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Esther Hopkin
Dance 342, Musil
April 2, 2013
ACL Injury Mechanics and Prevention in Female Dancers
Every year, 100,000-250,000 people in the general population of the United States injure
their ACL (Webb). That equates to one in every 3,000 of the general public (Torry). Of these,
70-80% are non-contact injuries (Torry, Hensch, Webb). Although the statistics vary from study
to study, movement scientists agree that females are much more prone to ACL injury than their
male counterparts (Fujii, Hensch, Wilde). In fact, Lynn Pantuosco-Hensch, assistant professor of
movement science at Westfield State University in Massachusetts, claims that one in ten female
college athletes and one in 100 female high school athletes sustain ACL injuries each year (18).
On top of this, recovery from injury can take up to a full year; the ability to run in and of itself
requires at least six months of post-surgery rehabilitation. Fujii et al. states that, Despite
improvements in anterior cruciate ligament reconstruction techniques, two- thirds of ACL
patients do not return to the pre-injury level of competitive sports by 12 months (Fujii, 255).
Clearly, ACL injuries place a hold on athletes careers and physical development. Especially
since a large number of dancers are female, and thus more susceptible to ACL injury, it is crucial
for them to increase their core stability and strengthen their hamstrings to have a better
quadriceps-hamstring strength ratio and allow for greater flexion in jumping, landing, and
locomoting.
Females skeletal make-up naturally lends itself to ACL injuries because of a tendency
toward knee valgus motion. Female pelvises in general are wider than males in order to
accommodate for pregnancy and labor. These wider hips, however, in turn cause a greater angle

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of decent of the quadriceps, or Q angle (Myer, Laughlin, Fujii, Wilde, Webb). Although this
greater Q angle does not always lead to a genu valgus skeletal deviation (commonly known as
knocked knees), it will lead to a non-vertical anterior line of gravity with the knees being more
medial than the hips. Following the laws of physics, the tibia and fibula would therefore be
much more likely to abduct, or have a knee valgus motion, than they would with a lesser Q
angle.
Another disadvantage that women have is that the ligaments in their knees are generally
more lax than mens (Fujii, 258). The study that discovered this, however, was done on
cadavers; thus, their test results provided no dynamic information on the impact that muscle
engagement would have in knee stability. This led the investigators to believe that muscle
activity would be even more important for womens knee protection than it would be for mens
(Fujii, 258). In addition, womens hormonal and chemical fluctuations in their menstrual cycle
affect how lax their ligaments are. Wilde et al. observes that the gender disparity in ACL
weakness does not begin until pubescence; at that point, injuries spike in the female population
much more than in males (497-498). Chappell et al. and Webb argue that the female hormones
somehow make the ligaments more lax throughout the body. Jeff Hopkin, family practitioner,
agrees, specifying progesterone as the predominant effector. Thus, every menstrual cycle sends
womens ligaments through a round of laxity and rigidity.
Of course women cannot change their skeletal or hormonal make-up to prevent ACL
injuries. Their weakness, however, is largely due to common biomechanics in jumping and
locomoting. Mostif not allmovement scientists note that women generally utilize less knee
flexion in drop landings, such as landing a jump or intense lift than men do (Myer, Chappell,
Laughlin, Fujii, Hensch, Webb). Myer et all recalls, [A] prospective study has shown that

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female athletes who subsequently sustained ACL injuries demonstrated significantly less knee
flexion during a drop vertical jump than those who did not sustain injury (Myer, 2285). In
an attempt to prevent the knee [and their body] from collapsing [to the ground] upon initial
contact with the ground (Wilde, 497), women engage their quadriceps muscles eccentrically,
causing increased knee extension, and therefore greater anterior drawer force (Chappell, 240). In
other words, when a subject engages his or her quadriceps, it pulls on the patellar tendon which
in turn pulls the proximal end of the tibia anteriorly, straining the anterior cruciate ligament.
Torry et al. found similar results, stating that women overuse the quadriceps muscles and
increase ACL loading during dynamic tasks such as the drop landing (1019).
Many dancers attempt to prevent over-engaging the quadriceps by relying on the muscles
of the feet and ankle to soften their jump landings. By rolling through the feet, as teachers
explain it, the ankles absorb much of the force, leaving less to transfer through the knees and
hips. However, this is still not adequate protection for the knee joint, especially for the anterior
cruciate ligament.
It is important to keep in mind that having stronger quadriceps than hamstrings is
expected for both genders; but women have an even larger imbalance between their knee
extensors and flexors than do men (Hensch, 18). In order to have greater knee flexion, one need
not only use the extensors less, but also engaged the flexorsin this case, the hamstrings
more.

Myer et al. writes, At low knee flexion angles, the hamstrings have little ability to

protect against ACL loads [However,] if the hamstrings are adequately activated at the proper
time, they can increase knee flexion and decrease ACL loading (2286). Laughlin et al echoes,
In vitro and in vivo studies have reported peak ACL force occurs between 15 and 40 of
knee flexion and diminish to zero beyond 40 (1845). Therefore, it is crucial for female

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dancers to not only rely on their quadriceps to prevent knee collapse, nor just their plantar flexors
and intrinsics in their ankles and feet to soften landings, but their hamstrings as well to increase
knee flexion.
In her article in the July 2007 Soccer Journal, Hensch suggested a ready position for
athletes on the field, consisting of being light on the feet with slight knee and hip flexiona
typical basketball player defense stance (18). Myer et al. concurs that a functionally stable
athletic position is with knees comfortably flexed, shoulders back, eyes up, feet
approximately shoulder-width apart, and the body mass balanced evenly over the balls of both
feet (2288). Maintaining such a stance in a dance setting would be absolutely preposterous; it
may work for some movement sequences, but the majority of choreography would still put
dancers in jeopardy.
Despite the fact that many preventative practices will not function in the dance discipline,
there are many other practices that will. One is to strengthen core support and apply it in
proprioception and balance (Laughlin, Webb), providing greater support for the rest of the body
(Hensch, 19). Myer et al. and Chappell found that hip abduction strength particularly helps to
control the bodys center. The former writes, exercise progressions have demonstrated that
increased hip abduction strength improves the ability of female athletes to control the body
center of mass and lower extremity alignment, which results in a decreased KAM [knee
abduction moments] during sports activities (2276).
These can both be put into practice by doing proprioception drills such as throwing and
catching a weighted ball while standing on a proprioception pillow or doing crunches on an
exercise ball. Webb also suggests a three-step stop with bent knees, where the dancer would gain
momentum with three steps, and immediately decelerate on one bent leg. Emphasizing the

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importance of stopping with a bent legespecially when doing quick weight shiftscan be the
difference between injury and safety. As Myer et al. explains, Once bilateral symmetry is
gained during a bipedal task, clinicians can incorporate single limb balance exercises on unstable
surfaces (Myer, 2289). Dancers must be sure to practice these actions on each individual leg as
well as in dynamic and static situations. Since dancers are asked to do all types of balances,
jumps, and weight shifts, it is necessary for them to be able to practice maintaining core
support before they are asked to perform on stage. In fact, Hensch specifically writes that such
exercises take plenty of repetition and drilling before mastery (19).
As previously alluded to, strengthening the knee flexors is one of the most effective
methods for preventing ACL injury (Myer, Chappell, Laughlin) because it takes some of the load
off of the ligament. Since the ACLs role in the knee is to prevent anterior tibial translation and
contracting the hamstring muscles during landing [imparts] a posterior tibial drawer force,
engaging those muscles more would let them [act] as a synergist to the ACL (Wilde, 497). In a
study examining lower limb biomechanics in pubescent girls, Wilde et al. discovered that girls
with lower hamstring strength experienced significantly greater estimated ACL forces (almost
double) at the time of the peak anteroposterior GRF [ground reaction forces] compared with their
higher hamstring strength counterparts. He continues, explaining that those with lower
hamstring strength tended to alter their landing mechanics, likely as a coping mechanism (Wilde,
502-503). It is clear that engaging the hamstrings in order to increase knee flexion and lighten
the load on the ACL will aid in preventing injury of the ligament. In fact, Laughlin et al.
attributes his observation of a 40% to 80% decrease in injury rates in his study to such an
increase in knee flexion in landing (1845).

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Fujii et al. and Wilde et al. specifically recommend strengthening the biceps femoris to
prevent injury. Part of the thinking is that internal rotation contributes to ACL ruptures, and
since the lateral hamstring muscle [inhibits] internal rotation, [it] would be more important than
the medial hamstring muscles for preventing noncontact ACL injuries (Fujii, 258). Wilde et al.
added in agreement that since the hamstrings control knee rotation, they can prevent such
rotation, which will further protect the knee from ACL injury (497-498). Thankfully the lateral
hamstring is generally the stronger of the three in dancers since their aesthetic relies so much on
outward rotation, or turn-out. For once dancers aesthetic may have a biomechanical
advantage over that of other athletes!
One of the best low-impact drills to strengthen the hamstrings is to perform simple knee
flexion movements against the resistance of a Thera-Band (Hensch, 19). Ronald Nuttall, dance
trainer at Brigham Young University, emphasizes the importance of targeting the individual
hamstrings in doing this drill by attempting to flex the knee more laterally, straight posteriorly,
and medially. There may not be much of a visible difference between the three directions, but
the imagery helps to engage the biceps femoris, semitendinosus, and semimembranosus
respectively. Hensch also recommends doing deep lunges in all directions to practice engaging
the hamstrings as well as the quadriceps in knee flexion (19).
Webb and Hensch also endorse plyometrics. Myer et al. presents (as example) a series of
jumps, progressing from low to high intensity. First, begin with wall jumpsa jump from two
feet to two feet, lifting the legs to partial knee and hip flexion (2279). Once dancers demonstrate
consistent and correct leg alignment (with knees tracking over toes) in the wall jumps, they are
ready to move on to tuck jumps. These are essentially the same as the wall jumps, but the
dancer attempts to jump higher and reach full hip and knee flexion (2286). Again, if dancers

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demonstrate unerring lower limb alignment in take off and landing, they can then progress to
broad jumps. In broad jumps, the dancer jumps from two feet to two feet, traveling as far
forward as possible, and stick the landing (2280). They must be extra careful in broad jumps to
maintain correct knee-over-toe tracking in the landing instead of the tendency to show knee
valgus motion.
Once again, when the dancer can perform these tasks with both feet, they should move on
to trying them on each foot individually. As Myer et al. discovered, Side-to-side imbalances in
muscular strength, flexibility, and coordination have been shown to be important predictors of
increased injury risk. In their sample of female athletes, there was a difference in maximum
valgus motion from leg to leg in injured women, but not among uninjured women (Myer, 2287).
Therefore, any of these prevention exercises would be best utilized if done equally on both the
right and left legs.
In the end, female dancers may have natural disadvantages to ACL safety in their skeletal
and chemical make-up, but if they understand those inherent weaknesses and train to counter
them, they can prevent serious injury. All of the quick accelerations/decelerations, jumping and
landing, running and cutting, and twisting that can commonly cause ACL injuries (Hensch,
Webb) can be approached confidently if they strengthen their core and their hamstrings and be
sure to land with significant knee flexion to absorb the force of impact.

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Works Cited
Chappell, Jonathan D., R. Alexander Creighton, Carol Giuliani, Bing Yu, and William E. Garrett.
"Kinematics and Electromyography of Landing Preparation in Vertical Stop-Jump Risks
for Noncontact Anterior Cruciate Ligament Injury."American Journal of Sports
Medicine. 35.2 (2007): 235-241. Web. 15 Mar. 2013.
<http://ajs.sagepub.com.erl.lib.byu.edu/content/35/2/235.full.pdf>.

Fujii, Meguru, Haruhiko Sato, and Naonobu Takahira. Muscle activity response to external
moment during single-leg drop landing in young basketball players: The importance of
biceps femoris in reducing internal rotation of knee during landing. Journal of Sports
Science and Medicine. 11.2 (2012): 255-259. Web. 30 Jan. 2013.
<http://www.jssm.org/vol11/n2/8/v11n2-8text.php>.

Hensch, Lynn Pantuosco. "ACL Injury Prevention: Why it should be on every coach's "to do"
list." Soccer Journal. Jul 2007: 18-22. Web. 29 Jan. 2013. <http://www.sirc.ca/
newsletters/mid-sept12/documents/Free/ACL Injury Prevention.pdf>.

Hopkin, Jeffrey. Personal Interview. 31 Mar. 2013.

Laughlin, Walter A., Joshua T. Weinhandl, Tom W. Kernozek, Stephen C. Cobb, Kevin G.
Keenan, and Kristian M. OConnor. The effects of single-leg landing technique on ACL
loading. Journal of Biomechanics. 44.10 (2011): 1845-1851. Web. 30 Jan. 2013.
<http://search.proquest.com/docview/1034965076?accountid=4488>.

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Myer, Gregory D., Kevin R. Ford, Jensen L. Brent, and Timothy E. Hewett. An integrated
approach to change the outcome part II: targeted neuromuscular training techniques to
reduce identified ACL injury risk factors. Journal of strength and conditioning
research / National Strength & Conditioning Association. 26.8 (2012):227292. Web. 30

Jan. 2013.

Nuttall, Ronald. Personal Interview. Feb 2013.

Torry, Michael R., Casey Myers, Kevin B. Shelburne, Daniel Peterson, Erik J. Giphart, W.
Wesley Pennington Jacob B. Krong, Savio L-Y Woo, and J. Richard Steadman.
Relationship of knee shear force and extensor moment on knee translations in females
performing drop landings: A biplane Fluoroscopy Study.

Clinical Biomechanics.

26.10 (2011): 1019-1024. Web. 30 Jan. 2013. <http://search.lib.byu.edu/byu/

id:sciversesciencedirect_elsevierS0268-0033(11)00166-5>.

Webb, Jeff. ACL Injury Prevention. PowerPoint Presentation. <http://gactaern.org/Unit

%20Plan/Physical%20Medicine/Principles%20of%20Physical%20Medcine/HS_PPM_3/
HS_PPM_3ACLInguryPreventionPresentation.pdf>.

Wilde, Catherine Y., Julie R. Steele, and Bridget J. Munro. "Insufficient Hamstring Strength
Compromises Landing Technique in Adolescent Girls." Medicine & Science in
Sports &

Exercise. 43.3 (2013): 497-505. Web. 21 Mar. 2013.