Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 2, pp 648–654 | Cite as

Nationwide study highlights a second peak in ACL tears for women in their early forties

  • Micah NichollsEmail author
  • Thor Aspelund
  • Thorvaldur Ingvarsson
  • Kristin Briem



Anterior cruciate ligament (ACL) rupture continues to be a focus of research on knee injuries. Despite this, data on the total number of ruptures on a national basis including both reconstructed (ACLR) and non-reconstructed injuries are limited. The purpose of this study was to describe the national incidence of MRI diagnosed ACL ruptures in Iceland and its subsequent rate of operation with regard to sex and age.


All MRI knee reports taken in Iceland between 2006 and 2011 were gathered to identify ACL ruptures. Software was written to search for phrases relating to ACL rupture. Duplicate records were removed and yearly incidence for sex and age groups was determined. Data from the Icelandic Social Insurance Administration were used identify all those who were operated and to determine the yearly incidence of ACLR. General additive models were used assuming either a Poisson or binomial distribution to model ACL rupture incidence and ACLR rate, respectively.


The average age was 33.9 (95% CI 33.1–34.6; Table 1). The average incidence of ACL tears per year was 75.1 (95% CI 71.3–79.1) per 100,000 person-years. For males the peak incidence was in their early twenties. Females showed two peaks, one in their teens and another in their forties resulting in an older average age at rupture compared to males (35 ± 16 vs 33 ± 13, p = 0.06). The main effects of age and sex and their interaction were significant (p < 0.001). The average incidence of ACLR was 39.4 (95% CI 36.7–42.4) per 100,000 person-years. Those operated were significantly younger than those who were not (27 ± 10 vs 42 ± 15 years, p < 0.001). The main effects of age and the interaction between sex and age were significant (p < 0.001).


This nationwide study indicates that ACL rupture incidence may be higher than previously thought, implying an underestimated impact of the burden of this serious knee injury. The incidence of injury peaked twice in the female population, a result not previously reported. Older persons are less likely to undergo ACLR and, therefore, sex-dependent differences in overall mean age at injury are contrary to previous reports. These data suggest that prevention programs focused solely on young girls should be extended to older women who are returning to sports.

Level of evidence



ACL tear ACL reconstruction ACL Epidemiology Incidence 



Anterior cruciate ligament


Anterior cruciate ligament reconstruction


Magnetic resonance imaging




Generalized additive model



The authors would like to thank Dr Vishal Kalia and Dr Vibhuti Kalia for their help in this project.

Author contributions

MN, TI and KB conceived and designed the study, collected the data and classified the reports. MN and TA analysed the data. MN wrote the initial manuscript. All authors contributed in revising the manuscript and gave their final approval of the submitted version.

Compliance with ethical standards

Conflict of interest

The Authors declare that they have no conflict of interest.

Informed consent

For this type of study formal consent is not required.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  1. 1.Faculty of Medicine, Research Centre for Movement SciencesUniversity of IcelandReykjavíkIceland
  2. 2.Faculty of Medicine, The Centre of Public Health SciencesUniversity of IcelandReykjavíkIceland
  3. 3.Department of Orthopaedic SurgeryUniversity of AkureyriAkureyriIceland

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