Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-013-2725-3
SPORTS MEDICINE
Prevention of anterior cruciate ligament injuries in sports—Part
I: Systematic review of risk factors in male athletes
Eduard Alentorn-Geli • Jurdan Mendiguchı́a •
Kristian Samuelsson • Volker Musahl •
Jon Karlsson • Ramon Cugat • Gregory D. Myer
Received: 6 August 2013 / Accepted: 14 October 2013
 Springer-Verlag Berlin Heidelberg 2013
Abstract
Purpose The purpose of this study was to report a com-
prehensive literature review on the risk factors for anterior
cruciate ligament (ACL) injuries in male athletes.
Methods All abstracts were read and articles of potential
interest were reviewed in detail to determine on inclusion
status for systematic review. Information regarding risk
factors for ACL injuries in male athletes was extracted
from all included studies in systematic fashion and classi-
fied as environmental, anatomical, hormonal, neuromus-
cular, or biomechanical. Data extraction involved general
characteristics of the included studies (type of study,
characteristics of the sample, type of sport), methodologi-
cal aspects (for quality assessment), and the principal
results for each type of risk factor.
Results The principal findings of this systematic review
related to the risk factors for ACL injury in male athletes
are: (1) most of the evidence is related to environmental
E. Alentorn-Geli (&)
Department of Orthopaedic Surgery, Hospital del Mar—Parc de
Salut Mar, Universitat Autonoma de Barcelona and Universitat
Pompeu Fabra, Passeig Marı́tim 25-29, 08003 Barcelona, Spain
e-mail: ealentorngeli@gmail.com
J. Mendiguchı́a
Department of Physical Therapy, Zentrum Rehab and
Performance Center, Barañain, Navarre, Spain
K. Samuelsson
J. Karlsson
Department of Orthopaedics, Sahlgrenska University Hospital,
Mölndal, Sweden
V. Musahl
Department of Orthopaedic Surgery, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
R. Cugat
Garcı́a-Cugat Foundation, Barcelona, Spain
and anatomical risk factors; (2) dry weather conditions may
increase the risk of non-contact ACL injuries in male
athletes; (3) artificial turf may increase the risk of non-
contact ACL injuries in male athletes; (4) higher posterior
tibial slope of the lateral tibial plateau may increase the risk
of non-contact ACL injuries in male athletes.
Conclusion Anterior cruciate ligament injury in male
athletes likely has a multi-factorial aetiology. There is a
lack of evidence regarding neuromuscular and biome-
chanical risk factors for ACL injury in male athletes.
Future research in male populations is warranted to provide
adequate prevention strategies aimed to decrease the risk of
this serious injury in these populations.
Level of evidence Systematic review on level I–IV stud-
ies, Level IV.
Keywords Prevention
ACL injury
Risk factors

Male athletes
R. Cugat
Mutualidad de Futbolistas, Federación Española de Fútbol—
Delegación Cataluña, Barcelona, Spain
G. D. Myer
Division of Sports Medicine, Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH, USA
G. D. Myer
Departments of Pediatrics and Orthopaedic Surgery, University
of Cincinnati, Cincinnati, OH, USA
G. D. Myer
The Micheli Center for Sports Injury Prevention,
Boston, MA, USA
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 Knee Surg Sports Traumatol Arthrosc

Introduction Table 1 Search strategy and keywords employed for the systematic
literature search
Anterior cruciate ligament (ACL) injuries are a common Database Search Keywords/query
and debilitating injury in competitive sports [10, 37, 67].
The costs of this injury are very high from both the Pubmed 1 (anterior cruciate ligament OR ACL) AND
(injuries OR injury OR tear OR tears OR
patient’s health and economic standpoints [33, 35, 36, 49]. tearing OR rupture OR ruptures)
The high incidence of ACL injury along with the poten- 2 Sports[mesh] OR sports[tw] OR sport[tw] OR
tially devastating long-term consequences on the knee has athletes[mesh] OR athletes[tw] OR
led to great research efforts focused on prevention and athlete[tw]
management of injuries. Many studies have been con- 3 #1 AND #2
ducted to better understand the inciting mechanisms of 4 ((animals[mh]) NOT (animals[mh] AND
ACL injury and the associated risk factors that contribute humans[mh]))
to increased risk for injury [3, 17, 38, 42]. While sub- 5 #3 NOT #4
stantive research efforts have been made to improve 6 (Editorial[ptyp] OR Letter[ptyp] OR
Comment[ptyp])
diagnosis and treatment strategies [5, 15, 19, 24, 45, 53, 55,
7 #5 NOT #6
56, 72, 77], the long-term consequence of ACL injuries is
8 #5 NOT #6 Filters: English
likely osteoarthritis, even in cases undergoing surgical
EMBASE 1 Exp anterior cruciate ligament/
treatment [49]. Therefore, the most effective strategy to
avoid joint damage is prevention. 2 (anterior cruciate ligament OR ACL). ti, ab,
kw
There has been a growing awareness on the relevance
3 #1 OR #2
of prevention of ACL injuries in athletes from health care
4 Exp injury/
providers who are faced to manage the injuries. Women
5 (injuries OR injury OR tear OR tears OR
have a higher risk of non-contact ACL injuries compared tearing OR rupture OR ruptures). ti,ab,kw
to their male counterparts [6, 10]; therefore, research on 6 #4 OR #5
mechanisms of injury, risk factors and prevention strate-
7 Exp sport/
gies of these injuries has predominately focused on the
8 Exp athlete/
female athlete [3, 4, 17, 18, 40, 42]. Most of the inves-
9 (sports OR sport OR athletes OR athlete). ti,
tigations only included females or compared females and ab, kw
males [3, 4, 17, 18, 40, 42, 56]. However, the overall 10 #7 OR #8 OR #9
incidence of ACL injuries is high in males as well [54], 11 #3 AND #6 AND #10
especially considering that males may be more exposed to 12 Limit 11 to (EMBASE AND English AND
high-risk sports [33]. Unfortunately, the available infor- (article OR conference paper OR ‘‘review’’))
mation on risk factors for non-contact ACL injuries spe- Cochrane 1 MeSH descriptor: [Anterior Cruciate
cifically in male has not been well documented to date. library Ligament] explode all trees
Thus, the exact information regarding the factors that 2 Anterior cruciate ligament OR ACL: ti, ab, kw
place a male athlete at greater risk of ACL injury is not (word variations have been searched)
well understood and data from female athletes are often 3 #1 OR #2
extrapolated to their male counterparts, which likely leads 4 MeSH descriptor: [Wounds and Injuries]
explode all trees
to sub-optimal intervention and management strategies for
5 Injuries OR injury OR tear OR tears OR
the male athlete. Therefore, the purpose of this systematic
tearing OR rupture OR ruptures: ti, ab, kw
review was to assimilate and synthesize the existing (word variations have been searched)
evidence on the risk factors for ACL injuries in male 6 #4 OR #5
athletes. 7 MeSH descriptor: [Sports] explode all trees
8 MeSH descriptor: [Athletes] explode all trees
9 Sports OR sport OR athletes OR athlete: ti, ab,
Material and methods kw (word variations have been searched)
10 #7 OR #8 OR #9
The methodology of this study was reported following the 11 #3 AND #6 AND #10
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) Statement for systematic systematic reviews or meta-analyses, and include: title,
reviews [52]. This is an evidence-based minimum set of abstract, introduction (rationale and objectives), methods
items that serve as a guide for authors when reporting (protocol and registration, eligibility criteria, information

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Knee Surg Sports Traumatol Arthrosc
sources, search, study selection, data collection process,
data items, risk of bias in individual studies, summary
measures, synthesis of results, risk of bias across studies,
and additional analyses), results (study selection, study
characteristics, risk of bias within studies, results of indi-
vidual studies, synthesis of results, risk of bias across
studies, and additional analysis), discussion (summary of
evidence, limitations, and conclusions), and funding.
Eligibility criteria
All prospective, cross-sectional or retrospective prognos-
tic human studies investigating risk factors for ACL
injury were evaluated for eligibility. Studies were inclu-
ded if they were: level of evidence between I and IV,
written in English language, and contained results speci-
fied for males. Studies only reporting issues other than
risk factors or studies investigating only female sample
were excluded. Studies not including ACL-injured sub-
jects or ACL injury as an outcome measure were exclu-
ded. Therapeutic and diagnostic studies were excluded.
Review articles, systematic reviews, and meta-analyses
were not included, but reference lists were examined to
ensure completeness of relevant studies. To avoid selec-
tion bias, studies comparing females and males were
reviewed in detail to assess for intra-group comparison in
males.
Information sources and search
Electronic search
A systematic electronic literature search was conducted
using the PubMed (MEDLINE) database and The Coch-
rane Library up to September 2012 (no start date), EM-
BASE database from 1980 to September 2012. Two expert
librarians in electronic search methods performed the lit-
erature search. The search strategy and keywords employed
in this study are summarized in Table 1.
Other search methods
The reference lists of all included articles were reviewed to
search for potential studies not previously identified.
Data collection and analysis
Study selection
All abstracts were read and articles of potential interest were
reviewed in detail (full text) by 3 authors (EAG, JM, and
GDM) to decide on inclusion or exclusion from this sys-
tematic review. In cases of disagreement, all three authors
reviewed and discussed the study and a final decision in
consensus. In all cases where the information regarding the
sex of the subject was not provided, a contact with the cor-
responding author was established to determine the sex of
the investigation subjects.
Data collection process
Information regarding risk factors for ACL injuries in
male athletes was extracted by the first author from all
included studies in systematic fashion following the
classification of risk factors suggested in the Hunt Valley
meeting [38]. Thus, risk factors were classified as envi-
ronmental, anatomical, hormonal, neuromuscular, and
biomechanical. Data extraction involved general charac-
teristics of the included studies (type of study, charac-
teristics of the sample, type of sport), methodological
aspects (for quality assessment), and the principal results
for each type of risk factor. One author (EAG) performed
all data extraction, which was then verified by two
authors (JM and GDM).
Assessment of the risk of bias
The methodological quality of all included studies was
evaluated with the assessment of the risk of bias in several
areas of a research project. This assessment was performed
by answering yes, no, unknown, or not applicable to the
following information from each study: prospective, con-
cealed allocation (yes = assignment was made by an
independent person who had no information about study
participants), similarities at baseline between groups
(yes = study groups were similar in demographic charac-
teristics), blinding of participants (yes = study population
blinding was clearly described and acceptable), blinding of
data collectors (yes = data collectors were blinded
regarding group assignments), blinding of outcome asses-
sors (yes = outcome assessors who evaluated the partici-
pants were blinded regarding group assignments), previous
knee injuries excluded, results specified for non-contact
injuries, influence of other risk factors controlled, accept-
able compliance (yes = compliance was regularly checked
or otherwise strictly supervised by someone other than
study participants, and it was more than 70 % in every
study group), dropout reasons reported, acceptable dropout
rate (yes = dropout rate was \30 %), duration of inter-
vention comparable between groups, and intention-to-treat
analysis (yes = all subjects assigned to a group at the
beginning of the study were included in the analysis). A
final quality score was given for each study, where ‘yes’
was 1 point and the other response was 0 points. The
assessment of the risk of bias in included studies was based
on the article by Aaltonen et al. [1].
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Pubmed 1821 External risk factors

EMBASE 1361
Cochrane 140
TOTAL 3322 Environmental risk factors

Duplicates excluded The evidence found for environmental risk factors for ACL
1495
injuries in male athletes was primarily related to weather
conditions, playing surface and shoe characteristics. Envi-
Title/Abstracts reviewed ronmental are the risk factors in which this systematic
1827 Excluded studies 1785
Reasons for exclusion: review found most of the references assessing risk factors
-Animal studies for ACL injuries in males. A total of 17 references were
-Cadaveric/in vitro studies
-Epidemiological studies found for environmental risk factors: 8 for weather con-
-Diagnostic studies ditions, 12 for playing surface, and 1 for footwear (some
-Therapeutic studies
-Prevention programs studies were classified in more than one group).
-Review studies
-Other type of studies
-Involved only females Weather conditions There were 3 studies investigating
Full-text articles assessing -Compared females vs males weather conditions in American football, 4 in Australian
risk factors football, and 1 in soccer. The approximate number of
42 Excluded 18
Reasons for exclusion:
subjects involved in the study of weather conditions was
-Not male vs male comparison 7,624.
-No ACL injuries involved Regarding American football, Scranton et al. [70]
Added from reference lists investigated 22 teams of the National Football League
10 during 5 seasons and found an increased incidence of non-
contact ACL injuries in dry compared to wet conditions.
Studies included in this review article The National Football League was also analysed by
34
Bradley et al. [11] in a descriptive epidemiology study
(seasons between 1986 and 1995). The authors reported
Fig. 1 Flow of information through the different phases of the
systematic literature search that practice-related ACL injuries were more common
during the pre-season months of July and August, with
constant numbers for the remaining season. Game-related
Results ACL injuries were highest in August and December.
Accordingly, increased injuries were reported in hot com-
Study selection pared to cold conditions. Orchard and Powell [62] evalu-
ated 5,918 National Football League games (seasons
The literature search elicited a total of 3,322 references, between 1989 and 1998) and found that weather conditions
from which 1,495 were duplicates and another 1,785 were had no influence on the risk of ACL sprains in natural
excluded (Fig. 1). A total of 42 studies were reviewed in grass. However, the risk was lower in artificial turf of open
full text, and 24 were included. In addition, ten articles stadiums during cold weather (with no effect of whether
were added after reviewing the reference lists of included the playing surface was wet or dry) compared to hot
studies. Therefore, 34 articles met the final inclusion cri- weather conditions. The incidence of ACL sprains was
teria for the current systematic review. lower during the cooler months of the season in open sta-
diums (both AstroTurf and natural grass) but not in domes
Characteristics of the studies [62].
There are a number of studies published on the influence
Of the 34 studies, 12 were prospective and 22 non- of weather conditions in injuries in male athletes partici-
prospective studies. Table 2 summarizes the assessment pating in Australian football [58–61]. Orchard et al. [59]
of the risk of bias for the included studies. The evaluated 2,280 matches (from 1992 to 1998) and found
approximate number of participants involved in the 34 that senior grade matches, high water evaporation in the
studies was 18,913 (some studies did not specify the month before the match, and low rainfall in the year before
total number of participants included), although it is the match were associated with increased risk of non-
likely that some subjects were employed for more than contact ACL injuries in male players. These results were
one study published by the same group of authors. confirmed by the same group 2 years later [60]. Using the
Table 3 summarized all the evidence extracted from the penetrometer measuring system for ground hardness, early
34 included studies. season matches and matches played at a warmer weather

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Table 2 Assessment of the risk of bias in the included studies

Study A B C D E F G H I J K L M N Score

Bradley 02 N N U NA U U U N N NA N U NA NA 0
Brandon 06 N N U NA U Y Y Y N U N U NA U 2
Dragoo 12a N N U NA U U U N N U N U NA U 0
Dragoo 12b N N U NA U U U N N U N U NA U 0
Evans 12 N N U N U U Y Y N Y Y Y NA N 5
Everhart 10 N N Y N U Y Y Y N U N U NA U 3
Fuller 07a Y N U U U U N N N U N U Y U 2
Fuller 07b Y N U U U U N N N U N U Y U 2
Fuller 10 Y N U U U U N N N U N U Y U 2
Gomes 08 N N N NA U U Y Y N U Y U NA N 3
Hashemi 10 N N N NA Y Y Y N N U N U NA U 2
Hohmann 11 N N Y NA Y Y Y Y N U N U NA U 4
Hudek 11 N N Y NA U U Y Y N U N U NA U 2
Lambson 96 Y N Y U U U Y N N U N U Y U 4
Meyers 04 Y N U U N Y Y N N U N U Y U 4
Olsen 03 Y N Y U U U U N N U N U Y U 3
Orchard 99 N N U U U U U N N U N U NA U 0
Orchard 01a Y N U U U Y U U N U N U Y U 3
Orchard 01b N N U U U U U Y N U N U NA U 1
Orchard 03 N N U U U U U U N U N U NA U 0
Orchard 05 N N U U U U U Y N U N U NA U 1
Philippon 12 N N Y NA U Y Y U N U N U NA U 3
Powell 12 N N U U U U U U N U N U NA U 0
Scranton 97 N N U U U U U Y N Y N U NA U 2
Sheehan 12 N N U NA U N U Y N NA N U NA U 1
Souryal 93 Y N U NA U Y Y Y N U N Y Y N 6
Stijak 08 N N Y U U U Y N N NA N U NA U 2
Teitz 97 N N U NA Y Y U Y N U N U NA U 3
Todd 10 N N U NA U N Y Y N U NA Y NA U 3
Uhorchak 03 Y N U N Y Y Y Y N U Y Y Y N 8
Walden 13 Y N U N U U U Y N U U U Y N 3
Woodford-Rogers 94 N N Y NA U U U N N U N U NA U 1
Zazulak 07a Y N Y U Y Y Y N N U N U Y U 6
Zazulak 07b Y N Y U Y Y Y N N U N U Y U 6
A, Prospective; B, Concealed allocation; C, Similarities at baseline; D, Participant blinding; E, Data collector blinding; F, Outcome assessor
blinding; G, Previous knee injuries excluded; H, Results specified for non-contact injuries; I, No influence of other risk factors; J, Acceptable
compliance; K, Dropout reasons reported; L, Acceptable dropout rate; M, Duration of intervention comparable; N, Intention-to-treat analysis

demonstrated a trend towards an increased risk of ACL
injury in Australian football [58]. Four years later, Orchard
et al. [61] published the results of the prospective follow-up
of their cohort of Australian football players. The authors
concluded that grass type more than ground hardness or
weather conditions would be responsible for the increased
risk of non-contact ACL injuries.
Finally, Waldén et al. [80] compared the incidence of
ACL injuries in professional soccer players from Europe
depending on the climate. The authors separated northern
countries with a humid subtropical weather (hot humid
summer and cool winter) and marine west coast (warm
summer but no dry season), and southern countries with
Mediterranean climate (warm/hot and dry summer together
with wet winter). The authors found that the incidence of
ACL injuries was lower in northern compared to southern
countries.
Playing surface There was 1 study investigating playing
surface in Australian football, 9 in American football, and

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 Knee Surg Sports Traumatol Arthrosc

Table 3 Summary of risk factors for anterior cruciate ligament injuries in male athletes
Risk factors Main findings N Quality* Potential preventive strategy

Environmental
Weather conditions Higher ACL injuries in dry conditions 5 1 (0–3) Wetting of the playing surface
Lower ACL injuries in cold weather of open stadiums 1 0 (-) –
Northern European countries lower ACL incidence compared to 1 3 (-) N-M preventive training
southern European countries
Playing surface Bermuda grass higher risk of injury than Rye grass 1 1 (-) Wetting of the playing surface
or plant Rye grass
Artificial turf higher risk of injury than natural grass 3 0 (0–0) Use of natural grass fields
Natural grass higher risk of injury than artificial turf 1 2 (-) Use of artificial turf fields
No influence of natural and artificial surfaces on injury risk 5 2 (0–4) –
Footwear Edge-type foot designs higher risk of injury 1 4 (-) Use of flat, screw-in, or pivot
disk foot designs
Anatomical
Intercondylar notch Narrow intercondylar notch higher risk of injury 2 7 (6–8) N-M preventive training
width No influence of intercondylar notch width on injury risk 2 4 (3–5) –
Greater anterior outlet width and the presence of bone ridge in 1 3 (–) N-M preventive training
intercondylar notch, greater risk of injury
BMI Higher BMI increases the risk of injury 1 3 (–) Decrease weight before
engaging in sports
Posterior tibial slope Higher posterior medial tibial slope higher risk of injury 2 2 (2) N-M preventive training
No influence of posterior medial tibial slope on injury risk 4 2.5 –
(2–4)
Higher posterior lateral tibial slope higher risk of injury 3 2 (2) N-M preventive training
Femoral neck-head Higher alpha angle higher risk of injury 1 3 (-) N-M preventive training
offset
Foot and ankle No influence of navicular drop and calcaneal eversion on injury risk 1 1 (-) –
N-M preventive training
Knee laxity Higher knee laxity higher risk of injury 1 1 (-) –
No influence of knee laxity on risk of injury 1 8 (-) N-M preventive training
Generalized joint Generalized joint laxity higher risk of injury 1 8 (-)
laxity
Neuromuscular
Muscle strength and No influence of quadriceps and hamstring strength (either concentric 1 8 (-) –
recruitment or eccentric) on injury risk
Biomechanical
Hip range of motion Lower hip range of motion higher risk of injury 1 3 (-) N-M preventive training
Body positioning No influence of trunk displacement on injury risk 1 6 (-) –
Higher COM-BOS distance and limb angle (hip flexion) higher risk 1 1 (-) N-M preventive training
of injury
Lower trunk angle (more erected position) higher risk of injury 1 1 (-) N-M preventive training
Trunk No influence of trunk proprioception on injury risk 1 6 (-) –
proprioception
ACL anterior cruciate ligament, N number of studies, N-M neuromuscular, BMI body mass index, COM-BOS centre of mass to base of support
* Median (range) of the quality score of studies involved in each risk factors

1 in rugby and handball, respectively. The approximate
number of subjects involved in the study of weather con-
ditions was 6,387 (although some studies did not specify
the total number of subjects involved).
Regarding Australian football, Orchard et al. [61]
observed that the type of grass was related to non-contact
ACL injuries in male athletes. The authors found that
Bermuda (couch) grass was associated with a higher risk of
this injury compared to Rye grass.
There are several studies investigating the risk of ACL
injuries in American football depending on the playing
surface [11, 22, 23, 31, 32, 51, 62, 66, 70]. Powell and

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Knee Surg Sports Traumatol Arthrosc
Schootman found an increased risk of ACL injuries in
artificial turf compared to natural grass after evaluating
National Football League games between 1980 and 1989
[66]. In contrast, Scranton et al. [70] found an increased
risk of non-contact ACL injuries in natural grass compared
to artificial turf during games of the National Football
League. A more recent investigation reported no differ-
ences in rates of non-contact ACL injuries between natural
grass and artificial surface throughout games of a 9-year
period [11]. These results were supported in the study by
Orchard and Powell [62], who found no increased risk of
ACL sprains in natural grass compared to dome and open
turf. However, when considering practice sessions, an
increased proportion of ACL injuries was reported on
natural (82 %) compared to artificial (18 %) surface [11].
Meyers et al. [51] evaluated male football of 8 high schools
over 5 competitive seasons and found non-significant dif-
ferences for both isolated and non-isolated ACL injuries
between artificial turf and natural. Similarly, Fuller et al.
[32] found no differences between artificial turf and natural
grass for the incidence of ACL injuries in male players,
either in practice and games [31]. Dragoo et al. [22, 23]
reported a descriptive epidemiology study over a period of
5 years in National Collegiate Athletic Association football
male athletes. The rate of ACL injuries in artificial surfaces
was increased relative to natural grass for both pre-season
and in-season periods, but not in the post-season period
[22, 23]. The increased risk of ACL injury in artificial
surfaces compared to natural grass was present in games,
scrimmages, and practices, and across all divisions [23].
The risk was higher in games compared to practice, and in
scrimmages compared to regular practice and walk-
throughs [22]. Regarding the specific type of artificial turf,
third-generation surfaces (with fill) had more risk of ACL
injury compared to first- and second-generation surfaces
(without fill) [23].
Regarding the evidence for other sports, an investigation
was performed to compare the risk of ACL injury between
artificial turf and natural grass in male rugby players during
2 seasons of match injuries sustained by 6 teams competing
in Hong Kong’s Division 1 and training injuries sustained
by 2 teams in the English Premiership [30]. The authors
reported no significant differences in ACL injuries between
artificial surface and natural grass. The risk of ACL injuries
in male handball athletes of the 3 top divisions of Norway
during 7 seasons was evaluated relative to the playing
surface (wooden floors, generally with lower friction, and
artificial floors, generally with higher friction) [57]. The
authors found that the type of floor was not a risk factor for
ACL injury in male handball players.
Footwear There is only 1 study included in this section.
Lambson et al. [48] reported a prospective study aimed to
evaluate torsional resistance of football cleats and its
relationship to ACL injuries in high school American
football players. The study included a sample of 3,119
players during the 1989–1991 competitive seasons. The
foot cleat designs evaluated were: edge (longer irregular
cleats placed at the peripheral margin of the sole with a
number of smaller pointed cleats positioned interiorly), flat
(cleats on the forefoot are the same height, shape, and
diameter, such as found on the soccer-style shoe), screw-in
(seven screw-in cleats of 0.5 inch height and 0.5 inch
diameter), and pivot disk (a 10-cm circular edge is on the
sole of the forefoot, with one 0.5-inch cleat in the centre)
[48]. The authors reported that the edge designs produced
significantly higher torsional resistance than the other
designs. In addition, this foot cleat design was significantly
associated with a higher risk of ACL injuries compared to
the other designs.
Internal risk factors
Anatomical risk factors
The evidence found for anatomical risk factors for ACL
injuries in male athletes was mainly related to morphologic
characteristics and knee laxity. The former has to do with
both knee (intercondylar notch and posterior tibial slope
characteristics) and hip morphology. A total of 13 refer-
ences were found for anatomical risk factors: 5 for in-
tercondylar notch width, 1 for body mass index, 9 for tibial
slope, 2 for knee laxity, and 1 for each hip morphology,
foot and ankle morphology, and generalized joint laxity.
Morphologic characteristics The 14 studies included in
morphologic characteristics involved approximately 3,891
participants, distributed in the following activities: Amer-
ican football (1 study), military subjects (3 studies), com-
bination of sports (2 studies), and undetermined activities
(3 studies).
The principal morphologic characteristics related to
ACL injuries reported for males are intercondylar notch
and posterior tibial slope. Regarding intercondylar notch
morphology, Souryal et al. [73] compared, in a prospective
(level II evidence) cohort study, the notch width index
between injured and uninjured high school male athletes.
The authors reported that ACL-injured males had signifi-
cantly narrower intercondylar notch compared to uninjured
subjects. In contrast, a similar investigation involving a
sample of 40 males (mean age 39 years, range 19–70)
found that in subjects with non-contact ACL injuries, there
were no differences in notch width index between the
injured and uninjured side [76]. In 2003, Uhorchak et al.
[79] reported in a prospective study with young military
cadets that injured subjects had significantly lower notch
123

width, tibial eminence width, notch width index, and tibial
eminence width index compared to non-injured males
cadets. The authors found no differences in notch width/
eminence width ratio were reported [79]. Interestingly, the
authors found a 7.8-fold increased risk for non-contact
ACL injury in men with both narrow femoral notch and
generalized joint laxity compared to those without both
factors [79]. Evans et al. [26] reported a retrospective
comparative study with young, athletic subjects, and found
no differences between both injured and non-injured males
for height, condylar width, notch width, and notch width
index. Injured subjects had significantly higher weight and
body mass index compared to uninjured subjects. A narrow
notch width was associated with elevated body mass index
and was also a significant risk factor for males. Everhart
et al. [27] compared the notch morphology between sub-
jects with non-contact ACL injuries (cases) and a sample of
matched controls for age, sex, height, and weight. The
authors found that healthy men had greater anterior femoral
notch outlet width compared to injured men. The presence
of an anteromedial bone ridge in the femoral notch
increased the risk of non-contact ACL injury in men. In
addition, healthy men had a ridge thickness significantly
lower compared to injured men.
There are several retrospective investigations that have
evaluated the influence of posterior tibial slope on the risk
of non-contact ACL injuries in males. Brandon et al. [12]
reported a prognostic case–control study where they found
that males with ACL injuries demonstrated increased
posterior-inferior medial tibial slope when compared to
male controls. In contrast, another study reported ACL-
injured young males (not necessarily athletes) demon-
strated increased posterior tibial slope of the lateral plateau
(but not medial plateau) along with increased difference of
the tibial slope on the lateral and medial tibial plateaus
compared to non-injured control males [74]. In a similar
study, Hashemi et al. [39] compared the morphology of the
proximal tibia between ACL-injured (cases) and uninjured
(controls) males (not necessarily athletes). The authors
reported that injured males demonstrated increased medial
tibial slope, lateral tibial slope, and medial tibial depth
compared to uninjured males. In another case–control
study, Todd et al. [78] found no differences in posterior
tibial slope of the medial plateau between injured and
uninjured males. Similarly, Hudek et al. [46] found that
posterior lateral (but not medial) tibial slope in men with
non-contact ACL injuries was significantly higher relative
to control males. The authors also found that the meniscal
slope of injured subjects in medial and lateral plateaus was
significantly different compared to control subjects [46].
These authors introduced the measure of the meniscal slope
(marked by the superior margins of the anterior and pos-
terior horns in each meniscus). A comparison of the values
123
Knee Surg Sports Traumatol Arthrosc
of the posterior tibial slope of the medial plateau between
males with and without ACL injuries was also reported by
Hohmann et al. [44]. As previously reported by other
authors [46, 74, 78], no significant differences in posterior
medial tibial slope between ACL-injured and control
groups were noted [44].
Recently, a retrospective investigation was performed to
determine the potential influence of the femoral neck-head
offset in the risk of ACL injuries [63]. The sample included
50 consecutive patients with primary ACL rupture and 50
consecutive patients with non-ACL injury (i.e. meniscus
tear, cartilage defect) [63]. The authors reported that male
patients with alpha-level angle over 60 were at a signifi-
cantly higher risk of ACL injury compared to male patients
with an alpha angle of 60 or less [63].
Finally, some aspects related to foot and ankle align-
ment were evaluated by Woodford-Rogers et al. [82]. The
authors compared the navicular drop (millimetre) and
calcaneal eversion in stance (degrees) of high school and
college male football players between the healthy limb of
non-contact ACL-injured and ACL-non-injured subjects.
They found no differences in navicular drop and calcaneal
eversion between injured and non-injured male football
players [82].
Knee laxity There were 2 studies reporting information
on the effects of knee laxity and generalized joint laxity on
the risk of ACL injuries. Both studies involved a total
sample of 767 individuals (28 American football players
and 739 military cadets).
Woodford-Rogers et al. [82] found that knee laxity (KT-
1000) of the uninvolved knee of subjects with an ACL
injury was increased relative to uninjured subjects. In
contrast, Uhorchak et al. [79] found no significant differ-
ences in specific knee laxity (KT-2000) between injured
and uninjured young male subjects. The authors also
reported that males with generalized joint laxity had a
relative risk of non-contact ACL injuries significantly
higher compared to subjects without generalized joint
laxity. They presented the relative risk of non-contact ACL
injuries in subjects with the combination of risk factors: the
risk of injury was significantly higher in subjects with
narrow notch width associated to generalized joint laxity
and specific knee laxity.
Neuromuscular risk factors
There was only 1 study included in this section. Uhorchak
et al. [79] reported a prospective investigation evaluating
several potential risk factors for non-contact ACL injuries
in a sample of 739 young male West Point cadets from the
United States Military Academy. Among other parameters,
the authors assessed the concentric and eccentric isokinetic
Knee Surg Sports Traumatol Arthrosc
strength of the knee extensors and flexors at 60 deg/sec
[79]. They observed no significant differences in quadri-
ceps and hamstrings strength, in either concentric or
eccentric muscle contractions, between non-contact ACL-
injured and non-injured males [79].
Biomechanical risk factors
The evidence found for biomechanical risk factors for ACL
injuries in male athletes was related to trunk and hip. Only 4
studies were found, which investigated the role of hip range
of motion (1 study), trunk and hip position (2 studies), and
trunk proprioception (1 study) on the risk of injury.
Trunk The investigation on the influence of trunk bio-
mechanics on the risk of ACL injuries in male athletes has
been reported in 3 studies. These studies involved a total
sample of 177 subjects from several types of sports (results
not specified by sport).
Zazulak et al. [85] reported a prospective biomechani-
cal-epidemiological prognosis study aimed to investigate
the influence of deficits in neuromuscular control of the
trunk to predict knee injury. Male athletes were tested for
trunk displacement after sudden force release and followed
for 3 years. Of the 137 male athletes initially evaluated, 14
male had knee injuries but there were only 2 ACL injuries.
The authors found no significant associations in maximal
trunk displacement (lateral, extension, and flexion trunk
displacement) between ACL-injured and uninjured males.
[85]. In a parallel publication, the same group found that
there were no significant differences in average error of
active proprioceptive repositioning of the trunk between
ACL-injured and ACL-uninjured male athletes [86].
In a recent publication, a case–control study was per-
formed that aimed to assess dynamic sagittal plane trunk
control during ACL injuries [71]. The authors conducted a
video analysis that compared movie captures of 20 athletes
performing a one-legged landing manoeuvre that resulted
in a torn ACL with matched movie captures of 20 athletes
performing a similar manoeuvre that did not result in an
ACL disruption (controls) [71]. They measured the dis-
tance of the centre of mass to base of support (normalized
by femur length) and measured the limb and trunk angles.
The trunk angle was defined as the angle from the vertical
to the centre line of the trunk [71]. The limb angle was
defined as the angle between the vertical and the thigh
(represented as the line from the centre of the knee joint to
the centre of the hip joint) [71]. A positive trunk and/or
limb angle indicated that the trunk and/or limb was rotated
anteriorly relative to the vertical [71]. ACL-injured males
had higher centre of mass to base of support distance and
limb angle, and lower trunk ankle, compared to uninjured
subjects. Essentially, injured subjects landed with a more
erect trunk and with more hip flexion when compared to
uninjured subjects.
Hip There was only 1 study included in this section. Gomes
et al. [34] investigated the association between hip range of
motion and non-contact ACL injuries in a case–control study
involving 100 male non-professional soccer players. Hip
range of motion was assessed in a supine position and with 908
of both hip and knee flexion. Findings were analysed
according to 2 cut-off points (70 and 80 of total internal-
external rotation sum) [34]. After adjusting for age, the
authors found reduced hip range of motion in injured com-
pared to control athletes, especially for internal rotation. Also,
there were significantly more subjects with\70 and\80 of
total internal-external hip rotation sum in the non-contact
ACL-injured group compared to the non-injured group [34].
Discussion
The principal findings of this systematic review related to
the risk factors for ACL injury in male athletes are: (1)
most of the evidence is related to environmental and ana-
tomical risk factors; (2) dry weather conditions may
increase the risk of non-contact ACL injuries in male
athletes; (3) artificial turf may increase the risk of non-
contact ACL injuries in male athletes; (4) higher posterior
tibial slope of the lateral tibial plateau may increase the risk
of non-contact ACL injuries in male athletes; and (5) there
is a lack of evidence regarding neuromuscular and bio-
mechanical risk factors for male athletes. The investigation
of both factors in relation to the risk of ACL injuries is an
area wide open for exploration in the future years.
The number of studies available in the literature evalu-
ating risk factors for ACL injuries in male athletes is much
lower compared to what is published for female athletes [3,
17, 38, 42, 65, 68]. Moreover, several of the reviewed
studies were not focused to compare injured and uninjured
male athletes, but to compare females vs. males for some
specific parameter [12, 26, 27, 63, 76, 85, 86]. These
studies were included because specific comparisons
between injured and uninjured males were also provided,
but it can be concluded that the investigation of risk factors
for ACL injuries in the male athlete has not awakened
much interest in the scientific community. Although the
risk of ACL injury is higher in the female athlete [3, 17, 38,
42, 65, 68], the relevance of the investigation of these
factors in males is important given the high overall number
of male athlete participants [33]. There are many studies
investigating neuromuscular and biomechanical risk factors
in males, but the data are limited which include ACL injury
as an outcome. Therefore, these studies could not be
included in this review because clear conclusions on the
123

influence of these factors on the risk of ACL injuries in
males cannot be drawn [2, 7–9, 13, 14, 16, 20, 21, 25, 28,
29, 47, 50, 64, 75, 81, 83, 84]. Prospective coupled bio-
mechanical-epidemiological data are even more spars in
male athletes. Including only those studies comparing
either prospectively or retrospectively injured and unin-
jured males, the evidence is much more limited, and has
been summarized in Table 3. As shown, most of the
included studies belong to environmental and anatomical
risk factors. Although neuromuscular and biomechanical
risk factors offer the greatest potential to support injury
prevention and likely provide a significant contribution to
risk, there is limited evidence available on these related
risk factors in males at this point. Interestingly, biome-
chanical risk factors have strong evidence for their rela-
tionships to ACL injury risk in female athletes [43, 85], and
these risk factors appear interrelated [41].
The investigation on the influence of environmental risk
factors for non-contact ACL injuries in male athletes may
have some limitations which include potential confounding
factors for weather conditions (type of surface itself, type of
shoe, biomechanical or neuromuscular risk factors), lack of
control for weather conditions where injuries did not occur,
differing type of activity (games or practice) played in
different type of surface (natural grass vs. artificial turf),
limited number of ACL injuries observed, or the inclusion
of both contact and non-contact ACL injuries [22, 23, 30,
62, 69, 70]. It is important to consider in the investigations
that included contact injuries in their analyses may have
limited relevance relative to measurement of injury risk
reduction from training. With contact injuries, the influence
of potential risk factors may be hidden because an external
load from other players likely has limited potential to be
effected by neuromuscular training aimed to prevent injury
[59]. It would be, therefore, mandatory to include this
information in any study dealing with risk factors or
preventive strategies for ACL injuries in male athletes.
However, only 14 of 33 studies reported the results for non-
contact ACL injuries (Table 2). Cumulatively, there does
not appear to be consensus regarding the effects of extrinsic
factors on ACL injury risk in male athletes. In addition, the
extent to which these factors can be modified is limited
which supports future investigations focused on risk
reduction based on intrinsic risk factors, specifically mod-
ifiable causative factors for ACL injury in male athletes.
Anatomical risk factors for ACL injury in male athletes
may have the limitation of potential influence of other non-
controlled associated risk factors. Cases and controls are
often not matched for height, weight, and type of activities
at risk of non-contact ACL injury [39, 44]. Another con-
cern is the type of control ‘‘data’’ employed for the com-
parison with injured subjects [82]. In general, how
anatomical factors modify knee kinetics and kinematics are
123
Knee Surg Sports Traumatol Arthrosc
not well understood. Overall, the study of the influence of
anatomical factors on the risk of non-contact ACL injuries
in males clearly needs more research, especially in athletes.
However, the potential for their modification via injury
prevention strategies is limited. The main interest of their
identification in an athlete would be to know those indi-
viduals in whom prevention programmes take even more
relevance to avoid ACL injury. Therefore, in athletes with
anatomical risk factors, prevention programmes empha-
sizing modification of neuromuscular and biomechanical
risk factors would be even more relevant to reduce injury
risk in male athletes.
As evidenced above, there is only 1 study pertaining to
neuromuscular control (level II evidence) [79]. Therefore,
there is not enough evidence to elaborate strong conclu-
sions on the influence of the neuromuscular system on non-
contact ACL injuries in male athletes. With respect to the
biomechanical risk factors category, the included studies
may have some limitations: low number of ACL injuries
observed, a mismatch between the time of injury and time
when the mechanism was assessed, difficulties at identi-
fying anatomical landmarks in clothed participants, and the
potential of a selection bias as the inclusion criteria were
based on a qualitative analysis [71, 85, 86]. Although there
is more information available for biomechanical compared
to neuromuscular risk factors (Table 3), this information is
still based on a low number of studies, therefore strong
conclusions can neither be elaborated.
Further research is clearly needed for neuromuscular and
biomechanical risk factors for non-contact ACL injuries in
male athletes. Some areas to be developed in the near future
regarding risk factors for non-contact ACL injury in males
are the comparison of injured and uninjured subjects for:
joint angles and moments during different playing actions
(landing, sidestep cutting, stop jump, etc.), muscle activa-
tion and recruitment patterns, muscle fatigue differences,
and trunk neuromuscular control, among others. Currently,
there is no clear explanation or robust model that consis-
tently demonstrates how all of the risk factors interact
because a reductionistic model does not consider the inter-
relationships and synergic interaction between them.
There are some potential limitations to this systematic
review. First, some studies may have been missed from the
current literature search. However, the employment of 3
databases and the thorough review of obtained references,
including a full-text reading of the most important refer-
ences, and the careful double-check of cited studies mini-
mized the risk. Second, many studies with the absence of
significance in the principal comparisons had a low number
of cases (ACL-injured males), so the risk of type-II error is
not negligible. Third, non-prospective studies may have a
high risk of bias, especially for those modifiable factors.
Case–control studies retrospectively look at some
Knee Surg Sports Traumatol Arthrosc
characteristics after cases (ACL-injured males) have been
identified. If the studied factors may be modified with time,
this comparison may be biased by the fact that the injury
elicited some changes in the knee. This is not the case for
most of the anatomical risk factors, but would be clearly
the case for neuromuscular and biomechanical risk factors.
In the latter, it is very important that adequate prospective
cohort studies are designed to assure confident conclusions,
controlling or adjusting the analysis for as much other risk
factors as possible. These types of studies would provide
the best causal-effect relationship between the factor and
the risk of non-contact ACL injuries.
Conclusions
The results of this systematic review indicate that ACL
injury in male athletes likely has a multi-factorial aetiol-
ogy. A thorough knowledge of these factors is crucial to
provide adequate prevention strategies aimed to decrease
the risk of this serious injury in the male athlete. The fol-
lowing conclusions may be elaborated regarding risk fac-
tors for non-contact ACL injuries.
• Most of the existing evidence is related to environ-
mental and anatomical risk factors for non-contact ACL
injuries.
• Dry weather conditions may increase the risk of non-
contact ACL injuries in male athletes.
• Artificial turf may increase the risk of non-contact ACL
injuries in male athletes compared to natural grass.
• Most of the studies of anatomical risk factors are not
specific for athletes.
• Higher posterior tibial slope of the lateral tibial plateau
may increase the risk of non-contact ACL injuries in
male athletes.
• The existing evidence for neuromuscular and biome-
chanical risk factors is low.
• The investigation of risk factors in male athletes,
especially neuromuscular and biomechanical, provides
possibility for future research.
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