The influence of gender-specific loading patterns of the stop-jump task on anterior cruciate ligament strain

doi:10.1016/j.injury.2006.12.024

Injury

Volume 38, Issue 8, August 2007, Pages 973-978

https://doi.org/10.1016/j.injury.2006.12.024 Get rights and content

Summary

Background

Studies have shown that women are at higher risk of sustaining noncontact anterior cruciate ligament (ACL) injuries in specific sports. Recent gait studies of athletic tasks have documented that gender differences in knee movement, muscle activation, and external loading patterns exist. The objective of this study was to determine in a knee cadaver model if application of female-specific loading and movement patterns characterised in vivo for a stop-jump task cause higher ACL strains than male patterns.

Methods

Gender-specific loading patterns of the landing phase of the vertical stop-jump task were applied to seven cadaver knees using published kinetic/kinematic results for recreational athletes. Loads applied consecutively included: tibial compression, quadriceps, hamstrings, external posterior tibial shear, and tibial torque. Knee flexion was fixed based on the kinematic data. Strain of the ACL was monitored by means of a differential variable reluctance transducer installed on the anterior-medial bundle of the ACL.

Findings

The ACL strain was significantly increased (P < 0.05) for the female loading pattern relative to the male loading pattern after the posterior tibial shear force was applied, and showed a similar trend (P = 0.1) to be increased after the final tibial torque was applied.

Interpretation

This study suggests that female motor control strategies used during the stop-jump task may place higher strains on the ACL than male strategies, thus putting females at greater risk of ACL injury. We believe these results suggest the potential effectiveness of using training programs to modify motor control strategies and thus modify the risk of injury.

Introduction

Injuries to the anterior cruciate ligament (ACL) are a common occurrence with an estimation of 80,000 to 200,000 injuries annually within the United States.3, 8 The majority of these injuries are sports-related and approximately 70% of these sports-related injuries occur by a noncontact injury mechanism.¹⁹ Studies have shown that women are at higher risk of sustaining noncontact anterior cruciate ligament injuries in specific sports manoeuvres, such as sidestepping, cutting, and stop-jumping.¹ These findings have stimulated intensive research to understand why women are at greater risk of these injuries. While anatomical, hormonal, and motor control factors have all been proposed to contribute to the higher incidence of ACL injuries in women, motor control factors are the most easily modifiable factor through injury prevention efforts.9, 10, 11, 13, 20 Motion analysis studies of men and women during athletic tasks have documented females display less knee flexion, greater quadriceps activation, decreased hamstrings activation, greater knee valgus, and increased body weight-normalised ground reaction force magnitudes than males during various athletic tasks.4, 5, 7, 15, 17, 18 In addition, cadaver studies that have examined these specific factors (i.e. knee flexion, quadriceps activation, etc.) in isolation have found many of these factors to cause increased strains or loads within the ACL.2, 6, 12, 16, 21, 23 However, no experimental studies have attempted to simulate gender-specific loading and movement patterns characterised for a specific at-risk athletic task in a cadaver model to determine if the detected female pattern in fact causes higher strains within the ACL and thus puts the ACL at an increased risk of failure. The primary hypothesis of this study is that the gender differences in external and muscular loading patterns of the knee during the stop-jump task will cause increased strains of the ACL in women.

Section snippets

Methods

Gender-specific loading patterns of the vertical stop-jump task (Fig. 1) were experimentally applied to seven fresh-frozen cadaver knees free of surgical scars. Gender-specific loads were based on the kinetic study of Chappell et al.⁴ for recreational athletes and corresponded with the point in time in the landing phase (during first stop) of the stop-jump task (Fig. 1) in which the proximal tibia anterior shear force was maximised. Knee extension moment demands are typically greatest at this

Results

Our results did not demonstrate a significant difference in ACL strain between groups after the final tibial torque was applied. However, the female loading pattern displayed a trend (P = 0.10) to be increased relative to the male pattern (Fig. 3). For this loading state the ACL strain was greater for the female loading pattern in five of the seven specimens (Fig. 4). During the application of the female external tibial torque some of the specimens displayed significant amounts of tibial torsion

Discussion

While anatomical, hormonal, and motor control factors have all been proposed to contribute to the higher incidence of ACL injuries in women, studies have been unable to identify which of these factors are most significant to injury risk. The findings of this study suggest that female motor control strategies used during the stop-jump task may place higher strains on the ACL than male strategies. These results are significant in that motor control factors are likely to be the most easily

Conclusions

Female motor control patterns used during the stop-jump task appear to place higher strains on the ACL than male patterns. Injury prevention efforts that focus on altering these motor control factors may be an effective strategy for reducing ACL injury risk.

Acknowledgements

This work was supported by a UNC-Chapel Hill Junior Faculty Award and Arthrex Inc.

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Musculoskeletal disorders: Sex and gender evidence in anterior cruciate ligament injuries, osteoarthritis, and osteoporosis
2020, How Sex and Gender Impact Clinical Practice: an Evidence-Based Guide to Patient Care
Bone and joint diseases and conditions are extremely common, affecting almost everyone at some point in their lives. There is extensive evidence of sex- and gender-based differences in anterior cruciate ligament (ACL) injuries, osteoarthritis (OA), and osteoporosis. Although men and women play similar sports, their risks for and mechanisms of injury differ; this is best demonstrated by ACL tears. Both men and women develop OA, the most common disease of the joints, and although the causes may differ between the sexes, there are no differences in treatment options. Osteoporosis, the most common bone disease, is much more prevalent among women. However, men with osteoporosis can have more significant consequences than do women and treatment options may differ based on sex and gender.
Prolonged running increases knee moments in sidestepping and cutting manoeuvres in sport
2018, Journal of Science and Medicine in Sport
Citation Excerpt :
Anterior cruciate ligament (ACL) injuries are a devastating soft tissue injury which frequently occur in sports that are characterised by a sudden change in direction or rapid deceleration.1,2 ACL injuries are a common costly injury in sport3 with reconstructive surgical costs in the USA alone amounting to USD$2 billion4,5 with annual costs in Australia ranging between AUD$1.5–$2 billion.6 Arguably, Australian Football (AF) has the highest rate of injuries of all sports in Australia, of which the majority (26%) is comprised of knee, lower limb and ankle injuries.3,6,7
To investigate how knee kinematics, kinetics and loading changes during sidestepping tasks following a prolonged running protocol performed in a laboratory setting.
All participants performed sidestepping, and crossover cutting tasks in a randomised order before and after a 60 min running protocol on a non-motorised treadmill that simulated an AF game.
Eight healthy male participants who partook in semi-professional and amateur Australian Football undertook a series of straight line runs, sidestepping (SS), and crossover cutting (XO) tasks before and after a simulated game of Australian football. Kinematic data were analysed at initial foot contact of the SS and XO manoeuvres and kinetic data were analysed during the weight acceptance phase of the stance.
The knee was significantly more flexed at foot contact following fatigue compared to pre-fatigue states. Fatigue was also a factor contributing to significant increases in internal knee extension moments. Significant differences were also observed between SS and XO trials with flexion/extension moments, with notable differences in varus/valgus and internal/external rotation moments.
Acute angles of knee flexion at foot strike in a fatigued state may place the joint at an increased risk of injury. Increases in knee extension moments in the fatigued state suggests the knee joint must withstand significantly high stresses once fatigued.
Bracing can partially limit tibial rotation during stressful activities after anterior crucial ligament reconstruction with a hamstring graft
2016, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
landing from a platform and subsequent pivoting [2,23] (Supplemental material). These pivoting tasks have been shown to produce high translational and rotational loads to the knee joint [24,25] These stressful tasks were executed under three conditions for the reconstructed knee: wearing a prophylactic brace (braced condition);
Hamstring graft has substantial differences with BPTB graft regarding initial mechanical strength, healing sequence, and vascularization, which may imply that a different approach during rehabilitation period is required. The purpose of this study was to investigate the influence of knee bracing on tibial rotation in ACL-reconstructed patients with a hamstring autograft during high loading activities. The hypothesis was that there would be a decrease in tibial rotation in the ACL-reconstructed braced knee as compared to the unbraced knee.
Twenty male patients having undergone unilateral ACL reconstruction with a semitendinosus/gracilis autograft were assessed. Kinematic data were collected with an eight-camera optoelectronic system during two stressful tasks: (1) descending from a stair and subsequent pivoting; and (2) landing from a platform and subsequent pivoting. In each patient, three different experimental conditions were evaluated: (A) wearing a prophylactic brace (braced condition); (B) wearing a patellofemoral brace (sleeved condition); (C) without brace (unbraced condition). The intact knee without brace served as a control.
Tibial rotation was significantly lower in the intact knee compared to all three conditions of the ACL-reconstructed knee (P ≤ 0.01 for both tasks). Presence of a brace or sleeve resulted in lower tibial rotation than in the unbraced condition (p = 0.003 for descending/pivot and P = 0.0004 for landing/pivot). The braced condition resulted in lower rotation than the sleeved condition for descending/pivoting (P = 0.031) while no differences were found for landing/pivoting (P = 0.230).
Knee bracing limited the excessive tibial rotation during pivoting under high loading activities in ACL-reconstructed knees with a hamstring graft. This partial restoration of normal kinematics may have a potential beneficial effect in patients recovering from ACL reconstruction with a hamstring autograft.
Level III, case-control therapeutic study.
Individuals with chronic ankle instability exhibit altered landing knee kinematics: Potential link with the mechanism of loading for the anterior cruciate ligament
2014, Clinical Biomechanics
Citation Excerpt :
Peak ATSF was calculated from forces that include all soft tissues around the knee, therefore, it is important to acknowledge that this does not represent the true load or strain encountered in the ACL. In addition to sagittal plane kinematics and posterior GRF, previous studies reported that frontal and transverse plane kinematics and kinetics of the knee and hip produced greater ACL shear forces during deceleration (Hewett et al., 2009; Kanamori et al., 2000; Markolf et al., 1995; Weinhold et al., 2007), thereby warranting consideration as mechanisms of ACL injury. Reduced frontal plane hip strength and altered hip and knee kinematic patterns in the frontal and transverse planes during functional tasks have been observed in CAI populations (Brown et al., 2011, 2012; Friel et al., 2006).
Alterations in sagittal plane landing biomechanics in the lower extremity have been observed within the chronic ankle instability (CAI) population. Interestingly, a potential link between the risk of anterior cruciate ligament (ACL) injury and ankle sprain history has been proposed. However, it is not known if the observed biomechanical changes associated with CAI could mimic factors related to the mechanism of ACL injury. We investigated the influence of CAI on anterior tibial shear force (ATSF), lower extremity sagittal plane kinematics, and posterior ground reaction force (GRF) in a jump landing task.
Nineteen participants with CAI and 19 healthy control participants performed a vertical stop jump. Peak ATSF was calculated during the first landing of the stop jump, with sagittal-plane kinematics and posterior GRF measured at peak ATSF. Independent t-tests, multiple linear regression, and Pearson bivariate correlation were used for statistical analysis.
Participants with CAI demonstrated less knee flexion at peak ATSF compared to the controls (P = .026). No group-differences were found for peak ATSF or the other biomechanical variables. Knee flexion was moderately correlated with peak ATSF (r = −0.544, P = .008); however, the contributing factor that most explained the variance in ATSF was posterior GRF (R2 = 0.449; P = .002) in the CAI group.
Our findings indicate that the CAI group may be exhibiting altered knee function during functional movement. Screening knee movement patterns in individuals with CAI may help develop preventative measures for future joint injury throughout the kinetic chain.
Measurement of in vivo anterior cruciate ligament strain during dynamic jump landing
2011, Journal of Biomechanics
Citation Excerpt :
Because ACL injury affects such a young population (Roos et al., 1995; Beynnon et al., 2005) and surgery has mixed results in preventing early-onset OA (Fithian et al., 2002; Lohmander et al., 2007), there has been great interest in developing ACL injury prevention programs (Hewett et al., 1999; Heidt et al., 2000; Myklebust et al., 2003; Gilchrist et al., 2008). Many studies have focused on non-contact ACL injury mechanisms, which account for 70% of all ACL injuries (McNair et al., 1990; Weinhold et al., 2007; Gianotti et al., 2008) and potentially could be prevented with an appropriate training program. However, the levels of success achieved by current prevention programs have shown varied efficacy (Hewett et al., 1999; Soderman et al., 2000; Myklebust et al., 2003; Mandelbaum et al., 2005; Pfeiffer et al., 2006; Barber-Westin et al., 2009) and despite their implementation, high rates of non-contact ACL injuries persist (Agel et al., 2005).
Despite recent attention in the literature, anterior cruciate ligament (ACL) injury mechanisms are controversial and incidence rates remain high. One explanation is limited data on in vivo ACL strain during high-risk, dynamic movements. The objective of this study was to quantify ACL strain during jump landing. Marker-based motion analysis techniques were integrated with fluoroscopic and magnetic resonance (MR) imaging techniques to measure dynamic ACL strain non-invasively. First, eight subjects’ knees were imaged using MR. From these images, the cortical bone and ACL attachment sites of the tibia and femur were outlined to create 3D models. Subjects underwent motion analysis while jump landing using reflective markers placed directly on the skin around the knee. Next, biplanar fluoroscopic images were taken with the markers in place so that the relative positions of each marker to the underlying bone could be quantified. Numerical optimization allowed jumping kinematics to be superimposed on the knee model, thus reproducing the dynamic in vivo joint motion. ACL length, knee flexion, and ground reaction force were measured. During jump landing, average ACL strain peaked 55±14 ms (mean and 95% confidence interval) prior to ground impact, when knee flexion angles were lowest. The peak ACL strain, measured relative to its length during MR imaging, was 12±7%. The observed trends were consistent with previously described neuromuscular patterns. Unrestricted by field of view or low sampling rate, this novel approach provides a means to measure kinematic patterns that elevate ACL strains and that provide new insights into ACL injury mechanisms.
Use of a Novel Multimodal Imaging Technique to Model In Vivo Quadriceps Force and ACL Strain During Dynamic Activity
2022, American Journal of Sports Medicine

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The influence of gender-specific loading patterns of the stop-jump task on anterior cruciate ligament strain

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgements

Arthroscopy

J Biomech

Clin Biomech (Bristol, Avon)

J Biomech

Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature

Am J Sports Med

Strain inhomogeneity in the anterior cruciate ligament under application of external and muscular loads

J Biomech Eng

A comparison of knee kinetics between male and female recreational athletes in stop-jump tasks

Am J Sports Med

Electromyographic and kinematic analysis of cutting maneuvers. Implications for anterior cruciate ligament injury

Am J Sports Med

The influence of muscle forces and external loads on cruciate ligament strain

Am J Sports Med

Valgus knee motion during landing in high school female and male basketball players

Med Sci Sports Exerc

Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies

J Am Acad Orthop Surg