ACL Injuries and Prevention by Brian Kitzerow, PT, DPT, OCS, CMPT

The  anterior cruciate ligament (ACL) is one of four ligaments that serve as the main stabilizers of the knee, maintaining contact between the thigh and the lower leg.

An ACL tear is a fairly common, but physically difficult injury with potentially long-term secondary effects. Anyone who has had an ACL tear will tell you that is painful and frustrating.  As physical therapists we want to reduce the pain and return the patient to function as quickly as possible.  When we first start with a patient, we strive to improve the immediate functionality as well as reduce any long-term secondary effects.  Here are some interesting facts and statistics regarding ACL repair.

Return to sports and previous level of activity may be restricted.
  • ACL rupture commonly limits return to previous level of activity and competition. One study noted that only 44% of athletes returned to sports after ACL rehabilitation.   Skilled rehabilitation emphasizing restoration of neuromuscular motor control and appropriate restoration of range of motion raises your chances of successful return to sports.
After initial ACL rupture you are at heightened risk of opposite knee ACL rupture
  • Due to the dysfunctional coordination and movement we see after an initial ACL tear the incidence of a second ACL tear to the opposite leg is as high as 30%. It is essential that you rehab the strength and motor control of both legs Knee2appropriately if you plan on returning to sports after an ACL tear.
Hamstring strength is essential to lower risk of ACL rupture
  • Hamstring to quadriceps ratio weakness is well known to place you at higher risk for ACL injury. Ideal hamstring to quad strength should be 1:2 to 3:4.
Not all ACL tears require surgical interventions to return to functional activities
  • One recent study suggested that up to 70% of patients may be able to stabilize their knee after ACL rupture without surgical intervention.
  • There is also a growing base of opinion that supports that patients should participate in an exercise based rehabilitation programs for at least 3 months post-ACL rupture before participating in ACL repair. Surgery brings with it the risk of both devastating infection and non-responsive scarring and will fundamentally alter your coordination and movement patterns.
Females are at higher risk for ACL tear than their male counterparts
  • Sports like soccer, basketball and skiing have as high as 3.5 times as many ACL tears in women than men
  • Year round female athletes who play soccer or basketball have about a 5% chance of having an ACL tearknees1
Hip and knee alignment when jumping and running appears to contribute greatly to ACL rupture risk
  • Strengthening of the hip external rotators, extensors and abductors can help to provide the strength to stabilize against dynamic forces that challenge the ACL.
  • More importantly coordination must be retrained to avoid the positions that damage and stress the ACL. This should be done in both controlled and dynamic positions that replicate your sport.
  • Physical therapy and work with a personal trainer can help to return you to play with lowered risk of repeated ACL injury.


    Podromos, C, et al. “A Meta-analysis of the Incidence of Anterior Cruciate Ligament Tears as a Function of Gender, Sport and a Knee Injury – Reduction Regimen.” Arthroscopy: the Journal of Arthroscopic & Related Surgery. vol 23.12 (2007): 1320-1325. Print.

    Macleod T, Snyder-Mackler L, Buchanan T. “Difference in Neuromuscular Control and Quadriceps Morphology Between Potential Copers and Noncopers Following Anterior Cruciate Ligament Injury.” The Journal of Orthopaedic and Sports Physical Therapy. vol. 44.2 (2014): 76-84. Print.

    Mclean, SG, et al. “Evaluation of a two dimensional analysis method as a screening and evaluation tool for anterior cruciate ligament injury.” British Journal of Sports Medicine. vol 39.6 (2005): 335-62. Print.

    Moksnes H, Snyder-Mackler L, Risberg M. “Individuals With an Anterior Cruciate Ligament-deficient Knee May Be Candidates For Nonsurgical Rehabilitation.” The Journal of Orthopaedic and Sports Physical Therapy. Vol 38.10 (2008): 586-595. Print.

    Di Stasi S, Myer G, Hewett T. “Neuromuscular Training to Target Deficits Associated with Second Anterior Cruciate Ligament Injury.” The Journal of Orthopaedic and Sports Physical Therapy. Vol 43.11 (2013): 777-792. Print.


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