Obstacle Course Races Present a Risk of Musculoskeletal, Knee, and Anterior Cruciate Ligament Injury, Especially in High-Impact Landing Maneuvers and Female Athletes: A Systematic Review

Abstract

Purpose

To determine the incidence rate (IR) of anterior cruciate ligament (ACL) and associated musculoskeletal injuries in recreational and/or military-training obstacle course races (OCRs) and to determine whether there are any risk factors or features of OCRs impacting the rate of ACL injury in race participants.

Methods

This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies were identified using the following electronic databases: PubMed, EMBASE, Cochrane, and Scopus. The inclusion criteria were studies that were published in English between 2000 and 2023 that included participants in recreational and/or military OCRs and categorized injuries relevant to the ACL, knee, and/or lower extremity and/or categorized ACL injury risk factors in context relevant to OCRs. Systematic reviews, narrative reviews, and non–peer-reviewed studies were excluded. For all studies meeting the inclusion criteria, the full text was reviewed. Analyses of the IR and male-female IR ratio were performed on data collected. IR by sex was compared using the 2-sample t test.

Results

The literature search yielded 2,896 studies for initial review; 16 studies met the inclusion criteria. Of these studies, 8 reported injury data and 2 provided specific ACL injury data; the remaining studies reported risk factors relevant to OCRs. The total IR of ACL injuries in OCRs was 0.45/1,000 athlete-exposures (AEs) ± 0.40/1,000 AEs. Female individuals had a higher IR than male individuals (1.51/1,000 AEs ± 1.42/1,000 AEs vs 0.29/1,000 AEs ± 0.23/1,000 AEs; IR ratio, 5.14 ± 1.95 [95% confidence interval, 1.23-9.05]; P = .001). Risk factors for ACL injury in OCRs included rubber-matting terrain and obstacles requiring high-impact landings and/or deceleration maneuvers.

Conclusions

OCRs require many high-impact and pivoting landings, thus presenting a notable risk of ACL and associated musculoskeletal injuries. The total IR of ACL injuries in OCRs was 0.45/1,000 AEs ± 0.40/1,000 AEs. The risk and IR of injury in OCRs are increased in female participants and on specific terrain (e.g., rubber matting).

Level of Evidence

Level IV, systematic review of Level II-IV studies.