Why Do Girls Sustain More Anterior Cruciate Ligament Injuries Than Boys?: A Review of the Changes in Estrogen and Musculoskeletal Structure and Function during Puberty

Sport is the leading cause of injury among adolescents and girls incur more non-contact anterior cruciate ligament (ACL) ruptures than boys, with this gender disparity in injury incidence apparent from the onset of puberty. Although the mechanisms for this gender disparity in ACL injuries are relatively unknown, hormonal, anatomical and biomechanical factors have been implicated. Puberty is associated with rapid skeletal growth and hormonal influx, both of which are thought to contribute to alterations in ACL metabolic and mechanical properties, as well as changes in lower limb strength and flexibility, ultimately influencing landing technique. Therefore, the aim of this review is to explain (i) the effects of changes in estrogen levels on the metabolic and mechanical properties of the ACL; (ii) changes in musculoskeletal structure and function that occur during puberty, including changes in knee laxity, and lower limb flexibility and strength; and (iii) how these hormonal and musculoskeletal changes impact upon the landing technique displayed by pubescent girls. Despite evidence confirming estrogen receptors on the ACL, there are still conflicting results as to how estrogen affects the mechanical properties of the ACL, particularly during puberty. However, during this time of rapid growth and hormonal influx, unlike their male counterparts, girls do not display an accelerated muscle strength spurt and the development of their hamstring muscle strength appears to lag behind that of their quadriceps. Throughout puberty, girls also display an increase in knee valgus when landing, which is not evident in boys. Therefore, it is plausible that this lack of a defined strength spurt, particularly of the hamstring muscles, combined with the hormonal effects of estrogen in girls, may contribute to a more ‘risky’ lower limb alignment during landing, in turn, contributing to a greater risk of ACL injury. There is, however, a paucity of longitudinal studies specifically examining the lower limb musculoskeletal structural and functional changes experienced by girls throughout puberty, as well as how these changes are related to estrogen fluctuations characteristic of puberty and their effects on landing biomechanics. Therefore, further research is recommended to provide greater insight as to why pubescent girls are at an increased risk of non-contact ACL injuries during sport compared with boys. Such information will allow the development of evidence-based training pro