Morphologic Characteristics Help Explain the Gender Difference in Peak Anterior Cruciate Ligament Strain During a Simulated Pivot Landing

Abstract

Background: Gender differences exist in anterior cruciate ligament (ACL) cross-sectional area and lateral tibial slope. Biomechanical principles suggest that the direction of these gender differences should induce larger peak ACL strains in females under dynamic loading. Hypothesis: Peak ACL relative strain during a simulated pivot landing is significantly greater in female ACLs than male ACLs. Study Design: Controlled laboratory study. Methods: Twenty cadaveric knees from height- and weight-matched male and female cadavers were subjected to impulsive 3-dimensional test loads of 2 times body weight in compression, flexion, and internal tibial torque starting at 15° of flexion. Load cells measured the 3-dimensional forces and moments applied to the knee, and forces in the pretensioned quadriceps, hamstring, and gastrocnemius muscle equivalents. A novel, gender-specific, nonlinear spring simulated short-range and longer range quadriceps muscle tensile stiffness. Peak relative strain in the anteromedial bundle of the ACL (AM-ACL) was measured using a differential variable reluctance transducer, while ACL cross-sectional area and lateral tibial slope were measured using magnetic resonance imaging. A repeated-measures Mann-Whitney signed-rank test was used to test the hypothesis. Results: Female knees exhibited 95% greater peak AM-ACL relative strain than male knees (6.37% [2.53%] vs 3.26% [1.89%]; P = .004). Anterior cruciate ligament cross-sectional area and lateral tibial slope were significant predictors of peak AM-ACL relative strain ( R2 = .59; P = .001). Conclusion: Peak AM-ACL relative strain was significantly greater in female than male knees from donors of the same height and weight. This gender difference is attributed to a smaller female ACL cross-sectional area and a greater lateral tibial slope. Clinical Relevance: Since female ACLs are systematically exposed to greater strain than their male counterparts, training and injury prevention programs should take this fact into consideration.