Limited data exist regarding the effect of the growth process on anterior cruciate ligament (ACL) injury risk in male versus female children.
Hypothesis:
The proportion of ACL injuries/sports injuries presenting to clinic will vary by age, sex, and body mass index (BMI).
Study Design:
Cross-sectional epidemiologic study.
Level of Evidence:
Level 3.
Methods:
The study group consisted of a randomly selected 5% probability sample of all children 5 to 17 years of age presenting to a sports medicine clinic from January 1, 2000 to December 31, 2009; 2133 charts were reviewed. Data collected included demographics, height and weight, injury mechanism, diagnosis, treatment, previous injury, and organized sports.
Results:
A total of 206 ACL tears were analyzed (104 girls, 102 boys). Girls were slightly older than boys (15.1 ± 1.7 vs 14.3 ± 2.1 years; P < 0.01). Male-female comparison of ACL injury/total injury by age revealed that girls had a steeper increase by age than boys. Among 5- to 12-year-olds, boys had a higher ACL injury/total injury ratio than girls (all P < 0.01). Children 13 to 17 years of age showed no significant difference for sex in ACL injury/total injury ratio. As age advanced, the proportion of ACL injuries/total injuries increased for both girls (P < 0.01) and boys (P = 0.04). BMI was independently associated with an ACL injury (P < 0.01).
Conclusion:
The proportion of ACL injuries/total injuries was similar for boys and girls aged 13 to 17 years. Girls showed a significantly steeper increase in ACL injury proportion versus boys through puberty.
Clinical Relevance:
This study will increase clinician awareness of ACL injury occurrence in young male and female athletes 5 to 12 years of age. Injury prevention efforts should target young girls before the onset of puberty and before injury occurs.
ArendtEDickR. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med. 1995;23:694-701.
2.
CaineDCochraneBCaineCZemperE. An epidemiologic investigation of injuries affecting young competitive female gymnasts. Am J Sports Med. 1989;17:811-820.
3.
ChandyG. Secondary school athletic injury in boys and girls: a three-year comparison. Phys Sportsmed. 1985;13:106-111.
4.
ClantonTODeLeeJCSandersBNeidreA. Knee ligament injuries in children. J Bone Joint Surg Am. 1979;61:1195-1201.
5.
DiFioriJPPufferJCAishBDoreyF. Wrist pain in young gymnasts: frequency and effects upon training over 1 year. Clin J Sport Med. 2002;12:348-353.
EmersonRJ. Basketball knee injuries and the anterior cruciate ligament. Clin Sports Med. 1993;12:317-328.
8.
FalcigliaFGuzzantiVDi CiommoVPoggiaroniA. Physiological knee laxity during pubertal growth. Bull NYU Hosp Joint Dis. 2009;67:325-329.
9.
FordKRMyerGDHewettTE. Increased trunk motion in female athletes compared to males during single leg landing. Med Sci Sports Exerc. 2007;39:S70.
10.
FordKRMyerGDHewettTE. Longitudinal effects of maturation on lower extremity joint stiffness in adolescent athletes. Am J Sports Med. 2010;38:1829-1837.
11.
FordKRShapiroRMyerGDVan Den BogertAJHewettTE. Longitudinal sex differences during landing in knee abduction in young athletes. Med Sci Sports Exerc. 2010;42:1923-1931.
HauckWWJrDonnerA. Wald’s test as applied to hypotheses in logit analysis. J Am Stat Assoc. 1977;72:851-853.
14.
HeitzNAEisenmanPABeckCLWalkerJA. Hormonal changes throughout the menstrual cycle and increased anterior cruciate ligament laxity in females. J Athl Train. 1999;34:144-149.
15.
HewettTELindenfeldTNRiccobeneJVNoyesFR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27:699-706.
16.
HewettTEMyerGD. The mechanistic connection between the trunk, hip, knee, and anterior cruciate ligament injury. Exerc Sport Sci Rev. 2011;39:161-166.
17.
HewettTEMyerGDFordKR. Decrease in neuromuscular control about the knee with maturation in female athletes. J Bone Joint Surg Am. 2004;86-A:1601-1608.
18.
HewettTEMyerGDFordKR. 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;33:492-501.
19.
HewettTEMyerGDFordKRSlauterbeckJR. Preparticipation physical examination using a box drop vertical jump test in young athletes: the effects of puberty and sex. Clin J Sport Med. 2006;16:298-304.
20.
HewettTEMyerGDZazulakBT. Hamstrings to quadriceps peak torque ratios diverge between sexes with increasing isokinetic angular velocity. J Sci Med Sport. 2008;11:452-459.
21.
HewettTEZazulakBTMyerGD. Effects of the menstrual cycle on anterior cruciate ligament injury risk: a systematic review. Am J Sports Med. 2007;35:659-668.
22.
IrelandM. Special Concerns of the Female Athlete. Baltimore, MD: Williams & Wilkins; 1994.
23.
IrelandML. The female ACL: why is it more prone to injury?Orthop Clin North Am. 2002;33:637-651.
24.
KnapikJJBaumanCLJonesBHHarrisJMVaughanL. Preseason strength and flexibility imbalances associated with athletic injuries in female collegiate athletes. Am J Sports Med. 1991;19:76-81.
25.
KrippendorffK. Content Analysis: An Introduction to Its Methodology. 2nd ed.Thousand Oaks, CA: Sage; 2004.
26.
LaPradeRFBurnettQM2nd. Femoral intercondylar notch stenosis and correlation to anterior cruciate ligament injuries. A prospective study. Am J Sports Med. 1994;22:198-202.
27.
McCarrollJRRettigACShelbourneKD. Anterior cruciate ligament injuries in the young athlete with open physes. Am J Sports Med. 1988;16:44-47.
28.
MicheliLJ. Overuse injuries in children’s sports: the growth factor. Orthop Clin North Am. 1983;14:337-360.
29.
MihataLCBeutlerAIBodenBP. Comparing the incidence of anterior cruciate ligament injury in collegiate lacrosse, soccer, and basketball players: implications for anterior cruciate ligament mechanism and prevention. Am J Sports Med. 2006;34:899-904.
30.
MyerGDBrentJLFordKRHewettTE. A pilot study to determine the effect of trunk and hip focused neuromuscular training on hip and knee isokinetic strength. Br J Sports Med. 2008;42:614-619.
31.
MyerGDChuDABrentJLHewettTE. Trunk and hip control neuromuscular training for the prevention of knee joint injury. Clin Sports Med. 2008;27:425-448.
32.
MyerGDFaigenbaumADFordKRBestTMBergeronMFHewettTE. When to initiate integrative neuromuscular training to reduce sports-related injuries and enhance health in youth?Curr Sports Med Rep. 2011;10:155-166.
33.
MyerGDFordKRPaternoMVNickTGHewettTE. The effects of generalized joint laxity on risk of anterior cruciate ligament injury in young female athletes. Am J Sports Med. 2008;36:1073-1080.
34.
MyerGDSugimotoDThomasSHewettTE. The influence of age on the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a meta-analysis. Am J Sports Med. 2013;41:203-215.
35.
NelderJAWedderburnRWM. Generalized linear models. J R Stat Soc A. 1972;135:370-384.
36.
O’NeillDBMicheliLJ. Overuse injuries in the young athlete. Clin Sports Med. 1988;7:591-610.
37.
PowellJWBarber-FossKD. Sex-related injury patterns among selected high school sports. Am J Sports Med. 2000;28:385-391.
38.
QuatmanCEFordKRMyerGDPaternoMVHewettTE. The effects of gender and pubertal status on generalized joint laxity in young athletes. J Sci Med Sport. 2008;11:257-263.
39.
Quatman-YatesCCMyerGDFordKRHewettTE. A longitudinal cohort evaluation of maturational effects on lower extremity strength in female adolescent athletes. Pediatr Phys Ther. 2013;25:271-276.
40.
RoseneJMFogartyTD. Anterior tibial translation in collegiate athletes with normal anterior cruciate ligament integrity. J Athl Train. 1999;34:93-98.
41.
RozziSLLephartSMGearWSFuFH. Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players. Am J Sports Med. 1999;27:312-319.
42.
SheaKGApelPJPfeifferRP. Anterior cruciate ligament injury in paediatric and adolescent patients: a review of basic science and clinical research. Sports Med. 2003;33:455-471.
43.
SheaKGPfeifferRWangJHCurtinMApelPJ. Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data. J Pediatr Orthop. 2004;24:623-628.
44.
ShelbourneKDLiottaFJGoodloeSL. Preemptive pain management program for anterior cruciate ligament reconstruction. Am J Knee Surg. 1998;11:116-119.
45.
SlauterbeckJRFuzieSFSmithMP. The menstrual cycle, sex hormones, and anterior cruciate ligament injury. J Athl Train. 2002;37:275-278.
46.
TurszACrostM. Sports-related injuries in children. A study of their characteristics, frequency, and severity, with comparison to other types of accidental injuries. Am J Sports Med. 1986;14:294-299.
47.
WildCYSteeleJRMunroBJ. Why do girls sustain more anterior cruciate ligament injuries than boys? A review of the changes in estrogen and musculoskeletal structure and function during puberty. Sports Med. 2012;42:733-749.
48.
WojtysEMHustonLJLindenfeldTNHewettTEGreenfieldML. Association between the menstrual cycle and anterior cruciate ligament injuries in female athletes. Am J Sports Med. 1998;26:614-619.
