Sports Medicine

, Volume 49, Issue 11, pp 1629–1635 | Cite as

Is Fatigue a Risk Factor for Anterior Cruciate Ligament Rupture?

  • Matthew N. BourneEmail author
  • Kate E. Webster
  • Timothy E. Hewett
Current Opinion


Neuromuscular fatigue is a commonly accepted risk factor for anterior cruciate ligament (ACL) injury. It has been proposed that fatigue leads to transient reductions in muscle strength, and deleterious changes in lower limb kinematics and kinetics, during potentially hazardous tasks such as cutting or landing. The purpose of this clinical commentary is to (1) highlight the complexity of fatigue; (2) discuss the theoretical basis by which it is thought to contribute to ACL injury; and (3) critically discuss the evidence underpinning this hypothesis. Despite a significant amount of research, none of the published fatigue protocols appear to have any consistent effect on any lower limb kinematic or kinetic variables known to increase ACL injury risk. On the contrary, fatigued athletes appear to land with greater peak knee and hip flexion angles, and lower landing forces than unfatigued athletes—all of which are considered favourable movement strategies for reducing ACL loading. These data support recent analyses demonstrating no relationship between player workload in training and competition and the occurrence of ACL injury in sport.


Compliance with Ethical Standards


No sources of funding were used to assist in the preparation of this article.

Conflict of Interest

Matthew Bourne, Kate Webster and Timothy Hewett declare that they have no conflicts of interest relevant to the content of this article.


  1. 1.
    Fortington LV, Donaldson A, Finch CF. Self-reported worst injuries in women’s Australian football identify lower limb injuries as a prevention priority. BMJ Open Sport Exerc Med. 2016;2(1):e000112. Scholar
  2. 2.
    Ardern CL, Webster KE, Taylor NF, Feller JA. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J Sports Med. 2011;39(3):538–43. Scholar
  3. 3.
    Hewett TE, Ford KR, Hoogenboom BJ, Myer GD. Understanding and preventing ACL injuries: current biomechanical and epidemiologic considerations—update 2010. N Am J Sports Phys Ther. 2010;5(4):234–51.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Barber-Westin SD, Noyes FR. Effect of fatigue protocols on lower limb neuromuscular function and implications for anterior cruciate ligament injury prevention training: a systematic review. Am J Sports Med. 2017;45(14):3388–96. Scholar
  5. 5.
    Benjaminse A, Webster KE, Kimp A, Meijer M, Gokeler A. Revised approach to the role of fatigue in anterior cruciate ligament injury prevention: a systematic review with meta-analyses. Sports Med. 2019;49(4):565–86. Scholar
  6. 6.
    Benjaminse A, Habu A, Sell TC, Abt JP, Fu FH, Myers JB, et al. Fatigue alters lower extremity kinematics during a single-leg stop-jump task. Knee Surg Sports Traumatol Arthrosc. 2008;16(4):400–7. Scholar
  7. 7.
    Kernozek TW, Torry MR, Iwasaki M. Gender differences in lower extremity landing mechanics caused by neuromuscular fatigue. Am J Sports Med. 2008;36(3):554–65. Scholar
  8. 8.
    Webster KE, Hewett TE. Meta-analysis of meta-analyses of anterior cruciate ligament injury reduction training programs. J Orthop Res. 2018;36(10):2696–708. Scholar
  9. 9.
    Enoka RM, Duchateau J. Muscle fatigue: what, why and how it influences muscle function. J Physiol. 2008;586(1):11–23. Scholar
  10. 10.
    Taylor JL, Todd G, Gandevia SC. Evidence for a supraspinal contribution to human muscle fatigue. Clin Exp Pharmacol Physiol. 2006;33(4):400–5. Scholar
  11. 11.
    Gandevia S. Spinal and supraspinal factors in human muscle fatigue. Physiol Rev. 2001;81(4):1725–89.PubMedCrossRefGoogle Scholar
  12. 12.
    McLean SG, Samorezov JE. Fatigue-induced ACL injury risk stems from a degradation in central control. Med Sci Sports Exerc. 2009;41(8):1661–72. Scholar
  13. 13.
    Cheng AJ, Place N, Westerblad H. Molecular basis for exercise-induced fatigue: the importance of strictly controlled cellular Ca(2 +) handling. Cold Spring Harb Perspect Med. 2018. Scholar
  14. 14.
    Enoka RM, Duchateau J. Translating fatigue to human performance. Med Sci Sports Exerc. 2016;48(11):2228–38. Scholar
  15. 15.
    Edgley SA, Winter AP. Different effects of fatiguing exercise on corticospinal and transcallosal excitability in human hand area motor cortex. Exp Brain Res. 2004;159(4):530–6. Scholar
  16. 16.
    Zebis MK, Bencke J, Andersen LL, Alkjaer T, Suetta C, Mortensen P, et al. Acute fatigue impairs neuromuscular activity of anterior cruciate ligament-agonist muscles in female team handball players. Scand J Med Sci Sports. 2011;21(6):833–40. Scholar
  17. 17.
    St Clair Gibson A, Baden DA, Lambert MI, Lambert EV, Harley YX, Hampson D, et al. The conscious perception of the sensation of fatigue. Sports Med. 2003;33(3):167–76. Scholar
  18. 18.
    Hickie IB, Hooker AW, Hadzi-Pavlovic D, Bennett BK, Wilson AJ, Lloyd AR. Fatigue in selected primary care settings: sociodemographic and psychiatric correlates. Med J Aust. 1996;164(10):585–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Mair SD, Seaber AV, Glisson RR, Garrett WE Jr. The role of fatigue in susceptibility to acute muscle strain injury. Am J Sports Med. 1996;24(2):137–43.PubMedCrossRefGoogle Scholar
  20. 20.
    Wojtys EM, Beaulieu ML, Ashton-Miller JA. New perspectives on ACL injury: on the role of repetitive sub-maximal knee loading in causing ACL fatigue failure. J Orthop Res. 2016;34(12):2059–68. Scholar
  21. 21.
    Kristianslund E, Faul O, Bahr R, Myklebust G, Krosshaug T. Sidestep cutting technique and knee abduction loading: implications for ACL prevention exercises. Br J Sports Med. 2014;48(9):779–83. Scholar
  22. 22.
    Hewett TE, Myer GD, Ford KR, Heidt RS, Colosimo AJ, McLean SG, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes. Am J Sports Med. 2005;33(4):492–501. Scholar
  23. 23.
    Donnelly CJ, Elliott BC, Ackland TR, Doyle TL, Beiser TF, Finch CF, et al. An anterior cruciate ligament injury prevention framework: incorporating the recent evidence. Res Sports Med. 2012;20(3–4):239–62. Scholar
  24. 24.
    Donnelly CJ, Lloyd DG, Elliott BC, Reinbolt JA. Optimizing whole-body kinematics to minimize valgus knee loading during sidestepping: implications for ACL injury risk. J Biomech. 2012;45(8):1491–7. Scholar
  25. 25.
    Doyle TL, Schilaty ND, Webster KE, Hewett TE. Meta-analysis: fatigue does not increase lower-limb injury risk. Clin J Sports Med (in press).Google Scholar
  26. 26.
    Liederbach M, Kremenic IJ, Orishimo KF, Pappas E, Hagins M. Comparison of landing biomechanics between male and female dancers and athletes, part 2: influence of fatigue and implications for anterior cruciate ligament injury. Am J Sports Med. 2014;42(5):1089–95. Scholar
  27. 27.
    Coventry E, O’Connor KM, Hart BA, Earl JE, Ebersole KT. The effect of lower extremity fatigue on shock attenuation during single-leg landing. Clin Biomech (Bristol, Avon). 2006;21(10):1090–7. Scholar
  28. 28.
    Madigan ML, Pidcoe PE. Changes in landing biomechanics during a fatiguing landing activity. J Electromyogr Kinesiol. 2003;13(5):491–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Thomas AC, Lepley LK, Wojtys EM, McLean SG, Palmieri-Smith RM. Effects of neuromuscular fatigue on quadriceps strength and activation and knee biomechanics in individuals post-anterior cruciate ligament reconstruction and healthy adults. J Orthop Sports Phys Ther. 2015;45(12):1042–50. Scholar
  30. 30.
    Kellis E, Kouvelioti V. Agonist versus antagonist muscle fatigue effects on thigh muscle activity and vertical ground reaction during drop landing. J Electromyogr Kinesiol. 2009;19(1):55–64. Scholar
  31. 31.
    Gehring D, Melnyk M, Gollhofer A. Gender and fatigue have influence on knee joint control strategies during landing. Clin Biomech (Bristol, Avon). 2009;24(1):82–7. Scholar
  32. 32.
    Thomas AC, McLean SG, Palmieri-Smith RM. Quadriceps and hamstrings fatigue alters hip and knee mechanics. J Appl Biomech. 2010;26(2):159–70.PubMedCrossRefGoogle Scholar
  33. 33.
    Orishimo KF, Kremenic IJ. Effect of fatigue on single-leg hop landing biomechanics. J Appl Biomech. 2006;22(4):245–54.PubMedCrossRefGoogle Scholar
  34. 34.
    Augustsson J, Thomee R, Linden C, Folkesson M, Tranberg R, Karlsson J. Single-leg hop testing following fatiguing exercise: reliability and biomechanical analysis. Scand J Med Sci Sports. 2006;16(2):111–20. Scholar
  35. 35.
    Padua DA, Arnold BL, Perrin DH, Gansneder BM, Carcia CR, Granata KP. Fatigue, vertical leg stiffness, and stiffness control strategies in males and females. J Athl Train. 2006;41(3):294–304.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Kernozek TW, Torry MR, Van Hoof H, Cowley H, Tanner S. Gender differences in frontal and sagittal plane biomechanics during drop landings. Med Sci Sports Exerc. 2005;37(6):1003–12.PubMedGoogle Scholar
  37. 37.
    Hollman JH, Hohl JM, Kraft JL, Strauss JD, Traver KJ. Effects of hip extensor fatigue on lower extremity kinematics during a jump-landing task in women: a controlled laboratory study. Clin Biomech (Bristol, Avon). 2012;27(9):903–9. Scholar
  38. 38.
    Quammen D, Cortes N, Van Lunen BL, Lucci S, Ringleb SI, Onate J. Two different fatigue protocols and lower extremity motion patterns during a stop-jump task. J Athl Train. 2012;47(1):32–41.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Geiser CF, O’Connor KM, Earl JE. Effects of isolated hip abductor fatigue on frontal plane knee mechanics. Med Sci Sports Exerc. 2010;42(3):535–45. Scholar
  40. 40.
    Thomas AC, Palmieri-Smith RM, McLean SG. Isolated hip and ankle fatigue are unlikely risk factors for anterior cruciate ligament injury. Scand J Med Sci Sports. 2011;21(3):359–68. Scholar
  41. 41.
    Wikstrom EA, Powers ME, Tillman MD. Dynamic stabilization time after isokinetic and functional fatigue. J Athl Train. 2004;39(3):247–53.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Webster KE, Santamaria LJ, McClelland JA, Feller JA. Effect of fatigue on landing biomechanics after anterior cruciate ligament reconstruction surgery. Med Sci Sports Exerc. 2012;44(5):910–6. Scholar
  43. 43.
    Brazen DM, Todd MK, Ambegaonkar JP, Wunderlich R, Peterson C. The effect of fatigue on landing biomechanics in single-leg drop landings. Clin J Sport Med. 2010;20(4):286–92. Scholar
  44. 44.
    Ortiz A, Olson SL, Etnyre B, Trudelle-Jackson EE, Bartlett W, Venegas-Rios HL. Fatigue effects on knee joint stability during two jump tasks in women. J Strength Cond Res. 2010;24(4):1019–27. Scholar
  45. 45.
    Ros AG, Holm SE, Friden C, Heijne AI. Responsiveness of the one-leg hop test and the square hop test to fatiguing intermittent aerobic work and subsequent recovery. J Strength Cond Res. 2013;27(4):988–94. Scholar
  46. 46.
    Moran KA, Marshall BM. Effect of fatigue on tibial impact accelerations and knee kinematics in drop jumps. Med Sci Sports Exerc. 2006;38(10):1836–42. Scholar
  47. 47.
    Cortes N, Onate J, Morrison S. Differential effects of fatigue on movement variability. Gait Posture. 2014;39(3):888–93. Scholar
  48. 48.
    Savage RJ, Lay BS, Wills JA, Lloyd DG, Doyle TLA. Prolonged running increases knee moments in sidestepping and cutting manoeuvres in sport. J Sci Med Sport. 2018;21(5):508–12. Scholar
  49. 49.
    Yamada RK, Arliani GG, Almeida GP, Venturine AM, Santos CV, Astur DC, et al. The effects of one-half of a soccer match on the postural stability and functional capacity of the lower limbs in young soccer players. Clinics (Sao Paulo). 2012;67(12):1361–4.CrossRefGoogle Scholar
  50. 50.
    McLean SG, Fellin RE, Suedekum N, Calabrese G, Passerallo A, Joy S. Impact of fatigue on gender-based high-risk landing strategies. Med Sci Sports Exerc. 2007;39(3):502–14. Scholar
  51. 51.
    Pappas E, Sheikhzadeh A, Hagins M, Nordin M. The effect of gender and fatigue on the biomechanics of bilateral landings from a jump: peak values. J Sports Sci Med. 2007;6(1):77–84.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Sanna G, O’Connor KM. Fatigue-related changes in stance leg mechanics during sidestep cutting maneuvers. Clin Biomech (Bristol, Avon). 2008;23(7):946–54. Scholar
  53. 53.
    Lucci S, Cortes N, Van Lunen B, Ringleb S, Onate J. Knee and hip sagittal and transverse plane changes after two fatigue protocols. J Sci Med Sport. 2011;14(5):453–9. Scholar
  54. 54.
    Cortes N, Greska E, Kollock R, Ambegaonkar J, Onate JA. Changes in lower extremity biomechanics due to a short-term fatigue protocol. J Athl Train. 2013;48(3):306–13. Scholar
  55. 55.
    Lessi GC, Dos Santos AF, Batista LF, de Oliveira GC, Serrao FV. Effects of fatigue on lower limb, pelvis and trunk kinematics and muscle activation: gender differences. J Electromyogr Kinesiol. 2017;32:9–14. Scholar
  56. 56.
    Zebis MK, Andersen LL, Bencke J, Kjaer M, Aagaard P. Identification of athletes at future risk of anterior cruciate ligament ruptures by neuromuscular screening. Am J Sports Med. 2009;37(10):1967–73. Scholar
  57. 57.
    Yao W, Fuglevand RJ, Enoka RM. Motor-unit synchronization increases EMG amplitude and decreases force steadiness of simulated contractions. J Neurophysiol. 2000;83(1):441–52.PubMedCrossRefGoogle Scholar
  58. 58.
    Bourne MN, Timmins RG, Opar DA, Pizzari T, Ruddy RD, Sims C, et al. An evidence-based framework for strengthening exercises to prevent hamstring injury. Sports Med. 2018;48(2):251–67. Scholar
  59. 59.
    Bourne MN, Williams MD, Opar DA, Al Najjar A, Shield AJ. Impact of exercise selection on hamstring muscle activation. Br J Sports Med. 2017;51(13):1021–8. Scholar
  60. 60.
    Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc. 1996;4(1):19–21.PubMedCrossRefGoogle Scholar
  61. 61.
    Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, Olsen OE, Bahr R. Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med. 2003;13(2):71–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Pfeiffer RP, Shea KG, Roberts D, Grandstrand S, Bond L. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. J Bone Jt Surg Am. 2006;88(8):1769–74. Scholar
  63. 63.
    Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ. 2005;330(7489):449. Scholar
  64. 64.
    Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003–10. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.School of Allied Health SciencesGriffith UniversityGold CoastAustralia
  2. 2.School of Allied HealthLa Trobe UniversityMelbourneAustralia
  3. 3.Mayo Clinic Biomechanics Laboratories and Sports Medicine Research Center, Departments of Orthopedic Surgery, and of Physical Medicine and of Physiology & Biomedical EngineeringMayo ClinicRochesterUSA

Personalised recommendations