49
Gender Issues in ACL Injury
Lori A. Bolgla, PT, PhD, MAcc, ATC
In 1972 the United States passed Title IX of the Educational
Act that mandates equal treatment of females in university-
level athletic programs. The passage of this act has fostered a
dramatic increase in the participation of females at all levels of
competition. With this change comes a significant increase in
the number of injuries sustained.
ACL INJURY IN THE FEMALE
ATHLETE
Overview
ACL injury represents one of the most serious knee injuries, with
annual costs for management exceeding $2 billion. Although
surgical reconstruction and rehabilitation significantly improve
the return to recreational and occupational activities, outcomes
from long-term studies suggest the eventual development of
knee osteoarthritis in many ACL-injured knees. The incidence
rate of ACL tears for female athletes ranges between 2.4 and
9.7 times their male counterparts competing in similar activ-
ities. Together, these findings have led researchers to identify
risk factors and develop prevention programs aimed at reducing
female ACL injuries.
More than 70% of all ACL injuries occur via a noncon-
tact mechanism during activities such as cutting and landing.
Evidence has shown that females perform these activities with
the knee positioned in maladaptive femoral adduction, femo-
ral internal rotation, and tibial external rotation (referred to as
dynamic valgus). These combined motions apply high valgus
loads onto the knee, which can lead to ACL injury (Fig. 49.1).
Another contributor to ACL injury is landing from a jump with
the knee in a minimally flexed position (rather than the more
desired flexed knee position). This position results in greater
quadriceps activation relative to the hamstrings, leading to
increased anterior tibial translation on the femur.
Of note, female athletes have been shown to perform athletic
maneuvers with maladaptive variation from their male coun-
terparts on landing including decreased knee and hip flexion,
increased quadriceps activation, and greater dynamic knee val-
gus angles and moments (Powers 2010).
Intrinsic and extrinsic factors (Box 49.1) may account for the
higher incidence of ACL injury in the female athlete. Intrin-
sic factors are anatomic or physiologic in nature and are not
amenable to change. Extrinsic factors are biomechanical or
neuromuscular in nature and are potentially modifiable. Clini-
cians have focused much attention on these extrinsic factors for
the development and implementation of ACL injury prevention
and rehabilitation programs.  vulnerable to ACL injury during running, cutting, and landing
Intrinsic Risk Factors
ACL injury commonly occurs with the knee positioned and
stressed close to full extension, causing an abutment of the ACL
326
within the intercondylar notch. Although a decreased intercon-
dylar notch size may contribute to ACL injury, data have not
supported a sex difference between intercondylar notch size and
ACL injury. Instead, individuals with a smaller intercondylar
notch appear to be more susceptible to ACL injury, regardless
of sex.
Recent attention has focused on ligament stiffness. Hash-
emi et al. (2008) reported that the ACL from female cadavers
exhibited a decrease in length, cross-sectional area, and volume
compared to males. They concluded that inherent ligament
weakness, in combination with a smaller intercondylar notch
size, might contribute to the ACL injury gender bias.
Physiologic laxity (e.g., general joint laxity and ligamentous
laxity) represents another intrinsic factor. Because the ACL pri-
marily limits excessive anterior tibial translation relative to the
femur, injury can occur when joint movement exceeds ligamen-
tous strength. Uhorchak et al. (2003) have reported that females
with physiologic laxity have a 2.7 times higher risk for sustain-
ing an ACL injury.
Finally, increased estrogen levels during the ovulatory and
luteal phases of the menstrual cycle may increase ACL laxity,
making the female athlete more prone to injury. To date, prior
works have not shown a strong association between hormone
fluctuations and ACL injury. The reader should note that prior
works have used small sample sizes and relied on subjective his-
tories to determine the phase of the menstrual cycle when an
injury occurred. Additional investigations are needed to better
understand this influence. 
Extrinsic Risk Factors
Extrinsic factors include biomechanical (e.g., kinematics and
kinetics) and neuromuscular (e.g., muscle strength, endurance,
and activation) characteristics. Unlike intrinsic factors, clini-
cians can modify these factors with interventions, providing
the basis for many ACL injury prevention and rehabilitation
programs.
As mentioned previously, dynamic knee valgus applies high
loads onto the ACL that can cause injury. During the past 10
years, researchers have ascertained that female athletes perform
higher demanding activities in positions making them more
vulnerable to ACL injury. It is important to note that struc-
tures both proximal and distal to the knee can influence ACL
loading. Ireland (1999) described the position of no return to
explain gender differences regarding trunk and lower extrem-
ity kinematics and muscle activity (Fig. 49.2). The following
summarizes extrinsic factors making the female athlete more
tasks:
• Overwhelming data infer that females perform these tasks
(e.g., landing) with increased dynamic knee valgus from
femoral internal rotation, femoral adduction, and tibial ex-
ternal rotation (Fig. 49.10, A).
 49  Gender Issues in ACL Injury 327

1 2 3
A B

C
Fig. 49.1  A, Dynamic knee valgus resulting from excessive hip adduction and internal rotation after landing from a box jump. Because the foot
is fixed to the floor, excessive frontal and transverse plane motion at the hip can cause medial motion of the knee joint, tibia abduction, and foot
pronation. B, Frontal plane motions of the pelvis and trunk can influence the moment at the knee. This example illustrates landing from a jump on
one foot. (1) With the pelvis level, the resultant ground reaction force vector passes medial to the knee joint center, thereby creating a varus mo-
ment at the knee. (2) Hip abductor weakness can cause a contralateral pelvic drop and a shift in the center of mass away from the stance limb. This
increases the varus moment at the knee (i.e., the perpendicular distance from the resultant ground reaction force vector and the knee joint center
increases). (3) Shifting the center of mass over the stance limb to compensate for hip abductor weakness can create knee valgus moment (i.e., the
ground reaction force vector passes lateral with respect to the knee joint center). In this scenario, medial movement of the knee joint center (i.e.,
valgus collapse) exacerbates the problem. C, Low-risk and high-risk landings. The figure on the left shows a high-risk participant where the patella
has moved inward and ended up medial to the first toe. The figure on the right shoes a low-risk participant where the patella has remained inward
in line with the first toe.

BOX 49.1  ACL INJURY IN THE FEMALE ATHLETE

INTRINSIC FACTORS ASSOCIATED WITH FEMALE ACL INJURY EXTRINSIC FACTORS ASSOCIATED WITH FEMALE ACL INJURY
Intercondylar notch size Kinematics
ACL size Kinetics
Physiologic laxity (generalized joint and ligamentous) Muscle strength
Hormonal fluctuations  Muscle endurance
Muscle activation
328 SECTION 5  Knee Injuries

Position of safety Position of no return

Muscle Muscle
activity Body alignment Body alignment activity
Back Normal lordosis Forward flexed,
rotated opposite side
Flexed
Hips Adduction
Neutral abduction/adduction
Internal rotation Flexors
Neutral rotation
Extensors Adductors
Abductors Iliopsoas
Gluteals

Knee Extensors
Flexors Flexed Less flexed, Quadriceps
Hamstrings valgus

Tibial Plantar Neutral External Dorsiflexors

rotation Flexors
Landing Both feet One foot
Gastrocnemius control out of control Peroneals
pattern
Posterior tibialis Balanced Unbalanced
Tibialis anterior

POSITION POSITION
OF SAFETY OF NO RETURN

Neutral Head Forward

Neck

Hyperlordotic

Neutral Lumbar
Spine Anteriorly
rotated
Neutral Pelvis

Femur

Knee

B
Fig. 49.2  A, Position of no return. (Copyright 2000 Mary Lloyd Ireland, MD.) B, In the “position of no return” (i.e., the high-risk position), the head
is forward, the lumbar spine is hyperlordotic, and the pelvis is anteriorly rotated. Internal rotation at the relatively straight knee and subsequent tibial
external rotation and foot pronation are also seen. The safe position shown on the left is more neutral and more flexed. (Reprinted with permission
from Ireland M. The Female Athlete. Philadelphia, Saunders, 2002. Fig. 43-4.)
 49  Gender Issues in ACL Injury 329

• Females utilize greater quadriceps activation relative to the

hamstrings. This muscle imbalance can lead to excessive tib-
ial anterior translation, especially with the knee positioned
close to full extension.
• Females tend to activate the quadriceps more than other
muscle groups such as the hip extensors and ankle plantar
flexors. Muscle activation throughout the entire lower ex-
tremity can dampen applied ground reaction forces and re-
duce valgus knee loading.
• Females with evident hip musculature weakness perform de-
manding tasks with increased dynamic valgus. The amount
of dynamic valgus exhibited during demanding tasks further
increases with the onset of gluteus medius fatigue.
• Preliminary evidence infers decreased trunk neuromuscular
control as a predictor of ACL injury. 

ACL INJURY PREVENTION AND

REHABILITATION PROGRAMS IN
FEMALE ATHLETES
Identification of these extrinsic factors thought to contribute 1 2
to ACL injury in the female athlete has provided the basis for
the development and implementation of ACL injury prevention 3 4
and rehabilitation programs. These programs typically include
strengthening and neuromuscular training in combination with
instruction on proper lower extremity alignment during cut-
Fig. 49.3  Cross hops. The athlete faces a quadrant pattern and stands
ting and landing tasks. Preliminary data have shown promis- on a single limb with the support knee slightly bent. She hops diago-
ing results for the effectiveness of these programs for preventing nally, lands in the opposite quadrant, maintains forward stance, and
ACL injury in high school and collegiate-level female athletes. holds the deep knee flexion landing for 3 seconds. She then hops later-
ACL injury prevention programs should incorporate ally into the side quadrant and again holds the landing. Next she hops
strengthening and neuromuscular training for the knee, hip, diagonally backward and holds the jump. Finally, she hops laterally into
the initial quadrant and holds the landing. She repeats this pattern for
and trunk muscles on both stable and unstable surfaces (Figs. the required number of sets. Encourage the athlete to maintain balance
49.3 through 49.6). The athlete should perform all plyometric- during each landing, keeping her eyes up and the visual focus away
type exercises with the knees in a more varus, flexed position from her feet. (Reprinted with permission from Myer G, Ford K, Hewett
to reduce valgus loading and facilitate quadriceps/hamstring T. Rationale and clinical techniques for anterior cruciate ligament injury
prevention among female athletes. J Athl Train 39(4):361, 2004.)
co-contraction (Fig. 49.7). Sport-specific drills that empha-
size proper lower extremity alignment are another important
consideration (Figs. 49.8 and 49.9). Throughout the process,
the clinician should provide the athlete with continual feed-
back regarding proper technique when performing cutting and
landing activities. The female athlete should practice proper
deceleration techniques during cutting maneuvers, with a spe-
cial emphasis on the avoidance of pivoting on a fixed foot. She
should perform landing activities with an emphasis on keeping
the knees over the toes (to minimize knee valgus) and landing
as softly as possible using increased knee flexion (to dampen
ground reaction forces).
An important aspect of rehabilitation prior to ACL recon-
struction is the restoration of knee ROM and strength. Although
quadriceps strengthening is an important component, Hartigan
et  al. (2009) reported on the importance of preoperative per-
turbation training on ACL reconstruction outcomes (see page
219). Perturbation training is a neuromuscular training pro-
gram aimed at improving dynamic knee stability (Box 49.2).
Fig. 49.4  Single-leg balance. The balance drills are performed on a
Regarding postoperative ACL rehabilitation, clinicians balance device that provides an unstable surface. The athlete begins on
should continue to follow protocols that emphasize symmet- the device with a two-legged stance with feet shoulder-width apart, in
ric knee ROM, gait normalization, and controlled weightbear- athletic position. As she improves, the training drills can incorporate ball
ing exercises. Other considerations include hip strengthening catches and single-leg balance drills. Encourage the athlete to maintain
deep knee flexion when performing all balance drills. (Reprinted with
exercises (Table 49.1). The clinician also should incorporate permission from Myer G, Ford K, Hewett T. Rationale and clinical tech-
neuromuscular retraining as indicated throughout the reha- niques for anterior cruciate ligament injury prevention among female
bilitation process through use of single-leg stance exercises athletes. J Athl Train 39(4):361, 2004.)
330 SECTION 5  Knee Injuries
Fig. 49.5  Bounding. The athlete begins this jump by bounding in
place. Once she attains proper rhythm and form, encourage her to
maintain the vertical component of the bound while adding some hori-
zontal distance to each jump. The progression of jumps advances the
athlete across the training area. When coaching this jump, encourage
the athlete to maintain maximum bounding height. (Reprinted with
permission from Myer G, Ford K, Hewett T. Rationale and clinical tech-
niques for anterior cruciate ligament injury prevention among female
athletes. J Athl Train 39(4):361, 2004.)
Fig. 49.6  Jump, jump, jump, vertical jump. The athlete performs three
successive broad jumps and immediately progresses into a maximum-
effort vertical jump. The three consecutive broad jumps should be per-
formed as quickly as possible and attain maximal horizontal distance.
The third broad jump should be used as a preparatory jump that will
allow horizontal momentum to be quickly and efficiently transferred
into vertical power. Encourage the athlete to provide minimal braking
on the third and final broad jump to ensure that maximum energy is
transferred to the vertical jump. Coach the athlete to go directly vertical
on the fourth jump and not move horizontally. Use full arm extension
to achieve maximum vertical height. (Reprinted with permission from
Myer G, Ford K, Hewett T. Rationale and clinical techniques for anterior
cruciate ligament injury prevention among female athletes. J Athl Train
39(4):361, 2004.)
Fig. 49.7  The athletic position is a functionally stable position with
the knees comfortably flexed, shoulders back, eyes up, feet approxi-
mately shoulder-width apart, and body mass balanced over the balls of
the feet. The knees should be over the balls of the feet and the chest
over the knees. This athlete-ready position is the starting and finishing
position for most of the training exercises. During some exercises, the
finishing position is exaggerated with deeper knee flexion to emphasize
the correction of certain biomechanical deficiencies. (Reprinted with
permission from Myer G, Ford K, Hewett T. Rationale and clinical tech-
niques for anterior cruciate ligament injury prevention among female
athletes. J Athl Train 39(4):361, 2004.)
Fig. 49.8  The 180-degree jump. The starting position is standing erect
with feet shoulder-width apart. The athlete initiates this two-footed
jump with a direct vertical motion combined with a 180-degree rota-
tion in midair, keeping her arms away from her sides to help maintain
balance. When she lands, she immediately reverses this jump into the
opposite direction. She repeats until perfect technique fails. The goal of
this jump is to achieve maximal height with a full 180-degree rotation.
Encourage the athlete to maintain exact foot position on the floor by
jumping and landing in the same footprint. (Reprinted with permission
from Myer G, Ford K, Hewett T. Rationale and clinical techniques for
anterior cruciate ligament injury prevention among female athletes. J
Athl Train 39(4):361, 2004.)
 49  Gender Issues in ACL Injury 331

Theraband

A Bridge resistance

Fig. 49.9  Single-leg hop and hold. The starting position is a semi­
crouched position on a single leg. The athlete’s arm should be fully ex-
tended behind her at the shoulder. She initiates the jump by swinging
the arms forward while simultaneously extending at the hip and knee.
The jump should carry the athlete up at an angle of approximately 45
degrees and attain maximal distance for a single-leg landing. She is in-
structed to land on the jumping leg with deep knee flexion (to 90 de-
grees) and to hold the landing for at least 3 seconds. Coach this jump
with care to protect the athlete from injury. Start her with a submaximal
effort on the single-leg broad jump so she can experience the level of
difficulty. Continue to increase the distance of the broad hop as the ath- B Clam resistance
lete improves her ability to “stick” and hold the final landing. Have the
athlete keep her visual focus away from her feet to help prevent too Fig. 49.10  A, Bridge with Theraband resistance. B, Hip strengthening
much forward lean at the waist. (Reprinted with permission from Myer G, with clam and Theraband resistance.
Ford K, Hewett T. Rationale and clinical techniques for anterior cruciate
ligament injury prevention among female athletes. J Athl Train 39(4):361,
2004.) with a progression toward perturbation training. Later stages
of rehabilitation should include plyometric-type exercises and
sport-specific drills similar to those used in ACL injury preven-
BOX 49.2 ACL INJURY: PREVENTION AND
tion programs. As with ACL injury prevention programs, the
REHABILITATION PROGRAMS clinician should provide the athlete with continuous feedback
regarding proper technique when performing cutting and land-
COMPONENTS OF A PERTURBATION TRAINING PROGRAM ing tasks.
• Double-limb to single-limb stance on moveable surfaces (e.g.,
tilt board with progression to roller board)
• Variable direction of applied perturbations to the moving sur-
Anterior Cruciate Ligament
face (e.g., anterior–posterior and medial–lateral directions) Reconstruction With Meniscal Repair
• Variable speed of applied perturbations to the moving surface
• Variable duration of applied perturbations to the moving sur- A lack of firm basic science and prospective outcome studies
face ranging from 1 to 5 seconds has resulted in a wide array of opinions regarding issues such
• Bout of exercise ranging from 1 to 1.5 minutes each as immobilization, ROM restrictions, and weightbearing status
Progression to roller board/stationary platform exercise (Patient
stands with the affected limb on a roller board and the unaffected after meniscal repair combined with ACL reconstruction. An
limb on a stationary platform of equal height. The clinician applies accelerated return to activities, with immediate weight bearing
perturbations to the roller board. The patient repeats the exercise and no ROM limitations in the early postoperative period, has
with the unaffected limb on the moving surface and the affected had results similar to those with more conservative rehabilita-
limb on the stationary platform.) (Fig. 49.10)
tion programs. We have found little justification for modify-
(Adapted from Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy
ing the standard rehabilitation protocol after meniscal repair
of perturbation training in nonoperative anterior cruciate ligament done with ACL reconstruction.
rehabilitation programs for physically active individuals. Phys Ther
80:128–140, 2000.)
332 SECTION 5  Knee Injuries

TABLE
Hip-Strengthening Exercises for ACL Rehabilitation (and Patellofemoral Rehabilitation) in Female Patients:
49.1 An Evidence-Based Approach for the Development and Implementation of a Progressive Gluteal Muscle
Strengthening Program

Lori A. Bolgla, PT, PhD, ATC

MUSCLE ACTIVATION*
Exercise Description Gluteus Maximus (%) Gluteus Medius (%)
Nonweightbearing Patient stands solely on the unaffected lower extremity and abducts N/A 33
standing hip the affected hip, keeping the pelvis in a level position.
abduction
Side-lying hip Patient positioned in side lying with the hips and knees in 0 degrees 39 42
abduction of flexion (unaffected lower extremity against the table). Patient
(Fig. 49.10) abducts the affected hip.
Weightbearing Patient stands solely on the affected lower extremity and abducts the N/A 42
isometric hip unaffected hip, keeping the pelvis in a level position.
abduction
Bridges side- Patient positioned in side lying with the hips flexed to 60 degrees and 39 38
lying clam the knees flexed to 90 degrees (unaffected lower extremity against
(Fig. 49.11) the table). Patient abducts and externally rotates the affected hip
while keeping the feet together.
Bridges with TheraBand resistance
Forward lunge Patient stands with the lower extremities shoulder-width apart. The 44 42
(Fig. 49.12) patient lunges forward with the affected lower extremity (to ap-
proximately 90 degrees of knee flexion) while maintaining the
pelvis in a level position and the trunk in a vertical position.
Pelvic drop Patient stands on the affected lower extremity on a 15-cm high step N/A 57
(Fig. 49.13) with both knees fully extended. Patient lowers the pelvis of the
unaffected lower extremity toward the floor and then returns the
pelvis to a level position.
Side hops Patient stands with the lower extremities shoulder-width apart. The 30 57
patient hops forward off the unaffected lower extremity and lands
solely on the affected lower extremity.
Lateral band step- Patient stands with the lower extremities shoulder-width apart and 27 61
ping (Fig. 49.14) the hips and knees in 30 degrees of flexion with an elastic band
tied around the ankles. Patient steps sideways, leading with the
affected lower extremity while maintaining constant elastic band
tension.
Single-leg squat Patient stands solely on the affected lower extremity with the hip and 59 64
knee in 30 degrees of flexion. Patient lowers the body (keeping the
knee over the toes to minimize knee valgus) until the middle finger
on the opposite side touches the ground. The patient returns to
the starting position.

N/A = data not available

*Expressed as a percentage of a maximum voluntary isometric contraction
Adapted from Bolgla LA, Uhl TL: Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Phys Ther
35:487–494, 2005 and Distefano LJ, Blackburn JT, Marshall SW, Padua DA: Gluteal muscle activation during common therapeutic exercises. J
Orthop Sports Phys Ther 39:532–540, 2009.

Fig. 49.11  Straight leg raise abduction. Fig. 49.12  Forward lunge.
 49  Gender Issues in ACL Injury 333

REFERENCES
A complete reference list is available at https://expertconsult
.inkling.com/.

FURTHER READING
Aldrian S, Valentin P, Wondrasch B, et  al. Gender differences following
computer-navigated single- and double-bundle anterior cruciate ligament
reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013;22.9:2145–
2152. Web.
Lipps DB, Oh YK, Ashton-Miller JA, et  al. Morphologic characteristics help
explain the gender difference in peak anterior cruciate ligament strain dur-
ing a simulated pivot landing. The American Journal of Sports Medicine.
2011;40.1:32–40. Web.
Noonan, Benjamin, Wojtys Edward M. Gender differences in muscular protec-
tion of the knee. ACL Injuries in the Female Athlete. 2012:125–136. Web.
Noyes, Frank R, Barber-Westin, Sue D. ACL injuries in the female athlete:
causes, impacts, and conditioning programs. N.p.: n.p., n.d. Print.
Tohyama H, Kondo E, Hayashi R, et al. Gender-based differences in outcome
after anatomic double-bundle anterior cruciate ligament reconstruction
with hamstring tendon autografts. The American Journal of Sports Medicine.
2011;39.9:1849–1857. Web.
A B
Fig. 49.13  Pelvic drop. During the exercise, the subject keeps both
knees extended. The movement occurs by dropping the contralateral
pelvis downward and then returning the pelvis to a level position (both
lower extremities remain in an extended position). The subject uses
the ipsilateral hip abductors to adduct and abduct the pelvis on the
femur. Anatomically, the alignment of the subject on the right (B) shows
a straight-as-an-arrow hip over knee over ankle. The subject on the
left (A) demonstrates hip adduction and internal rotation with anteri-
orly rotated pelvis, excessive genu valgum, and external tibial rotation
and subsequent pronation of the foot. (Reprinted with permission from
Ireland M. The Female Athlete. Philadelphia, Saunders, 2002, p. 518,
Fig. 43-2.)

Fig. 49.14  Lateral band stepping, “monster walk.”

Check online video: Side-lying Clam (Video 49.1).

REFERENCES
Hartigan E, Axe MJ, Snyder-Mackler L. Perturbation training prior to ACL
reconstruction improves gait asymmetries in non-copers. J Orthop Res.
2009;27(6):724–729.
Hashemi J, Chandrashekar N, Mansouri H, et al. The human anterior cruciate
ligament: sex differences in ultrastructure and correlation with biomechani-
cal properties. J Orthop Res. 2008;26:945–950. 18302253.
Ireland ML. Anterior cruciate ligament injury in female athletes: epidemiology.
J Athl Train. 1999;34(2):150–154.
Uhorchak JM, Scoville CR, Williams GN, et  al. Risk factors associated with
noncontact injury of the anterior cruciate ligament: a prospective four-year
evaluation of 859 West Point cadets. Am J Sports Med. 2003;31:831–842.
14623646.
Powers CM. The influence of abnormal hip mechanics on knee injury: a biome-
chanical perspective. J Orthop Sports Phys Ther. 2010;40(2):42–51. 20118526.
333.e1