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Sex Differences in Biomechanical Properties of the Achilles Tendon May Predispose Men to Higher Risk of Injury

Sex Differences in Biomechanical Properties of the Achilles Tendon May Predispose Men to Higher Risk of Injury

Arianna L Gianakos, DO, UNITED STATES Hayden Hartman, BS, UNITED STATES Gino M. M. J. Kerkhoffs, MD, PhD, Prof., NETHERLANDS John G. Kennedy, MD, FRCS, UNITED STATES James D. Calder, OBE, MBBS, MD, PhD, FRCS, FFSEM(UK), UNITED KINGDOM

NYU Langone Health, New York, New York, UNITED STATES

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Summary: Our study demonstrates variations between men and women in Achilles tendon length, thickness, cross-sectional area, stiffness, force, and response to loading; all of which may contribute to differences in AT injury between men and women.


Men have a higher risk of Achilles tendon (AT) injury, and the impact of morphological and mechanical sex differences may play a role. The aim of this study is to systematically review the literature to determine whether there are sex-specific differences in AT morphological and mechanical properties and analyze how these differences may impact AT injury in both men and women.


A systematic literature search of articles published between 2001 to 2021, in the MEDLINE, EMBASE, and Cochrane databases was performed during May 2022 according to PRISMA. The primary outcome measures included sex-related differences in the mechanical and morphological properties of the Achilles tendon. Secondary outcomes included impact of sex on Achilles tendon properties and adaptation.


Nineteen studies with a total of 1,143 participants (613 men and 530 women) were included in this systematic review. Men had increased measurements when compared with women in the following: AT length, thickness, cross-sectional area (CSA), stiffness, peak force, loading rate, and voluntary muscle contraction. Women had an increase in CSA deformation, strain, and compliance.


Our study demonstrates that men have an increased AT length, thickness, and CSA, indicating that men may be subjected biomechanically to higher loads in their day to day activities. In addition, men have lower deformation and compliance properties, along with increased AT stiffness, reducing their capacity to adapt during loading, potentially increasing their risk of injury. Understanding the various differences in muscle and tendon biomechanical properties between men and women is important to better individualize the management and treatment following an AT injury.

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