Advances in Female ACL Injury Recovery

With females at greater risk of the injury, how effective are prevention methods?

For years, the three most dreaded letters in sports were “A-C-L.” Once simply known as ‘tearing up your knee,’ specifics of the injury became known by the general public in the late 1980s and ended or irrevocably altered hundreds of athletic careers.

But by the late 1990s and early 21st century, doctors and rehab professionals had made significant progress in hastening and improving recovery methods to the point that numerous athletes, such as San Francisco 49ers legend Jerry Rice were able to return from the injury in a reasonable amount of time and continue enjoying productive careers.

Today, ACL injuries are still serious and potentially career-altering—but they are no longer death sentences for an athletic career at any level. One problem persists, however—as more and more young girls become active in various sports, they do so with a much greater risk of tearing their anterior cruciate ligament—or ACL—than their male counterparts.

Depending on which resource you believe, female athletes are anywhere from three to six times more likely to sustain a (non-contact) ACL tear than a male athlete. But can anything be done to reduce the risk?


To be sure, there are some physiological differences between men and women that make the female gender more prone to non-contact tears. The two most important differences are:

  • The groove in the femur known as the intracondylar notch, through which the ACL passes, is smaller in women, meaning the ligament itself is smaller and more prone to injury
  • Women tend to have a more ‘knock-kneed’ alignment due to their wider hips, which causes their knees to bend inward when landing after jumping. If the knee buckles as a result, it places greater strain on the ACL to maintain its’ stability

And there’s only so much we can do about anatomy. Differences in training techniques and style of play, however, are within the control of coaches, trainers, physical therapists, and others.

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A few key differences in technique include:

  • Greater flexibility in the female knee can be a blessing and a curse; in this case, the problem starts when hyperextensions occurs, placing undue stress on the surrounding tendons and ligaments
  • The upper leg and trunk muscles tend to be larger and stronger in males, and this disparity causes the knee to absorb more of the stress from a landing or change in direction in a female athlete when compared to a male
  • Women tend to run in a more upright position than men, again increasing the stress placed upon the knee

Physical therapists and other professionals have conducted numerous studies over the past decade or so to determine the most effective methods of injury prevention for the vulnerable female ACL. One of the first such studies yielded the Prevent Injury, Enhance Performance (PEP) program, and was designed by physical therapists at Santa Monica Orthopedic and Sports Medicine Group.

Using Division 1 soccer players as test subjects, the almost 1,500 athletes who participated in the PEP program had an ACL injury rate 41 percent lower than their counterparts who completed their normal warmup. The PEP program, consists of sport-specific agility exercises to address potential deficits in the strength and neuromuscular coordination of the stabilizing muscles around the knee joint.

“The program was created to address the deficits that are seen in female athletes, particularly weakness in the lateral hip muscles, gluteal, and core muscles,” said Holly Silvers, MPT, who helped to develop the program at the time.

Interestingly, when applies to even younger athletes (14–18 years of age) across a two-year period, the group completing the PEP program saw an astounding 88 percent reduction in ACL injuries in year one and a still-impressive 74 percent reduction in year two. A presentation offered by a group of physical therapists at the 2016 Combined Sections Meeting in Anaheim, CA, took a thorough look at the research to that point and concluded that of the numerous interventions and studies performed, the PEP program was ‘most effective in reducing ACL injuries.’

So what is the PEP Program? First of all, it’s a soccer-oriented program designed specifically to reduce the incidence of injuries in soccer. That doesn’t mean it can’t have some benefits to athletes participating in other sports, but the design was conducted with soccer specifically in mind. The program takes about 15–20 minutes to complete each session, can be performed right on the field, and is an advisable replacement for a conventional warm-up routine.

Overall, there are 20 PEP exercises, and they are separated into five categories:

  • Avoidance
  • Flexibility
  • Strengthening
  • Plyometrics
  • Agilities

In addition, there are four “cool-down” exercises that are optional for performance at the end of a session before players go home.

Optimally, the program is performed 2–3 times per week, and is not recommended for athletes under the age of 12.

It’s important that exercises are performed in the order exhibited here.

Changing a female athlete’s physiological makeup or eradicating the propensity for increased ACL injuries is simply not an attainable goal. But with specialized, specific, and dedicated training, female athletes can greatly reduce their exposure to ACL injuries and enjoy productive, uninterrupted experiences or careers in high-level athletics.

SOURCES: APTA, LA84 Foundation

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