ACL Injury Prevention

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ACL Prevention Programming

The medical community has demonstrated evidence that well designed and supervised injury prevention programs reduce the risk of ACL rupture. ACL injury prevention programs are becoming a mainstay of preparation for sports and recreation with today’s active adolescents and adults.

Those who are already at risk for injury (females or those in pivoting/cutting, high risk sports) are particularly likely to see marked reduction in their risk when engaged in such programs. Since some of the risk factors are non-modifiable (for example, gender), effort focuses on modifiable risk factors, such as neuromuscular control. Maximizing strength, neuromuscular control and technique are the goals of a fruitful ACL injury prevention program, with visual and verbal feedback as a key component of the client’s success.

A safe and effective ACL injury prevention program includes appropriate instruction and supervision.    Ideally, in order to prevent bad habits early-on, ACL prevention programs are initiated at or prior to the onset of puberty. Prevention programs should begin at least 6 weeks prior to the athletic season, with a maintenance program incorporated in-season.

Programming begins with a dynamic warm-up, followed by strength training, plyometrics, agility drills and technique training. Strength training focuses on improving the strength of the core, hip, and gluteal and thigh musculature. Strengthening programs in isolation do not reduce the number of ACL injuries, yet when combined with plyometric training there is a significant reduction in ACL injuries, specifically female athletes.

Plyometric training focus on improving landing biomechanics while incorporating balance training attempts to eliminate or minimize limb asymmetries, which is a potential risk for ACL injury. Cutting and jumping drills comprise the technique training portion. Each of the aspects of training should include frequent feedback cueing, if possible, via video analysis.


The program begins with a dynamic warm-up instead of static stretching to prepare the client’s muscles and joints for the day’s exercises. Strengthening of the quadriceps, hamstrings, hip abductors and core is essential to any ACL injury prevention program. When designing the strength training portion of the program, fitness professionals should think creatively about their client’s preferred sport or recreational activity and how those muscle will be utilized. For example, programming may emphasize eccentric loading reps when working with clients who need to do quick decelerations or stops. Alternatively, an athlete may need to come out more explosively from a static position, such as with a running back, therefore, the chosen exercises should reflect that need.

Plyometric and balance exercises may include single or double-legged hops, box jumps or box drops. These drills may be performed at timed intervals (for example, 30 seconds) or repetition-based (10 repetitions of single-leg hops). Verbal and visual cueing will enable the client to improve their functional and jump landing mechanics. Progression of plyometric and balance drills should remove supports the client uses to perform the exercises.

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For example, once a simple single leg balance exercise has been mastered, the client can close their eyes to remove the assistance they receive through their visual sense. Another technique would be to have them do a ball toss while remaining in single leg stance to draw their visual sense to the ball instead of a focused point in the distance.

Agility and sport-specific drills are the most difficult exercises for a client to maintain proper joint mechanics and neuromuscular control. During drills such as running backward, stop and start shuttle runs or crisscross lateral running, the fitness professional must be highly focused on providing verbal cueing as these drills most closely represent the real-world demands when returning to sport.

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Video analysis, even via a cellular phone camera, is a great tool to implement, as it may be difficult for some clients to incorporate verbal feedback with visual feedback. The choice of agility drills is dependent on the clients preferred sport or activity, and should attempt to simulate those activities. Proper mechanics emphasize symmetric lower extremity takeoff and landing for bilateral limb exercises, suitable trunk control and proper knee alignment during takeoff and landing for bilateral and unilateral drills. Proper knee alignment includes knees aligned over toes and toes pointed in a forward direction.

When the athlete is in-season, a maintenance program begins. Maintenance programming should not be performed on game days; instead, perform the program prior to practice or conditioning two to three times per week while in-season.

Author Bio: Catherine A. Logan, MD, MBA, MSPT is an orthopedic surgeon specializing in sports medicine in . She’s also a team physician for the U.S. Ski & Snowboard Association. Logan was a physical therapist and personal trainer for 7 years before attending medical school. She focuses her research on post-surgical rehabilitation protocols and return to play.

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