The Relationship Between Hand Dominance and ACL Tears in Competitive Volleyball Athletes

Abstract

Background:

Knee injuries are common in volleyball athletes, often resulting from the sport's unique movement requirements. Among these, anterior cruciate ligament (ACL) tears are particularly prevalent, and while the existing literature has examined risk factors such as biomechanical asymmetries and landing mechanics, there is limited research on the relationship between hand dominance and the side of injury.

Purpose:

To examine the relationship between hand dominance and ACL tear laterality in competitive volleyball players diagnosed with first-time unilateral ACL tears.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

After a medical record review of 1529 consecutive patients, 149 met the inclusion criteria, resulting in a study population of 124 females and 25 males. Data on sex, age, body mass index, handedness, and ACL tear laterality were collected from the medical records. A Fisher exact test was used to assess the association between handedness and ACL tear laterality, while binomial tests evaluated differences in ACL tear laterality within each handedness group.

Results:

Among the 136 right-handed players, 81.62% tore their left ACL, while 18.38% tore their right ACL. Among the 13 left-handed players, 84.62% tore their right ACL, while 15.38% tore their left ACL. A statistically significant association was found between hand dominance and ACL tear laterality (P < .001). Additionally, statistical significance was found between right-handed players tearing their left ACL (P < .001) and left-handed players tearing their right ACL (P < .05).

Conclusion:

This study suggests a significant relationship between hand dominance and ACL tear laterality in competitive volleyball players. Right-handed volleyball players were significantly more likely to tear their left ACL, whereas left-handed players predominantly tore their right ACL. These findings suggest a biomechanical or sports-specific risk factor contributing to ACL injury patterns in volleyball players.

Anterior cruciate ligament (ACL) tears are a serious sports injury among athletes that often result in surgical intervention, prolonged recovery times, and potential long-term consequences such as posttraumatic osteoarthritis and decreased return-to-sport rates in competitive settings.^2,20 These injuries occur through both contact and noncontact mechanisms, with noncontact injuries being the most common in sports that involve rapid deceleration, pivoting, and jump-landing maneuvers. ⁴ Studies have indicated that volleyball, alongside basketball and soccer, is among the high-risk sports for ACL injuries, with female athletes being particularly vulnerable, especially during landing, the most common noncontact injury mechanism.^10,28 Although ACL tears are often considered career-altering injuries, some authors suggest that many athletes are able to return to preinjury performance levels after surgical reconstruction and rehabilitation.^8,26

ACL injuries are multifactorial, with risk factors spanning age, sex, hormonal influences, and sports-specific biomechanics. ²⁷ In the context of volleyball, the unique demands of the sport, such as explosive jumping, quick directional changes, and asymmetrical landing mechanics, can place significant biomechanical stress on the knee. The literature suggests that factors such as dynamic knee valgus, insufficient hip and knee flexion, and imbalances in neuromuscular control substantially contribute to the risk of ACL injury.^15,32,35 The role of limb dominance and its association with ACL injury remains a topic of debate. While some studies have found no clear relationship between leg dominance and ACL injury risk,^6,9 a 2010 study reviewing ACL injuries in male and female soccer players suggested that lower limb dominance may serve as a causative factor in ACL tears within this population. ⁵

Currently, there is a lack of literature directly examining the relationship between hand dexterity and ACL injuries. Most studies focus on factors such as landing biomechanics, neuromuscular control, and lower limb dominance. Given this gap, we believe that investigating whether hand dexterity correlates with ACL tear laterality in volleyball players could help inform injury prevention strategies, optimize rehabilitation protocols, and enhance athlete screening for ACL injury risk.

Methods

This retrospective cross-sectional study includes patients from the clinic of 2 sports medicine specialist orthopaedic surgeons (C.J.P.L. and G.P.R.). The sample consisted of competitive volleyball players of any level, including high school, college, and national-level leagues diagnosed with a first-time unilateral ACL tear between January 2013 and February 2025. A record review of 1529 cases of all-cause ACL tears was performed, of which only 156 were volleyball players who met the initial eligibility requirements described below. Furthermore, 7 cases were excluded due to incomplete medical records, resulting in a final study population of 149 participants, consisting of 25 males and 124 females (Figure 1).

Figure 1.

Flowchart of case screening and eligibility.

Patients were then selected based on specific inclusion and exclusion criteria. Inclusion criteria were (1) male or female volleyball players of any age with a preoperative diagnosis of first-time unilateral ACL tear confirmed by magnetic resonance imaging between January 2013 and February 2025, and (2) indoor volleyball players. The exclusion criteria were (1) patients with bilateral ACL tears, (2) knees with retear that underwent revision ACL reconstruction, (3) patients with neuromuscular disorders, (4) patients with unclear or missing documentation on hand dominance, (5) pregnant women, (6) inmates, and (7) ambidextrous patients. Handedness in this study was determined through self-reporting and denotes the player's hand dominance while playing volleyball, that is, the hand the players use to hit, serve, and spike the ball. This study was approved by the institutional review board of Ponce Research Institute–Ponce Health Sciences University, and informed consent was waived (IRB No. 2503247659).

Statistical Analysis

A descriptive analysis of patient characteristics (sex, age, and body mass index [BMI]), self-reported hand dominance, and ACL tear laterality was performed. A Fisher exact test was conducted to assess the relationship between volleyball players’ handedness and ACL tear laterality. Binomial tests were conducted to determine differences in ACL tear laterality within each group (right-handed vs left-handed). All statistical analyses were performed using RStudio (Posit). A P value <.05 was considered statistically significant.

Results

From 149 competitive volleyball players (124 female, 25 male) meeting the inclusion criteria, 136 were right-handed and 13 were left-handed. The mean age ± standard deviation of participants was 19.15 ± 6.8 years (range, 11-46 years), and their mean BMI was 23.40 ± 4.04 (range, 17.2-41.6). The distribution of handedness and ACL tear laterality is shown in Table 1, with corresponding percentages detailed in Table 2. Table 3 shows the distribution of the study sample by level of competition.

Table 1.

Distribution of Handedness and Side of ACL Tear Among Competitive Volleyball Players ^a

	Total	Female	Male
Right-handed
Right ACL	25	23	2
Left ACL	111	91	20
Left-handed
Right ACL	11	9	2
Left ACL	2	1	1

^aACL, anterior cruciate ligament.

Table 2.

Percentage of ACL Tear Side in Relation to Hand Dominance ^a

	Right ACL Tear	Left ACL Tear	Total
Right-handed	25 (18.38)	111 (81.62%)	136 (100)
Left-handed	11 (84.62)	2 (15.38)	13 (100)
Total	36 (24.16)	113 (75.84)	149 (100)

^aData are presented as n (%). Fisher exact test, P < .001. ACL, anterior cruciate ligament.

Table 3.

Sample Distribution by Level of Competition

Level of Competition	No. of Patients
Middle school	18
High school	70
Collegiate	37
Professional	18
Masters	6

Handedness and ACL Tear Laterality

Analysis of ACL tear laterality in relation to handedness revealed a statistically significant association (Fisher exact test, P < .001). This finding suggests that handedness plays a role in the likelihood of tearing a specific ACL. A summary of this association, along with P values for subsequent binomial tests, is presented in Table 4.

Table 4.

Statistical Significance of Important Findings ^a

Finding	P Value
There is an association between ACL tear side and handedness.	<.001
Right-handed volleyball players significantly tear their left ACL more than their right ACL.	<.001
Left-handed volleyball players significantly tear their right ACL more than their left ACL.	.02246

^aACL, anterior cruciate ligament.

Handedness-Specific ACL Tear Distribution and Overall Likelihood Ratio

To further explore whether ACL tears were equally distributed between the right and left knee within each handedness group, binomial tests were performed under the null hypothesis of a 50/50 right/left ACL tear distribution. If no directional bias existed, the probability of tearing either ACL should be equal within each group.

Among right-handed players (n = 136), ACL tears occurred significantly more often in the left knee than the right (binomial test, P < .001). The 95% confidence interval for this group ranged from 74.1% to 87.7%, suggesting that the true proportion of left ACL tears in the overall population of right-handed players falls within this range (observed proportion: 81.6%).

A similar pattern of opposite-side ACL tears was observed in left-handed players (n = 13), with a greater proportion experiencing right ACL tears. Left-handed players were significantly more likely to tear their right ACL (binomial test, P < .05), with an observed proportion of 84.6%. The 95% confidence interval for this group ranged from 54.6% to 98.1%, indicating greater variability due to the smaller sample size compared with the right-handed group. While the result remains statistically significant, the higher P value compared with right-handed players suggests a reduced statistical power, likely due to the limited number of left-handed players represented in the population analyzed.

When comparing the relative likelihood of ACL tears, right-handed players were 4.44 times more likely to tear their left ACL than their right ACL, while left-handed players were 5.5 times more likely to tear their right ACL than their left ACL.

Discussion

This study investigated the relationship between hand dominance and ACL tear laterality in competitive volleyball players and found that athletes were significantly more likely to sustain an ACL tear in the knee opposite of their self-reported dominant hand. The predominance of females in this cohort mirrors established epidemiological trends, as female athletes are at greater risk for ACL injury due to a combination of anatomic, hormonal, and neuromuscular factors.^11-14,30 Additionally, the mean age of participants also aligns with prior reports showing that incidence peaks during adolescence and young adulthood, with females remaining at highest risk into their late teens and beyond.^3,19,22 Interestingly, the ratio of right- to left-handed participants in this study (10.5:1) is consistent with that of the general population, ²³ further supporting the representativeness of the present sample.

Despite these established trends, few studies have specifically examined the role of limb dominance in ACL tears.^6,17,21 In addition, even fewer studies have suggested that a significant relationship exists. ⁵ Negrete et al ²¹ investigated 302 patients with a relatively equal sex distribution to assess the link between leg dominance and noncontact ACL injuries. While they did not find a statistically significant association, they reported a strong trend in female athletes, who were more likely to tear their left ACL, ²¹ a pattern that aligns with the findings of this study. Furthermore, Ruedl et al ²⁴ found that female skiers were twice as likely to sustain an ACL tear in their nondominant leg, which was commonly reported as the left, further demonstrating comparable results in other sports.

The observed association between hand dominance and a higher likelihood of ACL tears occurring in the contralateral leg may be influenced by underlying biomechanical factors and variations in landing patterns. Volleyball athletes naturally develop an asymmetrical movement pattern based on their dominant hand, leading to an uneven force distribution and increased stress on the nondominant limb when landing.^7,18 Furthermore, strength imbalances between the quadriceps and hamstrings may also contribute to injury risk. Wang et al ³¹ recently reported that interlimb asymmetries in quadriceps and hamstring strength significantly increased the risk of noncontact lower limb injuries in elite volleyball players. Similarly, Heinert et al ¹³ demonstrated that athletes with lower hamstring-to-quadriceps ratios exhibited significantly greater ligament and tibiofemoral shear, vertical joint force, and quadriceps force during landing tasks, suggesting that such strength discrepancies are directly associated with increased knee forces and ACL loading.

Research suggests that volleyball players frequently land on one leg after a spike, particularly the left leg in right-handed players, due to a shift in their center of gravity caused by the asymmetric technique required for the jump.^1,33 Furthermore, Marquez et al ¹⁶ analyzed landing mechanics in right-handed male volleyball players and found that, despite landing with both feet simultaneously, the motion remained asymmetric, placing greater stress on the left leg. Similarly, Taylor et al ²⁹ studied landing biomechanics in collegiate-level female volleyball players and found significant kinematic and kinetic asymmetries in lower extremity biomechanics during landing tasks. This and additional research suggest that asymmetries may predispose athletes to higher unilateral forces, potentially increasing injury risk.^1,16,33

Interestingly, not all studies point to greater stress on the nondominant limb. Sinsurin et al ²⁵ examined single-leg landings in female volleyball players and found that their dominant limbs exhibit poorer coordination than their nondominant limbs, suggesting a higher injury risk for the dominant limb. Additionally, the study by Zaheri et al ³⁴ on fatigue and its effect on the lower limb joint suggests that the dominant leg may be at increased risk of ACL injury due to a weakened ankle-hip connection when compared to the nondominant leg. These contrasting findings highlight the complexity of biomechanical asymmetries in volleyball and emphasize the need for further research to better understand their role in ACL injury risk.

The findings of this study may have important implications for injury prevention strategies and athlete screenings in volleyball players. In particular, understanding the association between hand dominance and ACL tear laterality may help guide focused training programs designed to correct biomechanical asymmetries and refine landing techniques, ultimately lowering the risk of noncontact ACL injuries in volleyball. We propose that prevention programs could benefit from tailoring exercises based on potential side-specific vulnerabilities caused from landing or from a sharp lateral moment. For example, right-handed players could benefit from additional neuromuscular training and landing mechanics drills emphasizing the nondominant leg. This approach could be incorporated into existing ACL prevention programs to enhance individualization and reduce injury risk. Future research should expand across different sports, as this could determine whether this relationship is unique to volleyball or represents a broader pattern in athletic populations.

Limitations

For this study, several potential limitations should be considered. First, only 13 left-handed individuals were included in the study, and although the hand dexterity ratio is comparable to that of the general population, ²³ this may limit the generalizability of findings for this subgroup. Second, while an association was established between hand dexterity and ACL tear laterality, factors such as strength movement mechanics and landing techniques were not directly analyzed. Third, these findings are specific to competitive volleyball athletes and may not be generalizable to other sports with different movement demands. Furthermore, several confounding variables were not accounted for, such as previous lower extremity injuries that might have led players to favor one leg over the other. Additionally, this study did not account for player position, mechanism of injury, or the setting in which the injury occurred, whether during practice or in a game. The intensity and movement demands may differ between these settings, potentially further influencing injury risk.

Conclusion

This study aimed to investigate the association between hand dominance and ACL tear laterality in competitive volleyball players. The results showed that right-handed individuals are significantly more likely to tear their left ACL, while left-handed individuals are significantly more likely to tear their right ACL. Furthermore, the study sample's handedness ratio is comparable to that of the general population, supporting the generalizability of these findings. The results provide strong evidence of an association between handedness and ACL tear laterality in competitive volleyball players.