Invest Clin 65(2): 192 - 205, 2024 https://doi.org/10.54817/IC.v65n2a06

Corresponding author: Adrián Feria Madueño. Department of Physical Education and Sport, University of Seville.

Pirotecnia Street, Seville, Spain. Phone: +0034 955420585. Fax: +0034 954229434. E-mail: aferia1@us.es

Gender-based comparative analysis of knee

injury risk during cutting maneuvers in

non-professional athletes: a kinetic and

kinematic perspective.

Adrián Feria-Madueño

, Timothy E. Hewett

2,3

and Borja Sañudo

Department of Physical Education and Sport, University of Seville. Pirotecnia Street,

Seville, Spain.

Department of Orthopedics, Marshall University Biomechanics Laboratories

and Sports Medicine Research, Marshall University, Huntington, West Virginia, USA.

Hewett Global Consulting, Newport, KY.

Keywords: anterior cruciate ligament; Q angle; accelerometry; force platform.

Abstract. This study aimed to compare the risk of knee injury between

men and women by integrating kinetic and kinematic parameters in a non-

professional athlete population. Two hundred non-professional athletes were re-

cruited for the present study. Three change of direction tests were conducted,

consisting of two open cuts at 30 (SC

) and 45 degrees (SC

) and one closed

cut at 45 degrees (SC

45cl

). Kinetic variables, including three-dimensional force

and accelerations in the three axes of movement and ground contact time, were

assessed using force platform and accelerometers. The initial and maximum an-

gles of the ankle, knee, hip, and trunk were analyzed by photogrammetry. The

data was compared between males and females to examine gender differenc-

es. Gender analysis demonstrated significant differences in force values, with

women displaying higher medial-lateral (ML) force in SC

and men exhibiting

higher vertical ground reaction force (VGRF) and anterior-posterior (AP) force

in SC

. Gender-specific analysis indicated higher partial knee accelerations in

women during SC

and SC

, with significant differences observed in accelera-

tion in the vertical axe. Gender differences were observed in certain kinematic

variables, with women displaying higher ankle flexion at initial contact in SC

and higher ankle flexion at maximum flexion and ankle dorsiflexion range in

. Men showed lower knee flexion angles in both SC

45cl

and SC

. These find-

ings provide valuable insights into the kinetics and kinematics of change of

direction movements and highlight gender-specific differences that may have

implications for training and injury prevention strategies. Further research is

needed to understand the underlying factors contributing to these differences

and their impact on performance and injury risk.

Gender differences in knee injury risk 193

Vol. 65(2): 192 - 205, 2024

Análisis comparativo, basado en el género, del riesgo

de lesión de rodilla durante cambios de dirección en atletas

no profesionales: una perspectiva cinética y cinemática.

Invest Clin 2024; 65 (2): 192 – 205

Palabras clave: ligamento cruzado anterior; ángulo Q; acelerómetro; plataforma de

fuerza.

Resumen. El objetivo de este estudio fue comparar el riesgo de lesión de

rodilla entre hombres y mujeres mediante la integración de parámetros cinéticos

y cinemáticos en una población de atletas no profesionales. Doscientos atletas no

profesionales fueron reclutados para el presente estudio. Se realizaron tres prue-

bas de cambio de dirección, consistentes en dos cortes abiertos a 30 (SC

) y 45

grados (SC

), y un corte cerrado a 45 grados (SC

45cl

). Se evaluaron las variables

cinéticas, incluida la fuerza tridimensional, así como las aceleraciones en los tres

ejes de movimiento y el tiempo de contacto con el suelo mediante plataforma de

fuerza y acelerometría. Se analizaron los ángulos iniciales y máximos del tobillo,

la rodilla, la cadera y el tronco a través de fotogrametría. Se realizó una compa-

ración de los datos entre hombres y mujeres para examinar las diferencias de

género. El análisis de género demostró diferencias significativas en los valores de

fuerza, mostrando las mujeres una mayor fuerza medial-lateral (ML) en SC

, y

los hombres una mayor fuerza de reacción vertical al suelo (VGRF) y fuerza an-

teroposterior (AP) en SC

. Los análisis específicos de género indicaron mayores

aceleraciones parciales de rodilla en las mujeres durante SC

y SC

, observándo-

se diferencias significativas en la aceleración en el eje vertical. Se observaron dife-

rencias de género en determinadas variables cinemáticas, mostrando las mujeres

mayor flexión del tobillo en el contacto inicial en SC

y mayor flexión del tobillo

en flexión máxima y rango de dorsiflexión del tobillo en SC

. Los hombres mos-

traron ángulos de flexión de rodilla más bajos tanto en SC

45cl

como en SC

. Estos

resultados proporcionan información valiosa sobre la cinética y la cinemática de

los movimientos de cambio de dirección y ponen de relieve las diferencias especí-

ficas de género que pueden tener implicaciones para las estrategias de entrena-

miento y prevención de lesiones. Se necesita más investigación para comprender

mejor los factores subyacentes que contribuyen a estas diferencias y su impacto

en el rendimiento y el riesgo de lesiones.

Received: 12-10-2023 Accepted: 08-02-2024

INTRODUCTION

Gender is a significant factor to consid-

er in the incidence and prevention of knee

injuries during changes of direction

1,2

. One

of the structures with a higher incidence

of injury is the anterior cruciate ligament

(ACL), and research has demonstrated that

women have an increased risk compared to

men in sports involving frequent changes of

direction and deceleration

From a kinetic standpoint, the mecha-

nism of injury during knee changes of direc-

tions involves a combination of torsional and

194 Feria-Madueño et al.

Investigación Clínica 65(2): 2024

axial loading forces applied to the ACL

. The

knee is vulnerable during direction changes

due to the combination of rotational and axi-

al loading movements on the ligament

. The

assessment of the ACL using force platforms

is well-established

5-7

. However, there is lim-

ited evidence on its analysis using other pa-

rameters such as accelerometry in each axis

and ground contact time during changes of

directions.

In women, hip anatomy and knee bio-

mechanics during changes of directions may

contribute to a higher incidence of ACL in-

juries

. Women have wider hips and a larger

Q angle, which can increase internal knee

rotation during direction changes and thus

increase the risk of ACL injuries

. Conse-

quently, women exhibit a smaller flexion an-

gle and greater dynamic valgus during knee

changes, associated with lower knee stability

and an increased risk of injury

These kinetic and kinematic factors re-

lated to the risk of knee injuries include not

only the direction and magnitude of forces

applied to the knee during changes of direc-

tion

, but also depend on the knee angle

maintained and ground contact time dur-

ing changes of direction

. However, there

is limited research integrating both factors.

Despite knowledge of the risk factors most

associated with an increased risk of knee in-

juries, there is a lack of evidence in evaluat-

ing these risk factors in a non-professional

athlete population, necessitating studies

that assess kinetic and kinematic parame-

ters, integrating them into a comprehensive

analysis with innovative parameters such as

acceleration or contact time.

Therefore, this study aimed to compare

the risk of knee injury between men and

women by integrating kinetic and kinemat-

ic parameters in a non-professional athlete

population.

MATERIALS AND METHODS

Subjects

Two hundred non-professional athletes

were recruited for the present study. After

the initial meeting, the inclusion criteria

were explained. These criteria consisted of

engaging in physical activity for at least 30

minutes per day, three days per week, and

having no history of knee or ankle injury in

the past 12 months. Following this meeting,

38 athletes withdrew from the study, result-

ing in one hundred sixty-two participants

(75% males, 25% females). All participants

completed surveys to assess their weekly

and daily levels of physical activity, as well

as their height and body mass (Table 1).

The potential risks of the tests were verbally

communicated to the participants, and they

provided signed informed consent. The Eth-

ics Committee of the University of Seville ap-

proved the study.

Table 1

Characteristics of the participants.

Variables Mean Men (n=122) Women (n=40) p

Age (years) 24 ± 3 25 ± 2 22 ±1 0.110

Body mass (Kg) 72.84 ± 12.76 76.92 ± 8.12 65.36 ± 4.52 0.103

Height (m) 1.74 ± 0.07 1.80 ± 0.09 1.63 ± 0.06 0.071

BMI (kg/m

) 23.78 ± 2.86 24.75 ± 1.12 21.34 ± 2.12 0.096

PA (hours/week) 8.38 ± 4.01 8.79 ± 3.96 7.91 ± 2.34 0.101

day

(hours/day) 1.97 ± 1.66 2.03 ± .098 1.86 ± 1.10 0.510

*p ≤ 0.05 Men vs Women. Statistical analysis was done using a repeated-measures two-way ANOVA. Results expres-

sed as mean±standard error of the mean. BMI: body mass index. PA: physical activity.

Gender differences in knee injury risk 195

Vol. 65(2): 192 - 205, 2024

Procedures

The participants completed a Maxi-

mum Voluntary Contraction (MVC) test us-

ing the Biodex Multi-joint System (Shirley,

New York). The exercise was knee flexion at

45° to assess the strength of the posterior

thigh musculature and knee extension at

45° to assess the anterior thigh muscula-

ture. Following this, they underwent a direc-

tional change test with the dominant foot,

which included two open cuts at 45° (SC

)

and 30° (SC

), as well as a closed cut (SC-

45cl

) on a force platform (Kistler 9260 AA6,

Winterthur, Switzerland). Prior to the test,

all participants underwent a standardized

warm-up, which involved a 5-minute cycling

session on a cycloergometer (Ergoline 900,

Ergometrics, Bitz, Germany) at an intensity

of 60 W (60 rpm). Additionally, they famil-

iarized themselves with sports-specific side-

cutting maneuvers through five to eight

practice attempts. The velocity of the move-

ments was regulated using a metronome set

at 4-5.5 m/s, and the designated direction

for the movements was indicated on the

floor using tape.

Kinetics

A force plate (Kistler 9260 AA6, Win-

terthur, Switzerland) assessed the Ground

Reaction Forces (GRF) in the vertical,

mediolateral, and anteroposterior axes.

Additionally, triaxial accelerometers (xyz-

PLUX, PLUX-Wireless Biosignals, S.A.,

Lisbon, Portugal) were employed to mea-

sure accelerations at the knee and ankle

joints. The knee accelerometer was posi-

tioned on the lateral condyle. In contrast,

the ankle accelerometer was placed on the

malleolus (Fig. 1). Antero-posterior (AP),

Medial-Lateral (ML), and Longitudinal (Z)

axes were calculated, and all signals were

recorded at a sampling rate of 1000 Hz.

Contact Time was determined during side-

cutting by measuring the duration from

the initial ground contact until the foot

entered the flight phase.

Kinematics

An analysis of knee, ankle, hip, and

trunk angles was conducted. Reflective

markers were positioned on the lateral mal-

leolus, lateral condyle, greater trochanter,

and acromion to capture the movements

precisely. The angles were calculated at two

specific time points: first, during the initial

contact between the foot and the ground,

and second, when the Vertical Ground Reac-

tion Force (VGRF) was recorded. Three video

cameras (240 Fps) were positioned perpen-

dicularly, one for each type of change of di-

rection, at a distance of two meters from the

central point of the force platform. Subse-

quently, the Kinovea software was employed

for digitization and angle extraction by 2D

analysis.

Statistical analysis

Statistical analysis was performed using

the SPSS 22.0 software package (SPSS Inc.,

Chicago, IL, USA). The Kolmogorov-Smirnov

Fig. 1. Location of accelerometers.

196 Feria-Madueño et al.

Investigación Clínica 65(2): 2024

test assessed the data distribution, and para-

metric variables were identified. Baseline data

were compared using an independent-sample

t-test. Potential statistical differences were

evaluated using a repeated-measures two-way

ANOVA (time x group). Mean values are re-

ported with standard deviation (SD), and sta-

tistical significance was set at p ≤ 0.05.

The effect size (Cohen’s d) was calcu-

lated by dividing the difference between the

means of the groups by the combined stan-

dard deviation of both groups, considering

the sample size. Effect sizes of 0.2 were con-

sidered small, 0.5 moderate, and 0.8 large.

RESULTS

Kinetic

During the SC

, subjects exhibited a

higher value of VGRF of 2135.49 ± 633.14

N, which corresponds to approximately three

times their body weight, while ML Force

(625.44 ± 170.99 N) and AP Force (945.62

± 421.53 N) were lower. For the SC

, VGRF

was lower compared to SC

, with a value

of 2015.83 (± 687.27 N), while ML Force

was 566.87 (± 189.22 N) and AP Force was

765.75 (± 417.06 N). In SC

45cl

, VGRF was

1790.60 (± 517.55 N), and ML Force ex-

hibited the smallest force value among all

measured changes of directions (515.41 ±

181.53 N), as well as in AP Force (670.37

± 368.42 N). For more specific results, the

force was normalized to each subject’s body

weight for each directional change, as shown

in Table 2.

Regarding the SC

, the results showed

the highest applied force in all axes, includ-

ing VGRF, AP Force, and ML Force. The gen-

der analysis in Table 2 revealed that during

the SC

directional change, women exhibit-

ed significantly higher force values than men

in ML Force (p = 0.045). On the other hand,

in the SC

, men demonstrated higher val-

ues than women in both VGRF (p = 0.025)

and AP Force (p = 0.020). Finally, in SC

45cl

significant differences were only observed in

the force exerted in AP Force, where women

displayed a higher force value than males (p

= 0.020).

The analysis of partial knee and ankle

accelerations during changes of directions is

presented in Table 3. The SC

exhibited the

lowest ACC

KNEE

AP (1.72 ± 1.48 g). Similarly,

ACC

ANKLE

Z had the lowest values compared

to the other changes of directions (4.11 ±

Table 2

Descriptive analysis of force during direction change.

Variables Mean Men Women p d-Cohen

VGRF (N/Kg) 29.49±7.75 29.54±7.42 29.33±8.81 0.465 0.02

ForceAP (N/Kg) 12.99±5.32 13.54±5.45 11.26±4.53 0.159 0.43

ForceML (N/Kg) 8.64±2.08 8.60±1.83 8.75±2.76 0.045* -0.07

VGRF (N/Kg) 27.70±7.81 28.20±8.32 26.14±5.76 0.025* 0.26

ForceAP (N/Kg) 10.54±5.39 11.14±5.68 8.68±3.90 0.020* 0.46

ForceML (N/Kg) 7.78±2.09 7.96±2.15 7.23±1.77 0.568 0.35

45cl

VGRF (N/Kg) 25.13±7.59 24.02±6.92 28.60±8.61 0.159 -0.62

ForceAP (N/Kg) 9.35±5.09 9.02±4.54 10.39±6.48 0.020* -0.26

ForceML (N/Kg) 7.17±2.40 7.13±2.40 7.32±2.45 0.612 -0.07

*p ≤ 0.05 Men vs Women. Statistical analysis was done using a repeated-measures two-way ANOVA. Results expres-

sed as mean±standard error of the mean. d-Cohen = the effect size. VGRF (N) = Ground reaction force. ForceML

(N) = Force in medio-lateral axe. ForceAP (N)= Force in antero-posterior axe.

Gender differences in knee injury risk 197

Vol. 65(2): 192 - 205, 2024

0.81). For the SC

, both ACC

KNEE

ML (2.39

± 1.58 g) and ACC

KNEE

Z (1.53 ± 1.30 g)

showed the lowest values. However, both AC-

ANKLE

ML and ACC

ANKLE

AP were higher than

in the other changes of directions (4.23 ±

0.75 g and 4.05 ± 0.92 g, respectively). Dur-

ing the SC

45cl

, the highest ACC

KNEE

ML (2.49

± 1.49 g), ACC

KNEE

Z (1.69 ± 1.40 g), and

ACC

ANKLE

Z (4.20 ± 0.79 g) were found. Con-

versely, ACC

ANKLE

ML and ACC

ANKLE

AP were

lower during this directional change (4.14

± 0.88 g and 3.98 ± 0.99 g, respectively).

On the other hand, gender-specific

acceleration was also evaluated (Table 4).

During the SC

, although no significant

differences were observed, partial knee ac-

celerations were higher in women than men.

In the ankle, only ACC

ANKLE

Z showed higher

values in women than men (4.20 ± 0.76 g).

In the case of SC

, there was a trend towards

higher acceleration in women compared to

men, both in the knee and ankle. Regard-

ing ACC

KNEE

Z, the difference between women

and men was significant (p=0.002), with

women displaying an acceleration of 1.82 ±

1.54 g compared to 1.44 ± 1.21 g exhibited

by men.

During the SC

45cl

, no significant gen-

der differences were found, except for ACC

K-

NEE

ML where men exhibited higher values

(2.49 ± 1.48 g). In the remaining partial

knee accelerations, women showed higher

values for this parameter, although they

were not statistically significant. Regarding

the ankle, only a trend towards higher values

in men than women was observed for ACC

AN-

KLE

Z (4.22 ± 0.81 g), although statistical sig-

nificance was not reached.

Kinematics

Kinematic factors were also studied

during changes of direction. Knee flexion

angles at initial contact (KneeFlexInit) and

maximum knee flexion angle (KneeFlexMax)

were analyzed. The range of ankle dorsiflex-

ion (AnkleDorsiRange), initial hip flexion

angle (HipFlexInit), maximum hip flexion

angle (HipFlexMax), initial trunk flexion

angle (TrunkFlexInit), and maximum trunk

flexion angle (TrunkFlexMax) were also ana-

lyzed.

Regarding the changes of directions

(Table 5), the highest value of KneeFlexInit

was observed in SC

(144.6° ± 7.6°), while

the lowest value of KneeFlexMax was found

during SC

(125.2° ± 8.9°). For the hip, the

maximum value of HipFlexMax was 60.6°

during SC

, while the trunk flexed 92.9°. Fi-

nally, a range of ankle dorsiflexion of 39.4°

was found between the initial contact of the

directional change and the maximum plan-

tar flexion during the change.

In SC

, KneeFlexMax was 125.2° (ex-

tension), similar to the value of 123.3° in

Table 3

Descriptive analysis of the acceleration in the three axes during direction changes.

45ml

ACC

KNEE_ML

2.46±1.50 2.39±1.58 2.49±1.49

ACC

KNEE_AP

1.72±1.48 2.03±1.55 2.08±1.55

ACC

KNEE_Z

1.63±1.37 1.53±1.30 1.69±1.40

ACC

ANKLE_ML

4.19±0.78 4.23±0.75 4.14±0.88

ACC

ANKLE_AP

4.04±0.98 4.05±0.92 3.98±0.99

ACC

ANKLE_Z

4.11±0.81 4.13±0.68 4.20±0.79

Results expressed as mean±standard error of the mean. ACC

KNEE

ML (g) = Acceleration in medio-lateral axe in knee.

ACC

ANKLE

AP (g) = Acceleration in antero-posterior axe in knee. ACC

ANKLE

Z (g) = Acceleration in vertical axe in knee.

ACC

ANKLE

ML (g) = Acceleration in medio-lateral axe in ankle. ACC

ANKLE

AP (g) = Acceleration in antero-posterior axe

in ankle. ACC

ANKLE

Z (g) = Acceleration in vertical axe in ankle.

198 Feria-Madueño et al.

Investigación Clínica 65(2): 2024

Table 4

Differences between men and women in acceleration during direction changes.

Variables Men Women p d-Cohen

ACC

KNEE_ML

2.33±1.47 2.86±1.56 0.558 -0.35

ACC

KNEE_AP

1.66±1.50 1.91±1.44 0.573 -0.16

ACC

KNEE_Z

1.57±1.30 1.84±1.55 0.080 -0.19

ACC

ANKLE_ML

4.20±0.73 4.14±0.94 0.215 0.07

ACC

ANKLE_AP

4.04±0.96 4.02±1.06 0.433 0.02

ACC

ANKLE_Z

4.08±0.83 4.20±0.76 0.413 -0.14

ACC

KNEE_ML

2.25±1.54 2.81±1.66 0.516 -0.35

ACC

KNEE_AP

1.92±1.57 2.35±1.49 0.563 -0.27

ACC

KNEE_Z

1.44±1.21 1.82±1.54 0.002* -0.29

ACC

ANKLE_ML

4.20±0.71 4.32±0.86 0.890 -0.16

ACC

ANKLE_AP

4.04±0.92 4.09±0.95 0.483 -0.05

ACC

ANKLE_Z

4.09±0.70 4.27±0.60 0.344 -0.26

45ml

ACC

KNEE_ML

2.49±1.48 2.48±1.55 0.866 0.01

ACC

KNEE_AP

1.96±1.53 2.46±1.58 0.795 -0.32

ACC

KNEE_Z

1.64±1.37 1.85±1.51 0.200 -0.14

ACC

ANKLE_ML

4.11±0.87 4.22±0.90 0.937 -0.12

ACC

ANKLE_AP

3.97±1.01 4.01±0.96 0.965 -0.04

ACC

ANKLE_Z

4.22±0.81 4.15±0.71 0.900 0.08

*p ≤ 0.05 Men vs Women. Statistical analysis was done using a repeated-measures two-way ANOVA. Results expres-

sed as mean±standard error of the mean. d-Cohen = the effect size. ACC

KNEE

ML (g) = Acceleration in medio-lateral

axe in knee. ACC

ANKLE

AP (g) = Acceleration in antero-posterior axe in knee. ACC

ANKLE

Z (g) = Acceleration in vertical

axe in knee. ACC

ANKLE

ML (g) = Acceleration in medio-lateral axe in ankle. ACC

ANKLE

AP (g) = Acceleration in antero-

posterior axe in ankle. ACC

ANKLE

Z (g) = Acceleration in vertical axe in ankle.

Table 5

Description of the kinematics in the experimental phase in direction change.

45cl

Variable Mean Mean Mean

Angle

Knee (degrees º) 144.63±7.65 143.45±17.86 141.43±9.87

Angle

max

Knee (degrees º) 123.33±10.00 125.16±8.91 119.97±14.18

Angle

Hip (degrees º) 42.50±2.94 41.54±5.63 40.92±4.56

Angle

max

Hip (degrees º) 60.57±5.50 51.21±6.36 54.37±5.37

Angle

Trunk (degrees º) 104.54±6.35 105.15±5.15 98.98±4.76

Angle

max

Trunk (degrees º) 92.99±5.36 95.02±5.73 77.77±6.54

Angle

Ankle (degrees º) 99.12±6.87 98.92±5.30 98.82±5.25

Angle

max

Ankle (degrees º) 59.70±7.45 57.19±5.40 56.97±4.28

Ankle_Dorsi_Angle (degrees º) 39.42±3.32 41.72±5.38 41.84±4.92

Results expressed as mean±standard error of the mean. Angle

Knee = Angle of knee in the first contact. Angle-

max

Knee = Angle of knee in the maximum flexion. Angle

Hip = Angle of hip in the first contact. Angle

max

Hip =

Angle of hip in the maximum flexion. Angle

Trunk = Angle of trunk in the first contact. Angle

max

Trunk = Angle of

trunk in the maximum flexion. Angle

Ankle = Angle of ankle in the first contact. Angle

max

Ankle = Angle of ankle

in the maximum flexion. Ankle_Dorsi_Angle = Range of ankle dorsiflexion.

Gender differences in knee injury risk 199

Vol. 65(2): 192 - 205, 2024

. At that moment, HipFlexMax was

51.21°, while TrunkFlexMax showed a flexion

of 95.1°. Additionally, the AnkleDorsiRange

was 41.7°, defined as the amount of flexion

from the first contact until maximum flexion

occurred.

In SC

45cl

, KneeFlexMax was 119.9°, rep-

resenting the most significant flexion of the

three change types. From initiating contact

to maximum knee flexion, the hip flexed by

13.5°. As for the trunk, it exhibited a flex-

ion of 77.8° at that moment. Finally, the An-

kleDorsiRange was 41.8°.

Finally, a gender analysis of kinemat-

ics during direction changes was performed

(Table 6). It was observed that during SC

women exhibited a significantly higher An-

kleFlexInit than men (p=0.040). However,

gender differences during SC

were found in

AnkleFlexMax (p=0.004) and AnkleDorsiR-

ange (p=0.007). Lastly, during SC

45cl

, gen-

der differences were found in KneeFlexInit

(p<0.001) and KneeFlexMax (p=0.006),

where men displayed a lower angle com-

pared to women.

DISCUSSION

The main objective of this study was to

compare the risk of knee injury between men

and women through the analysis of kinetic

and kinematic parameters in a population of

non-professional athletes. Both kinetic as-

pects, such as GRF and accelerations, as well

as kinematic elements, such as angles at the

moment of directional change, have proven

to be crucial, with women likely presenting a

higher risk of injury.

Kinetics

During changes of directions, the VGRF

relative to body weight was significantly

higher in SC

(29.49 N/kg ± 7.75) com-

pared to SC

(27.70 N/kg ± 7.81; p=0.004)

and SC

45cl

(25.13 N/kg ± 7.59; p<0.001).

One possible explanation for these differenc-

es is that greater force needs to be exerted

in the medial-lateral (ML) axis to perform

more forceful or larger amplitude chang-

es (remember that 30° is measured above

the horizontal plane). According to Nigg’s

paradigm

, which compiled studies span-

ning over 25 years, it became evident that

VGRF plays a particularly important role in

injuries among individuals engaged in physi-

cal activities such as running, especially in

situations where pronation is accentuated,

such as during changes of directions. This

possibility is also supported by the values of

ML force found in our study, as the analyzed

subjects displayed significantly higher values

during SC

(8.64 N/kg ± 2.08) compared

to SC

(7.78 N/kg ± 2.08, p<0.001) and

45cl

(7.17 N/kg ± 2.40, p<0.001). There-

fore, higher levels of force, especially in the

ML axis, which need to be attenuated by the

lower extremities, suggest the need for in-

creased preventive strategies in these types

of actions common in various sports. It is es-

sential to highlight that these 30°-changes

of directions do not only increase the ML

force but also the AP force (12.9 N/kg ±

5.32) when compared to SC

(10.54 N/kg ±

5.39, p<0.001) or SC

45cl

(9.35 N/kg ± 5.09,

p<0.001), suggesting that biomechanical

modifications in the different involved joints

occur in response to these increments, as

will be discussed later.

Despite numerous studies regarding

the biomechanical and kinetic factors mani-

fested during direction changes, the results

are contradictory

. The aspect that seems

most relevant in explaining this disparity of

results may be the variety of procedures car-

ried out in different studies. Brughelli et al.

differentiate between anticipated and un-

anticipated changes of directions, changes

towards the dominant or non-dominant foot,

as elements that influence the final results.

Regardless of the methodological variety, it

is evident that both VGRF, ML-force, and AP-

force are variables closely related to the on-

set of injury processes

and should be con-

trolled and attenuated as much as possible.

While it is evident that higher forces in

both axes are associated with a greater risk

200 Feria-Madueño et al.

Investigación Clínica 65(2): 2024

Table 6

Kinematics during direction changes and differences between men and women.

45cl

Variables Men Women p d-Cohen Men Women p d-Cohen Men Women p d-Cohen

Angle

Knee

(degrees º)

144.04±7.48 146.56±8.06 0.080 -0.33 145.33±7.53 145.13±6.43 0.891 -0.23 139.88±9.39 146.32±10.01 0.000* -0.67

Angle

max

Knee

(degrees º)

122.86±9.28 125.13±11.97 0.229 -0.23 124.74±8.80 126.75±9.22 0.239 -0.09 118.20±14.34 125.56±12.40 0.006* -0.53

Angle

Hip

(degrees º)

42.63±3.00 42.13±2.77 0.366 0.17 41.42±5.66 41.94±5.68 0.623 -0.15 40.93±4.74 41.00±4.01 0.938 -0.02

Angle

max

Hip

(degrees º)

60.97±5.28 59.37±6.12 0.125 0.29 51.01±6.67 51.97±5.29 0.427 -0.05 54.29±5.42 54.43±5.22 0.891 -0.03

Angle

Trunk

(degrees º)

104.45±6.53 104.72±5.87 0.819 -0.04 105.07±5.39 105.32±4.39 0.799 -0.12 98.91±4.87 99.08±4.44 0.855 -0.04

Angle

max

Trunk

(degrees º)

93.09±5.56 92.59±4.76 0.624 0.09 94.82±5.92 95.51±5.10 0.524 0.04 78.00±6.61 76.72±6.18 0.299 0.20

Angle

Ankle

(degrees º)

98.47±6.58 101.13±7.55 0.040* -0.39 99.01±5.51 98.81±4.56 0.837 0.56 98.59±4.98 99.51±6.12 0.357 -0.17

Angle

max

Ankle

(degrees º)

59.10±7.22 61.48±8.05 0.091 -0.32 57.91±5.29 54.97±5.25 0.004* -0.52 57.13±4.31 56.37±4.24 0.351 0.18

Ankle_Dorsi_

Angle (degrees º)

39.36±3.26 39.64±3.56 0.658 -0.08 41.10±5.10 43.83±5.81 0.007* -0.23 41.46±4.81 43.13±5.18 0.072 -0.34

*p ≤ 0.05 Men vs Women. Statistical analysis was done using a repeated-measures two-way ANOVA. Results expressed as mean±standard error of the mean.

d-Cohen = the effect size. Angle

Knee = Angle of knee in the first contact. Angle

max

Knee = Angle of knee in the maximum flexion. Angle

Hip = Angle of hip

in the first contact. Angle

max

Hip = Angle of hip in the maximum flexion. Angle

Trunk = Angle of trunk in the first contact. Angle

max

Trunk = Angle of trunk

in the maximum flexion. Angle

Ankle = Angle of ankle in the first contact. Angle

max

Ankle = Angle of ankle in the maximum flexion. Ankle_Dorsi_Angle =

Range of ankle dorsiflexion.

Gender differences in knee injury risk 201

Vol. 65(2): 192 - 205, 2024

of injury in this population group, it is es-

sential to mention the differences observed

in the different variables according to gen-

der. Sigward and Powers

suggested that

an increased risk of knee injury through

increased valgus can occur due to greater

forces in either axis in both men and women.

In fact, their work reflected values that were

very similar to those found in the present

study regarding VGRF during changes of di-

rections. Our results show that during SC

where women sustained higher relative loads

than men (p=0.045), there were significant

differences in the force exerted in the ML

axis. This finding has been widely observed

in studies with athletes, where women have

shown significantly greater valgus than men

. Differences in the ML axis between men

and women could be related to an increased

risk of injury in females due to the biome-

chanical position of the knee in abduction or

adduction during ground contact

1,16

On the other hand, during SC

, the

differences were found in VGRF (p=0.025)

and AP force (p=0.020), where men signifi-

cantly exceeded women. Our results are con-

sistent with those of Liu et al.

, who related

a reduction of VGRF and Force

with a re-

duction of the load supported by the knee

during open direction changes. However,

authors such as James et al.

found the op-

posite during maximum speed changes of di-

rections. One possible explanation for these

differences could be the openness of the di-

rectional change at a non-maximal speed.

may involve less demand than SC

, so

being a more vertical change and closer to

straight-line running, it is possible that AP

force is increased, as well as VGRF in men.

Another important finding was that

women exhibited a significantly higher AP

force during SC

45cl

(p=0.020) than men.

Our results align with those presented by

McLean et al.

, who found higher AP force

in women compared to men during a direc-

tional change with an angle of exit between

35° and 55° (women = 1.80BW [± 0.54];

men 1.54BW [± 0.76]). Moreover, although

not statistically significant, women in our

study also showed higher VGRF during SC-

45cl

. Recently, de Hoyo et al.

reported very

similar data in male athletes who performed

a closed change with a 60° opening (24.1

N/kg ± 8.4). Unfortunately, these authors

only conducted their intervention with male

subjects, making a comparison impossible.

Nevertheless, there is limited research on

the role of gender in VGRF during closed

changes of directions. This is the first study

to assess vertical force in men and women

during closed changes.

What seems evident is the increased

risk of knee injury through ML force val-

ues during changes of directions based on

gender

. Authors like Sigward and Powers

indicated that women who exerted greater

ML force also exhibited a greater valgus mo-

ment, which increased the risk of a knee

injury. Although our results do not provide

data on impulse outcomes, a possible contri-

bution can be inferred from the partial knee

and ankle acceleration. As described previ-

ously, women reported significantly higher

ML force during SC

than men and a slightly

higher trend was observed in this variable

during SC

45cl

. In this regard, it can also be

observed that women experience 18.53%

more ML knee acceleration than men dur-

ing SC

and 19.93% during SC

, with al-

most no difference (0.4%) during SC

45cl

. This

ML knee acceleration could represent valgus

moments, although this fact should be cor-

roborated in future studies through a kine-

matic analysis in the frontal plane.

There were significant differences be-

tween the different changes of direction.

ACC

KNEE

AP was significantly higher in SC

45cl

compared to SC

(p=0.006). This finding

suggests an increased risk in closed changes

compared to open changes, as the load is

mobilized more rapidly in the sagittal axis,

potentially leading to an increase in tibial

translation. However, ForceAP was signifi-

cantly lower in SC

45cl

than SC

(p<0.001).

These differences also existed between open

changes, as ACC

KNEE

AP was significantly

202 Feria-Madueño et al.

Investigación Clínica 65(2): 2024

higher in SC

than SC

(p=0.023). One pos-

sible explanation for these differences could

be the biomechanical demand, with SC

be-

ing less demanding than SC

, resulting in

a faster strategy during less open changes.

Analyzing ACC

KNEE

ML between changes of di-

rections, SC

showed a significantly higher

acceleration than SC

(p<0.001) and SC

45cl

(p<0.001). Sigward and Powers

suggest

that frontal plane control is necessary to

reduce the relative risk of knee injury. Our

data indicate that SC

poses an increased

risk compared to the other changes of direc-

tions, characterized by higher ForceML and

ACC

KNEE

ML, which are associated with an in-

crease in knee valgus.

Regarding gender differences during

changes of directions, significant differenc-

es were found only in SC

(p≤0.05), with

women exhibiting higher ACC

KNEE

Z than

men. One possible explanation could be that

Chapell et al.

suggested that women expe-

rience greater shear force in the tibia dur-

ing ground contact. This negative strategy

indicates that energy absorption by women

is less efficient than in men, or at least fast-

er, which may be related to an increased risk

of knee injury. Surprisingly, this trend is not

observed in SC

, which would be expected

to be more demanding at this level. However,

the trend still favored women, who present-

ed 14.67% more ACC

KNEE

Z during SC

and

11.35% more during SC

45cl

Kinematics

It is evident that a knee angle close to

the extension increases the risk of injury

20-

. Our results indicate a higher KneeAnglein

during SC

compared to the other changes

of directions (144.63° ±7.65). However, the

maximum KneeAngle reached is highest

during SC

(125.16° ±8.91). Concerning

the 180° representing full knee extension,

the KneeAngle during SC

averaged 35.37°.

Markolf et al.

mentioned that knee flex-

ion of 40º or less increases tibial translation

supported by the ACL and, consequently, the

tension sustained by the joint complex, lead-

ing to an increased risk of injury. A preven-

tive strategy should involve increasing knee

flexion to absorb impact. Cochrane et al.

went further by identifying angles below 30º

of flexion during initial contact as a critical

factor in ACL injuries during changes of di-

rections. Consistent with Markolf et al.

, our

results showed that for all changes of direc-

tions, the KneeAnglein exceeded 30° (SC

= 35.37°; SC

= 36.55°; SC

45cl

= 38.57°) but

remained below 40°, suggesting that partici-

pants subjected the joint to excessive stress,

which could partially explain the previously

reported increases in force.

Despite the relationship between knee

flexion angle and the relative risk of joint

injury, it is evident that the biomechanical

strategy during direction changes is not ex-

clusive to the knee. Several studies have at-

tributed a determining role to other joints

reflecting greater or lesser knee flexion.

Imwalle et al.

confirmed a direct influ-

ence of the hip on the knee during direc-

tion changes. Potter et al.

stated that open

and closed changes of directions influence

the biomechanical strategies manifested by

subjects, with significantly greater hip flex-

ion in open changes than in closed changes.

However, our results do not align with those

reported by these authors, as hip flexion was

practically the same regardless of the type

of directional change. One possible explana-

tion could be that kinematic aspects were

evaluated in an agility circuit with open and

closed changes of direction, where athletes

performed different direction changes de-

pending on their own technique.

Moreover, gender-based differentiation

in knee kinematics has been observed, show-

ing different biomechanical strategies relat-

ed to an increased risk of knee injury between

men and women

. In our study, during SC

women exhibited a KneeAnglemax (in exten-

sion) of 33.4°, although without significant

differences compared to men (p = .080),

who exhibited an angle close to 36°. Signifi-

cant differences were found during SC

45cl

Gender differences in knee injury risk 203

Vol. 65(2): 192 - 205, 2024

where women had a KneeAnglein close to

146° and men to 140°. Additionally, signifi-

cant gender differences were found in Knee-

Anglemax (p = 0.006), with women exhib-

iting more significant knee extension than

men, indicating a higher injury risk. These

results are consistent with those reported by

James et al.

, who conducted a compara-

tive study by gender during closed direction

changes to 60° and found a KneeAnglein in

women 5.8° lower than in men. In our study,

during SC

45cl

, women flexed 6.4° less than

men, with significant differences compared

to men. This indicates that the directional

change technique employed by women may

be associated with an increased risk of knee

injury during closed direction changes. Fur-

thermore, in the study mentioned above, the

researchers found that women significantly

exceeded men in KneeAnglemax, with great-

er extension (64.1° and 61.4°, respectively).

Our results are very similar, with men exhib-

iting an average of 61.8° and women 54.4°.

Regarding open changes of directions,

a slightly higher, but not significant, trend

in extension can be observed in women com-

pared to men during SC

. Additionally, dur-

ing SC

, the KneeAnglein values are practi-

cally the same in men and women, with an

increase in knee extension in women at the

moment of VGRF. Dai et al.

evaluated knee

kinematics in men and women during SC

and also found greater extension in women

compared to men at the moment of VGRF.

A greater range of knee flexion during the

first contact could serve as a biomechani-

cal strategy to absorb impact and reduce

the load. In this sense, women have a higher

relative risk of knee injury than men, as they

exhibit more significant knee extension dur-

ing changes of direction

In conclusion, the study highlights the

importance of controlling GRF and biome-

chanical strategies during changes in di-

rection to reduce the risk of knee injuries.

Significant gender differences in forces and

accelerations during changes of directions

were observed, underscoring the need to

consider specific gender factors in injury

prevention. Variables such as VGRF, Force

and ForceAP, as well as acceleration in the

vertical axis, appear to be deterministic ki-

netic variables that explain these gender dif-

ferences and knee flexion angles. The results

can be helpful in informing the design of

preventive strategies in the sports field and

improving the understanding of the under-

lying mechanisms of knee injuries during

changes of direction.

Funding

None.

Conflict of interests

The authors declared that they have no

competing interests.

Authors´ ORCID

• Adrián Feria-Madueño (AFM):

0000-0001-7425-8694

• Timothy E. Hewett (TH):

0000-0001-9729-7573

• Borja Sañudo (BS):

0000-0002-9969-9573

Contributions of authors

Conception (AFM), design and acqui-

sition of data (AFM), formal analysis (BS),

interpretation of data (AFM and BS), inves-

tigation (AFM and BS), writing the original

draft preparation (AFM), writing the review

and editing (TH), supervision (TH and BS).

REFERENCES

1. Hewett TE, Myer GD, Ford KR, Heidt

RS, Colosimo AJ, McLean SG, van den

Bogert J, Paterno MV, Succop P. Bio

mechanical measures of neuromuscular

control and valgus loading of the knee

predict anterior cruciate ligament injury

risk in female athletes: a prospective stu

dy. Am J Sports Med 2005;33(4):492-501.

doi:10.1177/0363546504269591

204 Feria-Madueño et al.

Investigación Clínica 65(2): 2024

2. McLean SG, Walker KB, Van Den Bogert

AJ. Effect of gender on lower extremity ki

nematics during rapid direction changes:

An integrated analysis of three sports move

ments. J Sci Med Sport 2005;8(4):411-422.

doi:10.1016/S1440-2440(05)80056-8

3. Hewett TE, Ford KR, Myer GD. Anterior

cruciate ligament injuries in female athle

tes: Part 2, A meta-analysis of neuromus-

cular interventions aimed at injury preven-

tion. Am J Sports Med 2006;34(3):490-498.

doi:10.1177/0363546505282619

4. Myer GD, Ford KR, Paterno MV, Nick

TG, Hewett TE. The effects of generalized

joint laxity on risk of anterior cruciate li

gament injury in young female athletes.

Am J Sports Med 2008;36(6):1073-1080.

doi:10.1177/0363546507313572

5. Chen CH, Condello G, Chen WH, Liu

TH, Tessitore A, Shiang TY, Liu C. Effects

of a novel inclined-adaptive footwear on

change-of-direction performance in male

athletes. Gait Posture 2022;94:189-194.

doi:10.1016/j.gaitpost.2022.03.010

6. Condello G, Kernozek TW, Tessito

re A, Foster C. Biomechanical analysis

of a change-of-direction task in college

soccer players. Int J Sports Physiol Per

form 2016;11(1):96-101. doi:10.1123/ij-

spp.2014-0458

7. McFadden C, Daniels KAJ, Strike S. Six

methods for classifying lower‐limb domi

nance are not associated with asymmetries

during a change of direction task. Scand

J Med Sci Sports 2022;32(1):106-115.

doi:10.1111/sms.14054

8. Olmsted LC, Carcia CR, Hertel J, Shultz

SJ. Efficacy of the star excursion balance

tests in detecting reach deficits in subjects

with chronic ankle instability. J Athl Train

2002;37(4):501-506.

9. Maniar N, Schache AG, Pizzolato C, Opar

DA. Muscle contributions to tibiofemoral

shear forces and valgus and rotational joint

moments during single leg drop landing.

Scand J Med Sci Sports 2020;30(9):1664-

1674. doi:10.1111/sms.13711

10. McBurnie AJ, Dos’Santos T, Jones

PA . Biomechanical associates of per

formance and knee joint loads during

A 70–90° cutting maneuver in subeli

te soccer players. J Strength Cond Res

2021;35(11):3190-3198. doi:10.1519/

JSC.0000000000003252

11. Nigg BM. The role of impact for

ces and foot pronation: A new para-

digm. Clin J Sport Med 2001;11(1):2-9.

doi:10.1097/00042752-200101000-00002

12. Griffin LY, Albohm MJ, Arendt EA, Bahr

R, Beynnon BD, Demaio M, Dick RW, En

gebretsen L, Garrett WE Jr, Hannafin JA,

Hewett TE, Huston LJ, Ireland ML, Jo

hnson RJ, Lephart S, Mandelbaum BR,

Mann BJ, Marks PH, Marshall SW, Mykle

bust G, Noyes FR, Powers C, Shields C

Jr, Shultz SJ, Silvers H, Slauterbeck J,

Taylor DC, Teitz CC, Wojtys EM, Yu B.

Understanding and preventing noncontact

anterior cruciate ligament Injuries: A re

view of the Hunt Valley II Meeting, January

2005. Am J Sports Med 2006;34(9):1512-

1532. doi:10.1177/0363546506286866

13. Brughelli M, Cronin J, Levin G, Chaouachi

A. Understanding change of direction ability

in sport: A review of resistance training stu

dies. Sports Med 2008;38(12):1045-1063.

doi:10.2165/00007256-200838120-00007

14. Sigward SM, Powers CM. Loading charac

teristics of females exhibiting excessive

valgus moments during cutting. Clin Bio

mech 2007;22(7):827-833. doi:10.1016/j.

clinbiomech.2007.04.003

15. Stoffel KK, Nicholls RL, Winata AR,

Dempsey AR, Boyle JJW, Lloyd DG.

Effect of ankle taping on knee and ankle

joint biomechanics in sporting tasks. Ed

Sci Sports Exerc 2010;42(11):2089-2097.

doi:10.1249/MSS.0b013e3181de2e4f

16. Wikstrom EA, Tillman MD, Chmie

lewski TL, Borsa PA. Measurement

and evaluation of dynamic joint sta

bility of the knee and ankle after in-

jury. Sports Med 2006;36(5):393-410.

doi:10.2165/00007256-200636050-00003

17. Liu H, Wu W, Yao W, Spang JT, Creighton

RA, Garrett WE, Yu B. Effects of knee ex

tension constraint training on knee flexion

angle and peak impact ground-reaction

force. Am J Sports Med 2014;42(4):979-

986. doi:10.1177/0363546513519323

Gender differences in knee injury risk 205

Vol. 65(2): 192 - 205, 2024

18. James CR, Sizer PS, Starch DW, Loc-

khart TE, Slauterbeck J. Gender differen-

ces among sagittal plane knee kinematic

and ground reaction force characteristics

during a rapid sprint and cut maneuver.

Res Q Exerc Sport 2004;75(1):31-38. doi:1

0.1080/02701367.2004.10609131

19. de Hoyo M, de la Torre A, Pradas F, Sa

ñudo B, Carrasco L, Mateo-Cortes

J, Domínguez-Cobo S, Fernandes O,

Gonzalo-Skok O. Effects of eccentric

overload bout on change of direction

and performance in soccer players. Int

J Sports Med 2014;36(04):308-314.

doi:10.1055/s-0034-1395521

20. Chappell JD, Herman DC, Knight

BS, Kirkendall DT, Garrett WE, Yu B.

Effect of fatigue on knee kinetics and

kinematics in stop-jump tasks. Am J

Sports Med 2005;33(7):1022-1029.

doi:10.1177/0363546504273047

21. Tillman MD, Hass CJ, Brunt D, Bennett

GR. Jumping and landing techniques in

elite women’s volleyball. J Sports Sci Med

2004;3(1):30-36.

22. Pappas E, Nightingale EJ, Simic M, Ford

KR, Hewett TE, Myer GD. Do exercises

used in injury prevention programmes mo

dify cutting task biomechanics? A systema-

tic review with meta-analysis. Br J Sports

Med 2015;49(10):673-680. doi:10.1136/

bjsports-2014-093796

23. Markolf KL, O’Neill G, Jackson SR, McA

llister DR. Effects of Applied quadriceps

and hamstrings muscle loads on forces in

the anterior and posterior cruciate liga

ments. Am J Sports Med 2004;32(5):1144-

1149. doi:10.1177/0363546503262198

24. Cochrane JL, Lloyd DG, Buttfield A,

Seward H, McGivern J. Characteris

tics of anterior cruciate ligament in-

juries in Australian football. J Sci Med

Sport 2007;10(2):96-104. doi:10.1016/j.

jsams.2006.05.015

25. Imwalle LE, Myer GD, Ford KR, Hewett

TE. Relationship between hip and knee

kinematics in athletic women during

cutting maneuvers: A possible link to

noncontact anterior cruciate ligament

injury and prevention. J Strength Cond

Res 2009;23(8):2223-2230. doi:10.1519/

JSC.0b013e3181bc1a02

26. Potter D, Reidinger K, Szymialowicz R,

Martin T, Dione D, Feinn R, Wallace D,

Garbalosa JC. Sidestep and crossover

lower limb kinematics during a prolonged

sport-like agility test. Sidestep and crosso

ver lower limb kinematics during a prolon-

ged sport-like agility test. Int J Sports Phys

Ther 2014;9(5):617-627.

27. Galloway RT, Xu Y, Hewett TE, Barber

Foss K, Kiefer AW, DiCesare CA, Mag

nussen RA, Khoury J, Ford KR, Diekfuss

JA, Grooms D, Myer GD, Montalvo AM.

Age-dependent patellofemoral pain: hip

and knee risk landing profiles in prepub

escent and postpubescent female athletes.

Am J Sports Med 2018;46(11):2761-2771.

doi:10.1177/0363546518788343

28. Dai B, Garrett WE, Gross MT, Pa

dua DA, Queen RM, Yu B. The Effects

of 2 landing techniques on knee kine

matics, kinetics, and performance du-

ring stop-jump and side-cutting tasks.

Am J Sports Med 2015;43(2):466-474.

doi:10.1177/0363546514555322

29. Mallinos A, Jones K, Davis BL. Compari

son of side-cutting maneuvers versus low

impact baseball swing on knee ligament

loading in adolescent populations. Clin

Biomech 2023;106:106004. doi:10.1016/j.

clinbiomech.2023.106004