Friday, 11 October 2013 10:16

AC Injury a Prevention

By James Markwica, MS PT | Families Today

The Anterior Cruciate Ligament, or ACL is one of the four major ligaments in the knee and the most commonly injured. Approximately 150,000 ACL injuries occur in the United States each year, many of which are devastating and require surgical repair. Female athletes in the US are roughly three times more likely to injure their ACL than males. Why is this?  


Typically, the potential of injury variation among females vs. male rests on two major factors: anatomical differences and biomechanical differences. Although there are many anatomic differences between the sexes, some that are believed to be factors that potentially affect ACL stress are pelvis width, Q-angle, ACL size and the size of the bony notch within the knee where the ACL crosses the joint line or the intercondylar notch. Although these differences are widely noted between males and females, no studies have directly been able to predesignate or predict ACL injuries from them. However, these differences alter the biomechanics of the knee and here in lies the problem.

Biomechanical differences between females and males, stability differences and strength differences are the problems. Static stability of the knee is provided by the four major ligaments that include the ACL, while dynamic stability of the knee is provided by the muscles and tendons that surround the joint. Females, due to their anatomical differences and subsequent mechanical alterations during movement patterns when jumping, landing and pivoting have lead to increased ACL stress and thus ACL injury.

So what does this all mean?  Well again, our bodies are different and our alignment is different. Alignment that can increase the normal stress to the ACL on an ongoing basis is collapsing of ones knee inward with the foot pronating or collapsing with one’s body weight transferring forward as the knee translates forward over the foot.  This creates a twisting motion in the knee with a ton of force that stresses the ACL. Add to this ones body weight, an attempt to start, stop, jump or land and you, my friend, have a problem. POP! The sound followed by severe short-lived pain that resolves rather quickly. Swelling. Difficulty walking. A feeling of your knee being extremely unstable. That was your ACL.

Rather than discussing the long-term rehabilitation program we will discuss the prevention of such sequence of events with the goal of eliminating the risk of an ACL injury. There are probably hundreds if not more wonderful injury prevention exercise programs out there. Although their specific exercises and drills may vary, they all include the following: dynamic warm-ups, flexibility, strength, core stability, balance, agility and plyometric training. Specifically, mastering the ability to jump and land safely. You can look around on the internet at all of these programs but a fantastic option for the independent athlete is by Michael Boyle at For something safe for someone who desires one on one feedback you can consult a trainer with experience with athletes and injury prevention.

Dynamic warm-ups are great because they prepare the muscles throughout your core, upper and lower body for the specific workout that is about to occur. Often times dynamic stretching is a key component of the warm-up that begins activating specific muscle groups while stretching the opposite muscle groups.

Flexibility training is important, as we theoretically want our “machine” to be mobile without restriction otherwise further injury can occur. Therefore, inclusion of stretches for your hips, thighs and calves are important and will minimize unnecessary strain on the knee allowing it to function normally.

Strength training with inclusion of core stability is essential. Often times the collapsing of the knee and ankle inward is due to poor strength of the hip and core. Hip external rotation (outward rotation) along with abduction is key to minimize any knee deviation inward that results in internal twisting of the knee.  When you see a young athlete running and it seems like they are knock-kneed and their feet flail a bit it is due to poor hip strength. This is fixable and may save this child’s knee, especially their ACL. By simply learning how to activate and then strengthen one’s hip muscles both while standing or walking and while running and jumping you will minimize injury and generate more power and speed in virtually every sport.  This phase will typically include lots of squatting and variations of single leg or one-legged squats in addition to planks, bridges and chops.

Balance and agility activities are often combined to provide neuromuscular demand and feedback to a young athlete as it includes coordination, holding positions or changing positions on purpose. While performing balance and agility activities, the key is to keep your hips over your knees and your knees over your ankles. Form while performing such activities is essential for success. As your strength improves so too will your ability to maintain this position. “Hips over knees, knees over ankles!”

Finally, plyometrics are on the table.  Jumping. But more important is landing correctly with minimal stress on your knee moving inward, without your body translating forward over your toes resulting in any twisting within the knee. This phase includes jumping with both legs, single leg, forward, laterally, backward, with rests, without rests, and with any combinations mentioned.  

Although I mentioned earlier that we wouldn’t go into the rehab routine of an injured ACL, I lied. All this and more is the basis for rehab after a sprain or rupture of an ACL if you are so unfortunate to injure yours. The good news is this, if you truly buy in and complete a progressive routine and prevention program as listed above, your knees will be healthier and your likelihood of injuring you knee will be minimized substantially. What you will also find after completing such a program is that you may be stronger and faster than ever before. Good Luck!

If you or someone you know suffers from knee pain, it is ill advised to begin a new exercise program without consulting first with your physician, physical therapist, certified athletic trainer, physiatrist or other specialist who regularly treats knee pain. It is important to first get an accurate diagnosis for the cause of pain, as the specific exercises recommended will depend on the cause.  



James Markwica, MS PT is a New York State Licensed Physical Therapist at LaMarco Physical Therapy, 417 Geyser Road in Ballston Spa and 30 Gick Road in Saratoga Springs.  For questions of follow-up, contact James at (518) 587-3256 or online at

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