury Rehabilitation), Department of Neurorehabilitation, TBI Unit, Rigshospitalet, Denmark.
¹¹ Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark.

Abstract

Purpose: To identify modifiable biomechanical and neuromuscular anterior cruciate ligament (ACL) injury risk factors for first-time ACL injury in adolescent female elite football and team handball players.

Methods: Adolescent female elite football and handball players with no previous ACL injury participated in the present study. At baseline, players were tested during side-cutting manoeuvres performed in a 3-dimensional motion analysis laboratory with concomitant electromyography (EMG) measurements. Maximal isometric lower limb muscle strength was assessed by handheld dynamometry. Players were prospectively followed for 2 years after baseline testing, and all magnetic resonance imaging (MRI) verified ACL injuries were registered. The effect of 16 risk factor candidates on the relative risk (RR) of ACL injury was estimated using Poisson regression analysis.

Results: Ninety players (age 16.9 ± 1.2 years) were included in the analyses. Nine first-time ACL injuries (injury incidence 10.0% (95% confidence interval (CI) 5.4-18.6%)) were registered during the 2-year follow-up period. Four risk factor candidates were significantly associated with the risk of ACL injury: (1) hip flexion angle at initial contact (IC) [RR 0.56, 95% confidence interval (CI) 0.34-0.92], (2) internal knee rotation angle at IC [RR 1.13, 95% CI 1.08-1.19], (3) semitendinosus EMG activity 50 ms prior to IC [RR: 0.62, 95% CI 0.43-0.89], and (4) external hip rotator strength [RR: 0.77, 95% CI 0.66-0.89].

Conclusion: Four distinct ACL injury risk factors related to the side-cutting manoeuvre were identified in a population of adolescent female elite football and team handball players with no previous ACL injury. As ACL injury typically occur during side-cutting, intervention programmes to modify these risk factors pose a promising strategy for ACL injury prevention in adolescent female elite football and team handball.

Level of evidence: II.

Keywords: ACL; Biomechanics; Electromyography; Female; Football; Handball; Screening.

MeSH terms

Adolescent
Anterior Cruciate Ligament Injuries* / epidemiology
Athletes
Athletic Injuries* / epidemiology
Female
Football* / injuries
Humans
Prospective Studies
Risk Factors