Clinical Sports Medicine Update

Anterior Cruciate Ligament Injury

Incidence in Adolescent Athletes
A Systematic Review and Meta-analysis
Joshua T. Bram,* BS, Lacey C. Magee,* BA, Nishank N. Mehta,* BA,
Neeraj M. Patel,y MD, MPH, MBS, and Theodore J. Ganley,*z MD
Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania, USA

Background: The incidence of anterior cruciate ligament (ACL) injuries among adolescent athletes is steadily increasing. Identi-
fication of the highest risk sports for ACL injuries by sex and competitive setting (ie, practice vs match) is important for targeting
injury prevention programs.
Purpose: To identify the risk of ACL injuries in adolescent athletes by sport, sex, and setting across a variety of common US and
international sports.
Study Design: Meta-analysis.
Methods: Essentially, 3 online databases (PubMed, Embase, and Cochrane Library) were searched for all studies of ACL injuries
per athlete-exposure (AE) or hours of exposure in adolescent athletes. Injuries were then pooled and incidence rates (IRs)
reported per 1000 AEs or hours of exposure, with the relative risk (RR) of injuries calculated for sex-comparable sports. IRs
per competitive setting (match vs practice) were also calculated.
Results: A total of 1235 ACL injuries over 17,824,251 AEs were identified (IR, 0.069 [95% CI, 0.065-0.074]), with 586 of these injuries in
girls across 6,986,683 AEs (IR, 0.084 [95% CI, 0.077-0.091]) versus 649 injuries in boys over 10,837,568 AEs (IR, 0.060 [95% CI, 0.055-
0.065]). Girls had a higher overall rate of ACL injuries (RR, 1.40 [95% CI, 1.25-1.57]), with the most disproportionate risk observed in
basketball (RR, 4.14 [95% CI, 2.98-5.76]). The risk of ACL injuries by sex was highest in girls’ soccer (IR, 0.166 [95% CI, 0.146-0.189])
and boys’ football (IR, 0.101 [95% CI, 0.092-0.111]). ACL injuries were over 8 (RR, 8.54 [95% CI, 6.46-11.30]) and 6 (RR, 6.85 [95% CI,
5.52-8.49]) times more likely to occur in a match versus a practice setting for female and male athletes, respectively.
Conclusion: The risk of ACL injuries overall approached nearly 1 per 10,000 AEs for female athletes, who were almost 1.5 times
as likely as male athletes to suffer an ACL injury across all adolescent sports. A multisport female athlete was estimated to have
a nearly 10% risk of ACL injuries over her entire high school or secondary school career. Specifically, male and female adoles-
cents playing soccer, basketball, lacrosse, and football appeared at particular risk of injuries, a finding that can be used to target
an injury intervention.
Keywords: ACL; incidence; adolescent; youth; epidemiology

z
Address correspondence to Theodore J. Ganley, MD, Children’s
Hospital of Philadelphia, 3401 Civic Center Boulevard, Wood Building,
2nd Floor, Philadelphia, PA 19104, USA (email: [email protected]). The incidence of anterior cruciate ligament (ACL) injuries
*Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA. among sports-playing youth athletes has been steadily
y
Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illi- increasing, particularly among female athletes, and was
nois, USA.
most recently estimated at over 400 tears per 100,000 per-
Submitted March 13, 2020; accepted June 3, 2020.
One or more of the authors has declared the following potential con-
son-years in adolescents.2 While a host of neuromuscular
flict of interest or source of funding: T.J.G. has received research support training programs have been instituted across a variety
from AlloSource, Vericel, and Arthrex; has received education support of sports in an effort to prevent ACL injuries,21 injury rates
from Arthrex and Liberty Surgical; and is an editor for AJSM. N.M.P. are still increasing, which could be caused by increased
has received educational support from Liberty Surgical. AOSSM checks
year-round sports participation among children, ineffective
author disclosures against the Open Payments Database (OPD). AOSSM
has not conducted an independent investigation on the OPD and dis- training programs, or incorrect application of injury pre-
claims any liability or responsibility relating thereto. vention efforts.12,32 Past studies have shown the ACL
tear risk to be highest among female soccer players and
The American Journal of Sports Medicine male football players,38 but several other sports such as
1–11
DOI: 10.1177/0363546520959619
gymnastics, rugby, and lacrosse demonstrate a similarly
Ó 2020 The Author(s) high ACL injury incidence.8,30,44

1
2 Bram et al The American Journal of Sports Medicine

Unfortunately, many studies report injury incidence activities. Age 19 years was utilized as the upper boundary
rates (IRs) per population or person-years, particularly to ensure the exclusion of the majority of collegiate athletes
among those utilizing data from large emergency depart- as well as to allow for the inclusion of internationally based
ment or billing databases such as the National Electronic (eg, Swedish) studies in which secondary school can
Injury Surveillance System.9,22 These metrics have the include children up to the age of 19 years.
downside of the inability to estimate the injury risk as it This search strategy, conducted according to PRISMA
relates to specific athlete-exposures (AEs) or time playing (Preferred Reporting Items for Systematic Reviews and
sports because these studies tend to include patients who Meta-Analyses) guidelines, generated 7087 articles for
simply report having participated in an athletic season in a title review after the removal of duplicates using a previ-
a binary manner. Additionally, many of these larger data- ously described methodology (Figure 1).4 Titles were then
bases do not explicitly report the ACL injury incidence and reviewed to eliminate those that were clearly irrelevant
instead record the rates of general ‘‘ligament’’ injuries or or non-English. Then, 1489 abstracts were scanned by 2
‘‘sprains/strains.’’ authors (J.T.B. and L.C.M.) to remove those that clearly
Older meta-analyses of adolescent ACL injury incidence did not report ACL injury rates. Abstracts receiving 1 or
have been published but failed to include studies reporting 2 ‘‘yes’’ votes were moved on to a full-text review. A thor-
injuries per hours of exposure in addition to AEs.17 Since ough review of the references of included articles was
then, several other large data sets have become available also completed by the 2 authors to identify articles missed
to clinicians for the calculation of national injury IRs, during the initial search strategy. Only studies reporting
such as the High School Reporting Information Online rates as injuries per 1000 AEs (1 game/practice) or time
(RIO) data collection tool as part of the National High (hours) were included. Articles that specifically noted
School Sports-Related Injury Surveillance Study.17 Fur- zero ACL injuries were included. Ultimately, 290 full-text
ther, these other studies were not as comprehensive in articles were reviewed.
that they did not include several increasingly common Historically, ACL injuries were specifically described as
US sports such as cheerleading and gymnastics as well either a complete or a partial tear (grade 2/3), those con-
as other international sports such as rugby or floorball, firmed via imaging or arthroscopic surgery, or those that
which might be of greater interest to readers outside of underwent reconstruction, which greatly limited our abil-
the United States.17,38 Also, they did not analyze rates by ity to include large national data sets.17 In an effort to
competitive setting. Therefore, the primary objectives of include as many studies as possible from larger national
this study were to provide updated ACL injury IRs and databases such as the RIO or the National Athletic Treat-
to identify the proportion of injuries that occur in match ment, Injury and Outcomes Network, we relied on the
versus practice settings across a variety of sports in the reported number of ACL injuries and the experience of
adolescent population. the treating athletic trainers, sports medicine physicians,
and other medical staff to ensure accurate reporting of
injuries. The RIO database is part of a large national
METHODS data set that categorizes schools based on geographic loca-
tion and size, with studies utilizing this repository being
We utilized 3 online databases (PubMed, Embase, and provided a random selection of 100 study schools to obtain
Cochrane Library) to search for all articles discussing the a nationally representative sample. Because several identi-
incidence of ACL tears in high school–aged patients as of fied studies used the RIO database and a similar sampling
October 23, 2019. Generally, ‘‘ACL’’ or ‘‘anterior cruciate of schools to evaluate overlapping sports and athletic sea-
ligament’’ was queried in addition to terms such as ‘‘inci- sons, we prioritized the inclusion of studies that addition-
dence’’ or ‘‘rate’’ and ‘‘high school’’ or ‘‘youth’’ or ‘‘adoles- ally reported injury rates by competitive setting but
cent.’’ Our specific search strategy can be found in the excluded other articles that presented overlapping data.
Appendix (available in the online version of this article). ACL injury IRs per sport were calculated by dividing
Only English-language level of evidence 1 to 2 articles pub- the pooled number of injuries by the number of exposures.
lished after the year 1990 were included. The rationale for Then, 95% CIs were calculated using the Poisson distribu-
using post-1990 studies was that school sports participa- tion. All injuries were reported as IRs per 1000 AEs or 1000
tion and adolescent athletics have drastically changed hours of exposure. For articles that did not report the total
over the past several decades, and it was thought that number of exposures or hours at risk but provided ade-
the inclusion of older studies would not make for reason- quate information for the calculation of these values (ie,
able comparisons with modern high school athletics. The provided an ACL injury count and the ACL injury rate
studies also had to include adolescent patients between per a certain number of exposures), the calculated expo-
the ages of 12 and 19 years. Articles describing the injury sure value was used for analysis. Several studies addition-
incidence in younger populations or college-aged or elite/ ally provided ACL injury rates for competitive matches and
professional athletes were excluded. This definition of ado- practices, which were reported where available to assess
lescence (12-19 years) was based on a combination of World the relative risk (RR) of injuries in match versus practice
Health Organization (10-19 years)48 and American Acad- situations. For sports commonly played in US high schools,
emy of Pediatrics (12-21 years)18 definitions. Age 12 years the per-season risk was calculated by multiplying the IR by
was thought to better represent the onset of puberty and the mean number of exposures per sports season according
the age at which adolescents begin more rigorous sporting to 2019-2020 Pennsylvania Interscholastic Athletic
AJSM Vol. XX, No. X, XXXX Incidence of ACL Tears in Adolescent Athletes 3

Figure 1. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) diagram of criteria utilized for study inclusion and
exclusion. ACL, anterior cruciate ligament.

Association (PIAA) schedules.35 All statistical analyses ACL injuries in match and practice settings were addi-
were run using SPSS Statistics Version 24.0 (IBM). A sig- tionally calculated for both male and female athletes based
nificance threshold of P \ .05 was used for all tests. on data provided in 3 studies (Table 5).23,43,47 The risks of
ACL injuries in matches and practices for girls were 0.191
(95% CI, 0.168-0.216) and 0.022 (95% CI, 0.017-0.029),
respectively, corresponding to an overall RR of 8.54 (95%
RESULTS CI, 6.46-11.30). In boys, the comparable rates were 0.174
(95% CI, 0.154-0.196) for matches and 0.025 (95% CI,
A total of 26 articles were identified that reported the ACL
0.021-0.030) for practices, yielding an overall RR of 6.85
injury incidence in high school–aged athletes across 14
(95% CI, 5.52-8.49). PIAA standard season lengths were
sports given a certain number of AEs or hours of exposure
determined for all varsity sports where possible, varying
(Table 1). Overall, 16 studies described injuries specifically
from approximately 11 (track and field) to 15 (basketball)
in high school athletes and 10 studies reported ACL inju-
weeks (Table 6). Using a mean of 6 practice or game expo-
ries in a similarly aged adolescent population. There
sures per week, as is standard in Pennsylvania, calculated
were 3 studies that included .1 million AEs.23,40,42
AEs per season ranged from 69 to 93 per athlete. The per-
Across 18 studies (Table 2), there were 1235 ACL inju-
season ACL injury risk (expressed as a percentage risk per
ries in 17,824,251 AEs (IR, 0.069 [95% CI, 0.065-0.073]).
athlete) ranged from 0.11% (track and field) to 1.21% (soc-
Of these, 586 injuries were in girls over 6,986,683 AEs
cer) in girls and from 0.03% (track and field) to 0.82% (foot-
(IR, 0.084 [95% CI, 0.077-0.091]), and 649 injuries were
ball) in boys.
in boys over 10,837,568 AEs (IR, 0.060 [95% CI, 0.055-
0.065]). There was a significantly higher rate of ACL inju-
ries in girls (Table 3), with a calculated RR of ACL injuries Basketball
overall for girls to boys of 1.40 (95% CI, 1.25-1.57). More-
over, 15 studies (Table 4) reported 131 ACL injuries over We identified 8 studies on ACL injuries in adolescent bas-
2,398,310 hours of exposure (IR, 0.055 [95% CI, 0.046- ketball athletes.3,15,19,23,28,36,40,45 Across 7 studies, there
0.065]), with 64 injuries over 858,388 hours in girls (IR, were 165 ACL injuries over 1,501,789 AEs (IR, 0.110
0.075 [95% CI, 0.057-0.095]) and 67 injuries across [95% CI, 0.094-0.128]) for girls and 45 ACL injuries over
1,538,922 hours in boys (IR, 0.044 [95% CI, 0.034-0.055]). 1,696,441 AEs (IR, 0.027 [95% CI, 0.019-0.035]) for boys
This led to a calculated RR of 1.71 (95% CI, 1.22-2.41). (Figure 2).3,19,23,28,36,40,45 The RR of ACL injuries in girls
4 Bram et al The American Journal of Sports Medicine

TABLE 1
Study Characteristicsa

Author (Year) Country/State LOE Study Topic Age Level No. of Seasons Exposure Type

Beynnon3 (2014) Vermont 2 Injury incidence HS 4 AE

Clifton6 (2017) USA 2 Injury incidence HS 2 AE
DeLee10 (1992) Texas 2 Injury incidence HS 1 AE and hours
Hewett19 (1999) Ohio 2 Injury intervention HS 1 AE
Joseph23 (2013) USA 2 Injury incidence HS 5 AE
Kerr25 (2016) Indiana, Massachusetts, 2 Injury incidence A 1 AE
South Carolina, Virginia
Kiani26 (2010) Sweden 2 Injury intervention A 1 AE and hours
Mandelbaum27 (2005) California 2 Injury intervention A 2 AE
Messina28 (1999) Texas 2 Injury incidence HS 1 AE and hours
Pasque34 (2000) Oklahoma 2 Injury incidence HS 1 AE and hours
Pfeiffer36 (2006) Idaho 2 Injury intervention HS 2 AE
Stanley40 (2016)b USA 2 Injury incidence HS 3 AE
Steffen41 (2008) Norway 1 Injury intervention A 1 AE and hours
Swenson42 (2013)b USA 2 Injury incidence HS 7 AE
Tadlock43 (2019) USA 2 Injury incidence HS 9 AE
Tsuda45 (2013)b Japan 2 Injury incidence HS 1 AE and hours
Turbeville46 (2003) Oklahoma 2 Injury incidence HS 2 AE
Walden47 (2012) Sweden 1 Injury intervention A 1 AE and hours
Brito5 (2012) Portugal 2 Injury incidence A 1 Hours
Froholdt13 (2009) Norway 2 Injury incidence A 1 Hours
Gomez15 (1996) Texas 2 Injury incidence HS 1 Hours
Gomez16 (1998) Texas 2 Injury incidence HS 1 Hours
Junge24 (2004) New Zealand 2 Injury incidence A 1 Hours
Palmer-Green33 (2013) UK 2 Injury incidence A 2 Hours
Soderman39 (2001) Sweden 2 Injury incidence A 1 Hours
Takazawa44 (2016)b Japan 2 Injury incidence HS 11 Hours

a
A, adolescent or youth; AE, athlete-exposure; HS, high school aged; LOE, level of evidence.
b
Determination of AEs or hours required calculation from provided injury totals and injuries per exposure.

versus boys was 4.14 (95% CI, 2.98-5.76), with a per-season over 12 weeks, which resulted in a mean of 73 AEs per sea-
risk in girls and boys of 1.03% and 0.25%, respectively, based son per player. This led to a calculated per-season risk of
on a mean of 93 AEs over a nearly 16-week season. One study ACL injuries of 0.25%.
reported ACL injuries in match (female IR, 0.266; male IR,
0.055) and practice (female IR, 0.033; male IR, 0.009) set- Football
tings, yielding an RR of 7.93 (95% CI, 4.88-12.91) in girls
and 6.09 (95% CI, 2.55-14.59) in boys for match to practice Ultimately, 6 studies (5 reporting or allowing for the calcu-
ACL injuries.23 Also, 3 studies reported ACL injuries per lation of rates per AE) evaluated ACL injuries in male ado-
hours, yielding 38 injuries over 568,530 hours in girls lescent football players.3,6,10,16,23,46 There were 435 ACL
(IR, 0.067 [95% CI, 0.048-0.092]) and 4 injuries over injuries resulting from 4,301,319 AEs (IR, 0.101 [95% CI,
169,885 hours (IR, 0.024 [95% CI, 0.006-0.060]) in boys.15,28,45 0.092-0.111]), with a per-season risk of 0.82% based on
a typical season lasting just under 14 weeks for a mean
Cheerleading of 81 AEs. Additionally, 2 studies reported injuries per
hours of exposure, totaling 40 injuries over 732,552 hours
Only 1 study examined the ACL injury incidence in girls’ (IR, 0.055 [95% CI, 0.039-0.074]).10,16 Again, 1 study of
cheerleading, with 5 ACL injuries over 365,584 AEs (IR, .2 million AEs reported ACL injuries per match (IR,
0.014 [95% CI, 0.005-0.030]).42 There were no studies on 0.467 [95% CI, 0.404-0.537]) and per practice (IR, 0.041
the rate in male athletes, and the per-season risk could [95% CI, 0.033-0.050]).23 The RR of ACL injuries compar-
not be calculated, as cheerleading is not a varsity sport ing matches with practices was calculated as 11.45 (95%
according to the PIAA. CI, 8.91-14.72).

Field Hockey Gymnastics

Overall, 2 studies evaluated ACL injuries in girls’ field A single study reported ACL injuries in female gymnasts,
hockey, with a total of 14 injuries across 402,095 AEs with a calculated 7 ACL injuries occurring over 61,466
(IR, 0.035 [95% CI, 0.019-0.058]).3,42 A high school field AEs (IR, 0.114 [95% CI, 0.046-0.235]) for a per-season
hockey season for 2019-2020 in Pennsylvania lasted just risk of 1.01%.42
AJSM Vol. XX, No. X, XXXX Incidence of ACL Tears in Adolescent Athletes 5

TABLE 2
Studies Reporting Incidence of ACL Injuries by Sex and Sport per 1000 AEs (1 Game or Practice)a

Female Male

Sport and Author (Year) ACL Injuries Exposures Incidence ACL Injuries Exposures Incidence RR

Basketball
Beynnon3 (2014) 6 98,296 0.061 4 108,622 0.037 1.66
Hewett19 (1999) 3 10,370 0.289 0 13,039 0.000 —
Joseph23 (2013) 92 894,391 0.103 25 1,106,060 0.023 4.55
Messina28 (1999) 11 85,440 0.129 4 105,084 0.038 3.38
Pfeiffer36 (2006) 2 18,076 0.111 — — — —
Stanley40 (2016) 35 289,256 0.121 12 363,636 0.033 3.67
Tsuda45 (2013) 16 105,960 0.151 — — — —
Total 165 1,501,789 0.110 45 1,696,441 0.027 4.14
Cheerleading
Swenson42 (2013) 5 365,854 0.014 — — — —
Field hockey
Beynnon3 (2014) 4 82,946 0.048 — — — —
Swenson42 (2013) 10 319,149 0.031 — — — —
Total 14 402,095 0.035 — — — —
Football
Beynnon3 (2014) — — — 8 114,233 0.070 —
Clifton6 (2017) — — — 98 1,233,637 0.079 —
DeLee10 (1992) — — — 37 331,562 0.112 —
Joseph23 (2013) — — — 286 2,580,637 0.111 —
Turbeville46 (2003) — — — 6 41,250 0.146 —
Total — — — 435 4,301,319 0.101 —
Gymnastics
Swenson42 (2013) 7 61,466 0.114 — — — —
Ice hockey
Swenson42 (2013) — — — 2 220,721 0.009 —
Lacrosse
Beynnon3 (2014) 6 86,160 0.070 7 121,583 0.058 1.21
Kerr25 (2016) — — — 0 8766 0.000 —
Stanley40 (2016) 32 101,266 0.316 22 166,667 0.132 2.39
Swenson42 (2013) — — — 27 339,552 0.079 —
Tadlock43 (2019) 69 769,153 0.090 — — — —
Total 107 956,579 0.112 56 636,568 0.088 1.28
Soccer
Beynnon3 (2014) 15 114,077 0.131 3 117,140 0.026 5.31
Hewett19 (1999) 2 9017 0.222 1 8513 0.118 1.89
Joseph23 (2013) 96 786,293 0.122 44 914,551 0.048 2.54
Kiani26 (2010) 5 47,124 0.106 — — — —
Mandelbaum27 (2005) 67 137,448 0.488 — — — —
Pfeiffer36 (2006) 1 9357 0.107 — — — —
Stanley40 (2016) 31 173,184 0.179 19 208,791 0.091 1.97
Steffen41 (2008) 5 45,471 0.110 — — — —
Walden47 (2012) 14 97,161 0.109 — — — —
Total 236 1,419,132 0.166 67 1,248,995 0.054 3.10
Softball/baseball
Joseph23 (2013) 21 657,246 0.032 6 861,964 0.007 4.59
Stanley40 (2016) 1 142,857 0.007 5 208,333 0.024 0.29
Total 22 800,103 0.028 11 1,070,297 0.010 2.68
Track and field
Swenson42 (2013) 10 623,077 0.016 4 781,609 0.005 3.20
Volleyball
Hewett19 (1999) 0 3751 0.000 — — — —
Joseph23 (2013) 20 841,608 0.024 — — — —
Pfeiffer36 (2006) 0 11,229 0.000 — — — —
Swenson42 (2013) — — — 0 35,714 0.000 —
Total 20 856,588 0.023 0 35,714 0.000 —

(continued)
6 Bram et al The American Journal of Sports Medicine

TABLE 2
(continued)

Female Male

Sport and Author (Year) ACL Injuries Exposures Incidence ACL Injuries Exposures Incidence RR

Wrestling
Joseph23 (2013) — — — 27 809,430 0.033 —
Pasque34 (2000) — — — 2 36,473 0.055 —
Total — — — 29 845,903 0.034 —
Overall total 586 6,986,683 0.084 649 10,837,568 0.060 1.40

a
Athletic exposures do not perfectly sum because of rounding of non-integer AE totals. Dashes indicate no available data. ACL, anterior
cruciate ligament; AE, athlete-exposure; RR, relative risk.

TABLE 3
IR and Per-Season Risk of ACL Injuries by Sex and Sport per 1000 AEsa

Female Male

Sport IR (95% CI) Per-Season Risk, % IR (95% CI) Per-Season Risk, % RR (95% CI)

Basketball 0.110 (0.094-0.128) 1.03 0.027 (0.019-0.035) 0.25 4.14 (2.98-5.76)

Cheerleading 0.014 (0.005-0.030) — — — —
Field hockey 0.035 (0.019-0.058) 0.25 — — —
Football — — 0.101 (0.092-0.111) 0.82 —
Gymnastics 0.114 (0.046-0.235) 1.01 — — —
Ice hockey — — 0.009 (0.001-0.033) — —
Lacrosse 0.112 (0.092-0.135) 0.81 0.088 (0.066-0.114) 0.64 1.28 (0.92-1.76)
Soccer 0.166 (0.146-0.189) 1.21 0.054 (0.042-0.068) 0.39 3.10 (2.36-4.07)
Softball/baseball 0.028 (0.017-0.042) 0.21 0.010 (0.005-0.018) 0.08 2.68 (1.30-5.52)
Track and field 0.016 (0.008-0.029) 0.11 0.005 (0.001-0.013) 0.03 3.20 (1.00-10.31)
Volleyball 0.023 (0.014-0.036) 0.17 0.000 (—) — —
Wrestling — — 0.034 (0.023-0.049) 0.32 —
Total 0.084 (0.077-0.091) — 0.060 (0.055-0.065) — 1.40 (1.25-1.57)

a
Dashes indicate no available data. ACL, anterior cruciate ligament; AE, athlete-exposure; IR, incidence rate; RR, relative risk.

Ice Hockey 0.008-0.032), for an RR of 14.85 (95% CI, 7.37-29.91) per

1000 AEs.43
One study examined the ACL injury incidence in male ado-
lescent ice hockey players per AE.42 There were 2 injuries
that occurred over 220,721 AEs (IR, 0.009 [95% CI, 0.001- Rugby
0.033]). Ice hockey is not a varsity sport in the state of Penn-
There were 3 studies of high school–aged male rugby play-
sylvania, and therefore, no per-season risk was calculated.
ers that reported 20 ACL injuries over 409,219 hours of
exposure (IR, 0.049 [95% CI, 0.030-0.075]).24,33,44

Lacrosse
Soccer
A total of 5 articles reviewed ACL injuries in adolescent
lacrosse athletes.3,25,40,42,43 For female athletes, there A total of 13 studies reported on ACL injuries in adolescent
were 107 ACL injuries over 956,579 AEs (IR, 0.112 [95% soccer players.§ Overall, 9 articles did so in regard to AEs,
CI, 0.092-0.135]) versus 56 injuries across 636,568 AEs with 236 female ACL injuries over 1,419,132 AEs (IR,
for male athletes (IR, 0.088 [95% CI, 0.066-0.114]). These 0.166 [95% CI, 0.146-0.189]) and 67 male ACL injuries
findings led to calculated per-season ACL injury risks of across 1,248,995 AEs (IR, 0.054 [95% CI, 0.042-0.068]) for
0.81% and 0.64% for girls and boys (mean length of 12 a calculated RR of 3.10 (95% CI, 2.36-4.07).|| The per-
weeks or 73 AEs), respectively, or an RR of 1.28 (95% CI, season risk over a 12-week soccer season and a mean of
0.92-1.76) when comparing girls with boys. One study
reported lacrosse-related ACL injuries per match and per
practice in girls, with a per-match rate of 0.252 (95% CI, §
References 3, 5, 13, 19, 23, 24, 26, 27, 36, 39-41, 47.
||
0.192-0.324) and a per-practice rate of 0.017 (95% CI, References 3, 19, 23, 26, 27, 36, 40, 41, 47.
AJSM Vol. XX, No. X, XXXX Incidence of ACL Tears in Adolescent Athletes 7

TABLE 4
Studies Reporting Incidence of ACL Injuries by Sex and Sport per 1000 Hours of Exposurea

Female Male

Sport and Author (Year) ACL Injuries Exposures Incidence ACL Injuries Exposures Incidence RR

Basketball
Gomez15 (1996) 11 107,353 0.103 — — — —
Messina28 (1999) 11 120,751 0.091 4 169,885 0.024 3.87
Tsuda45 (2013) 16 340,426 0.047 — — — —
Total 38 568,530 0.067 4 169,885 0.024 2.84
Football
DeLee10 (1992) — — — 37 717,345 0.052 —
Gomez16 (1998) — — — 3 15,207 0.197 —
Total — — — 40 732,552 0.055 —
Rugby
Junge24 (2004) — — — 1 6876 0.145 —
Palmer-Green33 (2013) — — — 3 2343 1.280 —
Takazawa44 (2016) — — — 16 400,000 0.040 —
Total — — — 20 409,219 0.049 —
Soccer
Brito5 (2012) — — — 1 161,850 0.006 —
Froholdt13 (2009) 1 16,855 0.059 — — — —
Junge24 (2004) — — — 0 9353 0.000 —
Kiani26 (2010) 5 66,505 0.075 — — — —
Soderman39 (2001) 1 11,689 0.086 — — — —
Steffen41 (2008) 5 65,725 0.076 — — — —
Walden47 (2012) 14 129,084 0.109 — — — —
Total 26 289,858 0.090 1 171,203 0.006 15.36
Wrestling
Pasque34 (2000) — — — 2 56,065 0.036 —
Overall total 64 858,388 0.075 67 1,538,922b 0.044 1.71

a
Athletic exposures do not perfectly sum because of rounding of non-integer AE totals. Dashes indicate no available data. ACL, anterior
cruciate ligament; RR, relative risk.
b
Hours do not perfectly sum because of rounding of non-integer hour totals.

73 AEs per player was calculated as 1.21% for girls and 0.08% in boys. One study recorded injuries per match or
0.39% for boys. Furthermore, 7 articles recorded ACL practice.23 There were 0.057 (95% CI, 0.031-0.098) and
injuries per hours of exposure, totaling 26 injuries in 0.010 (95% CI, 0.002-0.029) ACL injuries per match for
289,858 hours of play for girls (IR, 0.090 [95% CI, 0.059- girls and boys, respectively, versus 0.019 (95% CI, 0.008-
0.131]) and 1 injury across 171,203 hours for boys (IR, 0.037) and 0.005 (95% CI, 0.001-0.016) per practice. The
0.006 [95% CI, 0.000-0.033]).5,13,24,26,39,41,47 Also, 2 studies calculated RR of match to practice ACL injuries was 3.10
reported soccer-related ACL injuries per match (female IR, (95% CI, 1.28-7.48) for girls and 1.83 (95% CI, 0.37-9.08)
0.308 [95% CI, 0.248-0.378]; male IR, 0.129 [95% CI, 0.090- for boys.
0.179]) and per practice (female IR, 0.031 [95% CI, 0.018-
0.049]; male IR, 0.014 [95% CI, 0.006-0.027]).23,47 The RR
Track and Field
of ACL injuries per 1000 AEs between matches and practi-
ces was 10.00 (95% CI, 6.03-16.56) for girls and 9.22 (95% There was only 1 study on ACL injuries in track and field
CI, 4.43-19.18) for boys. athletes, allowing for a calculated 10 ACL injuries over
623,077 AEs (IR, 0.016 [95% CI, 0.008-0.029]) for girls
Softball/Baseball and 4 injuries over 781,609 AEs (IR, 0.005 [95% CI,
0.001-0.013]) for boys, for an RR of 3.20 (95% CI, 1.00-
There were 2 articles that studied ACL injuries in baseball 10.31).42 These rates corresponded to a per-season risk
(male) or softball (female).23,40 These sports were grouped (an 11-week and 4-day season, amounting to 69 AEs per
for analysis given the similarities in gameplay. There athlete) of 0.11% in girls and 0.03% in boys.
were 22 ACL injuries over 800,103 AEs (IR, 0.028 [95%
CI, 0.017-0.042]) in girls and 11 injuries in 1,070,297 AEs
(IR, 0.010 [95% CI, 0.005-0.018]) for boys (RR, 2.68 [95% Volleyball
CI, 1.30-5.52]). Baseball and softball seasons were 13
weeks in length, resulting in 78 AEs per player, leading Overall, 3 articles reported 20 ACL injuries over 856,588
to a calculated per-season risk of 0.21% in girls and AEs (IR, 0.023 [95% CI, 0.014-0.036]) in female volleyball
8 Bram et al The American Journal of Sports Medicine

TABLE 5
IR of ACL Injuries by Sex and Sport per 1000 Game and Practice Exposuresa
Female Male

Sport Game IR (95% CI) Practice IR (95% CI) RR (95% CI) Game IR (95% CI) Practice IR (95% CI) RR (95% CI)

Basketball 0.266 (0.207-0.335) 0.033 (0.021-0.051) 7.93 (4.88-12.91) 0.055 (0.032-0.087) 0.009 (0.004-0.019) 6.09 (2.55-14.59)
Football — — — 0.467 (0.404-0.537) 0.041 (0.033-0.050) 11.45 (8.91-14.72)
Lacrosse 0.252 (0.192-0.324) 0.017 (0.008-0.032) 14.85 (7.37-29.91) — — —
Soccer 0.308 (0.248-0.378) 0.031 (0.018-0.049) 10.00 (6.03-16.56) 0.129 (0.090-0.179) 0.014 (0.006-0.027) 9.22 (4.43-19.18)
Softball/baseball 0.057 (0.031-0.098) 0.019 (0.008-0.037) 3.10 (1.28-7.48) 0.010 (0.002-0.029) 0.005 (0.001-0.016) 1.83 (0.37-9.08)
Volleyball 0.053 (0.029-0.087) 0.009 (0.003-0.021) 5.87 (2.13-16.15) — — —
Wrestling — — — 0.065 (0.036-0.109) 0.022 (0.017-0.037) 2.97 (1.40-6.32)
Total 0.191 (0.168-0.216) 0.022 (0.017-0.029) 8.54 (6.46-11.30) 0.174 (0.154-0.196) 0.025 (0.021-0.030) 6.85 (5.52-8.49)

a
Dashes indicate no available data. ACL, anterior cruciate ligament; IR, incidence rate; RR, relative risk.

TABLE 6 ACL injury risk in female volleyball players was 0.17%.

High School Sports Seasons One study found a per-match ACL injury rate of 0.053
Season Length,a Athlete-Exposuresb
(95% CI, 0.029-0.087) versus a per-practice rate of 0.009
Sport Weeks 1 Days per Season (95% CI, 0.003-0.021) in girls, for an RR of 5.87 (95% CI,
2.13-16.15).23
Baseball/softball 13 1 0 78
Basketball 15 1 4 93
Field hockey 12 1 1 73 Wrestling
Football 13 1 4 81
Gymnastics 14 1 5 88 There were 2 studies that described ACL injuries in male
Lacrosse 12 1 1 73 adolescent wrestlers, with a total of 29 injuries over
Soccer 12 1 1 73 845,903 AEs (IR, 0.034 [95% CI, 0.023-0.049]).23,34 For
Track and field 11 1 4 69
a 15-week (93 AEs) season, the calculated per-season risk
Volleyball 12 1 1 73
Wrestling 15 1 3 93
was 0.32%. One study also reported 2 ACL injuries over
56,065 hours of exposure (IR, 0.036 [95% CI, 0.040-
a
Calculated as time from first practice to first playoff game 0.129]).34 One study reported per-match (IR, 0.065 [95%
according to 2019-2020 Pennsylvania Interscholastic Athletic CI, 0.036-0.109]) and per-practice (IR, 0.022 [95% CI,
Association schedules. 0.017-0.037]) ACL injury rates, allowing for the calculation
b
Calculated based on a mean of 6 practices or games (estimated) of an overall RR of 2.97 (95% CI, 1.40-6.32).23
per week.

DISCUSSION
As the rate of sports participation increases among teen-
agers, adolescent athletes are at a progressively higher
risk of ACL injuries today than during the 1990s. Thus,
it is important for coaches and physicians to be knowledge-
able on how to recognize and diagnose ACL tears, as con-
tinued play with a torn ACL can result in further
injuries to the meniscus and cartilage of the knee.11 Iden-
tification of the highest risk sports can aid in targeting
injury prevention programs toward athletes who will ben-
efit most from them. We sought to determine the likelihood
of ACL injuries based on sex, sport played, and competitive
setting in adolescent athletes in an effort to identify possi-
ble intervention points.
Figure 2. Incidence of anterior cruciate ligament injuries per In total, we identified over 1200 ACL injuries across
1000 athlete-exposures by sex and sport. .15 million AEs and 12 individual sports. Girls experi-
enced a nearly 1.4-fold higher rate of ACL injuries com-
pared with boys, likely based on the many reported risk
players, while 1 study reported zero ACL injuries over factors for an ACL injury in female athletes such as
35,714 AEs (IR, 0.000) in male players.19,23,36,42 Over smaller notch width, genu valgum, greater anterior tibial
a 12-week regular season and 73 AEs, the per-season laxity, and lower hamstring strength.14 The RR of ACL
AJSM Vol. XX, No. X, XXXX Incidence of ACL Tears in Adolescent Athletes 9

injuries for female versus male athletes in sex-comparable high-risk sports for the implementation of neuromuscular
sports in our study ranged from 1.28 in lacrosse to 3.10 in training programs for ACL injury prevention as opposed
soccer and 4.14 in basketball. These are comparable with to targeting only female athletes, as athletes of both sexes
rates observed in collegiate athletes, with Prodromos can be considered high risk.
et al37 noting an approximate 3-fold higher RR seen in To further complement the relatively limited literature
female compared with male athletes, while Beynnon on this topic, we calculated ACL injury rates both per AE
et al3 observed a 2.1-fold RR. Although these are higher and per hours of exposure, which allowed for the inclusion
than the 1.4-fold disparity that we saw in our population, of an additional 8 studies. Although the RR of ACL injuries
our RR across all sports was approximately equivalent to between male and female athletes based on AEs was 1.40,
the 1.6 RR observed in a similar meta-analysis by Gor- the calculated RR between sexes based on hours of expo-
nitzky et al.17 This discrepancy is likely a result of pooling sure was higher at 1.71. Interestingly, the injury rate per
noncomparable male sports such as football and wrestling, hour and AE was similar for girls (0.075 and 0.084, respec-
which have high rates of ACL injuries. It is thought that as tively) but was lower per hour compared with per AE in
the female athlete matures and her level of play increases boys (0.044 vs 0.060, respectively). This discrepancy could
(ie, collegiate or professional athletics), the RR of ACL inju- be because male and female practices and games may dif-
ries compared with male athletes decreases, while the fer in average length of time across all studies and by
overall risk of injuries for both male and female athletes sport, although these data were not available for review.
increases over 2-fold from the high school to professional Nevertheless, while injuries per hour calculations were
level.38 based on fewer exposures (~900,000 hours of exposure vs
Soccer and gymnastics had the highest rates of ACL ~7 million AEs in girls) and perhaps represent a less accu-
injuries in female adolescent athletes. For male athletes, rate estimate of the ACL injury risk, the inclusion of other
football was found to have the highest risk of ACL injuries. international sports in our study, such as rugby, is impor-
After soccer and football, other high-risk sports for both tant for a country with an increasingly diverse population.
sexes included lacrosse and basketball, along with wres- Further, injuries per hour rather than AE is useful for
tling and soccer for boys and field hockey for girls, which application to sports without standard seasons or those
has been reported similarly in previous studies.29 The low- that more typically involve year-round play.
est ACL injury rates were observed in cheerleading for In addition to examining the ACL risk per sport and
girls, volleyball for boys, and track and field for both sexes. sex, a limited number of studies have reported ACL inju-
Joseph et al23 also found that while female high school stu- ries in different competitive settings. Based on these
dents had an increased overall rate of ACL injuries com- articles, it was found that athletes were much more likely
pared with male students, football players had among to sustain injuries to their ACL during competitive game-
the highest rates of ACL injuries, behind only girls’ soccer, play compared with practices. Specifically, girls were
in the 9 sports that they included in their study. It should nearly 9 times as likely to suffer an ACL injury during
be noted that for sports such as track and field and cheer- a game compared with a practice, while boys were nearly
leading in which athletes do not participate in the same 7 times as likely. These rates are even greater than those
events (eg, track vs field) or activities (eg, flyer vs catcher), reported by Hootman et al,20 who found a nearly 3-fold
there may be differences in ACL injuries for jumpers and higher rate of injuries in match versus practice settings,
pole vaulters compared with sprinters. Other sports such and similar to those reviewed by Barber Foss et al1 in
as football and/or soccer may similarly observe different female lacrosse athletes. However, the rates of ACL inju-
rates of ACL injuries for running backs or midfielders com- ries in match settings have been shown to be as high as
pared with linemen and goalkeepers. However, this was 50 times greater compared with in training.31 The
not able to be stratified for analysis in this study as the observed higher rate of injuries during match settings is
included articles did not address these differences, but consistent with what is likely a greater intensity of athletic
which could be evaluated in future research endeavors. activity during games compared with practices. Practices
Despite the relatively few studies on the ACL injury more often involve noncontact drills, frequent breaks,
incidence in adolescent athletes, many previous articles and lowered aggressiveness, all factors that may assist in
have focused on these injuries at the collegiate level. The preventing ACL injuries.
IRs of ACL injuries for nearly all included sports were It is also important to be aware of the ACL injury
lower than those reported in collegiate athletes by Prodro- risk per season, particularly when counseling patients
mos et al37 and Renstrom et al.38 Specifically, female about the RR of injuries when choosing between sports.
lacrosse and soccer ACL IRs per 1000 AEs for athletes in Using PIAA guidelines, typical season lengths of 3 to 4
our study were 0.112 and 0.166 compared with 0.18 and months were calculated where possible.35 Assuming
0.32 in the studies of Prodromos et al and 0.17 and 0.28 a mean of 6 practice or game exposures per week as the
in Renstrom et al for female collegiate lacrosse and soccer standard in Pennsylvania, the mean number of AEs per
athletes, respectively. Interestingly, our IRs were higher season ranged from 69 to 93 per athlete. The risk of ACL
for certain sports such as wrestling compared with the injuries per season for girls was highest in sports such as
study by Prodromos et al (0.034 vs 0.019, respectively). soccer (1.21%) and basketball (1.03%) but dropped to as
Overall, at the collegiate level, lacrosse for both sexes, low as 0.11% in track and field. The per-season risk of
women’s gymnastics and soccer, and men’s football had ACL injuries ranged from 0.03% (track and field) to
the highest risk.38 Therefore, it is important to target 0.82% (football) in boys.
10 Bram et al The American Journal of Sports Medicine

Per-season rates are even more useful when considering CONCLUSION

young athletes who participate in several different sports
within 1 season or several different seasons of sports per This study serves to demonstrate the high rate of ACL
year. Specifically, some sports such as gymnastics and injuries in adolescent athletes while accounting for sex
cheerleading include nearly year-round competition. As and sports differences. Additionally, this study is able to
previously described by Gornitzky et al,17 per-season risks provide useful information on the risk in different compet-
of ACL injuries for individual sports can be added together itive settings, the per-season risk, and the risk per hour of
for athletes participating in 2 or 3 sports seasons (eg, fall, sports exposure. Female athletes had a 1.4-fold increased
winter, spring) annually. For female atheltes, the highest risk of ACL tears per AE compared with male athletes,
risk combination of sports in Pennsylvania per year would although male football players saw the highest number of
be fall soccer, winter basketball, and spring lacrosse (1.21% overall ACL injuries given their .4 million pooled AEs.
1 1.03% 1 0.81% = 3.05%), leading to a greater than 12% The results of this study can help trainers and schools tar-
risk of ACL tears over a 4-year high school career. In boys, get intervention programs toward injury reduction in high-
an athlete who participates in fall football, winter basket- risk athletes and sports as well as provide a format for
ball, and spring lacrosse (0.82% 1 0.25% 1 0.64% = developing similar studies looking at ACL injury rates in
1.71%) will have a nearly 7% chance of incurring ACL inju- other age groups.
ries during high school. This risk does not even consider
that the summers between seasons host many nearly
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