Title: “Sit Like a Lady”: Gender-related sociocultural constructs and implications for anterior
cruciate ligament injury risk in active women.
Version: 2 Date: 29 Jan 2025
Reviewer's report:
This is an interesting and innovative study investigating gender roles, self-objectification,
and the biopsychosocial context of their potential  impact on kinematic strategies related to
ACL-injury risk. The authors should be commended for investigating connections between
socialization and embodiment of gender stereotypes, and movement patterns in sport/injury risk.
This is an ambitious project, and the authors emphasize that this is an exploratory study seeking
to initiate investigations into this specific issue. Although there are significant limitations in the
study design, I think these are fine in the context of its exploratory nature, and given  that the
authors are aware of most of them and thus come to appropriately modest conclusions. As the
foundation for ongoing work, this is a potentially important paper.  Thus, my comments are
mostly limited to data presentation and some additional thoughts on possible limitations and
confounders.
Data presentation:
1) I think the results lend themselves better to figures than tables. The reader would benefit
from being able to visualize the data, particularly in the case of the correlations between survey
scores and kinematic outcomes. I recommend presenting the kinematic outcome distributions
(Tables 1 and 2, w/o the normality statistics which I don't see as particularly important in a
small exploratory study where nonparametric approaches are being use anyway) as boxplots,
and presenting the correlation data (Table 3) as scatter plots.
2) In addition to means and SDs, please present the ranges for age,  GRSS, and TSOS.
3) Given the seemingly very small variation in height along with considerable variation in
weight, it would be good to see BMI presented as well. An additional sub-analysis of interest
may be to determine if BMI is correlated with GRSS or TSOS scores, and what the partial
correlations between GRSS/TSOS and kinematic outcomes are after controlling for BMI.
Limitations:
1) Disordered eating was mentioned in association with the validity of the TSOS. Was disordered
eating an exclusion criterion for this study? If not, why not? I could see eating disorders as
relating to GRSS/TSOS scores as well as physical function, and thus acting as a confounder.
Please provide a rationale for not excluding subjects on this basis, and comment as to whether
this is a limitation.
2) The point about different footwear affecting kinematic outcomes is acknowledged, but as a
counterpoint, how does unfamiliar footwear affect these results? Are subjects behaving normally
in lab footwear they have not previously work and which is not broken in to their specific feet?
Please comment/discuss as a limitation.
3) The potential priming of subjects with the video about "sitting like a lady" was noted by the
authors as a limitation, but my question is why include this portion of the video at all? Is this
needed in order to obtain accurate answers on the surveys? Please include the rationale as to
why this video section was included, because it seems like a clear confounder and without a
rationale the reader is left with concerns about this aspect of the study design.
4) The age of the GRSS as a tool is mentioned as potentially making it outdated, leading to
a lack of effect on kinematic outcomes in the relatively young subject sample. However, the
TSOS is  of similar age (27-28 years old it looks like). Does the same concern not apply to the
TSOS then, and correspondingly its significant relationships? If age/outdatedness is a concern
for the contemporary validity of the GRSS, then the same concern needs to be raised for TSOS
and discussed as a potential limitation, or, alternatively, if the two surveys should be considered
differently with respect to their age, then that needs to be discussed.
Other:
1) Could you please provide more in-depth qualitative descriptions of the characteristics
associated with each extreme endpoint of the GRSS and TSOS?  I think this might give the
reader better context with which to interpret the results, especially if the results are presented
graphically.
2) This is pure speculation on my part, and so may not warrant inclusion in the paper, but
maybe consider it if you think it has any merit. The authors emphasize that they are exploring
non-anatomical factors underlying ACL-risk-related kinematics, but do not control for any
anatomical variables in the analysis. That's probably fine given the nature of this study in
particular, and more broadly if anatomy and the biopsychosocial scales are truly independent.
However, is it possible that anatomical factors associated with ACL injury risk ALSO affect
the manner in which women experience external objectification in society, which then may
reflect back on them and become internalized in a way that affects kinematic strategies? In
other words, are their relationships between lower extremity anatomy and the propensity to
fall in a particular spot on the GRSS/TSOS scales?  I'm thinking primarily of evolutionary
psychology concepts related to waist to hip ratio (which I recognize have in many cases
been found scientifically lacking when subjected to critical evaluation...), and how a given
individual's anatomy may affect both her inherent kinematic profile, as well as biopsychosocial
constraints on how she actually uses her neuromusculoskeletal system to move.  The validity
of specific evol psych constructs aside,  is it possible that a subset of specific anatomical
features affects the inherent physical, structural risk to the ACL, while also mediating the
experience of external- and self-objectification that then constrains movement patterns? If
so, could this be a confounder in the present study, and would controlling for anatomical
variation in future analyses of biopsychosocial effects be warranted? On a grander scale, how
do these anatomical and socialization components change over the lifespan, particularly through
the pubertal transition from childhood to adulthood when ACL injury risk is high, but also
throughout adulthood and across the menopausal transition? These are more just questions
based on my own interest in the subject, not necessarily suggestions for revisions to this paper
specifically. More than anything I would like to hear the authors' thoughts on this. However if
you think this concept has any merit and want to include a sentence or two on it in the discussion
that would not detract from the paper.