Research Article| Volume 40, P135-142, January 2023

Download started.


Age, female sex, and oral contraceptive use are risk factors for anterior cruciate ligament reconstruction: A nationwide database study

Published:November 23, 2022DOI:



      The purpose of this study was to investigate risk factors affecting anterior cruciate ligament (ACL) tears and outcomes following ACL reconstruction in males versus females. This study also analyzed oral contraceptive pill (OCP) use, demographics (e.g., body mass index [BMI], age group), comorbidities (e.g., diabetes, hypertension), and post-operative systemic complications (e.g., anemia, malignant hyperthermia) in patients undergoing ACL reconstruction.


      Medical records of patients undergoing ACL reconstruction from 2010–2018 were queried from the PearlDiver administrative claims database current procedural terminology (CPT) and international classification of disease (ICD) codes. The following information was collected using ICD-9/ICD-10 codes: concurrent use of OCPs, concomitant meniscus repair, demographics, age, comorbidities, and systemic complications. The number of ACL reconstructions in females and males were analyzed using multivariate regressions.


      Of 11,498 ACL reconstructions, 5,967 (51.9%) were in females and 5,531 (48.1%) were in males. The majority of patients were ages 15–19 (24.1%) and were not obese (BMI < 30 kg/m2) (35.9%). A greater proportion of female patients undergoing ACL reconstruction were between 15–19 years old (P < 0.001) and obese (BMI > 40 kg/m2) (P < 0.001). A larger proportion of females aged 15–39 taking OCPs underwent ACL reconstruction compared to those not taking OCPs within the same age group (P < 0.001).


      ACL tears are more common in female patients compared to males and are more commonly treated with ACL reconstruction. This study identified several factors that may be associated with the increased risk of ACL tears in females, including young age (age 15–39), obesity (BMI > 40 kg/m2), and the use of OCPs prior to ACL reconstruction, which warrant further investigation and attention from surgeons.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Knee
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bansal A.
        • Lamplot J.D.
        • VandenBerg J.
        • Brophy R.H.
        Meta-analysis of the risk of infections after anterior cruciate ligament reconstruction by graft type.
        Am J Sports Med. 2018; 46: 1500-1508
        • Sanders T.L.
        • Maradit Kremers H.
        • Bryan A.J.
        • Larson D.R.
        • Dahm D.L.
        • Levy B.A.
        • et al.
        Incidence of anterior cruciate ligament tears and reconstruction: A 21-year population-based study.
        Am J Sports Med. 2016; 44: 1502-1507
        • Gianotti S.M.
        • Marshall S.W.
        • Hume P.A.
        • Bunt L.
        Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study.
        J Sci Med Sport. 2009; 12: 622-627
        • Janssen K.W.
        • Orchard J.W.
        • Driscoll T.R.
        • van Mechelen W.
        High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model?.
        Scand J Med Sci Sports. 2012; 22: 495-501
        • Magnussen R.A.
        • Trojani C.
        • Granan L.-P.
        • Neyret P.
        • Colombet P.
        • Engebretsen L.
        • et al.
        Patient demographics and surgical characteristics in ACL revision: a comparison of French, Norwegian, and North American cohorts.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 2339-2348
        • Fabricant P.D.
        • Kocher M.S.
        Anterior cruciate ligament injuries in children and adolescents.
        Orthop Clin North Am. 2016; 47: 777-788
        • Dodwell E.R.
        • Lamont L.E.
        • Green D.W.
        • Pan T.J.
        • Marx R.G.
        • Lyman S.
        20 years of pediatric anterior cruciate ligament reconstruction in New York State.
        Am J Sports Med. 2014; 42: 675-680
        • Gornitzky A.L.
        • Lott A.
        • Yellin J.L.
        • Fabricant P.D.
        • Lawrence J.T.
        • Ganley T.J.
        Sport-specific yearly risk and incidence of anterior cruciate ligament tears in high school athletes: A systematic review and meta-analysis.
        Am J Sports Med. 2016; 44: 2716-2723
        • Arendt E.
        • Dick R.
        Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature.
        Am J Sports Med. 1995; 23: 694-701
        • Belmont Jr, P.J.
        • Shawen S.B.
        • Mason K.T.
        • Sladicka S.J.
        Incidence and outcomes of anterior cruciate ligament reconstruction among U.S. Army aviators.
        Aviat Space Environ Med. 1999; 70: 316-320
        • Shea K.G.
        • Pfeiffer R.
        • Wang J.H.
        • Curtin M.
        • Apel P.J.
        Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data.
        J Pediatr Orthop. 2004; 24: 623-628
        • Hewett T.E.
        Neuromuscular and hormonal factors associated with knee injuries in female athletes. Strategies for intervention.
        Sports Med. 2000; 29: 313-327
        • Wojtys E.M.
        • Huston L.J.
        • Boynton M.D.
        • Spindler K.P.
        • Lindenfeld T.N.
        The effect of the menstrual cycle on anterior cruciate ligament injuries in women as determined by hormone levels.
        Am J Sports Med. 2002; 30: 182-188
        • Kaeding C.C.
        • Léger-St-Jean B.
        • Magnussen R.A.
        Epidemiology and Diagnosis of Anterior Cruciate Ligament Injuries.
        Clin Sports Med. 2017; 36: 1-8
        • Barber-Westin S.D.
        • Noyes F.R.
        • Andrews M.
        A rigorous comparison between the sexes of results and complications after anterior cruciate ligament reconstruction.
        Am J Sports Med. 1997; 25: 514-526
        • Agel J.
        • Rockwood T.
        • Klossner D.
        Collegiate ACL injury rates across 15 sports: National collegiate athletic association injury surveillance system data update (2004–2005 Through 2012–2013).
        Clin J Sport Med. 2016; 26: 518-523
        • Agel J.
        • Arendt E.A.
        • Bershadsky B.
        Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review.
        Am J Sports Med. 2005; 33: 524-530
        • Deitch J.R.
        • Starkey C.
        • Walters S.L.
        • Moseley J.B.
        Injury risk in professional basketball players: a comparison of Women's National Basketball Association and National Basketball Association athletes.
        Am J Sports Med. 2006; 34: 1077-1083
        • Prodromos C.C.
        • Han Y.
        • Rogowski J.
        • Joyce B.
        • Shi K.
        A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen.
        Arthroscopy. 2007; 23: 1320-1325.e6
        • Sutton K.M.
        • Bullock J.M.
        Anterior cruciate ligament rupture: differences between males and females.
        J Am Acad Orthop Surg. 2013; 21: 41-50
        • Lipps D.B.
        • Oh Y.K.
        • Ashton-Miller J.A.
        • Wojtys E.M.
        Morphologic characteristics help explain the gender difference in peak anterior cruciate ligament strain during a simulated pivot landing.
        Am J Sports Med. 2012; 40: 32-40
        • Chappell J.D.
        • Yu B.
        • Kirkendall D.T.
        • Garrett W.E.
        A comparison of knee kinetics between male and female recreational athletes in stop-jump tasks.
        Am J Sports Med. 2002; 30: 261-267
        • Ford K.R.
        • Myer G.D.
        • Hewett T.E.
        Valgus knee motion during landing in high school female and male basketball players.
        Med Sci Sports Exerc. 2003; 35 (PMID: 14523314): 1745-1750
        • Ford K.R.
        • Myer G.D.
        • Smith R.L.
        • Vianello R.M.
        • Seiwert S.L.
        • Hewett T.E.
        A comparison of dynamic coronal plane excursion between matched male and female athletes when performing single leg landings.
        Clin Biomech (Bristol, Avon). 2006; 21: 33-40
        • Ford K.R.
        • Myer G.D.
        • Toms H.E.
        • Hewett T.E.
        Gender differences in the kinematics of unanticipated cutting in young athletes.
        Med Sci Sports Exerc. 2005; 37: 124-129
        • Hewett T.E.
        • Ford K.R.
        • Myer G.D.
        • Wanstrath K.
        • Scheper M.
        Gender differences in hip adduction motion and torque during a single-leg agility maneuver.
        J Orthop Res. 2006; 24: 416-421
        • Hewett T.E.
        • Myer G.D.
        • Ford K.R.
        Decrease in neuromuscular control about the knee with maturation in female athletes.
        J Bone Joint Surg Am. 2004; 86: 1601-1608
        • Kernozek T.W.
        • Torry M.R.
        • Van Hoof H.
        • Cowley H.
        • Tanner S.
        Gender differences in frontal and sagittal plane biomechanics during drop landings.
        Med Sci Sports Exerc. 2005; 37: 1003-1013
        • McLean S.G.
        • Huang X.
        • Su A.
        • Van Den Bogert A.J.
        Sagittal plane biomechanics cannot injure the ACL during sidestep cutting.
        Clin Biomech (Bristol, Avon). 2004; 19: 828-838
        • Ford K.R.
        • Shapiro R.
        • Myer G.D.
        • Van Den Bogert A.J.
        • Hewett T.E.
        Longitudinal sex differences during landing in knee abduction in young athletes.
        Med Sci Sports Exerc. 2010; 42: 1923-1931
        • Tursz A.
        • Crost M.
        Sports-related injuries in children. A study of their characteristics, frequency, and severity, with comparison to other types of accidental injuries.
        Am J Sports Med. 1986; 14: 294-299
        • Zazulak B.T.
        • Paterno M.
        • Myer G.D.
        • Romani W.A.
        • Hewett T.E.
        The effects of the menstrual cycle on anterior knee laxity: a systematic review.
        Sports Med. 2006; 36: 847-862
        • Somerson J.S.
        • Isby I.J.
        • Hagen M.S.
        • Kweon C.Y.
        • Gee A.O.
        The menstrual cycle may affect anterior knee laxity and the rate of anterior cruciate ligament rupture: A systematic review and meta-analysis.
        JBJS Rev. 2019; 7: e2
        • Liu S.H.
        • Al-Shaikh R.A.
        • Panossian V.
        • Finerman G.A.
        • Lane J.M.
        Estrogen affects the cellular metabolism of the anterior cruciate ligament. A potential explanation for female athletic injury.
        Am J Sports Med. 1997; 25: 704-709
        • Yu W.D.
        • Panossian V.
        • Hatch J.D.
        • Liu S.H.
        • Finerman G.A.
        Combined effects of estrogen and progesterone on the anterior cruciate ligament.
        Clin Orthop Relat Res. 2001; 383: 268-281
        • Lee H.
        • Petrofsky J.S.
        • Daher N.
        • Berk L.
        • Laymon M.
        Differences in anterior cruciate ligament elasticity and force for knee flexion in women: oral contraceptive users versus non-oral contraceptive users.
        Eur J Appl Physiol. 2014; 114: 285-294
        • Gray A.M.
        • Gugala Z.
        • Baillargeon J.G.
        Effects of Oral Contraceptive Use on Anterior Cruciate Ligament Injury Epidemiology.
        Med Sci Sports Exerc. 2016; 48: 648-654
        • Herzberg S.D.
        • Motu'apuaka M.L.
        • Lambert W.
        • Fu R.
        • Brady J.
        • Guise J.M.
        The effect of menstrual cycle and contraceptives on ACL injuries and laxity: A systematic review and meta-analysis.
        Orthop J Sports Med. 2017; 5 (2325967117718781)
        • Lee H.
        • Petrofsky J.S.
        • Yim J.
        Do oral contraceptives alter knee ligament damage with heavy exercise?.
        Tohoku J Exp Med. 2015; 237: 51-56
        • Samuelson K.
        • Balk E.M.
        • Sevetson E.L.
        • Fleming B.C.
        Limited evidence suggests a protective association between oral contraceptive pill use and anterior cruciate ligament injuries in females: A systematic review.
        Sports Health. 2017; 9: 498-510
        • DeFroda S.F.
        • Bokshan S.L.
        • Worobey S.
        • Ready L.
        • Daniels A.H.
        • Owens B.D.
        Oral contraceptives provide protection against anterior cruciate ligament tears: a national database study of 165,748 female patients.
        Phys Sportsmed. 2019; 47: 416-420