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I can’t tell you the number of times patients or clients ask me, “Hey Jules – what’s the best exercise for (insert injury here)?”
While the round about answers of the world also annoy me, I usually rely, “It depends.”
Rehabilitation, and exercise prescription for that matter, is both a science and an art. Clinicians must continually assess, diagnose, and select corrective exercise based on every patient or client’s unique individual needs. What may be best for one is not necessarily best for another. This is why “cookie-cutter” time-based rehab protocols are slowly moving out of favor, with milestone or criteria-based protocols quickly taking over.
When I was asked to select my five favorite exercises for ACL injury prevention, I thought long and hard about what to write. Research has shown that neuromuscular training can reduce the risk of non-contact ACL tears by as much as 67% in female athletes. Research has also shown that female athletes are anywhere from 4-8x more likely to tear their ACL compared to male counterparts, and that approximately 1 in 80 athletes involved in high-risk sports (like soccer) will tear their ACL each season. I obviously knew that injury prevention was effective, but how could I select just five exercises?
Then I remembered a journal article I read back in July of 2018. In this paper, researchers analyzed a bunch of studies with over 27,000 female athletes in the hopes that they could identify the most important components of a successful ACL prevention program. With only 13-20% of female high-school athletic teams implementing injury prevention programs (and only 4% in extremely rural areas), the researchers also aimed to develop an efficient, user-friendly tool for coaches and practitioners alike to assess the effectiveness of their ACL injury prevention programs.
What they found was super interesting! The most effective ACL injury prevention programs included certain lower body strength exercises (the Nordic hamstring exercise, lunges, and calf raises) and certain landing stabilization exercises (the “jump and hold” and drop landings). They also found that programs that included balance, core strengthening, static stretching, or agility, compared with programs that did not incorporate these components, were no more effective in regards to ACL injury prevention.
Now, don’t get me wrong – do not go and completely throw these components out of your training sessions! They are definitely efficacious from a general injury prevention standpoint (i.e. ankle sprains, etc.). Just make sure to prioritize posterior chain strengthening and landing stabilization exercises when training female athletes with specific hopes of reducing ACL injury. Exercises that strengthen the posterior chain (or the muscles on the back of your leg like the glutes, hamstrings, and calves) help to protect the ACL when put under stress. Similarly, exercises that teach you how to jump and land correctly (landing softly with your knees over your toes) also help protect the ACL.If you are a soccer player or coach, try incorporating the five exercises below and you might just get more “bang” for your injury prevention “buck.”
- Nordic Hamstring Exercise
DO: Start by kneeling on a soft surface with your knees about hip-width apart. Have your partner kneel behind you with both hands gripped on your lower legs just above the ankles, pushing them down into ground with her bodyweight. Slowly lean forward while trying to hold the position with your hamstrings. When you can no longer hold the position, gently take your weight on your hands, falling into a press-up position. Beginners: 1 set of 3-5 repetitions. Intermediate: 1 set of 7-10 repetitions. Advanced: 1 set of 12-15 repetitions.
DON’T: Do not tilt your head backwards or bend at the hips.
DO: Start by standing with your feet about hips-width apart and your hands on your hips. Slowly lunge forward until your leading knee is bent to about 90 degrees. Do not let your knee extend beyond your toes and maintain an upright chest. Try 2 sets of 10 repetitions on each side!
DON’T: Do not let your leading knee extend beyond your toes. Do not let your leading knee collapse inward. Do not let your upper body lean to either side.
- Calf Raises
DO: Start with your feet about hips-width apart. Slowly push through your ankles so that you bear your weight through the balls of your feet, coming up onto your toes. Slowly lower yourself down. For increased challenge, try bearing your one through one leg or perform on a step. Try 2 sets of 10-15 repetitions!
DON’T: Do not use momentum and/or speed to push through this exercise. Control is key! Try controlling your body weight as slowly as possible on the way down to the ground.
- Jump and Hold
DO: Start with your feet about hips-width apart. Bend your hips, knees, and ankles and jump up in the air, landing gently on the balls of your feet, sitting back into your hips with bent knees. Stick the landing for 2-3 seconds. Once you have mastered vertical jumping, try jumping forward sticking the landing for 2-3 seconds. Then try jumping sideways sticking the landing for 2-3 seconds. Then try jumping and rotating 90 degrees in the air before landing, sticking the landing for 2-3 seconds. Progress to single leg jumping as tolerated. Try 2 sets of 10 repetitions, but remember: quality is more important than quantity.
DON’T: Do not let your knees collapse inwards on the take off or the landing. Do not land flat footed. Do not land with straight knees. Do not lean to either side with your trunk.
- Drop Landings
DO: Start by standing on a box or step about 4-6 inches from the floor. Step off of the box with your right leg, landing softly on your left leg. The ankle, knee, and hip should slowly flex, bringing you into a good single-leg squat position. Maintain a slightly flexed trunk position throughout. Stick the landing for 2-3 seconds.
DON’T: Do not let your knee collapse inward. Do not land with a stiff knee. Do not let your trunk bend excessively forward or to the side. Do not land flat-footed.
While the goal of this particular study was not to determine frequency or duration of effective ACL prevention training, the researchers found that, on average, participants performed these exercises for 24 minutes 2-3 times a week. They also found that injury prevention programs that target middle or high-school-aged athletes are more effective than programs initiated in college-years, and that programs must be implemented in pre-season, as well as during season, to be beneficial. Lastly, they found that injury prevention programs implemented by coaches who were specifically trained or educated on injury prevention were more effective. Now, consider yourselves educated. Check out the cool checklist below to see just how effective your injury prevention program is. Until next time, be well!
- Petushek, E., Sugimoto, D., Stoolmiller, M., Smith, G., & Myer, G. (2018). Evidence-Based Best-Practice Guidelines for Preventing Anterior Cruciate Ligament Injuries in Young Female Athletes: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. (78), 6-6.
- Webster KE, Hewett TE. Meta-analysis of meta-analyses of anterior cruciate ligament injury reduction training programs. J OrthopRes 2018.
- Joy EA, Taylor JR, Novak MA, Chen M, Fink BP, Porucznik CA. Factors influencing the implementation of anterior cruciate ligament injury prevention strategies by girls’ soccer coaches. J Strength Cond Res. 2013; 27(8): 2263-2269.
- Norcross MF, Johnson ST, Bovbjerg VE, Koester MC, Hoffman MA. Factors influencing high school coaches’ adoption of injury prevention programs. J Sci Med Sport. 2016; 19(4): 299-304.
- Sugimoto D, Mattacola CG, Bush HM, et al. Preventive neuromuscular training for young female athletes: comparison of coach and athlete compliance rates. J Athl Train. 2017; 52(1): 58-64.