Female Athletes Are Underrepresented in Anterior Cruciate Ligament Reconstruction Rehabilitation Studies: A
Gabrielle Crowell1, Jacob Adams2, Ian Harmon3
1Kansas University Medical Center, Kansas City, Kansas, U.S.A..
Purpose:
To systematically review the representation of female athletes in the current primary literature available on rehabilitation after anterior cruciate ligament reconstruction (ACLR).
Methods:
A systematic review was conducted using PubMed to provide a comprehensive analysis of female representation in ACLR postoperative rehabilitation protocols. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. Studies were analyzed based on nine factors: study population, athletic caliber, menstrual status, research theme, journal impact factor, sample size of male and female participants, time to return to sport, and graft failure rate. Population categories included males-only, females-only, mixed-sex, and male vs. female comparisons. Athletic caliber had 6 tiers. Menstrual status was categorized as natural, hormonal contraception, irregularities, mixed, or unclassified. Research themes were health-focused, performance-focused, or combined. Study impact was assessed via journal impact factor.
Results:
Thirty-three studies were included. Females comprised 3031/6798 (44.6%) of ACLR participants. No female-only studies were found; male-only studies accounted for 3 of 33 (9%), mixed-sex for 25 of 33 (69.7%), male versus female subanalysis for 3 of 33 (9%), and male versus female features for 2 of 33 (6%). No studies investigated outcomes for the highest athletic levels. Menstrual status was not considered. No studies focused on performance outcomes; 25 of 33 (69.7%) had a health research focus. Female athletes were under-represented in studies evaluating return to sport timeline and graft failure rate.
Conclusions:
Female athletes face a 2 to 8 times greater risk of ACL injury but are under-represented in ACLR postop rehabilitation studies, with only 44.6% participation compared with 55.4% for male athletes. In 9 studies, female athletes comprised 30% or less of participants. Even studies including female athletes at near-equal rates failed to address menstrual status or sex hormones on injury and rehabilitation.
Level Of Evidence:
Level IV, systematic review of Level I-IV studies.
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