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Extrinsic Risk Factors for Primary Noncontact Anterior Cruciate Ligament Injury in Adolescents Aged between 14 and 18 years: A Systematic Review

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Abstract

Background

Adolescents present a high incidence of ACL injury compared with other age groups. Examining the risk factors that predispose adolescents to primary noncontact ACL injury is a key strategy to decrease the number of injuries in this population.

Objective

The aim of this systematic review was to summarise the existing literature investigating extrinsic risk factors that have been linked with primary noncontact ACL injury risk (identified either using ACL injury occurrence or using screening tests measuring biomechanical mechanisms for noncontact ACL injury) in adolescents including research investigating: (1) the association between extrinsic risk factors and primary noncontact ACL injury risk; and (2) whether primary noncontact ACL injury risk was different in populations or groups exposed to different extrinsic risk factors in adolescents.

Methods

The same search strategy was used in MEDLINE, SPORTDiscus, CINAHL, PubMed and Embase. Articles were included if: written in English; published in peer-reviewed journals; investigating and discussing primary noncontact ACL injury risk associated with extrinsic risk factors; they were original research articles with an observational design; and participants presented a mean age ranging between 14 and 18 years. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (QATOCCS) was used to assess the quality and risk of bias of the articles included in this systematic review.

Results

The systematic review included 16 eligible articles published up to August 2022 about extrinsic risk factors for primary noncontact ACL injury including: sport (8 studies); sport exposure amount (5); sport level (3); sport season (1); environment (2); equipment (1). Differences in biomechanical risk factors predisposing to ACL injury were reported by sport in female adolescents playing basketball and soccer; however, no good evidence of differences in primary noncontact ACL injury rate by sport was reported in both male and female adolescents. There was contrasting evidence about associations between sport exposure and biomechanical and neuromuscular risk factors predisposing to ACL injury or primary noncontact ACL injury rate in both male and female adolescent players from different sports. There was weak evidence of differences in biomechanical risk factors predisposing to ACL injury by environmental condition in both male and female adolescents playing soccer and season phase in male adolescents playing basketball. Lastly, few good-quality articles suggested that higher sport level might be associated with increased primary noncontact ACL injury rate in female adolescents playing basketball and floorball and that bracing might not prevent primary noncontact ACL injuries in both male and female adolescent players from different sports.

Discussion

The findings emphasise the need for further research to clarify the evidence about extrinsic risk factors and primary noncontact ACL injury in adolescents to develop ACL injury prevention guidelines that would help practitioners and researchers identify adolescents at risk and design future interventions. Future epidemiological studies should collect data about extrinsic factors as well as data about primary noncontact injury separately from secondary injuries or contact injuries to better inform primary noncontact ACL injury prevention in adolescents.

Registration

https://doi.org/10.17605/OSF.IO/VM82F (11/08/2021).

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Acknowledgements

The authors of this paper would like to thank Tess Rolley for her contribution to the literature screening for this systematic review.

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Authors and Affiliations

  1. Centre for Physical Activity, Sport and Exercise Science, Coventry University, Coventry, UK

    Matteo Crotti, Theresa Heering & Michael J. Duncan

  2. School of Health and Social Development, Deakin University, Melbourne, VIC, Australia

    Theresa Heering & Lisa M. Barnett

  3. School of Exercise and Nutrition Science, Deakin University, Melbourne, VIC, Australia

    Aaron Fox

  4. Institute for Physical Activity and Nutrition, Deakin University, Melbourne, VIC, Australia

    Natalie Lander & Lisa M. Barnett

Authors
  1. Matteo Crotti
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  2. Theresa Heering
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  3. Natalie Lander
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  4. Aaron Fox
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  5. Lisa M. Barnett
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  6. Michael J. Duncan
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Corresponding author

Correspondence to Matteo Crotti.

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Registration and Protocol

The protocol for this review was registered within the OSF online platform (https://doi.org/10.17605/OSF.IO/VM82F), and it can be accessed using the following link: https://osf.io/vm82f/. Two separate reviews were developed from this project after registration to investigate different aspects of ACL injury risk and different age groups.

Funding

No sources of funding were used to assist in the preparation of this review.

Conflict of Interest

The authors declare that they have no conflicts of interest with the content of this article.

Author Contributions

MC, TH, NL, AF, LB and MD conceptualised the study. The literature screening process was performed by MC, TH, NL, AF, LB and MD. The data extraction was completed by MC and checked by TH, while the risk-of-bias assessment was completed by MC and TH. The first draft of the manuscript was written by MC, and subsequently all authors critically revised the manuscript and agreed to its final version.

Data Availability

The data extracted from the articles included in this systematic review are available in the Supplementary Material 2 data extraction table.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 21 kb)

Supplementary file2 (DOCX 37 kb)

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Crotti, M., Heering, T., Lander, N. et al. Extrinsic Risk Factors for Primary Noncontact Anterior Cruciate Ligament Injury in Adolescents Aged between 14 and 18 years: A Systematic Review. Sports Med 54, 875–894 (2024). https://doi.org/10.1007/s40279-023-01975-1

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