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Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study
Abstract
Background: Female athletes participating in high-risk sports suffer anterior cruciate ligament injury at a 4- to 6-fold greater rate than do male athletes. Hypothesis: Prescreened female athletes with subsequent anterior cruciate ligament injury will demonstrate decreased neuromuscular control and increased valgus joint loading, predicting anterior cruciate ligament injury risk. Study Design: Cohort study; Level of evidence, 2. Methods: There were 205 female athletes in the high-risk sports of soccer, basketball, and volleyball prospectively measured for neuromuscular control using 3-dimensional kinematics (joint angles) and joint loads using kinetics (joint moments) during a jump-landing task. Analysis of variance as well as linear and logistic regression were used to isolate predictors of risk in athletes who subsequently ruptured the anterior cruciate ligament. Results: Nine athletes had a confirmed anterior cruciate ligament rupture; these 9 had significantly different knee posture and loading compared to the 196 who did not have anterior cruciate ligament rupture. Knee abduction angle (P <. 05) at landing was 8° greater in anterior cruciate ligament-injured than in uninjured athletes. Anterior cruciate ligament-injured athletes had a 2.5 times greater knee abduction moment (P <. 001) and 20% higher ground reaction force (P <. 05), whereas stance time was 16% shorter; hence, increased motion, force, and moments occurred more quickly. Knee abduction moment predicted anterior cruciate ligament injury status with 73% specificity and 78% sensitivity; dynamic valgus measures showed a predictive r2 of 0.88. Conclusion: Knee motion and knee loading during a landing task are predictors of anterior cruciate ligament injury risk in female athletes. Clinical Relevance: Female athletes with increased dynamic valgus and high abduction loads are at increased risk of anterior cruciate ligament injury. The methods developed may be used to monitor neuromuscular control of the knee joint and may help develop simpler measures of neuromuscular control that can be used to direct female athletes to more effective, targeted interventions.
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“In clinical practice, the quality of SLS performance is often rated visually on a 10-point ordinal scale, with poor scores (typically < 5) indicating a propensity for common degenerative and traumatic musculoskeletal injuries. 4-6”
From Lower-Limb Kinematics of Single-Leg Squat Performance in Young Adults (2014) · cites this paper as [5]
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“Furthermore, Hewett and colleagues 5 prospectively followed a large cohort of female athletes and found that those who demonstrated large knee abduction angles or dynamic valgus during baseline landing tasks were most likely to experience an ACL injury in the future.”
From Lower-Limb Kinematics of Single-Leg Squat Performance in Young Adults (2014) · cites this paper as [5]
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Metadata
- Authors
- Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., van den Bogert, A. J., Paterno, M. V., & Succop, P.
- Affiliations
- Cincinnati Children's Hospital Medical Center (US)
- Wellington Orthopaedic and Sports Medicine Center, Cincinnati, Ohio
- University of Cincinnati (US)
- Cleveland Clinic (US)
- Department of Biomedical Engineering and Orthopaedic Research Center, Cleveland Clinic Foundation, Cleveland, Ohio
- ORCID
- Venue
- The American Journal of Sports Medicine
- Publisher
- SAGE Publications
- Published
- 2005-04
- Volume
- 33
- Issue
- 4
- Pages
- 492-501
- ISSN
- 0363-5465 (ISSN-L)
- 1552-3365
- OpenAlex
- W2086656914
- Cited by
- 3,577
- References
- 41
- Citations by year
- 2026: 193 · 2025: 217 · 2024: 238 · 2023: 185 · 2022: 188 · 2021: 289 · 2020: 243 · 2019: 245 · 2018: 225 · 2017: 197 · 2016: 202 · 2015: 192 · 2014: 169 · 2013: 154 · 2012: 155
- FWCI
- 53.57
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The American Journal of Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- EngagedScholarship @ Cleveland State University (Cleveland State University) (submittedVersion)
- Funders
- National Institutes of Health
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01AR049735, R101-ARO49735-01A1)
- Topics
- Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
- Physical Sciences › Engineering › Biomedical Engineering › Lower Extremity Biomechanics and Pathologies
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports injuries and prevention
- Keywords
- anterior cruciate ligament injury, female athletes, neuromuscular control, valgus loading, knee abduction moment, knee abduction angle, jump landing, injury prediction, knee joint loading, ground reaction force, high-risk sports
- MeSH terms
- Anterior Cruciate Ligament Injuries, Adolescent, Basketball, Biomechanical Phenomena, Epidemiologic Methods, Female, Humans, Kinesis, Knee Injuries, Knee Joint, Rotation, Rupture, Sex Factors, Soccer, Task Performance and Analysis, Weight-Bearing
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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