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‘What’s my risk of sustaining an ACL injury while playing football (soccer)?’ A systematic review with meta-analysis
  1. Alicia M Montalvo1,
  2. Daniel K Schneider2,3,
  3. Paula L Silva4,
  4. Laura Yut5,
  5. Kate E Webster6,
  6. Michael A Riley4,
  7. Adam W Kiefer2,4,7,
  8. Jennifer L Doherty-Restrepo1,
  9. Gregory D Myer7,8,9,10
  1. 1Department of Athletic Training, Florida International University, Nicole Wertheim College of Nursing and Health Sciences, Miami, Florida, USA
  2. 2Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
  3. 3College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
  4. 4Center for Cognition, Action, & Perception, Department of Psychology, University of Cincinnati, Cincinnati, Ohio, USA
  5. 5Department of Biostatistics, Robert Stempel School of Public Health and Social Work, Florida International University, Miami, Florida, USA
  6. 6School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
  7. 7Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, The SPORT Center, Cincinnati, Ohio, USA
  8. 8Departments of Pediatrics and Orthopaedic Surgery, University of Cincinnati, Cincinnati, Ohio, USA
  9. 9The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
  10. 10Department of Orthopaedics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Gregory D Myer, Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, The SPORT Center, Cincinnati OH 45229, USA; greg.myer{at}


Objective To estimate the incidence proportion (IP) and incidence rate (IR) of ACL injury in football players.

Design Systematic review with meta-analysis.

Data sources PubMed, CINAHL and SPORTDiscus electronic databases were searched from inception to 20 January 2017.

Eligibility criteria for selecting study Studies that reported the total number of participants/population by sex, total number of ACL injuries by sex and total person-time by sex were included.

Results Twenty-eight studies were included. The IP and IR of ACL injury in female football players were 2.0% (95% CI 1.2% to 3.1%) and 2.0/10 000 athlete exposures (AEs) (95% CI 1.6 to 2.6; I2=91%) over a period of one season to 4 years. The IP and IR of ACL injury in male players were 3.5% (95% CI 0.7% to 8.2%) and 0.9/10 000 AEs (95% CI 0.7 to 1.1; I2=94%). Studies that evaluated matched cohorts of female and male players showed no difference in IP (relative risk=1.2; 95% CI 0.9 to 1.6; P=0.47) over a period of one season to 4 years. Women were at greater risk than men (incidence rate ratio (IRR)=2.2; 95% CI 1.6 to 3.1; I2=83%; P<0.001). When accounting for participation level, the difference in IR between women and men was greatest for intermediate players (IRR=2.9; 95% CI 2.4 to 3.6) compared with amateur (IRR=2.6; 95% CI 1.4 to 4.8) and elite (IRR=2.0; 95% CI 1.1 to 3.4) players.

Summary/conclusion Overall, more men sustained ACL injury in football. There was no difference in the relative risk of ACL injury between female and male football players in a window that spanned one season to 4 years. The IR of ACL injury among women was 2.2 times higher than the IR of ACL injury among men. The reported sex disparity in ACL injury was independent of participation level.

  • epidemiology
  • knee
  • acl
  • sports

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  • Contributors All authors contributed significantly to the conception, design and writing of this manuscript.

  • Funding We acknowledge funding support from the National Institutes of Health/NIAMS Grant R21AR065068!01A1 and U01AR067997.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data in this review are available in the journal in which they were published.

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