Anterior Cruciate Ligament Injury Risk in Sport: A Systematic Review and Meta-Analysis of Injury Incidence by Sex and Sport Classification

Abstract

Objective: To evaluate sex differences in incidence rates (IRs) of anterior cruciate ligament (ACL) injury by sport type (collision, contact, limited contact, and noncontact).

Data sources: A systematic review was performed using the electronic databases PubMed (1969-January 20, 2017) and EBSCOhost (CINAHL, SPORTDiscus; 1969-January 20, 2017) and the search terms anterior cruciate ligament AND injury AND (incidence OR prevalence OR epidemiology).

Study selection: Studies were included if they provided the number of ACL injuries and the number of athlete-exposures (AEs) by sex or enough information to allow the number of ACL injuries by sex to be calculated. Studies were excluded if they were analyses of previously reported data or were not written in English.

Data extraction: Data on sport classification, number of ACL injuries by sex, person-time in AEs for each sex, year of publication, sport, sport type, and level of play were extracted for analysis.

Data synthesis: We conducted IR and IR ratio (IRR) meta-analyses, weighted for study size and calculated. Female and male athletes had similar ACL injury IRs for the following sport types: collision (2.10/10 000 versus 1.12/10 000 AEs, IRR = 1.14, P = .63), limited contact (0.71/10 000 versus 0.29/10 000 AEs, IRR = 1.21, P = .77), and noncontact (0.36/10 000 versus 0.21/10 000 AEs, IRR = 1.49, P = .22) sports. For contact sports, female athletes had a greater risk of injury than male athletes did (1.88/10 000 versus 0.87/10 000 AEs, IRR = 3.00, P < .001). Gymnastics and obstacle-course races were outliers with respect to IR, so we created a sport category of fixed-object, high-impact rotational landing (HIRL). For this sport type, female athletes had a greater risk of ACL injury than male athletes did (4.80/10 000 versus 1.75/10 000 AEs, IRR = 5.51, P < .001), and the overall IRs of ACL injury were greater than all IRs in all other sport categories.

Conclusions: Fixed-object HIRL sports had the highest IRs of ACL injury for both sexes. Female athletes were at greater risk of ACL injury than male athletes in contact and fixed-object HIRL sports.

Keywords: athletes; epidemiology; knee; sprain.

Figures

Figure 1

Flow chart of the literature review process.

Figure 2

Forest plot for the total incidence rate of anterior cruciate ligament injury in male and female collision-sport athletes combined. a Sports are provided in Table 2. Abbreviation: CI, confidence interval.

Figure 3

Forest plot for the incidence rate of anterior cruciate ligament injury in female collision-sport athletes. a Sports are provided in Table 2. b We substituted 0.1 for 0 to estimate an extremely low rate that could be used in the analysis. Abbreviation: CI, confidence interval.