Title: “Sit Like a Lady”: Gender-related sociocultural constructs and implications for anterior
cruciate ligament injury risk in active women.
Version: 2 Date: 19 Feb 2025
Reviewer's report:
Thank you for the invitation to review this paper. The authors have conducted a cross-sectional
study, relating two sociological questionnaires to a biomechanical varables collected from two
tasks. Well done to the authors on preparing their manuscript, it has been clearly written and has
been thoroughly put together. It is great to see research into women’s specific elements relating
to musculoskeletal conditions. Despite this I struggle with the rationale that underpins the study.
Central to much of your studies hypothesis is that of abnormal movement mechanics relating to
ACL injury – specifically you mention a ‘high risk position’ or ‘position of no return’. In support
of these in your introduction, you cite a single clinical commentary paper from over 20 years ago.
These positions however have not consistently been linked with ACL injury risk, e.g. see recent
systematic review Cronstrom et al 2020 BMC Musculoskeletal 10.1186/s12891-020-03552-3.
You are therefore trying to link constructs to a movement pattern that has not been conclusively
linked to risk of injury.
Further, I am unclear on the theoretical underpinning for the proposed relationships investigated
in your study. I completely agree that sociocultural factors likely have a number of impacts on
things like women’s attitudes and participation in sport, their opportunities, and no doubt health
outcomes, especially in the post-injury space. The team I work in has several projects in this
area, so I commend the interest in this space. What I am less clear on is how these very broad
concepts e.g. objectification might influence kinematics of a stand to sit task, especially without
any preliminary or exploratory evidence to support this.
Another key concern is that you even if a theoretical link might exist, you have primed your
participants – in your methods you explain details of the study, including an “Introduction to
postures associated with self-objectification and/or gender roles, such as "sitting like a lady."”
prior to commencing the procedures. This has the potential to introduce bias.
Lastly I am concerned over potentially spurious findings, reporting bias for your results and
over-interpretation of your findings. It is unclear exactly how many correlations you ran, though
you have 2 tasks, 2 joints and both dominant and non-dominant limb, which you presumably
correlated with 2 scales – this is a lot of comparisons, some lacking theoretical underpinning.
In your results section you only present some of these, and then report them as consistent/non-
consistent with a ‘high risk position’ – one of the key issues discussed above. Later you report
“It is important to note the statistical significance of a correlation does not determine clinical
meaning as the relationship may be clinically relevant without achieving statistical significance”
– I cannot agree with this. I support moving away from a frequentist approach to reporting of
results in research, and not relying overly on ‘statistical significance, however in this setting
there are no measures of uncertainty/variance provided and with your exploratory study in a
small population with many statistical comparisons provided. Without significant theoretical
underpinning to justify how self-objectification alters movement biomechanics, it is difficult to
accept such statements that extend the results much further than the tests run.
Other specific comments:
Introduction – paragraphs 3 and 4 discuss a variety of broad sociocultural topics but do not
specifically link them in a relevant way to the present study. Frequently statements are not
backed up by empirical evidence.
“self-objectification often results in timid and incomplete movement patterns by decreasing the
manipulated degrees of freedom.” – This is a very strong statement that is intended to underpin
your rationale yet you have not provided any citation for it.
The subsequent sentences also lack contemporary empirical evidence – e.g. citation from >40
years ago. To be clear – I am not disputing many of the points raised in this paragraph around
objectification of women as a social construct – these are clearly large issues in society. My
issue is their relevance to movement biomechanics, so called ‘optimal movement patterns’ and
your study in general.
Introduction aims: “injury-prone lower limb movement patterns.” – please change this, there is
insufficient evidence to say this, and you have not defined what these movement patterns are
up front.
Methods: well done on providing a great deal of detail for most aspects of your methods section.
2.1 – please provide IRB approval number.
2.2 – your sample size calculation is based on an effect size comparing differences in kinematic
variables between men and women – this is not relevant to your study. I am also unsure how
you arrived at this statement: “Although no formal sample size calculation was conducted
specifically for correlation analysis, the sample size of N=15 was expected to provide adequate
power to detect moderate correlations (correlation coefficient r#0.3).”
TSOS – you cite reliability and validity – however this questionnaire has no published reliability
– the paper you cites, in-fact cites unpublished data on the TSOS reliability by the creator.
2.6 – hip and knee ROM in the three planes – is that peak? You have means in brackets, is that
the mean of peaks of each trial?
2.7 – could you please provide justification for conducting simple correlation analysis as
opposed to regression analysis (where you might be able to include important covariates and
confounders etc).
Results
You include several sections regarding normality tests etc – I don’t think these are necessary to
include, though the editor can also advise.
3.3 – some directionality may help in the communication and interpretation of these = i.e. what
does “a moderate positive correlation with non-dominant frontal plane hip kinematics during the
STS and TSOS mean” – greater hip flexion associated with greater TSOS? Again a regression
analysis here allows for greater interpretation of your findings.
Table 3 feels a little like you have picked certain variables, without presenting all findings. E.g.
the non-dominant hip, non-dominant knee etc. It is also confusing when for the non-dominant
knee you report tibial IR (reporting negative correlation), but then for the dominant knee you
report tibial ER (reporting positive correlation).
Title: though catchy, your title does not really reflect what your study is about. As discussed
later I don’t think ACL injury should be included in your title either.
For now I have not commented specifically on your discussion, as I think my prior concerns
regarding the rationale, justification and analysis approach are important to address and may
significantly change your paper.