ACL PREVENTION

What is the ACL?

The ACL (Anterior Cruciate Ligament) is just one of four main ligaments in the knee,
which help it to function properly. It’s attached to the femur and the tibia. Its primary
function is to guard against the tibia sliding forward and to keep the knee bending along a
relatively straight axis. It also has a major role in resisting internal rotation. SEE FIG. 1

It is composed primarily of tightly packed parallel arrangements of collagen bundles,

which are found in all tendons and ligaments. These collagen fibers contain very few
cells, but do have their own direct blood supply.

Along with the collagen fibers, it also contains elastin, which is an extensible protein that
helps to give a degree of flexibility to aid in proper range of knee motion.

How is the ACL usually injured?

Studies have shown that overall, ACL injuries occur during non-contact injuries such as
planting and cutting, straight-knee landing and one-step stop landing with the knee
hyperextended. Pivoting and sudden deceleration are also common reasons of noncontact
ACL injuries.

Why are women more susceptible to ACL tears than men?

According to an article published by the NY Times, women are two to eight times more
likely to tear a ligament than men who play the same sport. There are a number of
reasons or theories to why women are more prone to ACL tears than men.

1. Hamstring – quadriceps strength imbalances: Studies have shown that across the
board, women’s hamstring strength is less than 50% that of their quadriceps strength.
Men’s ratio of hamstring strength to quad strength is usually in the 70%+ range. It is
because of this huge imbalance that there are more torn ACL’s among women.

2. Smaller ligament and notch connection: Women traditionally have smaller ligaments
and therefore a smaller notch connection to the bone because they usually do little, if
any, weight training exercises before getting to college.

3. Wider hips: Women’s hip angles are much greater than a man’s leaving many
women predisposed to knee injuries and being “knock-kneed”. These angles,
commonly referred to as the “Q (quadriceps) Angle” are determined by the
intersection of a line from the outer hip to the center of the patella to the head of the
tibia (where the ACL attaches). Angles up to 17 degrees are considered normal in
females.
4. Hormonal changes: Because the ACL has been proven to be a receptor to estrogen,
hormonal changes among women have been recently studied. And although no
evidence proves that an elevation of estrogen levels during certain phases of the
menstrual cycle are causing ACL tears, there is substantial evidence which points to
the fact that it does play a significant role. Studies have indicated that during the
ovulatory phase (days 10-14) that women suffer greater than expected percentage of
ACL tears.

5. Poor neuromuscular control: Finally, women are not taught correct running, jumping,
landing and cutting techniques, and therefore have poor neuromuscular control and
spatial awareness of their bodies. Women rely more on their quadriceps to hold their
body weight versus men, who rely more on their hamstrings to control their athletic
movements. This is not a good method considering that the quadriceps are the
antagonist (work against) to the ACL, and the hamstrings are the agonist (coordinate
with the ACL). Women, too, have a tendency to land more knock-kneed from jumps
compared to men who land with their knees in a straight-ahead motion.

How do ligaments / tendons get stronger?

Ligaments and tendons increase in strength three areas:

1. In the junction between the ligament and bone surface
2. Within the body of the ligament
3. In the network of fascia within the skeletal muscle*

*this one does not apply to the ACL because it is not embodied in a muscle

Evidence has shown in animals trained on uneven surfaces that they develop greater
ligament-bone junction strength compared to animals trained on smooth surfaces. This
helps to prevent the ligament coming off the bone, but not necessarily a rupture within
the belly of the ligament.

Moderate > low intensity training doesn’t change collagen content of a ligament, but high
intensity loading of the musculoskelatal system has been proven to result in net growth of
connective tissues.

Ligaments and tendons get stronger before muscle does, because they must be prepared
to support the torque of a stronger muscle.

What can be done to help prevent ACL tears?

Teaching good technique while jumping, landing and cutting. By putting more emphasis
on the form in which these functions are preformed, a better sense of body and spatial
awareness can be attained.
Key points to emphasize are:
• keeping the chest over the knees, over the balls of the feet when jumping;
• keeping shoulders up and spine in good neutral position while jumping;
• upon landing, recoil as if jumping again, holding the majority of the weight in the
hamstrings;
• lower center of gravity while performing cutting moves;
• land in a stable, athletic position with the body under control

Full range weight training. Studies have shown that performing limited range of motion
lifts can actually enhance chances of tearing the ACL. The theory being, that most sports
are played in a full range scale, it is better to train the muscle groups, ligaments and
tendons in that full range scale as well. This way, they are stronger throughout their
entirety rather than just in one area, therefore leaving other weaker areas more susceptible
to injury.

Free weights versus machines. Studies have shown that doing a leg extension produces
more stress on the ACL compared to the stress measured during a parallel squat.

Working on flexibility. Although it has been said that too much laxity in muscles can be
a contributing factor to tearing ACLs, having poor range of motion is also a factor. It is
important to try to find that medium ground where athletes are not too flexible
(gymnasts) to where they aren’t flexible enough (soccer, volleyball, etc). By realizing an
athlete’s flexibility needs as a coach, stretching can be an aid in helping to prevent ACL
injuries.

Athlete awareness. By teaching / coaching / educating athletes about what the ACL is
and how injuries to it can possibly be helped, the athletes is at least informed enough to
realize what the training goals are. Have the athletes practice thinking about their spatial
and body awareness as well as thinking about lowering their hips while working on
cutting drills. Let them know that this is a mark of a great athlete.

What are other programs doing?

Cincinnati Sportsmetrics – This institute has developed, through research, a program

designed for ACL tear prevention. The program, shown on a video, includes 3 phases of
training:
1. Warmup / Technique; this phase emphasizes correct warmup procedures and
emphasizes proper jumping techniques like: correct posture, elimination of side to
side movements, soft landings and instant recoil.
2. Technique / Strength; this phase continues with the same principles learned in Phase
1, but now increases the volume of prescribed exercises such as: wall jumps, tuck
jumps, broad jumps, squat jumps, cone hops, bounding, scissor jumps, etc.
3. Performance; in this phase, the volume is decreased while stressing quality jumping
technique.
Wake Forest University – On speaking with Head Strength and Conditioning Coach,
Ethan Reeve, he emphasized the importance of athleticism. While at Ohio University
(6yrs), Reeve’s athletes incurred only 4 ACL tears, and he attributes that statistic to the
fact that the athletes were trained always in full range of motion exercises, supplemented
by a good warm up consisting of a generic tumbling routine. At Wake Forest, he has
continued this philosophy and emphasizes less weight and full range of motion. He
currently is in the process of experimenting with supersetted light stepups or lunges in
between sets of squats. On the topic of agility, he stresses keeping the hips low,
especially in cutting motions. “A true athlete should never stand with their knees in a
locked out position …. ever.”

University of Minnesota – On speaking with the Assistant Strength and Conditioning

Coach, Sara Wiley, she stressed the issue that women are much more susceptible than
men to ACL injuries. In her programs with her women athletes, she spends time on
teaching proper jumping / landing techniques as well as trying to raise their spatial
awareness. She does medicine ball tosses where the athletes stand on one foot with their
weight back in their glutes and hamstrings. This helps to have the athlete feel where to
hold their weight properly … versus always holding in the quads. She also does speed
ladder work with the emphasis being on keeping the hips in a good, low athletic position,
as well as depth jumps where the landing and recoil phase are the main area of concern.

University of Tennessee – According to an article, which appeared in the New York

Times, the Lady Vols sometimes train while wearing thick tubing connected at the ankles
to help strengthen and induce flexing of the hips and knees. They also play a form of
twister, train on rocker boards and stand on uneven surfaces on one foot to help with
balance.