scholarly journals Do Sex-Specific Differences Exist in ACL Attachment Location? An MRI-Based 3-Dimensional Topographic Analysis

2020 ◽  
Vol 8 (11) ◽  
pp. 232596712096447
Author(s):  
Dimitris Dimitriou ◽  
Zhongzheng Wang ◽  
Diyang Zou ◽  
Naeder Helmy ◽  
Tsung-Yuan Tsai
Keyword(s):  
Risk Factor ◽  
Female Athletes ◽  
Cruciate Ligament ◽  
Magnetic Resonance Images ◽  
Acl Rupture ◽  
Level Of Evidence ◽  
Predisposing Factor ◽  
Topographic Analysis ◽  
3 Dimensional ◽  
Flexion Extension

Background: Female sex is an independent risk factor for an anterior cruciate ligament (ACL) injury, as the incidence of an ACL rupture is 4- to 6-fold higher in female athletes compared with their male counterparts. The ACL attachment location as a potential risk factor for the increased ACL rupture rate in women has never been reported in the literature. Purpose/Hypothesis The purpose of the present study was to investigate the 3-dimensional topographic anatomy of the ACL bundle attachment in female and male patients, with and without an ACL rupture, and identify potential sex-related differences. We hypothesized that the ACL attachment location would be significantly different between men and women, in both the intact- and ruptured-ACL states. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Magnetic resonance images of the knee from 90 patients (55 men, 35 women) with a ruptured ACL and 90 matched controls (55 men, 35 women), who suffered a noncontact knee injury without ACL rupture, were used to create 3-dimensional models of the femur and tibia. The ACL bundles’ origin and insertion were outlined on each model, and their location was measured using an anatomical coordinate system. A 2-way analysis of variance was used to compare the ACL attachment location between male and female patients, with and without an ACL rupture. Results: No significant differences were found between female and male participants regarding ACL attachment location (femoral origin and tibial insertion). Patients with a ruptured ACL demonstrated a significantly different ACL origin compared with the participants with an intact ACL by an average difference of 8.9% more posterior ( P < .05) and 4.0% more proximal ( P < .05) in men and 13.0% more posterior ( P < .05) and 5.5% more proximal ( P < .05) to the flexion-extension axis of the knee in women. Conclusion: The ACL attachment location should not be considered a risk factor for the increased ACL rupture rates in female compared with male athletes. However, a more posterior and proximal location of the femoral ACL origin might be a predisposing factor to an ACL rupture regardless of sex.

The Femoral Footprint Position of the Anterior Cruciate Ligament Might Be a Predisposing Factor to a Noncontact Anterior Cruciate Ligament Rupture

2019 ◽  
Vol 47 (14) ◽  
pp. 3365-3372 ◽  
Author(s):  
Dimitris Dimitriou ◽  
Zhongzheng Wang ◽  
Diyang Zou ◽  
Tsung-Yuan Tsai ◽  
Naeder Helmy
Keyword(s):  
Anterior Cruciate Ligament ◽  
Matched Control ◽  
Cruciate Ligament ◽  
Magnetic Resonance Images ◽  
Small Sample ◽  
Transverse Plane ◽  
Acl Rupture ◽  
Coronal Plane ◽  
Predisposing Factor ◽  
Anterior Cruciate

Background: Although the femoral tunnel position is crucial to anatomic single-bundle anterior cruciate ligament (ACL) reconstruction, the recommendations for the ideal femoral footprint position are mostly based on cadaveric studies with small sample sizes, elderly patients with unknown ACL status, and 2-dimensional techniques. Furthermore, a potential difference in the femoral ACL footprint position and ACL orientation between ACL-ruptured and ACL-intact knees has not been reported in the literature. Hypothesis: The femoral ACL footprint position and ACL orientation vary significantly between ACL-ruptured and matched control ACL-intact knees. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Magnetic resonance images of the knees of 90 patients with an ACL rupture and 90 matched control participants who had a noncontact knee injury without an ACL rupture were used to create 3-dimensional models of the femur and tibia. The ACL footprints were outlined on each model, and their positions (normalized to the lateral condyle width) as well as ACL orientations were measured with an anatomic coordinate system. Results: The femoral ACL footprint in patients with an ACL rupture was located at 36.6% posterior and 11.2% distal to the flexion-extension axis (FEA). The ACL orientation was 46.9° in the sagittal plane, 70.3° in the coronal plane, and 20.8° in the transverse plane. The ACL-ruptured group demonstrated a femoral ACL footprint position that was 11.0% more posterior and 7.7% more proximal than that of the control group (all P < .01). The same patients also exhibited 5.7° lower sagittal elevation, 3.1° higher coronal plane elevation, and 7.9° lower transverse plane deviation (all P < .01). The optimal cutoff value of the femoral ACL footprint position to prevent an ACL rupture was at 30% posterior and 12% distal to the FEA. Conclusion: The ACL femoral footprint position might be a predisposing factor to an ACL rupture. Patients with a >30% posterior and <12% distal position of the femoral ACL footprint from the FEA might have a 51.2-times increased risk of an ACL rupture.

scholarly journals Sub-SMAS Transposition of the Buccal Fat Pad

2019 ◽  
Author(s):  
Ozan Bitik
Keyword(s):  
Magnetic Resonance ◽  
Magnetic Resonance Images ◽  
Surface Measurement ◽  
Fat Pad ◽  
Buccal Fat Pad ◽  
Level Of Evidence ◽  
Curvilinear Surface ◽  
3 Dimensional ◽  
Volume Deficit ◽  
Dimensional Models

AbstractBackgroundRegardless of the technique chosen to treat the aging midface, the isolated lateral approach facelift has a limited impact on the midface volume deficit. In an effort to overcome this limitation, modern facial rejuvenation procedures incorporate an additional modality for replenishing the midface volume. Some of the author’s facelift patients present with bulging buccal fat pads despite volume deficiency in the inframalar region. The author’s technique is designed to utilize the buccal fat pad to replenish the inframalar volume deficit.ObjectivesThe author sought to present the fat pad transposition surgical technique along with objective outcome data.MethodsThis study was a retrospective review of nonconsecutive cases where the sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad was performed. A total of 22 patients underwent the fat pad transposition technique by the author (O.B.) between July 2013 and December 2017. Patient data were obtained from patient records, 3-dimensional models, magnetic resonance images, and standardized photography. Preoperative differences in midface volume were assessed utilizing curvilinear surface measurements on 3-dimensional models and the Allergan midface volume deficit scale on standardized photography.ResultsThe average midface volume deficit score significantly improved, and the average midfacial curvilinear surface measurement significantly increased after surgery. Magnetic resonance imaging confirmed a stable position of the buccal fat pad after surgery.ConclusionsThe sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad is an effective technique that can be safely employed for autologous inframalar augmentation in patients with a favorable facial morphology.Level of Evidence: 4

scholarly journals Anterior Cruciate Ligament, Acute Tears. Spontaneus Healing, is True or False

2018 ◽  
Vol 6 (12_suppl5) ◽  
pp. 2325967118S0020
Author(s):  
Lucas Marangoni ◽  
Bernardo Murillo ◽  
Damián Bustos ◽  
Pablo Bertiche ◽  
Iván Bitar ◽  
...  
Keyword(s):  
Cruciate Ligament ◽  
Subjective Evaluation ◽  
Specific Treatment ◽  
Acl Rupture ◽  
Post Injury ◽  
Level Of Evidence ◽  
Size Limitation ◽  
Resting Time ◽  
Anterior Cruciate

Objectives: To identify patients with a diagnosis of acute and complete ACL rupture that healed spontaneously, and to determine whether such healing is related to age, sex, type of rupture, resting time, and trauma mechanisms. Materials and Methods: 30 patients with complete acute ACL rupture were evaluated by clinical diagnosis and Magnetic Resonance Image (MRI). Both Lysholm test and IKDC 2000 were used for subjective evaluation. Results: All patients improved from the first to the second consult, with the following results: Lachman (p <0.0406), pivot shift (p = 0.071), and anterior drawer (p <0.001). During the follow-up MRI, all patients showed signs of healing in ACL. With an average follow-up of 12 months for men (95% CI 6-17) and 13 months for women (95% CI 31 max.), a nearly complete clinical recovery could be inferred, as well as healing occurring independently of variables such as age, sex, or specific treatment (p = 0.795 and p = 0.841). Discussion: Despite this study size limitation, the objectives were achieved. There would be spontaneous ACL healing associated with a 3-month post-injury resting time, but it is unrelated to age, sex, specific physiotherapy treatments, or the use of immobilizers. Level of evidence: level of evidence IV

scholarly journals “I don't opt out of things because I think I will get a sore knee, but I don't expose myself to stupid risks either”: patients’ experiences of a second ACL injury—an interview study

2021 ◽  
Author(s):  
Annette Heijne ◽  
Karin Grävare Silbernagel ◽  
Mari Lundberg
Keyword(s):  
Qualitative Content Analysis ◽  
Cruciate Ligament ◽  
Acl Injury ◽  
Acl Rupture ◽  
Common Denominator ◽  
Activity Levels ◽  
Level Of Evidence ◽  
Major Life ◽  
Life Goal ◽  
Coping Process

Abstract Purpose The purpose of this qualitative study was to describe women’s experiences with anterior cruciate ligament reconstruction (ACLR) and a subsequent ACL rupture, and to identify potential facilitators and barriers for coping with rehabilitation after the second injury. Methods Eight women between 17 and 36 years (mean 26, SD 6.5) who had experienced ACLR, followed by another ACL rupture, participated in the study. Semi-structured interviews were conducted, and data were analyzed using qualitative content analysis. Results One overarching theme, “Rehabilitation after a second ACL injury—A lifelong adaptive coping process”, emerged from analyses. Undergoing a second rehabilitation is described as a process of adaptation, beginning with the first injury and still ongoing, more than 5 years later. Participants applied different coping strategies to adapt to these life-altering injuries, but the common denominator was of major life adjustments with no return to previous activity levels. Initially, after the reinjury, it was about coping with the catastrophe of the dreaded second injury. Over time, they accepted their “new” life and reset their recovery/rehabilitation goal not just as “return to sport” but rather as a “personal life goal”. Conclusion Undergoing a second ACL injury is a long process that challenges the patient’s coping skills. Given these results, rehabilitation programs need to be more person centred according to the patients-adjusted life goals. Level of evidence 3.

Anterior Cruciate Ligament Reconstruction in Young Female Athletes: Patellar Versus Hamstring Tendon Autografts

2019 ◽  
Vol 47 (9) ◽  
pp. 2086-2092 ◽  
Author(s):  
Hytham S. Salem ◽  
Vahe Varzhapetyan ◽  
Nimit Patel ◽  
Christopher C. Dodson ◽  
Fotios P. Tjoumakaris ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Graft Failure ◽  
Female Athletes ◽  
Cruciate Ligament ◽  
Age Groups ◽  
Age Group ◽  
Level Of Evidence ◽  
Young Females ◽  
Significant Difference ◽  
Anterior Cruciate

Background: Female athletes are 2 to 8 times more prone to anterior cruciate ligament (ACL) rupture than males. Furthermore, reinjury to the ipsilateral or contralateral knee can occur in >20% of athletes. Female sex and younger age are known risk factors for graft failure. The optimal graft choice for young females remains unknown and poorly studied. Purpose/Hypothesis: The authors aimed to compare clinical outcomes in young females who underwent ACL reconstruction (ACLR) with bone–patellar tendon–bone (BTB) and quadrupled hamstring (HS) autografts. It was hypothesized that no significant differences in outcomes exist between graft choices. Study Design: Cohort study; Level of evidence, 3. Methods: Female patients aged 15 to 25 years who underwent primary ACLR with BTB or HS autograft were included for review. Patients were subdivided into 2 age groups: 15 to 20 years and 21 to 25 years. The occurrence of chondral, meniscal, or ligamentous injury to either knee was recorded for comparison. Results: A total of 256 females were included (BTB, n = 175; HS, n = 81). The majority of patients were between the ages of 15 and 20 years (BTB, 80%; HS, 77.8%). Overall, graft rupture occurred in 23 patients (9%) and contralateral ACL tear occurred in 18 (7%). Subgroup analysis showed that 75% of BTB and 100% of HS graft retears occurred in females aged 15 to 20 years. Within this age group, there was a significantly lower rate of graft ruptures in the BTB group (6.4%) as compared with the HS group (17.5%, P = .02). Allograft augmentation was used in 4 of the 11 HS grafts that retore. When allograft-augmented grafts were excluded, there was no significant difference in graft failure rate between graft choices. Fifteen patients in the BTB group (12%) as opposed to 1 in the HS group (2%) reported extreme difficulty or the inability to kneel on the front of the knee ( P = .04). Conclusion: In females aged 15 to 20 years undergoing ACLR, BTB autograft may lead to fewer graft ruptures than HS autograft. While this difference was not observed in females aged 21 to 25 years, a larger sample may be required to accept the null hypothesis in this age group. BTB autograft significantly increased the risk of kneeling pain as compared with HS regardless of age.

scholarly journals Superior 2-Year Functional Outcomes Among Young Female Athletes After ACL Reconstruction in 10 Return-to-Sport Training Sessions: Comparison of ACL-SPORTS Randomized Controlled Trial With Delaware-Oslo and MOON Cohorts

2019 ◽  
Vol 7 (8) ◽  
pp. 232596711986131 ◽  
Author(s):  
Jacob J. Capin ◽  
Mathew Failla ◽  
Ryan Zarzycki ◽  
Celeste Dix ◽  
Jessica L. Johnson ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Female Athletes ◽  
Controlled Trial ◽  
Cruciate Ligament ◽  
Return To Sport ◽  
Young Female ◽  
Activity Levels ◽  
Postoperative Rehabilitation ◽  
Level Of Evidence ◽  
Sport Training

Background: Outcomes after anterior cruciate ligament reconstruction (ACLR) are not uniformly good and are worse among young female athletes. Developing better rehabilitation and return-to-sport training programs and evaluating their outcomes are essential. Purpose: (1) Test the effect of strength, agility, plyometric, and secondary prevention (SAPP) exercises with and without perturbation training (SAPP + PERT) on strength, hops, function, activity levels, and return-to-sport rates in young female athletes 1 and 2 years after ACLR and (2) compare 2-year functional outcomes and activity levels among young female athletes in the Anterior Cruciate Ligament Specialized Post-Operative Return-to-Sports (ACL-SPORTS) trial to homogeneous cohorts who completed criterion-based postoperative rehabilitation alone (Multicenter Orthopaedic Outcomes Network [MOON]) and in combination with extended preoperative rehabilitation (Delaware-Oslo). Study Design: Randomized controlled trial, Level of evidence, 1; and cohort study, Level of evidence, 3. Methods: A total of 40 level 1 and level 2 female athletes were enrolled after postoperative impairment resolution 3 to 9 months after primary ACLR. Participants were randomized to 10 SAPP or SAPP + PERT sessions and were tested 1 and 2 years after ACLR on quadriceps strength, hop tests, functional outcomes, and return-to-sport rates. Participants were then compared with homogeneous cohorts of young (<25 years) female athletes who completed criterion-based postoperative rehabilitation alone (MOON) and in combination with extended preoperative rehabilitation (Delaware-Oslo) on 2-year functional outcomes. Results: No significant or meaningful differences were found between SAPP and SAPP + PERT, so groups were collapsed for comparison with the other cohorts. At 2-year follow-up, ACL-SPORTS had the highest scores ( P < .01) on the Marx activity rating scale (ACL-SPORTS, 13.5 ± 3.3; Delaware-Oslo, 12.5 ± 2.7; MOON, 10.6 ± 5.1); International Knee Documentation Committee Subjective Knee Evaluation Form (96 ± 7, 92 ± 9, and 84 ± 14, respectively); and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales for Pain (98 ± 4, 94 ± 9, and 90 ± 10, respectively), Symptoms (94 ± 6, 90 ± 9, and 83 ± 14, respectively), Activities of Daily Living (100 ± 1, 99 ± 4, and 96 ± 7, respectively), Sports and Recreation (94 ± 8, 86 ± 15, and 82 ± 17, respectively), and Quality of Life (89 ± 14, 78 ± 18, and 76 ± 19, respectively). The Patient Acceptable Symptom State threshold on the KOOS–Sports and Recreation was achieved by 100% of the ACL-SPORTS cohort compared with 90% of Delaware-Oslo and 78% of MOON ( P = .011). Conclusion: Although perturbation training provided no added benefit, 10 sessions of return-to-sport training, compared with criterion-based postoperative rehabilitation alone, yielded statistically significant and clinically meaningfully higher 2-year functional outcomes among young, high-level female athletes after ACLR. Registration: NCT01773317 ( ClinicalTrials.gov identifier).

Introducing the Lateral Femoral Condyle Index as a Risk Factor for Anterior Cruciate Ligament Injury

2019 ◽  
Vol 47 (10) ◽  
pp. 2420-2426 ◽  
Author(s):  
Sandro Hodel ◽  
Method Kabelitz ◽  
Timo Tondelli ◽  
Lazaros Vlachopoulos ◽  
Reto Sutter ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Femoral Condyle ◽  
Cruciate Ligament ◽  
Area Under The Curve ◽  
Acl Injury ◽  
Tibial Slope ◽  
Acl Rupture ◽  
Control Group ◽  
Predictive Risk

Background: The asymmetry of the medial and lateral knee compartments contributes significantly to femorotibial biomechanics and pivoting, and it is reported to be a relevant risk factor for an anterior cruciate ligament (ACL) injury. Purpose: (1) To assess the role of femoral condyle sphericity as a risk factor for an ACL rupture and rerupture. (2) To compare the new risk factor with existing bony morphological risk factors via magnetic resonance imaging (MRI) and to assess the most predictive risk factor for an ACL rupture. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective case-control study of 60 patients was conducted. Three age- and sex-matched cohorts (each n = 20) were analyzed: ACL reruptures, primary ACL ruptures, and a control group consisting of isolated meniscal tears or patients with anterior knee pain without signs of trochlear dysplasia. The lateral femoral condyle index (LFCI) as a novel MRI measurement was developed to quantify femoral sphericity. In addition, previously known MRI risk factors associated with ACL injury were analyzed (notch width index, medial tibial slope, lateral tibial slope, medial tibial depth, and lateral tibial height). Differences among groups were compared; cutoff values were defined; and diagnostic performance of the risk factors was assessed. The risk factors were subsequently analyzed with multiple logistic regression. Results: The LFCI was significantly smaller in knees with ACL reruptures (median, 0.67; range, 0.59-0.75) and primary ACL ruptures (0.67; range, 0.60-0.75) than in the control group (0.76; range, 0.6-0.81; P < .01). The LFCI yielded the highest area under the curve among the analyzed risk factors: 0.82 (95% CI, 0.7-0.9). A cutoff of 0.70 yielded a sensitivity of 78% and a specificity of 80% to predict an ACL rupture or rerupture (odds ratio, 13.79; 95% CI, 3.67-51.75). In combination with lateral tibial height (cutoff, 3.8 mm) and lateral tibial slope (cutoff, 2.9°), the diagnostic performance was improved. The area under the curve was 0.86 (95% CI, 0.75-0.94), with a sensitivity of 90% and a specificity of 70% (odds ratio, 21.00; 95% CI, 5.10-85.80). Conclusion: A decreased LFCI is associated with an ACL injury. The LFCI, lateral tibial height, and lateral tibial slope are the most predictive risk factors for an ACL injury. These findings might aid clinicians in identifying patients at risk for an ACL injury and inform the patient after reconstruction for a higher risk of rerupture.

scholarly journals Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study

2019 ◽  
Vol 47 (4) ◽  
pp. 807-814 ◽  
Author(s):  
Louise M. Thoma ◽  
Hege Grindem ◽  
David Logerstedt ◽  
Michael Axe ◽  
Lars Engebretsen ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Cohort Study ◽  
Strength Training ◽  
Cruciate Ligament ◽  
Return To Sport ◽  
Acl Rupture ◽  
Level Of Evidence ◽  
Before And After ◽  
Anterior Cruciate

Background: Some athletes demonstrate excellent dynamic stability after anterior cruciate ligament (ACL) rupture and return to sport without ACL reconstruction (ACLR) (copers). Others demonstrate persistent instability despite rehabilitation (noncopers) and require surgical stabilization. Testing to determine coper classification can identify potential copers early after rupture. It is unclear how coper classification changes after a brief intervention and how early classification relates to long-term outcomes. Purpose: (1) To evaluate the consistency of early coper classification (potential coper vs noncoper) before and after progressive neuromuscular and strength training (NMST) among athletes early after acute ACL rupture and (2) to evaluate the association of early coper classification with 2-year success after ACL rupture. Study Design: Cohort study; Level of evidence, 2. Methods: This was a prospective analysis from the Delaware-Oslo ACL Cohort Study, composed of athletes consecutively enrolled early after ACL rupture. Participants (n = 271) were tested and classified as potential copers or noncopers according to established criteria before and after a 10-session NMST program. Success 2 years after ACLR or nonoperative rehabilitation was defined as meeting or exceeding sex- and age-matched norms for knee function, no ACL graft rupture, and ≤1 episode of giving way within the previous year. The McNemar test evaluated changes in coper classification pre- to posttraining. Logistic regression adjusted for baseline characteristics was used to evaluate the association of early coper classification and surgical status with 2-year success. Results: Of 300 athletes enrolled, 271 (90%) completed the posttraining data collection, and 219 (73%) returned for the 2-year follow-up. The coper classifications were different between time points: nearly half of those classified initially as noncopers became potential copers ( P < .001). At the 2-year follow-up, 66% of the ACLR group and 74% of the nonoperative group were successful. Athletes who were potential copers posttraining and chose ACLR or nonoperative rehabilitation had 2.7 (95% CI, 1.3-5.6) and 2.9 (95% CI, 1.2-7.2) times the odds of success, respectively, as compared with noncopers who chose ACLR. Conclusion: Coper classification improved after NMST; more athletes became potential copers. Athletes who were potential copers after NMST were more likely to succeed 2 years later regardless of whether they had surgery, strongly supporting the addition of NMST before ACLR. Persistent noncopers fared poorly, indicating that more intensive rehabilitation may be needed.

scholarly journals The Anterolateral Ligament: An Anatomic Study on Sex-Based Differences

2017 ◽  
Vol 5 (2) ◽  
pp. 232596711668938 ◽  
Author(s):  
Matt Daggett ◽  
Camilo Helito ◽  
Matthew Cullen ◽  
Andrew Ockuly ◽  
Kyle Busch ◽  
...  
Keyword(s):  
Female Athletes ◽  
Cruciate Ligament ◽  
Lateral Meniscus ◽  
Knee Laxity ◽  
Anterolateral Ligament ◽  
Acl Rupture ◽  
Significant Difference ◽  
Length Width ◽  
The Difference ◽  
Anterior Cruciate

Background: The anterolateral ligament (ALL) has been shown to have an important role in rotatory stability of the knee. While there is abundant research on sex-based differences related to anterior cruciate ligament (ACL) rupture, there is a paucity of literature related to such differences in the ALL. Purpose: To define any sex-based differences in the ALL with regard to length, width, and thickness. Study Design: Descriptive laboratory study. Methods: The ALL was initially evaluated in 165 unpaired knees (92 males and 65 females after exclusion criteria applied). The length, width, and thickness of the ALL were measured using a digital caliper. Width and thickness were measured at the joint line just superior to the lateral meniscus. The Mann-Whitney test and Student t tests were used to compare measurements between males and females. The Pearson product-moment correlation was subsequently used to determine the correlation between height and weight and the statistically different morphometric variables. Results: The mean (±SD) thickness of the ALL in males was 2.09 ± 0.56 mm, almost twice as thick as females (1.05 ± 0.49 mm; P = 8.8 × 10−20). There was also a statistically significant difference in ALL length ( P = 3.8 × 10−7), but no significant difference was found for width. A moderate association was found between donor height and ALL thickness and length. Conclusion: The anatomic measurements of the ALL demonstrate a difference between sexes, and the ALL is significantly thicker in males than females. Clinical Relevance: As the role of the ALL in rotatory stability of the knee becomes better understood, the difference in the thickness of the ALL we have found between the sexes may be another factor why female athletes have an increased incidence of ACL rupture compared with males. This may also help explain why females have issues with knee laxity and rotatory instability.

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