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.