Annotated Source List

ACL Injuries in Women. (n.d.). Steward Orthopedic & Sports Medicine. Retrieved
November 22, 2020, from http://www.utahorthopediccenters.com/knee/
acl-injuries-in-women/ #:~:text=In%20the%20knee%2C%20an%20intercondylar,a%2
smaller%20notch%20than%20males.

Summary
This article explains how women are more prone to ACL injuries. The article states,
“ACL injuries are ten times more frequent in females than males” due to a woman's anatomy,
hormones, bone alignment, flexibility and muscle strength. One control discussed is that the
intercondylar space in a woman's knee is significantly smaller. This space “sits in the middle of
the two rounded ends of the femur” and holds the Anterior Cruciate Ligament in between. The
ACL moves between the femur and tibia, and gives “the knee stability.” Because a women’s
space is smaller, the ACL “gets pinched by the femur as the knee straightens and bends,
particularly while twisting or doing hyperextension movement.”

Application to Research
This article can be used to explain the significance of the intercondylar space in its role
in the frequency of ACL tear.

Anterior cruciate ligament (ACL) injury. (n.d.). University of Florida Health.

https://ufhealth.org/anterior-cruciate-ligament-acl-injury

Summary:
This website article explains what an ACL tear is and its causes along with the
anatomy of a knee, prevention of tears and what to do if the ligament is torn. The anterior
cruciate ligament sits in the middle of the knee and prevents the tibia (shin) from sliding to far.
The ligament can be torn if one gets hit really hard on the side of the knee, a quick change of
movements or abrupt stopping and an overextension of the knee. These types of injuries do not
heal on their own and require a reconstruction surgery. If an injury to an ACL occurs, one must
stop play and RICE (rest, ice, compression and elevate) the injured area. However, to prevent
this injury, one should stretch well before any sort of vigorous activity and learn to put less
weight on their ACL.

Application to Research:
This source can be used to explain what an ACL injury is and how it applies to my
research topic.
Anderson, A. F., Lipscomb, B., Liudahl, K. J., & Addlestone, R. B. (1987).
Analysis of the intercondylar notch by computed tomography. American
Journal of Sports Medicine, 15(6). https://doi.org/10.1177/
036354658701500605

Summary
This journal article compares the intercondylar notches of healthy knees to knees with
unilateral and bilateral ACL tears to decipher a correlation between both. All patients were
scanned and were tested for ligamentous laxity. It was noted that there is a general correlation
between laxity and ligament tears including ACL tears.

Application to Research
Can be used to explain some catalysts for ACL injuries.

Becker, R. (2020, December 3). [Telephone interview by R. Nayfeh].

Summary
This interview was for the purpose of filling in gaps within my research. There is a
general trend of a smaller body habitus seen in females that plays into why their intercondylar
spaces may be smaller. With a smaller notch there is an increase in ACL stress and less laxity.
It may also be fixated tighter onto the femur, giving it less space and laxity to stress.

Application to Research
This source will be used as background information and an explanation towards my
thesis.

Chan, J. (2007, March 15). All Knees Are Not Created Equal. University of South
California News. Retrieved October 3, 2020, from https://news.usc.edu/19138/
All-Knees-Are-Not-Created-Equal/

Summary:
This website article explains how a woman's knee is different from a man’s knee. It is
known that women tend to live longer than men, causing them to have “more joint wear.”
However, after increasing knee replacements, doctors including Donald Longjohn, assistant
professor of orthopaedic surgery at the Keck School of Medicine of USC,
realised that “the size and shape of the female knee bones, including the femur, tibia and
patella, are significantly different from men.” Longjohn also stated, “Female knees are thinner
and have a slight difference in angle between the femur and tibia than male knees, so the
gender-specific knee ensures precise articulation that allows for a more natural movement,”
Longjohn said. Thus, a new knee implant was created to be more gender specific: the ML
(medial-lateral) dimension is smaller in the female knee. It’s also thinner to eliminate
bulkiness, allows for more free movement, and a shape specifically contoured to the shape of a
female knee.

Application to Research:
This article can be used to explain how a female’s knee is different from a male’s knee
and how doctor’s have accommodated their procedures to receive the best outcomes.

Charlton,, W. P.H., St. John, T. A., Ciccotti, M. G., Harrison, N., &
Schweitzer, M. (2002). Differences in Femoral Notch Anatomy between Men and
Women. The American Journal of Sports Medicine, 30(3). https://doi.org/
10.1177/03635465020300030501

Summary
This journal article discusses a study conducted by a group of doctors. The study
focuses on the differences of the intercondylar notch in women and men. They found that “men
were found to have significantly larger femoral notch volumes than women (men, 6047 mm3 ;
women, 4330 mm3 ; P 0.001).” They also found that height and weight are variables in the
size of the intercondylar notch: taller and heavier people tend to have a much larger notch than
those of shorter and lighter people. The article states, “[m]en had larger notch volumes because
men were, on the whole, larger in size” and that “[m]en had a significantly larger ACL volume
than women (men, 839 mm3 ; women, 652 mm3 ; P 0.016).” Ultimately, there is a significant
correlation between intercondylar notch volume and ACL volume.

Application to Research
Can be used to explain the differences in intercondylar notches in a man and woman.

Cluett, J. (2020, September 30). ACL Tears More Common in Women and Girls. Very
Well Health.

Summary:
This website article explains why females are more likely to get ACL tears. Females
are “two to eight times higher [to tear their ACLs] than in male counterparts.” The type of sport
that a female athlete participates in plays a role in her likelihood to tear her ACL. However,
female anatomy and endocrinology play a larger role. Women have different pelvis widths,
Q-angles, sizes of their ACLs and a smaller intercondylar notch compared to that of a male.
Unfortunately, these differences are not studied. Further, ACLs have estrogen and progesterone
receptors, but researchers have found that an increase in hormone concentration has a slight
effect. Next, women have different knee movement when doing activities like pivoting,
jumping and landing-- all are activities where a tear of the ligament is very common. When
women land after a jump, they tend to land with their knees straight, making their knees absorb
the majority of the impact. In contrast, when men land, their knees are bent and the energy is
absorbed equally. Lastly, women have an increased Valgus angle of their knees and their
movements of their extremities put more stress on the knee ligaments.

Application to Research:
This information can be used to support why women are more prone to ACL injuries. It
also explains in further detail why biomechanical movements of females are different and how
it plays a role in their likelihood of an injury.

Gottsegen, C. J., Eyer, B. A., White, E. A., Learch, T. J., & Forrester, D.
(n.d.). Avulsion Fractures of the Knee: Imaging Findings and Clinical
Significance. RadioGraphics.

Summary
This journal article goes in detail about the different indicators of an ACL injury.
There are a “variety of avulsion fractures” that can occur. However most importantly are the
“segond and reverse segond fractures.” When an ACL is torn the tibia moves backwards 2 mm
(Segond) or 2 mm forwards (Reverse Segond). Furthermore, ACL Avulsion fractures are also
evident. It causes an appearance of a “tiny bone fragment in the intercondylar notch.” An MRI
makes this osseous fragment more visible.

Application to Research
I will use this article to explain how to view an ACL tear on an MRI and how to
identify ACL associates.

Hirst, S. E., Armeau, E., & Parish, T. (n.d.). Recognizing Anterior Cruciate
Ligament Tears in Female Athletes: What Every Primary Care Practitioner
Should Know. The Internet Journal of Allied Health Sciences and Practices,
5(1).

Summary
This journal article cites controls as to why females may be more likely to tear their
ACLs. It was found that women have smaller intercondylar notch width in comparison to men
and a “smaller, narrower posterior notch might predispose a person to an ACL injury.” A
woman upon flexion, their ACL comes into contact with their “medial margin of the lateral
femoral condyle and upon extension the ACL impinges on the anterior intercondylar notch.” A
study was conducted with “714 patients who underwent ACL construction.” Their notches
were measured by taking a weight bearing posteroanterior radiograph. The study concluded
that patients who tore their ACLs had narrower intercondylar notches than those who did not
tear their ACL. It was also found that there is a significant correlation between “notch stenosis
and ACL injuries.”

Application to Research
Further explain differences and reasons the width contributes to a tear.

Hirtler, L., Sebastian, S., & Franz, F. (n.d.). The Femoral Intercondylar Notch
During Life: An Anatomic Redefinition With Patterns Predisposing to
Cruciate Ligament Impingement Read More: https://www.ajronline.org/doi/full/
10.2214/AJR.16.16015. American Journal of Roentgenology.
https://www.ajronline.org/doi/full/10.2214/AJR.16.16015

Summary
This journal excerpt explains the findings of a study conducted. The study includes
“329 participants” that were “divided into six age groups.” The study specifically focuses on
the intercondylar notch through the lens of an MRI. The findings state that there are three
shapes that an a notch can take: An A shape, an inverse U and a Ω shape. Younger patients tend
to have an A shape, but due to the changing nature of the notch, most end up with a Ω shape
later in life. Further, the study suggests that there is a greater vulnerability for an ACL rupture
in narrower notches. These narrow notches are mainly found in women. The article states, “[i]n
male subjects, the following diameters were larger:” the bicondylar widths, lateral condylar
widths, medial condylar and notch widths. Females were also found to have a higher
probability of Ω shape notches.

Application to Research
This can be used to explain the differences of a female’s knee versus a male’s knee.

Ireland, M. L., Ballantyne, B. T., Little, K., & McClay, I. S. (2001). A

radiographic analysis of the relationship between the size and shape of the
intercondylar notch and anterior cruciate ligament injury. Knee Surgery,
Sports Traumatology, Arthroscopy, 9, 200-205. https://doi.org/10.1007/
s001670100197

Summary
This journal article explains the differences in shape and size of the intercondylar
space in correlation with ACL injuries. The study mentioned in the article showed that the
differences of knee shape does not necessarily correlate with gender. A smaller intercondylar
space is seen in knees with an A-shape; a smaller space does increase the likelihood of an
injury. It was also noted that women tear their ACLs more compared to men and the majority
of those tears are a result of a narrower space.
Application to Research
Includes a counter-claim or a claim to dispute.

LaPrade, R. F., & Burnett, Q. M., I I. (1994). y Femoral Intercondylar Notch

Stenosis and Correlation to Anterior Cruciate Ligament Injuries : A
Perspective Study [PDF]. American Journal of Sports Medicine, 22(2).
https://doi.org/10.1177/036354659402200208

Summary:
This journal excerpt shares findings of a two year study of athletes at a Division 1
school. The study began with x-rays of cadaver knees, which revealed that any sort of
“abduction-adduction caused distortion of the outlines of the intercondylar space.” From there,
the x-rayed 5 test subjects are in a position where they are on their hands and knees, with their
knees flexed 45 degrees. In this position, the doctors found no difference in measurements of
the intercondylar space, but found a statistical difference between knees photographed without
the ‘standard position.’ As a result of this study, doctors discovered a difference between NWI
(knee notch width) in males and females. “The NWI showed an average [of] NWI of 0.244 ±
0.036 for men and 0.238 ± 0.037 for women.” They also noted a “trend toward women being
more predisposed to ACL tears than men.”

Application to Research:
This source can be used for more background information about the differences in
NWIs in women and men.

MacMillen, C. (2020, February 14). Are ACL Tears Really More Common in Women?
Yale Medicine. Retrieved December 1, 2020, from
https://www.yalemedicine.org/news/sports-injuries-gender

Summary
This article discusses a woman's likelihood for an ACL tear. Ever since the passage of
the 1972 Title IX, a mandate for equality in sports, there has been an increase in the amount of
orthopedic injuries in women. A woman’s “pelvis is wider, which changes the mechanics of
how the thigh bone, tibia, and femur function.” In turn, “this puts more stress on the soft tissues
that support your joints.” The ACL lacks elasticity and absorbs a lot of stress, until it can’t
anymore, causing a tear. Further, “women have less muscle mass around their knees than men”
and leads “to instability and a higher chance of tearing a ligament if it is overstretched.” In
addition, it was noted that increases in estrogen when a woman is on her menstrual cycle,
causes such ligaments to become more loose. To decrease chances of a tear, women should
focus on strengthening their hamstrings because it keeps the knee stable and to enroll in
neuromuscular classes that teach proper methods for pivoting, jumping and more.

Application to Research
Information presented in this article will be used as background information to explain
how women are more prone to ACL injuries.

Shelbourne, K., Facibene, W. & Hunt, J. Radiographic and intraoperative intercondylar notch
width measurements in men and women with unilateral and bilateral anterior cruciate
ligament tears. Knee Surgery 5, 229–233 (1997). doi.org/10.1007/s001670050055

Summary
This journal article explains the significance between a women’s intercondylar notch
and their likelihood for an ACL tear. There a multiple factors as to why one may get an ACL
tear including: “sport played at the time of injury, shoe-surface interface, field conditions, body
movement, strength, endurance/conditioning, reaction time, muscle imbalance, skill level, joint
laxity, limb alignment, fatigue, age, gender, ligament size, and intercondylar notch size.” A
study was conducted with 100 men and 100 women and all the data was put into different
tables. The scientist concluded that “all groups of women (control, unilateral, and bilateral) had
significantly smaller NWs than all of the groups of men (P < 0.01).” Because women are more
likely to tear their ACLs than men, it is evident that the width of the intercondylar notch plays
a role in it.

Application to Research
Evidence from this article can be used as a conclusion to my research. Essentially it can
be used as support for my claim.

Tanaka, M. J., Szymanski, L. M., Dale, J. L., Dixit, S., & Jones, L. C. (n.d.).
Team Approach: Treatment of Injuries in the Female Athlete. The Journal of
Joint and Bone Surgery. https://doi.org/10.2106/jbjs.rvw.18.00011

Summary
This journal article explains the treatment methods for injuries seen in female athletes.
There has been an increase in ACL injuries since the 1972 Title IX and “more recent data has
shown that the rate of ACL reconstruction in women continues to increase 3 times the rate of
that in men.” Women are also “4 to 8 times more likely” to tear their ACLs. Women have
multiple biomechanical deficits including: ligament, quadriceps, trunk dominance and core
dysfunctions. It is recommended that women enroll in courses that help with neuromuscular
training that place an emphasis on “restoration of proper biomechanics during landing drills to
correct the valgus angle by minimizing leg rotation.”
Application to Research
This article will be used as an outline for prevention methods and background
information about female ACL tears.

Tanaka, M. (2020, December 1). [Videoconference interview by the author].

Summary
This interview was for the purpose of filling in gaps within my research. Women in
general are much smaller than men and thus, they would have smaller intercondylar notches.
However, the width of the intercondylar notch does not play a significant role in a likelihood
for a tear. If anything, having a smaller intercondylar notch “can impinge on the ACL.”
Essentially, a smaller intercondylar notch rubs “against the ACL and weaken[s]” it. Women
also have weaker cores, hamstrings, and hips that affect the overall stability of the knee. If
these groups work well together, an ACL can be avoided (neuromuscular control).

Application to Research
This interview will be used as clarification and explain how a smaller intercondylar
notch affects the ACL.

The Risk of ACL Injuries in Female Athletes. (n.d.). Beacon Orthopaedics and
Medicine. Retrieved October 8, 2020, from https://www.beaconortho.com/blog/
risk-acl-injuries-female-athletes/

Summary:
This website article explains why women are more prone to ACL tears. The article
states that “The anterior cruciate ligament (ACL) is a flexible band of tissue that runs
diagonally in the middle of the knee, providing it with the stability that is necessary for
rotational movement. When the ACL has been stretched too far, it will sprain or tear, causing
knee pain and occasional instability. When the ACL completely tears, the knee won’t be able to
support any weight.” For females, this may occur as a result of a smaller intercondylar notch
and a smaller ACL. In addition, women have wider pelvis’ which causes women to place
added stress to their ligament and also greater ligament flexibility than males. Women need to
do strength exercises for their muscles and cores, improve their balance/speed, and learn proper
jumping and landing techniques. By doing this, they will significantly lessen the risk of an
ACL injury.

Application to Research:
 This article can be used to describe the location of the ACL and what it is along with
explaining the differences of anatomy of a male and a female knee. It also can be used to
outline prevention methods.

Uppal, A. ." (Director). (2020). ACL Injuries [Film].

Summary
This video is a powerpoint that explains ACL injuries in depth. The ACL is made up of
2 bundles: small anterolateral and large posterolateral ligaments. Together, they restrain any
sort of tibia displacement. The ACL is attached to a fossa on the posteromedial aspect of the
lateral femoral condyle and extends to the anterior medial tibial intercondylar space. Most
injuries to the ACL occur as a result of a pivot shift or dashboard injuries. It can be diagnosed
using the Lachman’s test--tests the movement of the tibia--or through an MRI. The video also
includes various images of avulsion fractures and different photos of the types of ACL tears.

Application to Research
Can be used as background information and to explain how to diagnose an tear.

Wang, H.-M., Shultz, S. J., Ross, S. E., Henson, R. A., Perrin, D. H., Kraft, R.
A., & Schmitz, R. J. (2019). Sex Comparisons of In Vivo Anterior Cruciate
Ligament Morphometry. Journal of Athletic Training, 54(5), 513-518.
https://doi.org/10.4085/1062-6050-371-17

Summary:
This journal excerpt compares the size of the ACL in males and females. Females are
“twice as likely to sustain first time ACL tears” when compared to the rate of males. A case
study led by Whitney et al. suggest that the ACL volume was an independent predictor of an
ACL injury among a combined-sex sample. Females have higher rates of ACL tears than their
male counterparts since females have a smaller absolute ACL size. These characteristics are
associated with “less ligamentous restraint capacity that, in turn, could potentially increase the
ACL injury risk.” However, knee measurements are inconsistent with these findings.
Researchers need to account for “bony geometry and body size” as it interacts “with ligament
size.” In specifics, a smaller femoral notch has been associated with smaller ACLs as a result it
“limits the size of the ligament and increases tension on the ACL.” Further, when body weight
is accounted, “Anderson et al. noted that the ACL CSA was smaller in females than in
age-matched males.” When measuring the NWI through MRIs, results showed that “men had a
larger ACL volume (t38 ¼ 4.67, P , .001, ES ¼ 1.47), ACL width (t38 ¼2.53, P ¼ .02, ES ¼
0.80), and femoral notch width (t38 ¼5.52, P , .001, ES ¼ 1.74) than women.” But there was
no sex difference in ACL CSA, but the ACL volume was significantly larger in men than in
females.
Application to Research:
This information could be used to assert the differences between males and females'
knees and what factors account for their differences in ACL volumes.

Wilson, R., & Barhorst, A. A. (n.d.). Intercondylar Notch Impingement of the

Anterior Cruciate Ligament: A Cadaveric In Vitro Study Using Robots.
Journal of Healthcare Engineering. https://doi.org/10.1155/2018/8698167

Summary
This article explains how a narrower intercondylar space affects the ACL. It is noted
within the article that “research has indicated that a smaller intercondylar notch could cause
contact between the anterior cruciate ligament and the femoral notch, which may predispose
individuals to an increased rate of anterior cruciate ligament injury.” During extension and
hyperextension, contact between the ACL and the intercondylar shelf in the joint has been
confirmed. It can also cause the ACL to come into close contact with the intercondylar notch
itself, causing an increase in stress concentrations. Further, “it has been theorized that a stenotic
intercondylar notch impinges with more force on an ACL than a normal intercondylar notch,
thus increasing the risk for injury during cutting and pivoting maneuvers.” Most ACL tears
occur as a result of having “excessive anterior translation or internal rotation of the femur
relative to the tibia.”

Application to Research
This article will be used to explain the significance of how a smaller intercondylar
space affects the knee.