Risk Factors Associated With a Noncontact Anterior Cruciate Ligament Injury to the Contralateral Knee After Unilateral Anterior Cruciate Ligament Injury in High School and College Female Athletes: A Prospective Study
Restricted accessResearch articleFirst published online December, 2019
Risk Factors Associated With a Noncontact Anterior Cruciate Ligament Injury to the Contralateral Knee After Unilateral Anterior Cruciate Ligament Injury in High School and College Female Athletes: A Prospective Study
The incidence of contralateral anterior cruciate ligament (CACL) injuries after recovery from a first-time anterior cruciate ligament (ACL) disruption is high in women; however, little is known about the risk factors associated with this trauma.
Hypothesis:
Patient characteristics, strength, anatomic alignment, and neuromuscular characteristics of the contralateral uninjured leg at the time of the first ACL trauma are associated with risk of subsequent CACL injury, and these risk factors are distinct from those for a first-time ACL injury.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Sixty-one women who suffered a first-time noncontact ACL injury while participating in high school or college sports and underwent measurement of potential risk factors on their contralateral limb soon after the initial ACL injury and before reconstruction were followed until either a CACL injury or an ACL graft injury occurred, or until the last date of contact.
Results:
Follow-up information was available for 55 (90.0%) of the 61 athletes and 11 (20.0%) suffered a CACL injury. Younger age, decreased participation in sport before the first ACL disruption, decreased anterior stiffness of the contralateral knee, and increased hip anteversion were associated with increases in the risk of suffering a CACL injury.
Conclusion:
A portion of CACL injury risk factors were modifiable (time spent participating in sport and increasing anterior knee stiffness with bracing), while others were nonmodifiable (younger age and increased hip anteversion). The relationship between younger age at the time of an initial ACL injury and increased risk of subsequent CACL trauma may be explained by younger athletes having more years available to be exposed to at-risk activities compared with older athletes. A decrease of anterior stiffness of the knee is linked to decreased material properties and width of the ACL, and this may explain why some women are predisposed to bilateral ACL trauma while others only suffer the index injury. The risk factors for CACL injury are unique to women who suffer bilateral ACL trauma compared with those who suffer unilateral ACL trauma. This information is important for the identification of athletes who may benefit from risk reduction interventions.
AjuiedAWongFSmithC, et al. Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med. 2014;42(9):2242-2252.
2.
Al AttarWSSoomroNPappasESinclairPJSandersRH. Reply to Thorborg et al.: High risk of bias and low transparency in “How effective are F-MARC injury prevention programs for soccer players? A systematic review and meta-analysis”. Sports Med. 2016;46(2):295-296.
3.
AmraeeDAlizadehMHMinoonejhadHRaziMAmraeeGH. Predictor factors for lower extremity malalignment and non-contact anterior cruciate ligament injuries in male athletes. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1625-1631.
4.
BeightonPSolomonLSoskolneCL. Articular mobility in an African population. Ann Rheum Dis. 1973;32(5):413-418.
5.
BeynnonBDHallJSSturnickDR, et al. Increased slope of the lateral tibial plateau subchondral bone is associated with greater risk of noncontact ACL injury in females but not in males: a prospective cohort study with a nested, matched case-control analysis. Am J Sports Med. 2014;42(5):1039-1048.
6.
BeynnonBDJohnsonRJToyamaHRenstromPAArmsSWFischerRA. The relationship between anterior-posterior knee laxity and the structural properties of the patellar tendon graft. A study in canines. Am J Sports Med. 1994;22(6):812-820.
7.
BeynnonBDVacekPMNewellMK, et al. The effects of level of competition, sport, and sex on the incidence of first-time noncontact anterior cruciate ligament injury. Am J Sports Med. 2014;42(8):1806-1812.
8.
ChungKSHaJKYeomCH, et al. Are muscle strength and function of the uninjured lower limb weakened after anterior cruciate ligament injury? Two-year follow-up after reconstruction. Am J Sports Med. 2015;43(12):3013-3021.
9.
CloningerCRSvrakicDMWetzelRD. The Temperament and Character Inventory (TCI): A Guide to Its Development and Use. St. Louis, MO: Center for Psychobiology of Personality, Washington University; 1994.
10.
FaltstromAHagglundMMagnussonHForssbladMKvistJ. Predictors for additional anterior cruciate ligament reconstruction: data from the Swedish national ACL register. Knee Surg Sports Traumatol Arthrosc. 2016;24(3):885-894.
11.
FlemingBCBrattbakkBPeuraGDBadgerGJBeynnonBD. Measurement of anterior-posterior knee laxity: a comparison of three techniques. J Orthop Res. 2002;20(3):421-426.
12.
FlynnRKPedersenCLBirminghamTBKirkleyAJackowskiDFowlerPJ. The familial predisposition toward tearing the anterior cruciate ligament: a case control study. Am J Sports Med. 2005;33(1): 23-28.
13.
GordonMDSteinerME. Anterior cruciate ligament injuries. In: GarrickJG, ed. Orthopaedic Knowledge Update Sports Medicine III. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004:169.
14.
HasueMFujiwaraMKikuchiS. A new method of quantitative measurement of abdominal and back muscle strength. Spine (Phila Pa 1976). 1980;5(2):143-148.
15.
HewettTEMyerGDFordKR. Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors. Am J Sports Med. 2006;34(2):299-311.
16.
HewettTEMyerGDFordKR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501.
17.
HofbauerMThorhauerEDAbebeEBeyMTashmanS. Altered tibiofemoral kinematics in the affected knee and compensatory changes in the contralateral knee after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(11):2715-2721.
18.
ImwalleLEMyerGDFordKRHewettTE. Relationship between hip and knee kinematics in athletic women during cutting maneuvers: a possible link to noncontact anterior cruciate ligament injury and prevention. J Strength Cond Res. 2009;23(8):2223-2230.
19.
JohnstonJTMandelbaumBRSchubD, et al. Video analysis of anterior cruciate ligament tears in professional American football athletes. Am J Sports Med. 2018;46(4):862-868.
20.
KaedingCCPedrozaADReinkeEKHustonLJConsortiumMSpindlerKP. Risk factors and predictors of subsequent ACL injury in either knee after ACL reconstruction: prospective analysis of 2488 primary ACL reconstructions from the MOON cohort. Am J Sports Med. 2015;43(7):1583-1590.
21.
KanekoMSakurabaK. Association between femoral anteversion and lower extremity posture upon single-leg landing: implications for anterior cruciate ligament injury. J Phys Ther Sci. 2013;25(10):1213-1217.
22.
LevinsJGArgentieriECSturnickDR, et al. Geometric characteristics of the knee are associated with a noncontact ACL injury to the contralateral knee after unilateral ACL injury in young female athletes. Am J Sports Med. 2017;45(14):3223-3232.
23.
LevinsJGSturnickDRArgentieriEC, et al. Geometric risk factors associated with noncontact anterior cruciate ligament graft rupture. Am J Sports Med. 2016;44(10):2537-2545.
24.
LeysTSalmonLWallerALinklaterJPinczewskiL. Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. Am J Sports Med. 2012;40(3):595-605.
25.
LohmanderLSOstenbergAEnglundMRoosH. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. 2004;50(10):3145-3152.
26.
MaletisGBInacioMCFunahashiTT. Risk factors associated with revision and contralateral anterior cruciate ligament reconstructions in the Kaiser Permanente ACLR registry. Am J Sports Med. 2015; 43(3):641-647.
27.
MarkolfKLMenschJSAmstutzHC. Stiffness and laxity of the knee—the contributions of the supporting structures. A quantitative in vitro study. J Bone Joint Surg Am. 1976;58(5):583-594.
28.
McLeanSGMallettKFArrudaEM. Deconstructing the anterior cruciate ligament: what we know and do not know about function, material properties, and injury mechanics. J Biomech Eng. 2015; 137(2):020906.
29.
MontalvoAMSchneiderDKYutL, et al. “What’s my risk of sustaining an ACL injury while playing sports?” A systematic review with meta-analysis. Br J Sports Med. 2019;53:1003-1012.
30.
NguyenADShultzSJSchmitzRJ. Landing biomechanics in participants with different static lower extremity alignment profiles. J Athl Train. 2015;50(5):498-507.
31.
NguyenADShultzSJSchmitzRJLuechtRMPerrinDH. A preliminary multifactorial approach describing the relationships among lower extremity alignment, hip muscle activation, and lower extremity joint excursion. J Athl Train. 2011;46(3):246-256.
32.
NoyesFRBarber-WestinSD. Neuromuscular retraining intervention programs: do they reduce noncontact anterior cruciate ligament injury rates in adolescent female athletes?Arthroscopy. 2014;30(2):245-255.
33.
OiestadBEHolmIAuneAK, et al. Knee function and prevalence of knee osteoarthritis after anterior cruciate ligament reconstruction: a prospective study with 10 to 15 years of follow-up. Am J Sports Med. 2010;38(11):2201-2210.
34.
PaternoMVKieferAWBonnetteS, et al. Prospectively identified deficits in sagittal plane hip-ankle coordination in female athletes who sustain a second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Clin Biomech (Bristol, Avon). 2015;30(10):1094-1101.
35.
PaternoMVRauhMJSchmittLCFordKRHewettTE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014;42(7):1567-1573.
36.
PaternoMVSchmittLCFordKR, et al. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med. 2010;38(10):1968-1978.
37.
PowersCM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010; 40(2):42-45.
38.
RameshRVon ArxOAzzopardiTSchranzPJ. The risk of anterior cruciate ligament rupture with generalised joint laxity. J Bone Joint Surg Br. 2005;87(6):800-803.
39.
RobertsDFridenTStombergALindstrandAMoritzU. Bilateral proprioceptive defects in patients with a unilateral anterior cruciate ligament reconstruction: a comparison between patients and healthy individuals. J Orthop Res. 2000;18(4):565-571.
40.
RoewerBDDi StasiSLSnyder-MacklerL. Quadriceps strength and weight acceptance strategies continue to improve two years after anterior cruciate ligament reconstruction. J Biomech. 2011;44(10):1948-1953.
41.
Ryman AugustssonSAgebergE. Weaker lower extremity muscle strength predicts traumatic knee injury in youth female but not male athletes. BMJ Open Sport Exerc Med. 2017;3(1):e000222.
42.
SalmonLRussellVMusgroveTPinczewskiLRefshaugeK. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy. 2005;21(8): 948-957.
43.
SchilatyNDNagelliCBatesNA, et al. Incidence of second anterior cruciate ligament tears and identification of associated risk factors from 2001 to 2010 using a geographic database. Orthop J Sports Med. 2017;5(8):2325967117724196.
44.
SchmitzRJFicklinTKShimokochiY, et al. Varus/valgus and internal/external torsional knee joint stiffness differs between sexes. Am J Sports Med. 2008;36(7):1380-1388.
45.
ShelbourneKDGrayTHaroM. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009;37(2):246-251.
ShultzSJNguyenADLevineBJ. The relationship between lower extremity alignment characteristics and anterior knee joint laxity. Sports Health. 2009;1(1):54-60.
48.
ShultzSJNguyenADWindleyTCKulasASBoticTLBeynnonBD. Intratester and intertester reliability of clinical measures of lower extremity anatomic characteristics: implications for multicenter studies. Clin J Sport Med. 2006;16(2):155-161.
49.
Silvers-GranelliHMandelbaumBAdenijiO, et al. Efficacy of the FIFA 11+ injury prevention program in the collegiate male soccer player. Am J Sports Med. 2015;43(11):2628-2637.
50.
SturnickDRVacekPMDeSarnoMJ, et al. Combined anatomic factors predicting risk of anterior cruciate ligament injury for males and females. Am J Sports Med. 2015;43(4):839-847.
51.
SturnickDRVan GorderRVacekPM, et al. Tibial articular cartilage and meniscus geometries combine to influence female risk of anterior cruciate ligament injury. J Orthop Res. 2014;32(11):1487-1494.
52.
TourvilleTWSmithHCShultzSJ, et al. Reliability of a new stabilized dynamometer system for the evaluation of hip strength. Sports Health. 2013;5(2):129-136.
53.
UhorchakJMScovilleCRWilliamsGNArcieroRASt PierrePTaylorDC. Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 West Point cadets. Am J Sports Med. 2003;31(6):831-842.
54.
UrbachDNebelungWWeilerHTAwiszusF. Bilateral deficit of voluntary quadriceps muscle activation after unilateral ACL tear. Med Sci Sports Exerc. 1999;31(12):1691-1696.
55.
VacekPMSlauterbeckJRTourvilleTW, et al. Multivariate analysis of the risk factors for first-time noncontact ACL injury in high school and college athletes: a prospective cohort study with a nested, matched case-control analysis. Am J Sports Med. 2016;44(6):1492-1501.
56.
WangHMShultzSJSchmitzRJ. Association of anterior cruciate ligament width with anterior knee laxity. J Athl Train. 2016;51(6):460-465.
57.
WebsterKEHewettTE. Meta-analysis of meta-analyses of anterior cruciate ligament injury reduction training programs. J Orthop Res. 2018;36(10):2696-2708.
58.
WhitneyDCSturnickDRVacekPM, et al. Relationship between the risk of suffering a first-time noncontact ACL injury and geometry of the femoral notch and ACL: a prospective cohort study with a nested case-control analysis. Am J Sports Med. 2014;42(8):1796-1805.
59.
WigginsAJGrandhiRKSchneiderDKStanfieldDWebsterKEMyerGD. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2016;44(7):1861-1876.
60.
WrightRWDunnWRAmendolaA, et al. Risk of tearing the intact anterior cruciate ligament in the contralateral knee and rupturing the anterior cruciate ligament graft during the first 2 years after anterior cruciate ligament reconstruction: a prospective MOON cohort study. Am J Sports Med. 2007;35(7):1131-1134.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
