Butcher Et Al VOR

Central Lancashire Online Knowledge (CLoK)
Title Maturation and biomechanical risk factors associated with Anterior cruciate
ligament injury: Is there a link? A systematic review
Type Article
URL https://clok.uclan.ac.uk/51750/
DOI ##doi##
Date 2024
Citation Butcher, Anna J, Ward, Sarah, Clissold, Tracey, Richards, James orcid
iconORCID: 0000-0002-4004-3115 and Hébert-Losier, Kim (2024)
Maturation and biomechanical risk factors associated with Anterior cruciate
ligament injury: Is there a link? A systematic review. Physical Therapy in
Sport, 68 . pp. 31-50. ISSN 1466-853X
Creators Butcher, Anna J, Ward, Sarah, Clissold, Tracey, Richards, James and Hébert-
Losier, Kim
It is advisable to refer to the publisher’s version if you intend to cite from the work. ##doi##
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Physical Therapy in Sport 68 (2024) 31–50
Contents lists available at ScienceDirect
Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp
Maturation and biomechanical risk factors associated with anterior cruciate

ligament injury: Is there a link? A systematic review
Anna J. Butcher a, * , Sarah Ward b , Tracey Clissold c , Jim Richards d , Kim Hébert-Losier a
a
Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Adams Centre for High Performance, 52 Miro
Street, 3116, Tauranga, New Zealand
b
Department of Exercise Sciences, University of Auckland, Suiter Street, Newmarket, New Zealand
c
Toi Ohomai Institute of Technology, 70 Windermere Drive, Poike, 3112, Tauranga, New Zealand
d
Allied Health Research Unit, University of Central Lancashire, Preston, England, United Kingdom
A R T I C L E I N F O A B S T R A C T
Handling Editor: Dr L Herrington Objective: To establish the potential link between sex-specific maturation and biomechanical factors associated
with ACL injury during dynamic tasks.
Keywords: Design: Systematic review.
Biomechanics Literature search: Five databases (CINHAL®, Cochrane Library, PubMed®, Scopus®, and SPORTDiscus) were
ACL
searched and monitored until 27 May 2024.
Injury risk
Study selection criteria: Cross-sectional, cohort, case-control, or interventional studies reporting one or more
Pubertal development
biomechanical variable linked with ACL injury and which assessed participants across two or more maturation
phases were considered eligible.
Data synthesis: Studies were assessed for risk of bias using a modified version of the Newcastle Ottawa Scale and
overall quality of evidence was rated using GRADE. Metrics and effect sizes were presented where available.
Results: Eighteen included studies examined 400 males, 1377 females, and 315 participants of undefined sex
across various maturation phases. The methodological quality of most studies (n = 16) was considered good, and
satisfactory for two. Knee abduction angle, knee abduction moment, knee flexion angle, and ground reaction
forces were most commonly reported. Knee abduction angles and moments and knee flexion angles were greater
in late and post-pubertal females than males and pre-pubertal females during both landing and cutting tasks.
When normalised for body mass, ground reaction forces were generally greater in males compared to females
overall and for less mature participants for both sexes. Overall quality of evidence was low or medium across the
four biomechanical measures.
Conclusion: Sex-specific maturation considerations are important in the targeted development and imple
mentation of ACL injury risk identification and prevention strategies.
1. Background (5–14 years) has also increased over the last 20 years in Australia, rising
10.4% in females and 7.3% in males (Maniar, Verhagen, Bryant, & Opar,
Anterior cruciate ligament (ACL) injury is one of the most common 2022). Although increases are apparent for both sexes, female athletes
and debilitating injuries among young athletes (Renstrom et al., 2008). demonstrate a two-to-four times greater incidence of non-contact ACL
Following the onset of puberty, ACL injury incidence rate in females injury and a younger average age of ACL injury than males across
appears to peak between the ages of 15–19 (Maniar et al., 2022; multiple sports and competition levels (Prodromos, Han, Rogowski,
Renstrom et al., 2008; Shea et al., 2004; Zbrojkiewicz et al., 2018). The Joyce, & Shi, 2007; Waldén, Hägglund, Werner, & Ekstrand, 2011).
annual incidence of ACL rupture in those under 25 years in Australia has Experts have suggested that prior to puberty, ACL injury rates are
increased by 74% over a 15-year period (Zbrojkiewicz, Vertullo, & similar between sexes (Shea, Pfeiffer, Wang, Curtin, & Apel, 2004) and
Grayson, 2018). Annual rates of ACL injuries at an even younger age lower than post-puberty (Shea et al., 2004; Slauterbeck, Hickox,
* Corresponding author.
E-mail address: [email protected] (A.J. Butcher).
@annajbutcher (A.J. Butcher), @sarahward_nz (S. Ward), @ProfJimRichards (J. Richards), @KimHebertLosier (K. Hébert-Losier)
https://doi.org/10.1016/j.ptsp.2024.06.002
Received 10 April 2024; Received in revised form 9 June 2024; Accepted 10 June 2024
Available online 14 June 2024
1466-853X/© 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A.J. Butcher et al. Physical Therapy in Sport 68 (2024) 31–50
Beynnon, & Hardy, 2006; Wild, Steele, & Munro, 2012). Furthermore, International Prospective Register of Systematic Reviews (PROSPERO;
pre-puberty, lower-extremity biomechanics (Wild et al., 2012), neuro registration ID: CRD42022345627).
muscular function (DiStefano et al., 2015), and ACL morphology [e.g.,
size, length, and cross-sectional area (Hosseinzadeh & Kiapour, 2021)] 2.1. Searches
are similar between sexes. Rapid skeletal growth; changes in body mass,
anatomy, and posture; and a lack of sufficient concomitant neuromus The electronic databases CINHAL®, Cochrane Library, PubMed®,
cular adaptations all likely contribute to the development of movement Scopus®, and SPORTDiscus were searched on 13 July 2022. These da
patterns associated with increased ACL injury risk with maturation tabases were also monitored for eligible studies up to 27 May 2024. The
(Hewett et al., 2004; Holden, Boreham, & Delahunt, 2016; Renstrom search included the following search terms: (ACL or anterior cruciate
et al., 2008; Shultz, Nguyen, & Schmitz, 2008). The development of ligament) AND (matur* OR pubert*) AND (biomechanic* or kinematic*
neuromuscular function in maturing individuals often does not progress or kinetic*) and were filtered for English language. The supplementary
linearly (DiStefano et al., 2015), likely contributing to variance in ability material contains a detailed description of the search syntax for each
to effectively mitigate forces to reduce ACL loading. database (Supplement 1). References from identified papers were
ACL injuries are more common from non-contact than contact manually checked to ensure inclusion of all relevant articles.
mechanisms and often non-contact injury risk can be reduced with tar
geted interventions (Hewett, Lynch, et al., 2010; Webster & Hewett, 2.2. Study inclusion and exclusion criteria
2018). Investigating potentially modifiable factors for reducing
non-contact ACL injury risk, specifically in maturing individuals, is Eligible studies included those published between journal inception
crucial for risk mitigation. Non-contact ACL injuries typically result and 27 May 2024. Inclusion criteria of individual studies was based on
from multiplanar loading during landing or cutting manoeuvres, which the PICOS framework: Participants, Interventions, Comparisons, Out
can involve large knee abduction angles and moments, internal tibial comes, and Study Type (Eriksen & Frandsen, 2018).
rotation, anterior tibial translation, and reduced knee flexion (Hewett, Participants: Studies that included uninjured adolescent/pre-
Ford, Xu, Khoury, & Myer, 2016; Kiapour et al., 2016; Koga et al., 2010; pubertal/pubertal/post-pubertal males or females were included. No
Levine et al., 2013; Olsen, Myklebust, Engebretsen, & Bahr, 2004; restriction was placed on participants’ level of physical activity or
Quatman, Ford, Myer, & Hewett, 2006). Dependent on maturation performance.
phase, sex, and training history (Hewett, Myer, & Ford, 2005; Quat Interventions: Studies using a dynamic task relevant to the assessment
man-Yates, Quatman, Meszaros, Paterno, & Hewett, 2012), these of ACL injury risk, such as landing or cutting, were eligible for inclusion.
neuromuscular variations can result in altered proprioceptive acuity Comparisons: The associations between sex-specific maturation and
(Lee, Ren, Kang, Geiger, & Zhang, 2015) and muscle activation patterns biomechanical risk factors for ACL injury were of interest. Therefore,
(Del Bel et al., 2018; Flaxman, Smith, & Benoit, 2014), which may be studies needed to operationally define maturational groups and assess
detrimental to sporting performance and safe landing and cutting ment methods; otherwise, studies were excluded. For an inclusive re
biomechanics. view, we did not set the operational definition for maturational status
Research exploring the association between sex-specific maturation although, studies needed to assess at least two maturational phases
and lower-extremity biomechanics has highlighted deviations in either at two different points in time where the maturation stage of the
movement mechanics and postural control across maturation (or be participant changed (longitudinal) or at the same point in time but
tween different maturational groups), typically during landing or cut comparing different maturational groups (cross-sectional).
ting tasks (Chia et al., 2021; Ford, Myer, & Hewett, 2010a; Sigward Outcomes: Studies needed to report one or more kinematic or kinetic
et al., 2012a, 2012b; Westbrook, Taylor, Nguyen, Paterno, & Ford, variable linked with ACL injuries.
2020). Biomechanical variables potentially associated with ACL injury Study type: Peer-reviewed original research that were cross-sectional,
include; increased knee abduction angle and moment, decreased knee cohort, case-control, or interventional studies published in English were
flexion, and increased ground reaction forces (GRFs) (Hewett, Myer, & eligible. These study designs reflect observational, analytical study de
Ford, 2005; Paterno et al., 2010). A recent review highlighted changes in signs according to the Centre for Evidence-Based Medicine
biomechanical risk factors associated with ACL injuries during (https://www.cebm.ox.ac.uk/resources/ebm-tools/study-designs).
jump-landing tasks in female athletes at various stages of maturity Only the baseline values from the interventional studies were included
(Ramachandran et al., 2024). They reported strong evidence for higher in the formal review process as these studies examined different matu
peak knee abduction angle, external knee abduction moment and in rational groups before and after an intervention aimed at altering their
ternal rotation moment, and lower relative peak vertical GRF in biomechanics. Qualitative studies, review articles, commentaries, case
post-pubertal female individuals compared with pre-pubertal girls reports, protocols, conference proceedings, and full-text articles in lan
(Ramachandran et al., 2024). While this review indicates maturation in guages other than English were excluded.
females can influence biomechanical risk factors related to ACL, it did All search results were imported into EndNote (EndNote 20.4.1,
not consider maturation in males and tasks other jump landing. Clarivate™, Philadelphia, PA, USA) and duplicates were removed. The
Confidence in the understanding of biomechanical differences asso remaining studies were imported into Rayyan, an online eligibility
ciated with ACL injury across maturational phases requires a critical screening and reviewer blinding tool (Ouzzani, Hammady, Fedorowicz,
evaluation and synthesis of the research, which must also consider sex & Elmagarmid, 2016) (http://rayyan.qcri.org). Two reviewers (AB and
and task differences. Such an examination would aid in the development SW) independently screened titles and abstracts in Rayyan. The same
of athlete monitoring and injury risk reduction tools specific to matu two reviewers independently screened the full-text articles. Studies that
ration phase and sex. This systematic review aimed to establish the did not meet eligibility criteria at either step were excluded. At each
potential link between maturation and biomechanical factors associated step, the two independent reviewers met to resolve disagreements in the
with ACL injury during dynamic tasks, while accounting for potential screening process. A third reviewer (KHL) was available when consensus
sex-specific differences. was not reached, but not required.
2. Methods 2.3. Study quality assessment
This systematic review was designed to meet the 2020 Preferred Two independent reviewers (AB and KHL) assessed the methodo
Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) logical quality and risk of bias of studies meeting inclusion using a
statement (Page et al., 2021). Pre-registration was completed with the modified version of the Newcastle Ottawa Scale (NOS) (Modesti et al.,
32
2016), shown in the supplementary material (Supplement 2). A third males and females with no inclusion restrictions regarding marginalised
reviewer (SW) was available if consensus was not established, but not groups. The influence of data availability regarding sexes and cultural
required. The modified NOS tool was selected as most studies were diversity on maturation and biomechanics associated with ACL injury is
observational (Modesti et al., 2016) and the NOS is deemed a suitable considered in the discussion.
alternative to the ROBINS-I (Sterne, Hernán, McAleenan, Reeves, &
Higgins, 2019). The NOS uses a star system, with a maximum of five 3. Results
stars for selection. A star was awarded if the item was deemed low risk of
bias and not awarded if deemed high risk of bias. The overall score is 10 3.1. Review statistics
stars, where a greater number indicates lower risk of bias and superior
methodological quality. The overall quality of studies was qualitatively The initial database search yielded 673 results, with 17 studies ul
evaluated as very good, good, satisfactory, and unsatisfactory when timately meeting inclusion. The search was monitored whilst the review
correspondingly allocated 9–10, 7–8, 5–6, and 4 or less stars based on was undertaken, and an additional study was included. The PRISMA
prior reviews (Naafs et al., 2020; Ortolan, Lorenzin, Felicetti, & flow diagram is presented in Fig. 1. Many biomechanical metrics were
Ramonda, 2021). examined across studies; however, a minimum of three studies reporting
The semiquantitative synthesis (Huguet et al., 2013) undertaken the same metric were required for inclusion in the narrative synthesis.
involved evaluating and rating the certainty of evidence for differences Knee abduction angle, knee abduction moment, knee flexion, and GRFs
in risk factors between maturation groups using a modified Grading of were the four most common metrics and were reported across at least
Recommendations Assessment, Development and Evaluation (GRADE) three studies; therefore, these metrics were included in the narrative
approach (Group, 2004). All domain ratings were considered when synthesis.
assigning the overall GRADE rating. Where an equal number of studies
were ranked as having no limitations and serious limitations for a spe 3.2. Study quality assessment
cific domain, the overall GRADE rating was lowered. Risk of bias
assessment, level of evidence, or study design ratings did not constitute The quality score and design for each study are reported in Table 1.
study exclusion. The methodological quality of most studies was considered good (n =
16, 89 %), and satisfactory for the remaining (n = 2, 11 %) based on the
2.4. Data extraction strategy NOS adapted for cross sectional studies (10-point scale: mean 7.2 ± 0.8
stars; range 5–8 stars). Reductions in study quality were commonly
One reviewer (AB) extracted variables of interest from the included caused by lack of selecting a representative sample, no presentation of
studies using a standardised data extraction template. A second reviewer sample size calculations, poor description of non-respondents, and
(SW) verified the accuracy and completeness of data extraction. The incomplete statistical reporting. The individual NOS item scores are
following data were extracted from studies: study characteristics, detailed for individual studies in Table 2.
participant characteristics, participant maturation phases, maturational
assessment method, dynamic task, relevant kinematic and kinetic vari 3.3. Semiquantitative analysis (evidence of effectiveness)
ables assessed, and key results. When not explicitly stated in text, the
country of investigation was based on the institution granting ethical When considering phase of studies, sample sizes, risk of bias, preci
approval, followed by the affiliation of the first author. We attempted to sion levels, and consistency in findings, the GRADE ratings indicate low-
contact the first authors of papers that appeared to involve the same to-moderate certainty of evidence regarding the link between matura
participants for confirmation, as it could introduce bias in the findings of tion and potential ACL injury biomechanical risk factors during dynamic
our review. tasks, as summarised in Tables 3–5, respectively. For drop vertical jump
(DVJ) tasks, GRADE ratings indicate moderate certainty of evidence for
2.5. Data synthesis and presentation knee flexion angle and low certainty of evidence for knee abduction
angle, knee abduction moment, and GRF. For cutting tasks, certainty of
Data extracted were compiled and analysed using Microsoft Excel evidence was moderate for knee abduction angle and low for the other
2019 (Microsoft Corp., Redmond, WA, USA). Due to the variation in three factors. For other dynamic tasks, certainty of evidence was mod
tasks used, maturation phases assessed, and biomechanical outcome erate for knee abduction angles but low for knee flexion angles, knee
variables reported, there was an insufficient amount of comparable data abduction moment, and GRF. It should be considered that the partici
to perform a meta-analysis. Therefore, a systematic narrative synthesis pants involved in both of the studies by Sigward and colleagues (Sigward
of the included studies was conducted, organising the results based on et al., 2012a, 2012b) were the same (confirmed via personal commu
tasks and narratively synthesising how maturation was associated with nications), which may introduce bias, although the studies assessed
biomechanical variables when reported in at least two studies. Double different tasks. Similarly, it is fair to assume that the participants were
and single leg performances of the same type of task were not grouped the same in both studies by Ford and colleagues (Ford et al., 2010a,
together given the significant differences in biomechanics between 2010b) given the reported sample size and participant demographics
double leg and single leg dynamic tasks (Taylor, Ford, Nguyen, & Shultz, (unconfirmed), although the studies report different metrics for the
2016). Hedges g effect size differences were calculated to quantify be same dynamic task.
tween group differences when data were provided in sufficient detail
using https://effect-size-calculator.herokuapp.com/. Paired effect size 3.4. Study characteristics
differences were used when data were longitudinal in nature. Effect size
inferences were determined using the thresholds <0.2, 0.2, 0.5, and 0.8 Sample size ranged from 22 to 315 participants. A total of 2092
for trivial, small, medium, and large, respectively (Cohen, 2013; Ellis, participants were represented across the 18 studies. Sex distribution was
2010). described across all studies except for one (Ford et al., 2010a) with a
total of 400 males (19.1 %), 1377 females (65.8 %), and 315 participants
2.6. Equity, diversity, and inclusion statement of undefined sex (15.1 %). Nine of the 18 studies (50 %) used a DVJ task
(Ford et al., 2010a, 2010b; Hass et al., 2005; Hewett et al., 2004, 2006;
The author group consists of four females and one male of whom are Otsuki et al., 2021; Quatman et al., 2006; Sigward, Pollard, & Powers,
junior, early-career, and senior researchers from different disciplines, 2012; Westbrook et al., 2020), four (22.2 %) used a cutting task (Chia
based in two countries. Our systematic review population included both et al., 2021, 2023; Colyer et al., 2021; Sigward, Pollard, Havens, &
33
Fig. 1. PRISMA flow diagram of the search strategy and study selection process.
Powers, 2012), two (11.1 %) assessed a single-leg drop landing (Kim and were observed in males (Chia et al., 2023). Furthermore, a third study by
Lim, 2014; Nasseri et al., 2021), and one study each (5.5 %) examined a Sigward et al. (Sigward, Pollard, Havens, & Powers, 2012) observed
drop and cut (Sayer et al., 2019), standing vertical jump (Swartz et al., significantly greater peak knee valgus angles in females than males
2005), and horizontal leap (Wild et al., 2016) task. Most studies (61.1 %, regardless of maturation phase; however, smaller angles were observed
n = 11) were cross-sectional (Colyer et al., 2021; Hass et al., 2005; in the more mature participants regardless of sex.
Hewett et al., 2004, 2006; Kim & Lim, 2014; Nasseri et al., 2021; Sig During a single-leg landing task, Kim (Kim & Lim, 2014) reported
ward, Pollard, & Powers, 2012; Swartz et al., 2005; Westbrook et al., that pubertal females demonstrated an increased peak knee abduction
2020), followed by longitudinal prospective cohort (33.3 %, n = 6) (Chia angle compared to pre-pubertal participants with a large effect size.
et al., 2021; Ford et al., 2010a, 2010b; Quatman et al., 2006; Sayer et al., Conversely, Swartz et al. (Swartz et al., 2005) detected significantly
2019; Wild et al., 2016), and interventional (5.6 %, n = 1) (Otsuki et al., lesser knee valgus angle at both initial contact (medium effect size) and
2021). at peak vertical GRF (small effect size) with maturation regardless of sex
in a vertical jump task.
3.5. Narrative synthesis 3.5.2. Knee abduction moment

When completing a DVJ task, four studies found that pubertal and
A summary of the proposed links between the commonly reported post-pubertal females generally demonstrated greater knee abduction
biomechanical metrics (knee abduction angle, knee abduction moment, moments than pre-pubertal females and males (Ford et al., 2010b;
knee flexion, and GRFs) and pubertal maturation is presented in Fig. 2. Otsuki et al., 2021; Sigward, Pollard, & Powers, 2012; Westbrook et al.,
2020), although the effect sizes were small and medium. Otsuki et al.
3.5.1. Knee abduction angle (Otsuki et al., 2021) reported increases in peak knee abduction moments
Amongst the four DVJ studies regarding knee abduction angle, over a six-month period in early pubertal females. Similarly, Ford et al.
Hewett et al. (Hewett et al., 2004), Ford et al. (Ford et al., 2010b), and (Ford et al., 2010b) observed larger knee abduction moments during
Westbrook et al. (Westbrook et al., 2020) reported significantly greater DVJ tasks in pubertal females with maturation with medium effect sizes.
peak knee abduction angles with maturation in females and significantly Ford et al. (Ford et al., 2010b) also found greater knee abduction mo
greater angles in females than males following the onset of puberty, with ments in females than males post-puberty, but no sex differences were
large, small, and medium effect sizes observed, respectively. Hass et al. observed pre-puberty.
(Hass et al., 2005), who had a lower methodological quality study, in Similar changes in knee abduction moments to those observed in the
contrast observed similar knee abduction ranges of motion between DVJ tasks were observed in three studies during cutting or horizontal
pre-pubertal and post-pubertal females. jump tasks (Kim & Lim, 2014; Westbrook et al., 2020; Wild et al., 2016)
Two studies incorporating a cutting task reported small but signifi with small effect sizes. Females post-puberty demonstrated greater peak
cantly greater maximum knee valgus angles with maturation in females abduction moments than females during pre- and mid-puberty
(Chia et al., 2021; Westbrook et al., 2020), no significant differences
34
Table 1
Qualitive synthesis of studies (n = 17) reporting on changes in biomechanics associated with ACL injury during different maturational phases.
Author Country Study design Females (n) Males (n) Maturation Biomechanical Results Effect sizes
of study and study phases and variables (Hedges’s g)a
quality identification
method
Qualitive synthesis of studies (n = 9) reporting on biomechanics in DVJ tasks

Ford et al. United Longitudinal 265 50 Pubertal, post- Ankle, knee and All athletes ↑ active Females
(2010a) States of prospective 142 pubertal 37 pubertal (age, pubertal hip: Stiffness, knee stiffness over Knee flexion
America cohort (age, 12.3 ± 0.8 13.0 ± 1.1 y; Modified PMOS flexion angle at a year (p < 0.05). angle at initial
8 stars: good y; height, 155.9 height, 165.2 ± initial contact, peak Only M had ↑ ankle contact (g
± 6.8 cm; mass, 10.2 cm; mass, angle, and peak and hip active − 0.127 trivial)
47.8 ± 10.2 kg), 54.5 ± 10.2 kg) moment stiffness (p < 0.05). Peak knee
120 post-pubertal 13 post-pubertal ↑ peak ankle (31.2 flexion angle (g
(age, 14.4 ± 1.4 (age, 15.1 ± 1.1 N m MD) and hip − 0.223 small)
y; height, 164.4 y; height, 180.8 (42.2 N m MD) Peak knee
± 5.8 cm; mass, ± 7.9 cm; mass, moments, but not flexion moment
59.0 ± 8.5 kg) 70.1 ± 8.4 kg) knee moments, in (g 0.842 large)
post-pubertal M but Males
not post-pubertal F Knee flexion
(p < 0.05). F had a angle at initial
↑ knee to hip contact = 0.419
moment ratio than small)
M (p < 0.05). Peak knee
flexion angle (g
0.021 trivial)
Peak knee
flexion moment
(g 1.362 large)
Ford, Shapiro, United Longitudinal 315 total (female Pubertal, post- Stature change, No sex differences Females
Myer, Van States of prospective or male pubertal knee abduction in peak knee Knee abduction
Den Bogert, & America cohort unspecified) Modified PMOS angle, knee abduction angle or moment (g
Hewett 8 stars: good 182 pubertal abduction moment moment during − 0.501 medium)
(2010b) 133 post-pubertal DVJ between Knee abduction
Female: pubertal pubertal M and F angle (g − 0.271
(age, 12.3 ± 0.8 (p > 0.05). Pubertal small)
y; height, 155.9 F ↑ peak abduction Males
± 6.8 cm; mass, angle from the first Knee abduction
47.8 ± 10.2 kg), to second year (1.6◦ moment (g 0.621
post-pubertal MD; p = 0.001), M medium)
(age, 14.4 ± 1.4 had no change (p = Knee abduction
y; height, 164.4 0.90). Following angle (g 1.088
± 5.8 cm; mass, puberty, peak large)
59.0 ± 8.5 kg) abduction angle
Male: pubertal and moment ↑ in F
(age, 13.0 ± 1.1 relative to M
y; height, 165.2 (angle: F − 9.3 ±
± 10.2 cm; mass, 5.7◦ , M − 3.6 ±
54.5 ± 10.2 kg) 4.6◦ , p = 0.001;
post-pubertal moment: F − 21.9
(age, 15.1 ± 1.1 ± 13.5 Nm, M
y; height, 180.8 − 13.0 ± 12.0 Nm,
± 7.9 cm; mass, p = 0.017).
70.1 ± 8.4 kg)
Hass et al. United Cross- 32 Pre-pubertal, Knee flexion angle Significant Females
(2005) States of sectional 16 pre-pubertal post-pubertal at touchdown, maturation level x Knee flexion
America 5 stars: (age, 9.0 ± 1.0 y; Pre-onset of landing phase landing sequence angle at initial
satisfactory height, 134.5 ± menarche, at duration, knee interactions for contact (g
9.1 cm; mass, least 6 y past flexion and knee post-pubertal who − 5.000 large)
33.1 ± 9.2 kg), menarche abduction ROM, had ↓ knee flexion Peak vertical
16 post-pubertal peak magnitude of (4.5◦ MD; p = GRF (g − 5.348
(age, 20.2 ± 1.2 posterior GRF, 0.005) at initial large)
y; height, 162.6 magnitude and contact, ↑ Peak knee
± 6.1 cm; mass, timing of peak mediolateral knee abduction
58.5 ± 7.2 kg) vertical GRF, peak joint forces [pre- moment (g 0.200
knee anterior- pubertal: 0.63 + small)
posterior and 0.21 N.(kg.√LH) ‘,
medial-lateral joint post-pubertal: 0.55
forces, and peak + 0.21 N-(kg√LH)-
knee extensor and f] 1.18 MD; p <
abduction- 0.001), and ↓ knee
adduction moment extensor moments
[pre-pubertal:
0.0124 + 0.001
Nm.(kg-BH.√LH)-‘,
post-pubertal:
0.0079 ± 0.001 N
(continued on next page)
35
Table 1 (continued )
method
m.(kg.BH.√LH)-1]
(0.0045 MD; p =
0.026) compared to
pre-pubertal.
*LH, landing
height; BH, body
height
Hewett et al., United Cross- 100 81 Pre-pubertal, Medial knee F landed with ↑ Females
2004 States of sectional 14 pre-pubertal 27 pre-pubertal early pubertal, motion, valgus total medial knee Pre vs early
America 7 stars: good (age, 11.5 ± 0.7 (age, 12.0 ± 0.6 late/post- angle at initial motion and (p < pubertal
y; height, 148.7 y; height, 151.3 pubertal contact and 0.01) ↑ maximum Knee valgus
± 5.9 cm; mass, ± 6.7 cm; mass, Modified maximum angle, knee valgus angle angle at initial
38.9 ± 5.9 kg), 41.9 ± 8.3 kg), PMOS, Tanner hamstring and (11◦ MD; p < 0.01) contact (g 0.632
28 early-pubertal 24 early-pubertal stages quadriceps peak vs M following medium)
(age, 12.6 ± 1.1 (age, 14.2 ± 1.4 torque onset of Peak knee valgus
y; height, 158.5 y; height, 169.7 maturation. F also angle (g 1.697
± 6.1 cm; mass, ± 9.9 cm; mass, had ↓ flexor torques large)
46.8 ± 5.5 kg), 59.4 ± 11.8 kg), (p < 0.01) vs M and Early vs late
58 late/post 30 late-post significantly pubertal
pubertal (age, pubertal (age, different maximum Knee valgus
15.5 ± 1.5 y; 15.8 ± 1.7 y; valgus angles angle at initial
height, 168.3 ± height, 179.2 ± between the contact (g 4.000
6.5 cm; mass, 8.4 cm; mass, dominant and non- large)
63.4 ± 10.9 kg) 70.8 ± 10.9 kg) dominant limbs Peak knee valgus
after maturation. angle (g 3.333
large)
Pre vs late
pubertal
Knee valgus
angle at initial
contact (g 4.525
large)
Peak knee valgus
angle (g 1.897
large)
Males
Values were not
provided.
Hewett, Myer, United Cross- 87 188 Tanner stages vGRF upon contact F had no change in Data
Ford, and States of sectional n for n for 1, 2, 3, 4 and 5 and take-off, vertical jump unavailable~
Slauterbeck America 6 stars: maturational maturational Tanner stages vertical jump height whereas M ↑
(2006) satisfactory groups and groups and height 12.5% on average
participant participant between pubertal
descriptives not descriptives not stages (p = 0.002).
reported reported The ratios of drop
landing force to
drop take-off and
maximum landing
force to maximum
take-off force ↓ in M
as they matured (p
< 0.05) but did not
change in F
between pubertal
stages.
Otsuki, Benoit, Japan Interventional 154 Early pubertal, Medial knee After six months of Data
Hirose, and 8 stars: good 17 (ctrl) and 18 late pubertal, displacement, knee training, medial unavailable~
Fukubayashi (int) early- post-pubertal flexion ROM, peak knee displacement
(2021) pubertal (age, Self- knee abduction significantly ↑ in
12.8 ± 0.7 y; administered moment early-pubertal
height, 151.1 ± rating scale for control (p = 0.02)
5.4 cm; mass, pubertal and did not change
41.0 ± 4.6 kg), development, in early-pubertal
22 (ctrl) and 28 Tanner stages training (p = 0.37).
(int) late-pubertal Knee flexion ROM
(age, 13.9 ± 1.0 significantly ↓ in
y; height, 161.2 early-pubertal
± 5.8 cm; mass, control (p = 0.01)
52.2 ± 6.2 kg), and did not change
36 (ctrl) and 33 in early-pubertal
(int) post training (p = 0.23).
pubertal (age, The probability of
16.0 ± 0.7 y; high knee
36
method
height, 161.5 ± abduction moment

5.7 cm; mass, ↑ in early-pubertal
55.0 ± 5.3 kg) control (p < 0.001),
but not in early-
pubertal training
(p = 0.13). The
probability of high
knee abduction
moment also ↓ in
post-pubertal
training (p <
0.001) but did not
change in post-
pubertal control (p
= 0.58).
Quatman et al. United Longitudinal 16 17 Pubertal, post- Vertical jump M ↑ vertical jump Females
(2006) States of prospective All pubertal first All pubertal first pubertal height, maximum height with Peak vertical
America cohort year (age, 12.6 ± year (age, 13.8 ± Modified GRF, GRF loading maturation (3.2 cm ground reaction
7 stars: good 1.0 y; height, 0.6 y; height, PMOS, Tanner rate MD; p < 00.001); F force (g 0.509
162.0 ± 7.9 cm; 173.0 ± 9.2 cm; stages did not. M medium)
mass, 47.5 ± 6.0 mass, 62.6 ± 7.6 significantly ↓ their Males
kg) and post- kg) and post- maximal GRF Peak vertical
pubertal second pubertal second (0.3BW MD; p = ground reaction
year (age, 13.6 ± year (age, 14.8 ± 0.005); F did not. force (g − 0.442
1.0 y; height, 1.4 y; height, Take-off force ↓ in small)
165.7 ± 8.4 cm; 177.0 ± 7.9 cm; females (0.1BW
mass, 53.2 ± 6.2 mass, 67.9 ± 5.5 MD; p = 0.003), but
kg) kg) not in M. Both M
and F ↓ loading
rates with
maturation (p <
0.001). F had
higher loading
rates than M at both
stages of
maturation (p =
0.037).
Sigward, United Cross- 60 59 Pre-pubertal, Internal knee When averaged Data
Pollard, & States of sectional 15 pre-pubertal 16 pre-pubertal pubertal, post- adductor moment, across maturation unavailable~
Powers America 7 stars: good (age, 10.2 ± 0.8 (age, 11.4 ± 1.0 pubertal, sagittal plane knee/ levels, F had ↑
(2012) y; height, 144.9 y; height, 146.9 young adult hip moment and internal knee
± 7.2 cm; mass, ± 8.9 cm; mass, Modified energy absorption adductor moments
37.3 ± 6.4 kg) 37.9 ± 5.6 kg) PMOS, Tanner ratios (0.06 ± 0.03 vs.
15 pubertal (age, 15 pubertal (age, stages 0.01 ± 0.02 Nm/
12.5 ± 0.7 y; 13.3 ± 1.2 y; kg*m; 0.05 Nm/kg
height, 156.9 ± height, 160.6 ± MD; p < 0.005),
6.8 cm; mass, 9.7 cm; mass, knee/hip extensor
47.8 ± 8.9 kg), 52.4 ± 7.8 kg), moment ratios (2.0
14 post-pubertal 14 post-pubertal ± 0.1 vs. 1.4 ± 0.1
(age, 15.7 ± 1.1 (age, 15.6 ± 1.1 Nm/kg*m; 0.6 Nm/
y; height, 166.3 y; height, 176.4 kg MD; p < 0.001),
± 6.7 cm; mass, ± 7.5 cm; mass, and knee/hip
59.7 ± 6.8 kg), 69.7 ± 10.2 kg), energy absorption
15 young adult 15 young adult ratios (2.9 ± 0.1 vs.
(age, 19.3 ± 1.1 (age, 19.8 ± 1.4 1.96 ± 0.1 Nm/
y; height, 166.1 y; height, 181.5 kg*m; 0.94 Nm/kg
± 5.7 cm; mass, ± 7.2 cm; mass, MD; p < 0.001) vs
64.9 ± 6.9 kg) 78.0 ± 6.6 kg) M.
Westbrook et al. United Cross- 138 Pre-pubertal, DVJ Post-pubertal had Females
(2020) States of sectional 17 pre-pubertal early pubertal, Knee abduction, significantly (p < Peak knee
America 7 stars: good (age, 10.3 ± 0.6 post-pubertal knee flexion, 0.001)↑ peak abduction angle
y; height, 137.0 Prediction of normalised knee abduction angles pre vs pub (g
± 6.8 cm; mass, percentage of moments and moments than 0.322 small)
34.2 ± 4.5 kg), adult stature pubertal and pre- pre vs post (g
32 pubertal (age, (Khamis-Roche pubertal (5.4◦ and 0.325 small)
11.9 ± 0.8 y; method) 3.4◦ , 10.1 Nm and pub vs post (g
height, 151.1 ± 14.2 Nm MD). Post- 0.679 medium)
5.7 cm; mass, pubertal and Peak knee
43.3 ± 6.0 kg), pubertal had ↑ peak abduction
90 post-pubertal knee flexion moment
(age, 14.6 ± 1.6 moments vs pre- normalised
y; height, 162.6 pubertal (54.2 Nm pre vs pub (g
and 36.3 Nm MD), 0.277
37
method
± 5.6 cm; mass, as did post-pubertal small)

56.2 ± 8.8 kg) vs pubertal (17.9 pre vs post (g
Nm MD). − 0.295 small)
pub vs post (g
− 0.448 medium)
Peak knee
flexion angle
pre vs pub (g
0.300 small)
pre vs post (g
0.380 small)
pub vs post (g
0.054)
Peak knee
flexion moment
normalised
pre vs pub (g
0.448 small)
pre vs post (g
0.636 medium)
pub vs post (g
0.257 small)
Qualitive synthesis of studies (n = 3) reporting on biomechanics in cutting tasks
Chia et al. United Longitudinal 172 Pre-pubertal, 45◦ unanticipated With maturation, ↓ Peak knee
(2021)) States of prospective 69 pre-pubertal mid-pubertal, cutting task sagittal plane hip flexion
America cohort (age, 11.8 ± 0.5 post-pubertal Trunk: total ROM (1.8–2.6◦ MD, p < pre vs pub (g
8 stars: good y; height, 148.3 Modified in all planes, peak 0.03) and knee − 0.492 small)
± 6.3 cm; mass, PMOS, Tanner trunk flexion, ROM (2.7–2.9◦ MD, pre vs post (g
38.1 ± 5.8 kg), stages lateral flexion, p < 0.01). ↓ peak − 0.395 small)
164 mid-pubertal rotation angles hip (2.9–3.2◦ MD, pub vs post (g
(age, 12.8 ± 0.9 Knee: total ROM in p < 0.02) and knee − 0.061 trivial)
y; height, 158.4 all planes, knee flexion angles Peak knee
± 5.8 cm; mass, flexion angle at (2.7–2.9◦ MD, p < abduction
49.5 ± 8.2 kg), initial contact, peak 0.01), indicating ↑ Pre vs pub (g
131 post-pubertal knee flexion and quadriceps 0.116 trivial)
(age, 14.6 ± 1.2 abduction angles dominance. Peak pre vs post (g
y; height, 163.4 Hip: total ROM in knee abduction 0.364 small)
± 5.5 cm; mass, all planes, hip angles ↑ (0.9–1.4◦ pub vs post (g
57.5 ± 8.5 kg) flexion angle at MD, p < 0.02), 0.219 small)
(monitored across initial contact, peak suggesting ↑ Initial contact
2–3 phases) hip flexion and ligament knee flexion
adduction angle dominance. Trunk Pre vs pub (g
frontal (2.5–5.7◦ − 0.245 small)
MD, p p ≤ 0.03) pre vs post (g
and sagittal plane − 0.387 small)
ROM ↓ (2.0◦ MD, p pub vs post (g
≤ 0.01), but trunk − 0.127 trivial)
transverse-plane
ROM ↑ (2.8–3.6◦
MD, p ≤ 0.02). ↓
peak trunk flexion
(3.8–7.8◦ MD, p ≤
0.01), hip flexion
(2.9–3.3◦ MD, p ≤
0.02), and knee
flexion angles
(2.0–3.0◦ MD, p ≤
0.03) at initial
contact; more
upright cutting
posture.
Chia et al. United Longitudinal 42 Pre-pubertal, 45◦ unanticipated With maturation, Peak knee
(2023) States of prospective 20 pre-pubertal mid-pubertal, cutting task hip sagittal-plane flexion
America cohort 8 (age, 12.3 ± 0.5 post-pubertal Trunk: total ROM RoM ↓ (5.57◦ MD, pre vs mid (g
stars: good y; height, 158.0 Modified in all planes, peak p ≤ 0.027). ↓ hip 0.082 trivial)
± 7.9 cm; mass, PMOS, Tanner trunk flexion, right flexion at IC and pre vs post (g
48.1 ± 9.4 kg), stages lateral flexion, peak hip flexion 0.091 trivial)
38 mid-pubertal right rotation from pre to mid mid vs post (g
(age, 13.6 ± 1.0 angles (6.25◦ MD, p ≤ 0.005 trivial)
y; height, 168.7 Knee: total ROM in 0.018; 5.95◦ MD, p Peak knee
± 1.0 cm; mass, all planes, knee ≤ 0.046). ↑ trunk abduction
56.2 ± 8.9 kg), flexion angle at contralateral Pre vs mid (g
30 post-pubertal initial contact, peak rotation from pre to 0.163 trivial)
38
method
(age, 15.0 ± 1.2 knee flexion and post (7.58◦ MD, p pre vs post (g
y; height, 178.3 abduction angles ≤ 5 0.027). No sig 0.171 trivial)
± 7.1 cm; mass, Hip: total ROM in diffs in knee mid vs post (g
68.4 ± 9.3 kg) all planes, hip variables. − 0.003 trivial)
(monitored across flexion angle at Initial contact
2–3 phases) initial contact, peak knee flexion
hip flexion and Pre vs mid (g
adduction angle − 0.149 small)
pre vs post (g
0.233 small)
mid vs post (g
0.091 trivial)
Colyer et al. United Cross- 35 91.2%–100% 90◦ unanticipated Significant bilateral Data
(2021) Kingdom sectional (age, 15.0 ± 1.0 adult stature cutting task asymmetries unavailable~
7 stars: good y; height, 166.1 Percentage of Peak external knee observed with ↑
± 7.1 cm; mass, predicted adult abduction moment, peak external knee
58.0 ± 6.6 kg) stature peak resultant GRF, abduction
knee abduction moments, ↑ GRF,
angle, knee internal and ↓ knee flexion
rotation, hip (from 0 to 18% and
internal rotation, 30–39% of contact)
and hip abduction during the non-
angle at initial dominant vs
contact dominant cuts (ES
= 0.36, 0.63 and
0.50, respectively).
Maturation did not
affect asymmetries;
however, ↓ hip
abduction (e.g.,
21–51% of contact
for dominant cuts)
with maturation.
Sigward, United Cross- 80 76 Pre-pubertal, 45◦ unanticipated No sex × Data
Pollard, States of sectional 15 pre-pubertal 16 pre-pubertal pubertal, post- cutting task maturation unavailable~
Havens, & America 8 stars: good (age, 10.2 ± 0.8 (age, 11.4 ± 1.0 pubertal, Peak knee valgus interactions for any
Powers y; height, 144.9 y; height, 146.9 young adult angle, knee variable. On
(2012) ± 7.2 cm; mass, ± 8.9 cm; mass, Modified adductor moments average, F had ↑
37.3 ± 6.4 kg) 37.9 ± 5.6 kg) PMOS, Tanner and GRFs in all knee abduction and
15 pubertal (age, 15 pubertal (age, stages planes adductor moments
12.5 ± 0.7 y; 13.3 ± 1.2 y; than M. Pre-
height, 156.9 ± height, 160.6 ± pubertal had ↑ knee
6.8 cm; mass, 9.7 cm; mass, adductor moments
47.8 ± 8.9 kg), 52.4 ± 7.8 kg), and GRFs than all
14 post-pubertal 14 post-pubertal other groups (p =
(age, 15.7 ± 1.1 (age, 15.6 ± 1.1 0.01).
y; height, 166.3 y; height, 176.4
± 6.7 cm; mass, ± 7.5 cm; mass,
59.7 ± 6.8 kg), 69.7 ± 10.2 kg),
15 young adult 15 young adult
(age, 19.3 ± 1.1 (age, 19.8 ± 1.4
y; height, 166.1 y; height, 181.5.1
± 5.7 cm; mass, ± 7.2 cm; mass,
64.9 ± 6.9 kg) 78.0 ± 6.6 kg)
Westbrook et al. United Cross- 138 Pre-pubertal, 90◦ cutting task Post-pubertal had Females
(2020) States of sectional 17 pre-pubertal early pubertal, Knee abduction, significantly (p < Peak knee
America 7 stars: good (age, 10.3 ± 0.6 post-pubertal knee flexion, 0.001)↑ peak abduction angle
y; height, 137.0 Prediction of normalised knee abduction angles pre vs pub (g
± 6.8 cm; mass, percentage of moments and moments than 0.095 trivial)
34.2 ± 4.5 kg), adult stature pubertal and pre- pre vs post (g
32 pubertal (age, (Khamis-Roche pubertal (3.1◦ and 0.482 small)
11.9 ± 0.8 y; method) 2.6◦ , 12.3 Nm and pub vs post (g
height, 151.1 ± 10.7 Nm MD). Post- 0.597 medium)
5.7 cm; mass, pubertal and Peak knee
43.3 ± 6.0 kg), pubertal had ↑ peak abduction
90 post-pubertal knee flexion moment
(age, 14.6 ± 1.6 moments vs pre- normalised
y; height, 162.6 pubertal (73.4 Nm pre vs pub (g
± 5.6 cm; mass, and 33.1 MD), as 0.595
56.2 ± 8.8 kg) did post-pubertal vs medium)
pubertal (40.3 Nm pre vs post (g
MD). 0.249 small)
pub vs post (g
39
method
− 0.413 small)
Peak knee
flexion angle
pre vs pub (g
− 0.499 small)
pre vs post (g
− 0.330 small)
pub vs post (g
0.330 small)
Peak knee
flexion moment
normalised
pre vs pub (g
0.478 small)
pre vs post (g
0.552 medium)
pub vs post (g
0.201 small)
Qualitive synthesis of studies (n = 5) reporting on biomechanics in other tasks
Kim & Lim Korea Cross- 22 Pre-pubertal, Single legged drop Post-menarche ↓ Peak knee
(2014) sectional 11 pre-pubertal post-pubertal landing maximum knee flexion angle (g
7 stars: good (age, 11.6 ± 2.2 Pre- or post- Max knee flexion flexion angle (5.56 − 3.791 large)
y; height, 135.4 menarcheal angle, max knee MD, p = 0.019) and Peak knee
± 9.0 cm; mass, onset abduction angle, ↑ maximum knee abduction angle
29.9 ± 5.8 kg), max knee internal abduction angle (g 32.438 large)
11 post-pubertal rotation angle, max (3.26 MD, p = Peak knee
(age, 19.1 ± 3.2 knee abduction 0.039), maximum abduction
y; height, 153.4 moment, and internal tibial moment (g 1.791
± 5.0 cm; mass, hamstring- rotation angle (5.73 large)
47.3 ± 5.6 kg) quadriceps MD, p = 0.043),
activation ratio maximum knee
abduction moment
(0.18 MD, p =
0.049), and
hamstring-
quadriceps muscle
activity ratio (p =
0.033) compared to
pre-menarche.
Nasseri et al. Australia Cross- 62 Pre-pubertal, Single legged drop Compared to pre- ACL force
(2021) sectional 19 pre-pubertal early/mid- landing and early-/mid- pre vs early/mid
8 stars: good (age, 9.8 ± 1.1 y; pubertal, late/ ACL force, plane pubertal, late-/ (g 3.994 large)
height, 140.1 ± post-pubertal loading for all post-pubertal had early/mid vs
0.1 cm; mass, Tanner stages planes, stance significantly ↑ ACL post (g 6.063
30.9 ± 4.5 kg), percentage force with MDs of large)
19 early/mid- 471 and 356 N pre vs post (g
pubertal (age, during the first 30% 11.905 large)
11.0 ± 1.3 y; and 48%–85% of
height, 150.0 ± stance, and 343 and
5.7 cm; mass, 274 N during the
37.4 ± 5.6 kg), first 24% and 59%–
24 late/post 81% of stance,
pubertal (age, respectively, which
19.9 ± 4.1 y; overlapped peaks
height, 160.0 ± in ACL force. At
0.1 cm; mass, peak ACL force,
59.8 ± 9.3 kg) contributions from
sagittal and
transverse plane
loading
mechanisms to ACL
force were ↑ in
late-/post-pubertal
than pre- and
early-/mid-
pubertal (ES: 0.44
to 0.77). No
differences
between pre- and
early-/mid-
pubertal in ACL
force or
contributors.
40
method
Sayer et al. Australia Cross- 93 Pre-pubertal, Single legged drop Late/post-pubertal Peak knee
(2019) sectional 31 pre-pubertal early/mid- lateral jump had ↑ peak KFM abduction
8 stars: good (age, 9.4 ± 1.2 y; pubertal, late/ Triplanar knee (0.17 N m/m and moment
height, 1.4 ± 0.1 post-pubertal moments and hip 0.45 N m/m), pre vs early/mid
m; mass, 30.0 ± Modified moments at the KAbM (0.17 N m/m (g 0.731
5.7 kg), Tanner stages time of peak knee and 0.45 N m/m), medium)
31 early/mid- moments and KIRM (3.53 N pre vs late/post
pubertal (age, m/m and 5.07 N m/ (g 1.541 large)
11.2 ± 1.4 y; m) than the early/ early/mid vs
height, 1.5 ± 0.1 mid and pre- late/post (g
m; mass, 38.4 ± pubertal group (p 0.926 large)
7.6 kg), < 0.05).
31 late/post- *KFM, knee flexion
pubertal (age, moment; KAM,
19.8 ± 4.0 y; knee abduction
height, 1.7 ± 0.1 moment; KabM,
m; mass, 60.8 ± knee abduction
8.8 kg) moment.
Swartz, United Cross- 29 29 Pre-pubertal, Standing vertical Significant main Female
Decoster, States of sectional 15 pre-pubertal 15 pre-pubertal post-pubertal jump effects for Knee flexion at
Russell, and America 7 stars: good (age, 9.2 ± 1.0 y; (age, 9.4 ± 1.1 y; Tanner stages Knee flexion, hip developmental initial contact
Croce (2005) height, 136.6 ± height, 136.6 ± flexion, knee valgus stage. Both M and F pre vs post (g
9.5 cm; mass, 12.2 cm; mass, at initial contact had ↓ knee valgus 0.128)
32.9 ± 7.9 kg), 34.8 ± 7.9 kg), and at peak vGRF, (5.83 and 1.93 MD) Knee flexion at
14 post-pubertal 14 post-pubertal peak vGRF, time to and ↑ hip flexion peak vGRF
(age, 24.2 ± 2.3 (age, 23.6 ± 3.2 peak vGRF, and (9.11 and 9.09 MD) pre vs post (g
y; height, 163.5 y; height, 178.3 impulse at maximum vGRF, 0.810 large)
± 6.2 cm; mass, ± 5.6 cm; mass, ↑ knee flexion at Knee valgus at
62.4 ± 9.1 kg) 83.3 ± 11.5 kg) maximum vGRF initial contact
(11.76 and 6.5 pre vs post (g
MD), ↓ maximum − 0.528 medium)
vertical force (3.67 Knee valgus at
and 2.93 MD) and peak vGRF
impulse (0.4 and pre vs post (g
0.3 MD), and a ↑ − 0.445 small)
time to maximum Peak vGRF
vertical force (0.2 Pre vs post (g
and 0.1 MD) with − 1.571 large)
maturation. No sex Male
differences among Knee flexion at
the biomechanical initial contact
variables. pre vs post (g
0.645 medium)
Knee flexion at
peak vGRF
pre vs post (g
0.708 medium)
Knee valgus at
initial contact
pre vs post (g
− 0.528 medium)
Knee valgus at
peak vGRF
pre vs post (g
− 1.209 large)
Peak vGRF
pre vs post (g
− 1.581 large)
Wild, Munro, Australia Longitudinal 33 Tanner stages Horizontal leap Throughout Knee flexion
and Steele prospective Stage 1 (age, 11.4 2, 3, and 4 task maturation, ↓ knee moment at peak
(2016) cohort ± 0.1 y; height, Tanner stages Ankle plantar flexion moment anteroposterior
7 stars: good 149.7 ± 0.8 cm; and estimated flexion/ (0.59 N m/kg/m GRF
mass, 40.1 ± 0.8 maturity offset dorsiflexion and MD, p = 0.028), ↑ phase 1 vs phase
kg), Stage 2 (age, calculation inversion/eversion, hip flexion (0.17 N 2 (g − 1.809
11.8 ± 0.1 y; knee flexion/ m/kg/m MD, p = large)
height, 152.7 ± extension and 0.047), ↑ external phase 1 vs phase
0.8 cm; mass, abduction/ knee abduction 3 (g − 2.869
42.2 ± 0.8 kg), adduction and moments (0.23 N large)
Stage 3 (age, 12.1 external/internal m/kg/m MD, p = phase 1 vs phase
± 0.1 y; height, rotation, and hip 0.008), and ↓ 4 (g − 3.001
155.2 ± 0.8 cm; flexion/extension external hip large)
mass, 44.2 ± 0.8 and abduction/ adduction moments phase 2 vs phase
kg), Stage 4 (age, adduction and (0.6 N m/kg/m 3 (g − 1.133
41
method
12.5 ± 0.1 y; external/internal MD, p = 0.003) large)

height, 157.9 ± rotation during landing. phase 2 vs phase
0.8 cm; mass, angles, ROM, and 4 (g − 1.593
46.7 ± 0.8 kg) moments for ankle, large)
Assessed over all knee and hip. phase 3 vs phase
phases 4 (g − 0.690
medium)
Knee abduction
moment at peak
anteroposterior
GRF
phase 1 vs phase
2 (g 3.802 large)
phase 1 vs phase
3 (g 8.229 large)
phase 1 vs phase
4 (g 5.023 large)
phase 2 vs phase
3 (g 2.4 large)
phase 2 vs phase
4 (g 4.197 large)
phase 3 vs phase
4 (g 2.399, large)
Notes. Abbreviations: ACL, anterior cruciate ligament; DVJ, drop vertical jump; CUT, cutting task; F, females; M, males; ROM, range of motion; GRF, ground reaction
force; PMOS, pubertal maturation observational scale; MD, mean difference; g, Hedge’s g, Data unavailable~, data needed to calculate effect size were not provided in
the manuscript.
Effect size inferences were determined using the thresholds 0.2, 0.5, and 0.8 for small, medium, and large effects, respectively (Cohen, 2013; Ellis, 2010).
a
In the effect size column, a +ve number indicates an increase with maturation, a -ve indicates a decrease with maturation.
(Westbrook et al., 2020). Pubertal females demonstrated greater peak higher loading rates than males across all maturational stages, but both
knee abduction moments than pre-pubertal females during single-leg sexes decreased DVJ landing loading rates with maturation (Quatman
landings (Nasseri et al., 2021). Knee abduction moment in an et al., 2006). Hewett et al. (Hewett et al., 2006) also found fluctuations
all-female cohort was also significantly greater in late/post-pubertal and in DVJ landing GRF across maturation, with females showing slight
early/mid-pubertal groups compared to the pre-pubertal group during a decreases in GRF pre-puberty, slight increases during puberty, and
drop land and cut task (Sayer et al., 2019). larger decreases again post-puberty. Similarly, a satisfactory quality
study by Hass et al. (Hass et al., 2005) indicated smaller GRFs, joint
3.5.3. Knee flexion angle forces, and peak forces in post-pubertal than pre-pubertal females dur
During a DVJ task, peak knee flexion angle was generally greater ing a DVJ task with a large effect size. Significantly larger ACL forces
with maturation regardless of sex, and females landed with larger knee were observed in late-pubertal compared to pre- and ear
flexion angles than males (Ford et al., 2010a), although the effect sizes ly-/mid-pubertal females in a single-leg drop jump task, although the
were trivial. Swartz et al. (Swartz et al., 2005) also detected significantly estimation method using computational modelling limits the compara
greater knee flexion angles at peak vertical GRF with maturation bility of this study to the other studies included in this review (Nasseri
regardless of sex during a vertical jump task. Despite having similar et al., 2021). Colyer et al. (Colyer et al., 2021) observed no differences in
magnitudes and timing of knee flexion, post-pubertal females landed GRFs with maturation during a non-dominant versus dominant limb
with lesser knee flexion at initial contact than pre-pubertal females with cutting task. Regardless of sex, lesser peak vertical GRF was observed
a small effect size, but the post-pubertal females demonstrated a larger with maturation during cutting (Sigward, Pollard, Havens, & Powers,
knee flexion range of motion in a DVJ with a large effect size (Hass et al., 2012) and DVJ (Quatman et al., 2006) tasks.
2005). Westbrook et al. (Westbrook et al., 2020) found no differences in
knee flexion between maturational groups in both DVJ and cutting tasks 4. Discussion
(small effect sizes), similarly Chia (Chia et al., 2023) found no significant
differences in males. Data from three studies indicated reduced knee Understanding the association between maturational development
flexion range of motion and peak angles during cutting (small effect size) and biomechanical risk factors associated with ACL injury is important
(Sigward, Pollard, & Powers, 2012), double-leg drop landing (Otsuki for addressing the increasing ACL injury incidence rates in adolescent
et al., 2021), and horizontal leap (Wild et al., 2016) tasks in females with athletes (Maniar et al., 2022). The purpose of this systematic review was
maturation. to establish potential associations between maturation and biome
chanical factors associated with ACL injury in males and females.
3.5.4. Ground reaction force Generally, the studies included were of moderate quality. The only
Using a DVJ task, three studies examined GRF (Hass et al., 2005; biomechanical factors commonly reported in the included studies (re
Hewett et al., 2006; Quatman et al., 2006). Quatman et al. (Quatman ported across at least three studies) were knee abduction angle, knee
et al., 2006) and Hewett et al. (Hewett et al., 2006) (satisfactory quality abduction moment, knee flexion, and vertical GRF, which are factors
study) found that maturation was linked with significantly smaller identified as potentially linked to ACL injury incidence (Hewett et al.,
landing GRFs in males, but not females, and smaller take-off forces in 2016; Myer, Ford, Khoury, Succop, & Hewett, 2011; Pappas, Shiyko,
females, but not males when normalised to body mass (small to medium Ford, Myer, & Hewett, 2016). These factors had either low or moderate
effect sizes). Partially aligning with these findings, females showed overall quality of evidence ratings as assessed by the modified GRADE
42
Table 2
Newcastle-Ottawa Scale quality stars awarded for each study.
regarding their association with maturation. For these metrics, both landing injury screening tasks with reports of 73% sensitivity and 78%
males and females tended to exhibit biomechanics suggestive of an specificity for ACL injury forecasting in females (Hewett et al., 2005a,
increased risk of ACL injury during various landing and cutting tasks 2005b); although, it has recently been argued that knee abduction
with maturation. Moreover, greater knee abduction angles, knee moment in isolation may not be a standalone ACL injury risk factor as
abduction moments, and vertical GRF, and lesser knee flexion angles other biomechanical measures may contribute to injury risk (Cronström,
were observed in females compared to males in the later maturation Creaby, & Ageberg, 2020).
stages. These findings support that females in the late and post-pubertal There is conflicting evidence for changes in knee flexion biome
maturational development stages tend to portray biomechanics associ chanics with maturation during dynamic tasks. As females matured,
ated with increased risk of ACL injury, which aligns with the rise in ACL knee flexion range of motion and knee flexion angles decreased (Della
injury occurrence observed in this demographic (Maniar et al., 2022). Villa et al., 2020; Hewett et al., 2009; Sigurðsson et al., 2021), although,
The increases in knee abduction angle and moment with maturation the effect sizes ranged from trivial to large. In contrast, two studies
in females may contribute towards their increased ACL injury sucsept showed that knee flexion angle upon initial contact and at peak GRF
ability in the late and post-pubertal maturational stages (Ford et al., increased (Swartz et al., 2005), (Ford et al., 2010a). The varied out
2010b; Hewett et al., 2004; Maniar et al., 2022; Otsuki et al., 2021; comes and effect sizes identified between studies may be partially due to
Renstrom et al., 2008; Sayer et al., 2019; Shea et al., 2004; Sigward, the different movement requirements of the tasks assessed. Decreases in
Pollard, & Powers, 2012; Westbrook et al., 2020; Zbrojkiewicz et al., knee flexion angle with maturation were generally observed in studies
2018). Although it should be noted that the effect sizes of these differ where tasks incorporated a horizontal component whereas those which
ences varied from small to large across studies. Larger knee abduction reported knee flexion angle increases generally assessed tasks which
angles and moments during landing, particularly when paired with were more vertical in nature. Landing with a more extended knee or ‘stiff
higher vertical GRF, have been suggested as contributing mechanistic knee strategy’ suggests a greater tendancy for using the quadriceps to
factors for non-contact ACL injury (Della Villa et al., 2020; Hewett, Torg, stabilise the knee joint (Chia et al., 2021; Hewett, Ford, Hoogenboom, &
& Boden, 2009; Sigurðsson, Karlsson, Snyder-Mackler, & Briem, 2021) Myer, 2010; Pappas et al., 2016). Knee flexion angles less than 22◦ upon
due to the increased anterior tibial translation and consequent increased landing may increase the potential for quadricep dominance and place
ACL load (Fukuda et al., 2003). The reported association between knee excess demands on the ACL, increasing the potential for injury (Colby
abduction moment during landing and tibia and femur length during the et al., 2000; Larwa, Stoy, Chafetz, Boniello, & Franklin, 2021; Leppänen
growth spurt (Hewett, Myer, Kiefer, & Ford, 2015) highlights the po et al., 2017; McNair, Marshall, & Matheson, 1990). Adopting a more
tential influence of rapid limb growth on increasing knee abduction flexed knee position during landing or cutting can improve force ab
moments (Wild, Steele, & Munro, 2013), substantiating this review’s sorption and consequently protect internal knee structures (Boden, Torg,
findings of increased moments with maturation. Knee abduction Knowles, & Hewett, 2009; Hass et al., 2005).
moment is commonly used as a predictor of ACL injury risk during jump Furthermore, stiff landings cause tibiofemoral compression, which
43
A.J. Butcher et al.
Table 3
Summary of findings regarding risk factors associated with ACL injury (knee abduction angle, knee abduction moment, knee flexion angle, ground reaction force) from studies examining the DVJ task.
Risk factor Certainty assessment Summary of findings
measured
Studies (n) Phase of Methodological weakness Inconsistency Indirectness Imprecision Publication Participants Results (direction of relationship with Overall certainty
investigation (study (risk of bias - from NOS) bias (n) maturation) of evidence
design) (GRADE)
Knee 411,28,31,49 Phase 1 (1) Phase 2 ✓ Unclear ✓(2) X(2) X(4) ✓(4) Unspecified Knee abduction angle increases with ☑☑☐☐
abduction (3) 182 pub maturation. Low
angle 133 post
Female
31 pre
45 early
32 pub
196 late/post
Male
27 pre
24 early
30 late/post
Knee 530,31,46,47,49 Phase 2 (5) ✓ Present ✓(4) X(1) X(5) ✓(5) Unspecified Knee abduction moment increases with ☑☑☐☐
abduction 182 pub maturation. Low
moment 133 post
Female
53 pre
17 early
62 pub
22 late
44
185 post
Male
32 pre
30 pub
43 post
Knee flexion 431,46,47,49 Phase 2 (4) ✓ Absent ✓(2) X(2) X(4) ✓(4) Female Knee flexion angle increases with ☑☑☑☐
angle 33 pre maturation. moderate
17 early
190 pub
22 late
262 post
Male
37 pub
13 post
Ground 321,47,48 Phase 2 (3) X Absent ✓(1) X(2) X(3) ✓(3) Female Landing GRF (normalised to body mass) ☑☑☐☐
reaction 87 not decrease with maturation in males. Take off Low
force specified GRF decrease with maturation in females.

16 pre
16 pub
32 post
Male
188 not
specified
17 pub
17 post
Abbreviations: ACL; Anterior cruciate ligament, GRADE; Grading of Recommendations Assessment, Development and Evaluation, NOS; Newcastle-Ottawa Scale, GRF; Ground Reaction Force.
A.J. Butcher et al.
Table 4
Summary of findings regarding risk factors associated with ACL injury (knee abduction angle, knee abduction moment, knee flexion angle, ground reaction force) from studies examining a cutting task.
measured
Studies (n) Phase of investigation Methodological weakness Inconsistency Indirectness Imprecision Publication Participants (n) Results Overall certainty of
(study design) (risk of bias - from NOS) bias evidence (GRADE)
Knee abduction 427,29,31,50,51 Phase 1 (2) ✓ Present ✓(5) ✓(2) X(3) ✓(4) X(1) Female Knee abduction angle ☑☑☐☐
angle Phase 2 (3) 35 not specified increases with maturation. Low
101 pre
212 pub
160 post
Male
36 pre
53 pub
59 post
Knee abduction 329,31,51 Phase 1 (1) ✓ Absent ✓(3) ✓(1) X(3) ✓(2) X(1) Female Knee abduction moment ☑☑☑☐
moment Phase 2 (2) 35 not specified increases with maturation. Moderate
32 pre
48 pub
29 post
Male
16 pre
45
15 pub
29 post
Knee flexion 327,31,50,51 Phase 1 (2) ✓ Present ✓(4) X(4) ✓(2) X(2) Female Knee flexion angle decreases ☑☑☐☐
angle Phase 2 (2) 35 not specified with maturation. Low
86 pre
197 pub
131 post
Male
20 pre
38 pub
30 post
Ground 229,51 Phase 1 (1) Phase 2 (1) ✓ Absent ✓(2) ✓(1) X(1) ✓(1) X(1) Female GRF (normalised to body ☑☑☐☐
reaction force 35 not specified mass) decrease with Low
15 pre maturation.
15 pub
29 post
Male

16 pre
15 pub
29 post
A.J. Butcher et al.
Table 5
Summary of findings regarding risk factors associated with ACL injury (knee abduction angle, knee abduction moment, knee flexion angle, ground reaction force) from studies examining other tasks.
measured
Studies Phase of investigation Methodological weakness Inconsistency Indirectness Imprecision Publication Participants Results Overall certainty of
(n) (study design) (risk of bias - from NOS) bias (n) evidence (GRADE)
Knee abduction 355-57 Phase 2 (3) ✓ Present ✓(3) ✓(2) X(1) ✓(3) Female Knee abduction angle decreases with ☑☑☑☐
angle 33 across 5 maturation in males and is unclear in moderate
stages females.
26 pre
55 post
Male
15 pre
14 post
Knee abduction 354,56,57 Phase 2 (3) ✓ Unclear ✓(2) X(1) ✓(1) X(2) ✓(3) Female Knee abduction moment increases ☑☑☐☐
moment 33 across 5 with maturation. Low
stages
42 pre
30 early
46
41 post
Knee flexion 354-57 Phase 2 (3) ✓ Absent ✓(2) X(1) ✓(1) X(2) ✓(3) Female Knee flexion angle decreases with ☑☑☐☐
angle 33 across 5 maturation. Low
stages
57 pre
30 early
55 post
Male
15 pre
14 post
Ground 255,56 Phase 2 (2) ✓ Present ✓(2) ✓(2) ✓(1) x(1) Female Ground reaction forces (normalised to ☑☑☐☐
reaction 34 pre body mass) decrease with maturation. Low
force 19 pub
38 post
Male
15 pre
14 post

Fig. 2. Summary of the observed links between maturation and changes in biomechanics associated with anterior cruciate ligament (ACL) injury as reported in the
literature.
Note: Red arrows indicate low certainty of evidence, yellow arrows indicate moderate certainty of evidence (as determined by GRADE). Two arrows suggest different
quality of evidence ratings for the different specified tasks, presented in order of mention. (For interpretation of the references to colour in this figure legend, the
reader is referred to the Web version of this article.)
loads the ACL (Meyer & Haut, 2008). During a DVJ task, stiff landings primarily in the sagittal plane. Single-leg tasks increase the load and task
have been associated with increased risk of ACL injury in young females difficulty. Cutting tasks impose a more frontal plane demand and are
(Hewett, Myer, Ford, et al., 2005; Leppänen et al., 2017). Specifically, more sport specific. Implementing both a single-leg landing and incor
athletes who went on to sustain ACL injuries displayed lower peak knee porating movements that reflect cutting or rotating manoeuvres for
flexion angle and higher peak GRF (Hewett, Myer, Ford, et al., 2005; assessment of high-risk biomechanics should be considered to improve
Leppänen et al., 2017). As females mature, GRF during dynamic tasks specificity for ACL injury risk screening (Koga et al., 2010; Westbrook
generally remains the same (Colyer et al., 2021; Hewett et al., 2006; et al., 2020).
Quatman et al., 2006), or may slightly decrease (Hass et al., 2005; Sig Definitions of maturation phases and phases examined also varied
ward, Pollard, Havens, & Powers, 2012; Swartz et al., 2005). GRF tends between studies, impacting the ability for cross-study inferences and
to decrease with maturation in males (Colyer et al., 2021; Hewett et al., strength of evidence on specific variables. Comprehensive and consis
2006; Quatman et al., 2006), suggesting greater improvements than tent reporting standards for maturation phase identification and
females in force attenuation with maturation. During a DVJ task, the grouping would enhance cross-study inferences (Koopman-Verhoeff,
spring-like behaviour observed via the force-time data profile (referred Gredvig-Ardito, Barker, Saletin, & Carskadon, 2020). Tanner stages, as
to as stretch-shortening cycle ability) generally improved with matura identified using the self-administered pubertal maturation observational
tion, but remained relatively poor in post-pubertal females (Pedley et al., scale, were used most often across the included studies. Tanner stages
2021). Stretch-shortening cycle ability is also impacted by an in via physical examination from a medical professional are deemed ‘gold
dividual’s neuromuscular development rate, which is not consistent standard’ for maturational phase identification (Rasmussen et al.,
across maturation (Hewett, Myer, Ford, et al., 2005; Quatman-Yates 2015); however, self-reported Tanner stages are valid for determining
et al., 2012). Inconsistent development in neuromuscular control may maturational status and less intrusive than other validated methods
explain individual differences or lack of improvement in force attenu (Leone & Comtois, 2007; Schmitz et al., 2004). Nonetheless, further
ation ability, which is often observed in pubertal females. investigation into the reliability and validity of the pubertal maturation
The differences in tasks, including the use of double or single limb observational scale in different demographics is warranted.
landing, likely contributed to the conflicting results regarding the link Reporting or controlling for menstrual cycle phase was rarely re
between maturation and biomechanics (Taylor et al., 2017). Over half of ported. Given the domination of female participants (65.8 %), future
the included studies used the DVJ task for identifying potential biome research should attempt to control for or report menstrual cycle phase
chanical risk factors. Although commonly used as a screening tool for and contraceptive usage status to better understand potential hormonal
ACL injury risk, biomechanics during a DVJ correlate poorly with cut influence on biomechanics (Balachandar, Marciniak, Wall, & Bala
ting biomechanics (Hanzlíková, Richards, Athens, & Hébert-Losier, chandar, 2017; Herzberg et al., 2017). Although more common in fe
2021), which limits comparability and pertinence of results (Kristians males (Joseph et al., 2013), non-contact ACL injury is relatively common
lund, Faul, Bahr, Myklebust, & Krosshaug, 2014). Regardless of the link in adolescent males (Maniar et al., 2022). The risk of ACL injury
between the task’s biomechanical variables and ACL injury risk, throughout maturation in males is relatively unknown and only one of
observed changes in dynamic tasks across maturation can be viewed the included studies examined the biomechanics of males alone (Chia
more holistically due to previous identification of the higher risk of ACL et al., 2023). The small amount of data available suggests significantly
injuries in post-pubertal females (Prodromos et al., 2007; Waldén et al., different biomechanical movement patterns in males compared to fe
2011). Tasks such as the DVJ involve deceleration and force attenuation, males. Hence, further research into ACL injury risk factors specific to
47
males should be considered. • As females mature, knee abduction angles and moments typically
This review specifically examined biomechanical risk factors asso increase whereas knee flexion angles generally decrease during dy
ciated with ACL injury; however, it should be noted that ACL injuries are namic tasks.
multifactorial in nature and factors such as the demands of the sport or • Maturation can influence biomechanics associated with ACL injury
an athlete’s position (Bram, Magee, Mehta, Patel, & Ganley, 2021), in during landing and cutting tasks, indicating that late-to post-pubertal
dividual anatomy and morphology (Bayer et al., 2020), cognitive ability females may be at increased risk of ACL injury.
(Bertozzi et al., 2023), and the gendered differences regarding coaching, • Few studies examined the same variables and those that did reported
training, and physical activity participation (Parsons, Coen, & Bekker, large standard deviations, presented limited or only statistically
2021) will contribute to overall risk of injury. significant findings, or had small sample sizes. The small quantity of
studies assessed for each domain, the generally low-to-moderate
5. Limitations levels of evidence, and the variations in effect sizes should be
considered when interpreting the results.
This systematic review is not without limitations. Firstly, few studies
assessed the same metric, used the same task, or considered the same Ethical statement
maturation phases, thereby restricting the ability for a meta-analysis to
be performed. Studies that did examine the same variables often re Institutional ethics were not required to be obtained for this sys
ported large standard deviations, presented limited or only statistically tematic review.
significant findings, or had small sample sizes; all factors likely to distort
the results of a meta-analysis if one had been undertaken. Most studies CRediT authorship contribution statement
were of good quality and two were of satisfactory quality in accordance
with the NOS, but the strength of the evidence was low-to-moderate Anna J. Butcher: Writing – review & editing, Writing – original
based on GRADE ratings. The small quantity of studies assessed for draft, Visualization, Validation, Methodology, Investigation, Formal
each domain and the variations in effect sizes should be considered analysis, Data curation, Conceptualization. Sarah Ward: Writing – re
when interpreting these results. We chose to include studies of varied view & editing, Visualization, Validation, Supervision, Methodology,
study designs (cross-sectional, longitudinal, and interventional) to Investigation, Formal analysis, Data curation, Conceptualization.
enhance the breadth of the review and data available for review, despite Tracey Clissold: Writing – review & editing, Supervision, Methodology,
longitudinal study designs potentially yielding more robust data to Conceptualization. Jim Richards: Writing – review & editing, Super
establish the potential link between maturation and biomechanical vision, Methodology, Conceptualization. Kim Hébert-Losier: Writing –
factors associated with ACL injury. Additionally, many of the studies review & editing, Visualization, Validation, Supervision, Methodology,
included researchers from the same group based in the USA, which may Investigation, Formal analysis, Conceptualization.
influence the generalisability of the results of the current review as well
as introduce bias through homogeneity of study findings. This overt
representation of these researchers and country may mean that many of Declaration of competing interest
the participants were from the same or a similar group (as was
confirmed or assumed in studies of the same author and year (Ford et al., The authors declare that they have no known competing financial
2010a; Ford et al., 2010b; Sigward, Pollard, Havens, & Powers, 2012; interests or personal relationships that could have appeared to influence
Sigward, Pollard, & Powers, 2012)), consequently limiting the cultural the work reported in this paper.
diversity and global applicability of findings.
Appendix A. Supplementary data
6. Conclusion
Supplementary data to this article can be found online at https://doi.
Late and post-pubertal females demonstrate lower-extremity org/10.1016/j.ptsp.2024.06.002.
biomechanics associated with increased ACL injury risk. Although the
evidence was of low-to-moderate quality and varied between studies,
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Contents lists available at ScienceDirect

Physical Therapy in Sport

Maturation and biomechanical risk factors associated with anterior cruciate

2. Methods 2.3. Study quality assessment

3.5. Narrative synthesis 3.5.2. Knee abduction moment

Qualitive synthesis of studies (n = 9) reporting on biomechanics in DVJ tasks

height, 161.5 ± abduction moment

± 5.6 cm; mass, as did post-pubertal small)

12.5 ± 0.1 y; external/internal MD, p = 0.003) large)

Physical Therapy in Sport 68 (2024) 31–50

Physical Therapy in Sport 68 (2024) 31–50

Physical Therapy in Sport 68 (2024) 31–50

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