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Cited by 108Knee injuries and reconstruction techniquesTendon Structure and TreatmentConnective tissue disorders research

Generalised joint hypermobility increases ACL injury risk and is associated with inferior outcome after ACL reconstruction: a systematic review

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Sundemo, David, Hamrin Senorski, Eric, Karlsson, Louise, Horvath, Alexandra, Juul-Kristensen, Birgit, Karlsson, Jon, Ayeni, Olufemi R, Samuelsson, Kristian·2019·BMJ Open Sport & Exercise Medicine
DOI 10.1136/bmjsem-2019-000620PMC PMC6863654
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Abstract

Objectives: To investigate the association between generalised joint hypermobility (GJH) and ACL injury risk. Secondary aims involved evaluating associations between GJH and postoperative outcome (including graft-failure risk, knee laxity and patient-reported outcome). Furthermore, we aimed to compare the performance of different grafts in patients with GJH. Methods: Databases MEDLINE/PubMed, EMBASE and the Cochrane Library were searched, including 2760 studies. Two reviewers independently screened studies for eligibility. A modified version of the MINORS score was applied for quality appraisal. Studies assessing GJH while reporting the risk of ACL injury and/or postoperative outcome were included. Results: Twenty studies were included, using several different methods to determine GJH. There was consistent evidence showing that GJH is a risk factor for unilateral ACL injury in males, while in females, the results were conflicting. There was limited evidence associating GJH with increased knee laxity 5 years postoperatively. There was consistent evidence of inferior postoperative patient-reported outcome in patients with GJH. Moreover, there was limited yet consistent evidence indicating that patellar-tendon autografts are superior to hamstring-tendon autografts in patients with GJH in terms of knee laxity and patient-reported outcome. There was insufficient evidence to draw conclusions regarding the outcomes of bilateral ACL injury and graft failure. Conclusions: In men, GJH was associated with an increased risk of unilateral ACL injury. Moreover, GJH was associated with greater postoperative knee laxity and inferior patient-reported outcome. Based on the available evidence, a patellar-tendon autograft appears to be superior to a hamstring-tendon autograft in patients with GJH. However, the included studies were heterogeneous and there is a need for consensus in the assessment of GJH within sports medicine.

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  • There is high quality evidence of an increased risk of soft tissue injuries in adolescents with identified EDS or joint hypermobility.

    “There is high quality evidence of an increased risk of soft tissue injuries in adolescents with identified EDS or joint hypermobility evolving from mixed pediatric and adult studies.”

    From Pediatric joint hypermobility: a diagnostic framework and narrative review (2023) · cites this paper as [27]

    The Results (GJH as a risk factor for ACL injury; page unavailable) report an association between generalised joint hypermobility and ACL injury, particularly in males, but conflicting results in females. The review does not establish increased risk across soft-tissue injuries in adolescents with EDS or hypermobility. Its Results (Appraisal of evidence; page unavailable) describe most comparative studies as fair quality, not high quality. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Hypermobile sporting participants (age range 9-39 years, Beighton score ≥ 7) have an increased risk of knee joint injuries compared to those with a Beighton score 4-6.

    “Further, hypermobile sporting participants (age range 9–39 years, Beighton score ≥ 7), have an increased risk of knee joint injuries compared to those with a Beighton score 4–6 [27].”

    From Pediatric joint hypermobility: a diagnostic framework and narrative review (2023) · cites this paper as [27]

    The Results section, ‘GJH as a risk factor for ACL injury’ (page unavailable), reports an association between generalised joint hypermobility and unilateral ACL injury, consistently in males; findings in females were conflicting. It does not establish increased risk of knee joint injuries generally for sporting participants aged 9–39, or the claimed comparison of Beighton scores ≥7 versus 4–6. (LLM, conf=0.88)

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Authors
Sundemo, D., Hamrin Senorski, E., Karlsson, L., Horvath, A., Juul-Kristensen, B., Karlsson, J., Ayeni, O. R., & Samuelsson, K.
Affiliations
  • University of Gothenburg (SE)
  • Department of Health and Rehabiltation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  • Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  • Department of Sports Science and Clinical Biomechanics, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
  • McMaster University (CA)
  • Sahlgrenska University Hospital (SE)
Corresponding author
Sundemo, David
ORCID
Venue
BMJ Open Sport & Exercise Medicine
Publisher
BMJ
Published
2019-11
Volume
5
Issue
1
Pages
e000620
ISSN
2055-7647 (ISSN-L)
DOI
10.1136/bmjsem-2019-000620
PMC
PMC6863654
OpenAlex
W2985848458
Cited by
108
References
12
Citations by year
2026: 13 · 2025: 24 · 2024: 17 · 2023: 21 · 2022: 9 · 2021: 19 · 2020: 4 · 2018: 1
FWCI
1.65
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • BMJ Open Sport & Exercise Medicine (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion, cc-by-nc)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Tendon Structure and Treatment
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Connective tissue disorders research
Keywords
generalized joint hypermobility, anterior cruciate ligament injury, anterior cruciate ligament reconstruction, graft failure, knee laxity, patient-reported outcomes, patellar tendon autograft, hamstring tendon graft, sex differences, injury risk factors

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