The effects of generalized joint laxity on risk of anterior cruciate ligament injury in young female athletes

Abstract

Background: Women who participate in high-risk sports suffer anterior cruciate ligament injury at a 4- to 6-fold greater rate than men.

Purpose: To prospectively determine if female athletes with decreased passive knee joint restraint (greater joint laxity) and greater side-to-side differences in knee laxity would be at increased risk of anterior cruciate ligament injury.

Study design: Case control study; Level of evidence, 3.

Methods: From 1558 female soccer and basketball players who were prospectively screened, 19 went on to tear their anterior cruciate ligaments. Four height- and mass-matched control subjects were selected from the uninjured screened athletes for comparison with each of the 19 injured subjects, making a total of 95 subjects (19 injured; 76 uninjured). Generalized joint-laxity tests and anterior-posterior tibiofemoral translation were quantified using the CompuKT knee arthrometer. A multivariable logistic regression model was constructed to determine predictors of anterior cruciate ligament injury status from recorded laxity measures.

Results: A multivariable logistic regression model (chi-square = 18.6; P = .002) used the independent variables laxity measures of knee hyperextension (P = .02), wrist and thumb to forearm opposition (P = .80), fifth-finger hyperextension > 90 degrees (P = .71), side-to-side differences in anterior-posterior tibiofemoral translation (P = .002), and prior knee injury (P = .22) to predict anterior cruciate ligament-injury status. The validated C statistic, or validated area under the receiver operating characteristic curve, was 0.72. For every 1.3-mm increase in side-to-side differences in anterior-posterior knee displacement, the odds of anterior cruciate ligament-injured status increased 4-fold (95% confidence interval, 1.68-9.69). A positive measure of knee hyperextension increased the odds of anterior cruciate ligament-injured status 5-fold (95% confidence interval, 1.24-18.44).

Conclusion: The current results indicate that increased knee-laxity measures may contribute to increased risk of anterior cruciate ligament injury. The methods to quantify knee joint laxity in this report may be used in conjunction with measures of neuromuscular control of the knee joint to identify high-risk female athletes with high accuracy. Once high-risk female athletes are identified, they may be targeted to the appropriate interventions to reduce injury risk.

Conflict of interest statement

No potential conflict of interest declared.

Figures

Figure 1

Knee hyperextension test. Each subject was placed in a supine position with a box placed under both ankles. The axis of the goniometer was aligned with the lateral epicondyle of the femur. The distal arm was positioned with the lateral malleolus, and the proximal arm was aligned with the greater trochanter. Hyperextension of the knee beyond neutral resulted in a positive indication for the knee hyperextension test.

Figure 2

Elbow hyperextension test. Each subject’s shoulder was abducted to approximately 80°, with the forearm supinated. The axis of the goniometer was placed over the lateral epicondyle of the humerus, with the distal end aligned with the radial styloid process, and the proximal arm aligned along the lateral midline of the subject’s humerus. Hyperextension beyond neutral resulted in a positive indication for the elbow hyperextension test.

Figure 3

Thumb to forearm test. Each subject flexed the wrist and pulled the thumb toward the forearm using the opposite hand. If the thumb could be abducted to touch the forearm, a positive indicator was given for the thumb to forearm test. Inability to touch the forearm resulted in a negative indication.

Figure 4

Fifth-finger hyperextension >90° test. Each subject’s forearm, wrist, and fingers were stabilized on a flat table. The tester passively extended the subject’s fifth finger as far as possible without pain. Hyperextension of 90° or greater resulted in a positive indication for the fifth-finger hyperextension >90° test.

Figure 5

Example of CompuKT2000 plots from 2 (A and B) study subjects. Anterior-posterior tibiofemoral translation was measured at ±134 N. Subject A presents greater side-to-side differences in AP knee laxity.