The association between patellar height and anterior cruciate ligament injury: a systematic review and meta-analysis patellar height

Study	Country	Study design	Sample size (ACL/Control)	Age(years) Mean ± SD	Sex (% Male)	Sport/activity	ISI measurement method	Measurement timing	ISI Mean ± SD (ACL/control)	Followup duration
Degnan et al.²³	USA	Case-control	70 (34/36)	ACL: 12.4 ± 1.4 Control: 12.8 ± 2.1	ACL: 73.5% Control: 80.6%	Youth athletes	Traditional ISI (MRI sagittal PD)	After ACL tear	ACL: 1.16 ± 0.16 Control: 0.99 ± 0.14	N/A
Kwak et al. ²⁴	South Korea	Prospective cohort	231 (116/115)	ACL: 14 ± 3.7 Control: 14.2 ± 3.6	100%	Soccer	Traditional ISI (MRI sagittal PD)	Before ACL tear	ACL: 0.90 ± 0.20 Control: 1.00 ± 0.20	N/A
Güven et al.²⁵	Turkey	Prospective cohort	210 (120/90)	ACL: 29.1. ± 8.2 Control: 31.8 ± 9.8	100%	Not specified	Traditional ISI (MRI sagittal PD)	Before ACL tear	ACL: 1.01 ± 0.15 Control: 0.96 ± 0.14	2014–2020
Lin et al. ²⁶	China	Prospective	380 (190/190)	ACL: 27.72 ± 7.55 Control: 30.30 ± 6.62	ACL: 75.3% Control: 63.2%	Not specified	Modified ISI (MRI sagittal PD/T2)	Before ACL tear	ACL: 1.74 ± 0.23 Control: 1.64 ± 0.15	2019–2023

1 ACL - anterior cruciate ligament, ISI -Insall-Salvati Index, MIS -modified Insall-Salvati Index, MRI -magnetic resonance imaging, N/A -not applicable, PD -proton density, SD -standard deviation

Table 2.

Quality assessment of included studies

Study	Selection (max 4✶)	Comparability (max 2✶)	Outcome (max 3✶)	Total score	Quality
Degnan et al.²³	✶ ✶✶☆	✶✶	✶✶✶	8/9	High
Kwak et al.²⁴	✶ ✶✶☆	✶ ☆	✶✶✶	7/9	High
Güven et al.²⁵	✶✶✶✶	✶✶	✶✶✶	9/9	High
Lin et al.²⁶	✶✶✶✶	✶✶	✶✶✶	9/9	High

Forest plot of the ISI in ACL - injured patients and controls. ACL - anterior cruciate ligament, CI - confidence intervals, ISI - Insall-Salvati index, PI - prediction interval, SD - standard deviation, SMD - standardised mean differences

Subgroup analysis by age group. CI - confidence intervals, SD - standard deviation, SMD - standardised mean differences

Subgroup analysis by measurement method. CI - confidence intervals, SD - standard deviation, SMD - standardised mean differences

Subgroup analysis by measurement timing. CI - confidence intervals, SD - standard deviation, SMD - standardised mean differences

Forest plot of the leave-one-out sensitivity analysis. CI - confidence intervals, SMD - standardised mean differences

Table 3.

GRADE Summary of findings for the association between patellar height (ISI) and ACL injury

Certainty assessment							No of patients		Effect		Certainty	Importance
No. of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	ACL injury	Non--ACL injury	Relative (95% CI)	Absolute (95% CI)
Outcome 1: ISI difference (overall) (assessed with: [ISI]; Scale from: 0 to 3)
4	Non-ran-domised studies	Not serious	Very serious^a	not serious	serious^b	none	460	431	-	SMD 0.35 SD higher (0.291 lower to 0.991 higher)	ⴲⵔⵔⵔ Very low^a,^b	CRITICAL
Outcome 2: ISI difference (age > 16 years) (assessed with: [ISI]; Scale from: 0 to 3)
2	Non-ran-domised studies	Not serious	Not serious	not serious	not serious	none	310	280	-	SMD 0.453 SD higher (0.289 higher to 0.617 higher)	ⴲⴲⵔⵔ Low	CRITICAL
Outcome 3: ISI difference (age ≤ 16 years) (assessed with: [ISI]; Scale from: 0 to 3)
2	Non-ran-domised studies	Not serious	Very serious^c	not serious	very serious^d	none	150	151	-	0.296 higher (1.29 higher to 1.882 higher)	ⴲⵔⵔⵔ Very low^c,^d	IMPORTANT
Outcome 4: ISI difference (measurement timing – before tear) (assessed with: [ISI] – prospective measurement)
3	Non-ran-domised studies	Not serious	Very serious^e	not serious	serious^f	none	426	395	-	SMD 0.122 SD higher (0.491 lower to 0.735 higher)	ⴲⵔⵔⵔ Very lowe^e,^f	IMPORTANT
Outcome 6: ISI difference (traditional measurement method) (assessed with: Traditional ISI [patellar tendon/patella length ratio])
3	Non-ran-domised studies	Not serious	Very serious^g	not serious	serious^h	none	270	241	-	SMD 0.301 SD higher (0.605 lower to 1.208 higher)	ⴲⵔⵔⵔ Very lowg^g,^h	IMPOR-TANTlea

1 CI - confidence interval, ISI - Insall-Salvati Index, SMD - standardised mean difference

1a Very high heterogeneity (I² = 93.9%, p < 0.0001) with unexplained variation in effect sizes across studies

1b Wide confidence interval crossing null (95% CI: −0.291 to 0.991) in random effects model

1c Very high heterogeneity (I² = 96.8%, p < 0.0001) with large variation in effect estimates between two studies

1d Very wide confidence interval (95% CI: −1.290 to 1.882) with small sample size (n = 301)

1e Very high heterogeneity (I² = 94.6%, p < 0.0001) with the opposite direction of effect in one study (Kwak 2021: SMD −0.498)

1f Wide confidence interval crossing null (95% CI: −0.491 to 0.735) despite adequate sample size

1g Very high heterogeneity (I² = 94.8%, p < 0.0001) with one study showing the opposite direction despite the same measurement method

1h Very wide confidence interval (95% CI: −0.605 to 1.208) including both negative and positive effects

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DOI: https://doi.org/10.2478/advrehab-2026-0009 | Journal eISSN: 1734-4948

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Language: English

Page range: 24 - 39

Submitted on: Jan 13, 2026

Accepted on: Apr 12, 2026

Published on: Jun 30, 2026

Published by: University of Physical Education in Warsaw

In partnership with: Paradigm Publishing Services

Publication frequency: 4 issues per year

Keywords:

knee,

Related subjects:

Physical and rehabilitation medicine,

Sports and recreation,

Sports and recreation, other

© 2026 Min Bong Kang et al.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Volume 40 (2026): Issue 2 (June 2026)

The association between patellar height and anterior cruciate ligament injury: a systematic review and meta-analysis patellar height

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