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Biomechanical Risk Factors for Increased Anterior Cruciate Ligament Loading and Injury: A Systematic Review.

Malachy Belkhelladi¹, Tanya Cierson¹, Paul A Martineau¹

¹Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada.

Orthopaedic Journal of Sports Medicine

|February 17, 2025

Summary

Identifying noncontact anterior cruciate ligament (ACL) injury risk factors is crucial for prevention. Biomechanical analysis reveals that trunk and hip alignment, along with specific foot and ankle positioning, significantly influence ACL loading and injury risk.

Keywords:

ACL biomechanics injury prevention knee joint kinematics noncontact injury risk factors

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Area of Science:

Biomechanics
Sports Medicine
Orthopedics

Background:

Understanding noncontact anterior cruciate ligament (ACL) injury biomechanical risk factors is essential for developing effective prevention and rehabilitation strategies.
Reducing the incidence and burden of ACL injuries in athletes and the general population is a key public health goal.

Purpose of the Study:

To systematically review and identify biomechanical risk factors associated with noncontact ACL injuries.
To determine factors contributing to increased knee loading during physical activity.

Main Methods:

A systematic literature search was conducted following PRISMA guidelines, including randomized, cohort, case-control, and cross-sectional studies published before May 2023.
Studies focused on noncontact ACL injury biomechanics, excluding contact injuries or post-injury assessments.
Biomechanical factors such as toe-in position, pelvic hike, hip rotation, ankle angles, and trunk alignment were analyzed.

Main Results:

Analysis of 28 studies (2819 athletes) indicated significant biomechanical associations with ACL injury risk.
Upper body (trunk flexion/extension) and hip biomechanics (abduction/internal rotation) were linked to increased ACL loading in 83% of relevant studies.
Foot and ankle (toe-in/toe-out landing) and knee (decreased flexion) biomechanics demonstrated higher ACL stress.

Conclusions:

Specific biomechanical factors, including medial knee alignment, sagittal trunk alignment, and decreased lateral trunk flexion, are associated with reduced knee loading and ACL injury risk.
Targeted interventions addressing high-risk biomechanics are needed to reduce ACL injury incidence.
Further research is required to optimize prevention and rehabilitation programs based on these biomechanical findings.