Non-contact Anterior Cruciate Ligament Injury Epidemiology in Team-Ball Sports: A Systematic Review with Meta-analysis by Sex, Age, Sport, Participation Level, and Exposure Type

Abstract

Background: Not all anterior cruciate ligament (ACL) injuries are preventable. While some ACL injuries are unavoidable such as those resulting from a tackle, others that occur in non-contact situations like twisting and turning in the absence of external contact might be more preventable. Because ACL injuries commonly occur in team ball-sports that involve jumping, landing and cutting manoeuvres, accurate information about the epidemiology of non-contact ACL injuries in these sports is needed to quantify their extent and burden to guide resource allocation for risk-reduction efforts.

Objective: To synthesize the evidence on the incidence and proportion of non-contact to total ACL injuries by sex, age, sport, participation level and exposure type in team ball-sports.

Methods: Six databases (MEDLINE, EMBASE, Web of Science, CINAHL, Scopus and SPORTDiscus) were searched from inception to July 2021. Cohort studies of team ball-sports reporting number of knee injuries as a function of exposure and injury mechanism were included.

Results: Forty-five studies covering 13 team ball-sports were included. The overall proportion of non-contact to total ACL injuries was 55% (95% CI 48-62, I² = 82%; females: 63%, 95% CI 53-71, I² = 84%; males: 50%, 95% CI 42-58, I² = 86%). The overall incidence of non-contact ACL injuries was 0.07 per 1000 player-hours (95% CI 0.05-0.10, I² = 77%), and 0.05 per 1000 player-exposures (95% CI 0.03-0.07, I² = 97%). Injury incidence was higher in female athletes (0.14 per 1000 player-hours, 95% CI 0.10-0.19, I² = 40%) than male athletes (0.05 per 1000 player-hours, 95% CI 0.03-0.07, I² = 48%), and this difference was significant. Injury incidence during competition was higher (0.48 per 1000 player-hours, 95% CI 0.32-0.72, I² = 77%; 0.32 per 1000 player-exposures, 95% CI 0.15-0.70, I² = 96%) than during training (0.04 per 1000 player-hours, 95% CI 0.02-0.07, I² = 63%; 0.02 per 1000 player-exposures, 95% CI 0.01-0.05, I² = 86%) and these differences were significant. Heterogeneity across studies was generally high.

Conclusion: This study quantifies several key epidemiological findings for ACL injuries in team ball-sports. Non-contact ACL injuries represented over half of all ACL injuries sustained. The proportion of non-contact to total ACL injuries and injury incidence were higher in female than in male athletes. Injuries mostly occurred in competition settings.