Sex-Specific Changes in Physical Risk Factors for Anterior Cruciate Ligament Injury by Chronological Age and Stages of Growth and Maturation From 8 to 18 Years of Age

Objective: To critically assess the literature focused on sexspecific trajectories in physical characteristics associated with anterior cruciate ligament (ACL) injury risk by age and maturational stage. Data Sources: PubMed, CINAHL, Scopus, and SPORTDiscus databases were searched through December 2021. Study Selection: Longitudinal and cross-sectional studies of healthy 8- to 18-year-olds, stratified by sex and age or maturation on ≥1 measure of body composition, lower extremity strength, ACL size, joint laxity, knee-joint geometry, lower extremity alignment, balance, or lower extremity biomechanics were included. Data Extraction: Extracted data included study design, participant characteristics, maturational metrics, and outcome measures. We used random-effects meta-analyses to examine sex differences in trajectory over time. For each variable, standardized differences in means between sexes were calculated. Data Synthesis: The search yielded 216 primary and 22 secondary articles. Less fat-free mass, leg strength, and power and greater general joint laxity were evident in girls by 8 to 10 years of age and Tanner stage I. Sex differences in body composition, strength, power, general joint laxity, and balance were more evident by 11 to 13 years of age and when transitioning from the prepubertal to pubertal stages. Sex differences in ACL size (smaller in girls), anterior knee laxity and tibiofemoral angle (greater in girls), and higher-risk biomechanics (in girls) were observed at later ages and when transitioning from the pubertal to postpubertal stages. Inconsistent study designs and data reporting limited the number of included studies. Conclusions: Critical gaps remain in our knowledge and highlight the need to improve our understanding of the relative timing and tempo of ACL risk factor development.