Evidence based exercises for ACL injury risk reduction

The highest incidences of ACL injuries are seen among athletes involved in sports that require pivoting and jumping, such as basketball, soccer and volleyball (McLean et al. 2005; Myer et al. 2005; Olsen et al. 2003). Deceleration when landing from a jump on one leg was reportedly one of the most serious ACL injury causing actions in sports and 70% of ACL injuries emanate from non-contact events (Yu et al. 2002; Boden et al. 2000).

Players returning from ACL injury show a significant decline in performance statistics. Busfield (2009) reported that 78% of players with ACL injury return to playing after surgery and 44% of them had a reduced player efficiency rating. Harris et al. (2013) also reported that NBA player performance upon return to play after ACL injury declined significantly (P< 0.05) showing less games played per season, less minutes, less points, less rebounds per game and a reduction in field goal percentage.

Understanding ACL injury risk factors is essential when formulating strategies that are designed to reduce the occurrence of such a detrimental injury. In general, there are many factors that contribute to injury risk and influencing all these factors takes accountability from the athlete and a great working relationship between the coaching, medical and performance staff.

Factors influencing injury risk generally fall under three inter-relating areas:

  • Life style
  • Training program
  • Efficiency

Lifestyle includes diet, stress levels and sleep habits. These are all factors that directly influence the quality and speed of an athlete’s recovery and directly influence their level of readiness to train and play. Sleep is especially important and Milewski et al. (2014) found that adolescent athletes who slept on average <8 hours per night were 1.7 times more likely to have had an injury compared with athletes who slept for more than 8 hours.

Regardless of how ‘ready’ an athlete is to train from a lifestyle perspective, if they are exposed to a training and playing program that isn’t specific to the demands of their sport or excessively overloads them acutely or chronically, they will be at higher risk to injury. Progressive gradual overload is essential for an athlete to safely develop long term fitness. Large increases in acute workload are associated with increased injury risk in elite athletes and reductions in pre-season training loads have been shown to reduce training injury rates and greater improvements in maximal aerobic power (Hulin et al., 2013; Gabbett, 2004).

Finally, an athlete’s efficiency relates to their functional strength, biomechanics, body awareness and movement technique.  An efficient athlete will be far more durable if they are ever exposed to changes in training and playing loads, making them better equipped to deal with the constantly varying movements and forces they are exposed to when training and playing. If we look specifically at the research surrounding ACL injury risk and the analysis of motion, there is evidence that shows athletes who perform sports-specific tasks (such as jump landing) with decreased lateral displacement control of the body’s core (through the hip and trunk) are at increased risk of ACL injury and recurrence (Zazulak et al, 2007; Di Stasi et al, 2013; Padua, 2015).


Dr. Andy Barr is an established world leader in the field of sports performance and injury risk reduction with elite level athletes and has over 20 years of experience working in professional sports. Specialties include injury risk assessment, movement screening & corrective retraining, high performance training & monitoring and injury treatment & rehabilitation. He is the Co-Founder of Total Performance, an innovative elite level diagnostic and performance consultancy service, which utilizes state-of-the-art modalities to deliver data-driven insights to help athletes reduce injury risk and maximize performance. A native of the UK, he started his career as a professional football (soccer) player with Luton Town F.C. but it was cut short by injury, which led to him studying for a Physiotherapy degree whilst playing semi-professional football. In 2001, he began his Physiotherapy career at Bolton Wanderers F.C. as the 1st Team Physiotherapist and later held roles with Southampton F.C. and Manchester City F.C. as the Head Physiotherapist (Athletic Trainer).  In 2009, he was head hunted by the New York Knicks’ during President Donnie Walsh’s tenure to serve the organization in an injury prevention and performance role and whilst working with Phil Jackson, he performed the role of Director of Performance and Rehabilitation. Andy also set up the medical and performance department for the new Major League Soccer team , New York City Football Club and served as the Director of Medicine and Performance during their inaugural season. He is a worldwide leader in sports performance, injury risk reduction and management and takes an integrated mind and body approach to rehabilitation and performance enhancement training. He has qualifications in Pilates, NSCA Strength & Conditioning and holds a Masters degree in Sports Science & injury and a Doctorate in Physical Therapy. Andy consults with multiple professional sports teams and athletes all around the world and also runs innovative sports injury prevention and performance courses. You can follow him on twitter @andybarrPT.  

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Tim DiFrancesco, PT, DPT, ATC, CSCS spent 6 seasons as the Head Strength & Conditioning Coach of the Los Angeles Lakers and is the founder of TD Athletes Edge.  He is nationally renowned for his evidence-based and scientific approach to fitness, training, nutrition, and recovery for athletes and fitness enthusiasts.Tim DiFrancesco, PT, DPT, ATC, CSCS is the Head Strength & Conditioning Coach of the Los Angeles Lakers and founder of TD Athletes Edge.  He is nationally renowned for his evidence-based and scientific approach to fitness, training, nutrition, and recovery for athletes and fitness enthusiasts.

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