Associations Between Cognitive Function and ACL Injury-Related Biomechanics: A Systematic Review

Context: Does lower baseline cognitive function predispose athletes to ACL injury risk, especially when performing unplanned or dual-task movements? Objective: To evaluate the association between cognitive function and biomechanics related to ACL injuries during cognitively challenging sports movements. Data Sources: PubMed (MEDLINE), Web of Science, Scopus, and SciELO databases were searched; additional hand searching was also conducted. Study Selection: The following inclusion criteria had to be met: participants completed (1) a neurocognitive test, (2) a cognitively challenging sport-related task involving lower limbs, and (3) a biomechanical analysis. The following criteria determined exclusion from the review: studies involving participants with (1) recent or current musculoskeletal injuries; (2) recent or current concussion; (3) ACL surgical reconstruction, reviews of the literature, commentary or opinion articles, and case studies. Study Design: Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement and registered at the International Prospective Register of Systematic Reviews (PROSPERO). Level of Evidence: Level 3. Data Extraction: Two of authors independently extracted data and assessed the methodological quality of the articles with the Downs and Black and ROBINS-I checklists, to assess methodological quality and risk of bias, respectively. Results: Six studies with different methodologies and confounding factors were included in this review. Of these 6 studies, 3 were ranked as high-quality, 3 demonstrated a low risk of bias, 2 a moderate risk, and 1 a severe risk. Five studies found a cognitive-motor relationship, with worse cognitive performance associated with increased injury risk, with 1 study reporting the opposite directionality for 1 variable. One study did not identify any interaction between cognitive function and biomechanical outcomes. Conclusion: Worse cognitive performance is associated with an increased injury risk profile during cognitively challenging movements.