Purpose of Review
Mechanisms leading to anterior cruciate ligament (ACL) injury have been identified, yet re-injury or a secondary injury persists in the athletic population. The purpose of this review is to identify risk factors associated with ACL injury and investigate programs to prevent injury.
Faulty mechanics during dynamic movement that cause excessive valgus force at the knee increases the risk of ACL injury. Faulty mechanics may be a result of lateral displacement of the trunk, unequal limb loading, and lack of control to avoid the valgus knee position. Altered movements that place the ACL at risk are best identified in a fatigued state; however, could be recognized in a standard dynamic assessment. The faulty movement patterns are modifiable and should be addressed in an injury prevention program. Prevention programs include various modes of exercise such as plyometrics, neuromuscular training, and strength training.
This review concludes that those programs which utilize neuromuscular training and strength training at a young age show the most promise in reducing ACL injuries. An ongoing thorough dynamic examination is necessary for all athletes while adjusting the intervention program in order to decrease the risk of ACL injury.
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Papers of particular interest, published recently, have been highlighted as: • Of importance
Meisterling SW, Schoderbek RJ, Andrews JR. Anterior cruciate ligament reconstruction. Oper Tech Sports Med. 2009;17:2–10.
Allografts in Sports Medicine: What do we know, need to know, and need to do? Round table discussion: American Orthopedic Society for Sports Medicine; 2006. Park City, UT
Holm I, Oiestad B, Risberg M, et al. No difference in prevalence of osteoarthritis or function after open versus endoscopic technique for anterior cruciate ligament reconstruction: 12-year follow-up report of randomized controlled trial. Am J Sports Med. 2012;40:2492–8.
Flynn RK, Pedersen CL, Birmingham TB, et al. The familial predisposition toward tearing the anterior cruciate ligament: a case control study. Am J Sports Med. 2005;33:23–8.
Dodwell E, LaMont L, Green D, et al. 20years of pediatric anterior cruciate ligament reconstruction in New York state. 2014;42:675–680.
Rugg C, Wang D, Sulzicki P, et al. Effects of prior knee surgery on subsequent injury, imaging and surgery in NCAA collegiate athletes. Am J Sport Med. 2014;42:959–64.
Wiggins A, Granhi R, Schneider D, et al. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sport Med. 2016;44:1861–76.
Amis AA. The functions of the fibre bundles of the anterior cruciate ligament in anterior drawer, rotational laxity and the pivot shift. Knee Surg Sports Traumatol Arthrosc. 2012;20:613–20.
Senter C, Hame S. Biomechanicial analysis of tibial torque and knee flexion angle. Sports Med. 2006;36(8):635–41.
Wunschel M, Muller O, Lo J, et al. The anterior cruciate ligament provides resistance to externally applied anterior tibial force but not to internal rotational torque during simulated weight-bearing flexion. Arthroscopy JArthrosc Relat Surg. 2010;26(11):1520–7.
Andersen HN, Dyhre-Poulsen P. The anterior cruciate ligament does play a role in controlling axial rotation in the knee. Knee Surg Sports Traumatol Arthrosc. 1997;5(3):145–9.
Baratta R, Solomonow M, Zhou BH, et al. Muscular coactivation: the role of the antagonist musculature in maintaining knee stability. Am J Sport Med. 1988;16(2):113–22.
Withrow TJ, Huston LJ, Wojtys EM, et al. The relationship between quadriceps muscle force, knee flexion, and anterior cruciate ligament strain in an in vitro simulated jump landing. Am J Sport Med. 2006;34(2):269–74.
• Hewett TE, Ford KR, Hoogenboom BJ, et al. Understanding and preventing ACL injuries: current biomechanical and epidemiologic considerations—update 2010. North American J Sports Phys Ther. 2010;5(4):234–50. Identifies biomechanical risk factors and mechanisms associated with ACL injury in high-risk individuals.
• Myer GD, Ford KR, Di Stasi SL, et al. High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: is PFP itself a predictor for subsequent ACL injury? Br J Sports Med. 2015;49:118–22. Identifies a large knee abduction moment during landing and reduced hamstrings-to-quadriceps ratio in ACL-injured athletes.
Huston LJ, Vibert B, Ashton-Miller JA, et al. Gender differences in knee angle when landing from a drop-jump. Am J knee Surg. 2001;14:215–20.
Myer GD, Ford KR, Brent JL, et al. Differential neuromuscular training effects on ACL injury risk factors in “high-risk” versus “low-risk” athletes. BMC Musculoskel Dis. 2007;8(39).
Sell TC, Ferris CM, Abt JP, et al. Predictors of proximal tibia anterior shear force during a vertical stop-jump. J Orthop Res. 2007;25(12):1589–97.
Dowling AV, Favre J, Andriacchi TP. Inertial sensor-based feedback can reduce key risk metrics for anterior cruciate ligament injury during jump landings. Am J Sport Med. 2012;40(5):1075–83.
Griffin L, Albohm M, Arendt E, et al. Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting, January 2005. Am J Sports Med. 2006;34:1512–32.
Hewett TE, Ford KR, Myer GD, et al. Anterior cruciate ligament injuries in female athletes. Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sport Med. 2006;34(3):490–8.
Yoo JH, Lim BO, Ha M, et al. A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes. Knee Surg Sports Traumatol Arthrosc. 2010;18(6):824–30.
National Collegiate Athletic Association. NCAA injury surveillance system summary. Indianapolis: National Collegiate Athletic Association; 2002.
Johnsen M, Guddal M, Smastuen M, et al. Sport participation and the risk of anterior cruciate ligament reconstruction in adolescents: a population-based prospective cohort study (The Young-HUNT Study). Am J Sport Med. 2016;44:2917–24.
Ford KR, Myer GD, Toms HE, et al. Gender differences in the kinematics of unanticipated cutting in young athletes. Med Sci Sports Exerc. 2005;37:124–9.
Lohmander LS, Englund PM, Dahl LL, et al. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35:1756–69.
Hill OT, Bulathsinhala L, Scofield DE, et al. Risk factors for soft tissue knee injuries in active duty US Army soldiers, 2000–2005. Mil Med. 2013;178(6):676–82.
Owens BD, Mountcastle SB, Dunn WR, et al. Incidence of anterior cruciate ligament injury among active duty US military servicemen and servicewomen. Mil Med. 2007;172(1):90–1.
Webster K, Feller J. Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sport Med. 2016;44:2827–32.
Oiestad BE, Holm I, Engebretsen L, et al. The prevalence of patellofemoral osteoarthritis 12 years after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013;21:942–9.
Sigward S, Powers C. Loading characteristics of females exhibiting excessive valgus moments during cutting. Clin Biomech. 2007;22:827–33.
Pollard C, Stearns K, Hayes A, et al. Altered lower extremity movement variability in female soccer players during side-step cutting after anterior cruciate ligament reconstruction. Am J Sports Med. 2015;43:460–5.
Kristinaslund E, Krosshaug T. Comparison of drop jumps and sport-specific sidestep cutting: implications for anterior cruciate ligament injury risk screening. Am J Sports Med. 2013;41:684–8.
Cortes N, Onate J, Van Lunen B. Pivot tasks increases frontal plane loading compared with sidestep and drop-jump. J Sports Sci. 2011;29:83–92.
• Stearns K, Powers C. Improvements in hip muscle performance result in increased use of the hip extensors and abductors during a landing task. Am J Sports Med. 2014;42:602–9. Describes in correlation of the magnitude of frontal plane motion to the adduction moment.
Moore I, Ranson C, Mathema P. Injury risk in international rugby union: three-year injury surveillance of the welsh national team. Orth J Sports Med. 2015;3:1–9.
Brazen D, Todd K, Ambegaonkar J, et al. The effect of fatigue on landing biomechanics in single-leg drop landings. Clin J Sport Med. 2010;20:286–2.
Borotikar B, Newcomer R, Koppes R, et al. Combined effects of fatigue and decision making on female lower limb landing postures: central and peripheral contributions to ACL risk. Clin Biomech. 2008;23:81–92.
Orishimo K, Kremenic I. Effect of fatigue on single leg hop landing biomechanics. J App Biomech. 2006;10:1–10.
• Frank B, Bell D, Norcross M, et al. Trunk and hip biomechanics influence anterior cruciate loading mechanisms in physically active participants. Am J Sports Med. 2013;41:2676–86. Describes the correlation of core stability to frontal plane motion.
Chaudhari A, McKenzie C, Pan X, et al. Lumbopelvic control and days missed because of injury in professional baseball pitchers. Am J Sports Med. 2014;42:2734–41.
Baldon R, Piva S, Silva R, et al. Evaluating eccentric hip torque and trunk endurance as mediators of changes in lower limb and trunk kinematics in response to functional stabilization training in women with patellofemoral pain. Am J Sport Med. 2015;43:1485–93.
Chaudhari AM, McKenzie C, Borchers J, et al. Lumbopelvic control and pitching performance of professional baseball players. J Strength Con Res. 2011;25:2127–32.
Hoshikawa Y, Iida T, Muramatsu M, et al. Effects of stabilization training on trunk muscularity and physical performance in youth soccer players. J Strength Con Research. 2013;27:3142–9.
Gaunt B, Curd D. Anthropometric and demographic factors affecting distance hopped and limb symmetry index for the crossover hop-for-distance test in high school athletes. J Orth Sport Phy Ther. 2001;31:145–51.
Noyes F, Barber S, Magine R. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19:513–8.
Ardern CL, Taylor NF, Feller JA, et al. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40(1):41–8.
Thomee R, Neeter C, Gustavsson A, et al. Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2012;20:1143–51.
Rohman E, Steubs T, Tompkins M. Changes in involved and uninvolved limb function during rehabilitation after anterior cruciate ligament reconstruction: implications for limb symmetry index measures. Am J Sport Med. 2015;43:1391–9.
Zwolski C, Schmitt L, Thomas S, et al. The utility of limb symmetry indices in return to sport assessment in patients with bilateral anterior cruciate ligament reconstruction. Am J Sport Med. 2016;44:2030–8.
Myer G, Schmitt L, Brent J, et al. Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. J Orth Sport Phy Ther. 2011;41:377–91.
Myer G, Paterno M, Ford K, et al. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orth Sport Phy Ther. 2006;36:385–408.
Weir A, Darby J, Inklaar H, et al. Core stability: inter- and intraobserver reliability of 6 clinical tests. Clin J Sport Med. 2010;20:34–8.
Ekstrom R, Donatelli R, Carp K. Electromyographic analysis of core, trunk, hip, thigh muscles during 9 rehabilitation exericses. J Orth Sport Phy Ther. 2007;37:754–62.
Cleather D, Goodwin J, Bull A. Hip and knee joint loading during vertical jumping and push jerking. Clin Biomech. 2013;28:98–103.
Nordin M, Frankel VH. Basic biomechanics of the musculoskeletal system. J of Biomech. 2002;35(6):871–2.
• Atkins S, Hesketh C, Sinclair J. The presence of bilateral imbalance of the lower limbs in elite youth soccer players of different ages. J Strength Cond Res. 2016;30:1007–13. Describes the impact lateral displacement of the pelvis has on force distribution and joint forces.
Nessler T. Using movement assessment to improve performance and reduce injury risk. J Athl Ther Train. 2013;18:8–12.
Wisloff U, Castagna C, Helgerud J, et al. Strong correlation of maximal squat strength with sprint performance and vertical jump height in elite soccer players. Br. J Sports Med. 2004;38:285–8.
Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training programs. J Bone Joint Surg Am. 2012;94:769–76.
Grimm N, Jacobs J Jr, Kim J, et al. Anterior cruciate ligament and knee injury prevention programs for soccer players: a systematic review and meta-analysis. Am J Sports Med. 2014;43(8):2049–56.
Gilchrist J, Mandelbaum BR, Melancon H, et al. A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med. 2008;36:1476–83.
Soderman K, Werner S, Pietila T, et al. Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? Knee Surg Sports Traumatol Arthrosc. 2000;8:356–63.
Heidt RS Jr, Sweeterman LM, Carlonas RL, et al. Avoidance of soccer injuries with preseason conditioning. Am J Sports Med. 2000;28:659–62.
Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Am J Sports Med. 1999;27:699–706.
Mandelbaum BR, Silvers HJ, Watanabe D, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: two-year follow-up. Am J Sports Med. 2005;33:1003–10.
Petersen W, Braun C, Bock W, et al. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg. 2005;125:614–6.
Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. J Bone Joint Surg Am. 2006;88:1769–74.
Kiani A, Hellquist E, Ahlqvist K, et al. Prevention of soccer-related knee injuries in teenaged girls. Arch Intern Med. 2010;170(1):43–9.
Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ. 2008;337
Soomro N, Sanders R, Hackett D, et al. The efficacy of injury prevention programs in adolescent team sports: a meta-analysis. Am J Sport Med. 2015;44(9):2415–24.
Donnell-Fink LA, Klara K, Collins JE, et al. Effectiveness of knee injury and anterior cruciate ligament tear prevention programs: a meta-analysis. PLoS One. 2015;10(12):1–17.
Hewett TE, Myer GD. The mechanistic connection between the trunk, knee, and ACL injury. Exerc Sport Sci Rev. 2011;39(4):161–6.
Sugimoto D, Myer GD, Micheli LJ, et al. ABCs of evidence-based anterior cruciate ligament injury prevention strategies in female athletes. Curr Phys Med Rehabil Rep. March 2015;3(1):43–9.
• Myer GD, Sugimoto D, Thomas S, et al. The influence of age on the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a meta-analysis. Am J Sports Med. 2013;41(1):203–15. This study displayed age influence on ACL injury reduction.
Steffen K, Myklebust G, Olsen OE, et al. Preventing injuries in female youth football—a cluster-randomized controlled trial. Scand J Med Sci Sports. 2008;18(5):605–14.
• Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492–501. The study explained the significance of faulty biomechanics and its relationship with risk for ACL injury.
Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism. Br J Sports Med. 2009;43(6):417–22.
Zazulak BT, Hewett TE, Reeves NP, et al. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med. 2007;35(7):1123–30.
Sugimoto D, Myer GD, Bush HM, et al. Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. J Athl Train. 2012;47(6):714–23.
van Reijen M, Vriend I, van Mechelen W, et al. Compliance with sport injury prevention interventions in randomised controlled trials: a systematic review. Sports Med. 2016;46:1125–39.
Joy E, Taylor JR, Novak M, et al. Factors influencing the implementation of ACL injury prevention strategies by girls soccer coaches. J Strength Cond Res. 2013;27(8):2263–9.
Benjaminse A, Gokeler A, Dowling AV, et al. Optimization of the anterior cruciate ligament injury prevention paradigm: novel feedback techniques to enhance motor learning and reduce injury risk. J Orthop Sports Phys Ther. 2015;45(3):170–82.
LaBella CR, Huxford MR, Grissom J, et al. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. Arch Pediatr Adolesc Med. 2011;165(11):1033–40.
Olsen OE, Myklebust G, Engebretsen L, et al. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ (Clinical research ed). 2005;330(7489):449.
• Sugimoto D, Myer GD, Foss KD, et al. Dosage effects of neuromuscular training intervention to reduce anterior cruciate ligament injuries in female athletes: meta- and sub-group analyses. Sports Med. 2014;44(4):551–62. This study generated evidence of inverse dose-response relationship.
Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior cruciate ligament injuries in soccer: a prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc. 1996;4:19–21.
Risberg MA, Mork M, Jenssen HK, et al. Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2001;31(11):620–31.
Wilk KE, Macrina LC, Cain EL, et al. Recent advances in the rehabilitation of anterior cruciate ligament injuries. J Orthop Sports Phys Ther. 2012;42(3):153–71.
Heitkamp HC, Horstmann T, Mayer F, et al. Gain in strength and muscular balance after balance training. Int J Sports Med. 2001;22:285–90.
Myklebust G, Engebretsen L, Braekken IH, et al. 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.
Conflict of Interest
The authors declare that they have no conflicts of interest.
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This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on ACL Rehab
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Nessler, T., Denney, L. & Sampley, J. ACL Injury Prevention: What Does Research Tell Us?. Curr Rev Musculoskelet Med 10, 281–288 (2017). https://doi.org/10.1007/s12178-017-9416-5
- Knee injury
- Anterior cruciate ligament (ACL)
- Prevention program
- Neuromuscular training
- Strength training