Female athletes are significantly more likely to sustain an ACL injury than males. There is ongoing research into why this is the case. Existing theories include anatomical differences between females and males, hormonal factors and biomechanical differences in landing posture. Possible extrinsic factors that may influence incidence levels are that current models of football boot are primarily designed around the male foot anatomy, gait and running kinematics. More research is needed to conclude how influential such factors are.
Common sports to injure the ACL in Australia include Netball, Australian Rules Football, Soccer, Gymnastics and Alpine Skiing.
I was 17 when I sustained my first ACL rupture, and 23 and a Physio student when I did my second. So, this article is dedicated to the research that I wish I had access to, and to hopefully raising awareness of how much we can be doing for both our female and male adolescent athletes to prevent ACL injury, as well as the physical, psychological and financial impacts that result.
MY ACL INJURIES:
My first ACL injury occurred whilst playing netball in 2013. I was playing in the circle, jumped to defend a shot, landed - and tried to jump again and I remember all I felt was a sharp burst of pain through my left knee that left me a screaming pile on the ground. My knee swelled up almost immediately, and then came the week of waiting to find out that I had ruptured my ACL. I had the surgery later that year and then spent the next 12 months in and out of the Physio, rehabbing my knee and preparing for my return to sport.
12 months later I was back running, playing netball, playing touch football and going to the gym. I was concerned about the risk of re-rupturing my ACL, and so I would go to the gym and strength train regularly, and ensure that I always completed some form of warm up pre-game. Little did I know that this was nowhere near enough to act as an effective form of prevention - and 6 years later whilst playing touch football I felt a pop in my right knee (the opposite side) and knew straight away that I was facing another 12 months on the sideline.
Fast forward to 2024 and I have now seen countless other ACL injuries in the clinic and within family/friends circles. Current research into ACL prevention programs demonstrates that at least some of these injuries, as well as my own 2 ACL’s may have been prevented if effective neuromuscular prevention programs were in place.
So what defines an effective ACL prevention program? Here are the components:
Must include landing stabilisation exercises and hamstring and calf strengthening exercises. Should be listed as an evidence based ACL Prevention Program. Examples of these programs and the corresponding key exercises are attached at the bottom of this article, and include the PEP, 11+ and the sportsmetric among others.
Should be implemented by trained personnel - i.e. coaches or health professionals who have been educated to instruct and monitor quality of movement during both the landing and strengthening exercises.
Completed both in pre-season training and during the season.
Completed both prior to training practice as well as prior to matches (i.e. multiple times per week).
The greatest reduction in ACL incidence is seen when these prevention programs are in place for athletes between the ages of 12 to 25 and involved in sports with a high risk of ACL injury.
Studies in the US show that despite the fact that these high quality exercise recommendations exist, there is currently only an uptake of 17% in female sports. There is not enough evidence to demonstrate the effect in the Australian population as yet.
Attached below are examples of recommended ACL prevention programs. If you or your child is interested in being proactive and preventing ACL injury, have a chat to your Physio to discuss how these evidence-based recommendations can be implemented.
Exercise-based ACL Prevention Programs:
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