How to Prevent ACL Injuries in Women

The ACL is the ligament that connects the thigh bone and the shin bone at the knee, and ACL tears are among the most common knee injuries for athletes who are active in sports like soccer, football, basketball, skiing or tennis. Women are particularly prone to these injuries. In fact, young female athletes are up to 8 times more likely to sustain ACL tears compared to male athletes.

"We have studied many potential risk factors for female athletes including anatomy, strength, and hormonal influences,” says Elizabeth Matzkin, MD, co-leader of Mass General Brigham Women’s Sports Medicine. "For example, females, when compared to males, may be more likely to rely on their quadricep muscles when slowing down, which could put extra stress on the ACL. We don’t just treat ACL injuries; we partner with athletes and apply learnings from our research to help prevent injuries in the first place."

As a women’s sports medicine surgeon, researcher, and head orthopedic surgeon for the National Women's Soccer League Boston Legacy FC, Dr. Matzkin recommends neuromuscular training exercises as one way to help reduce risk of ACL injury. These are exercises designed to increase strength and proper balance awareness, especially for sports performance.

“Our multidisciplinary team tailors each training plan to the individual athlete’s sport, injury history, and goals. We recommend starting neuromuscular training as early as possible—teen athletes in particular benefit from strengthening the muscles early in their athletic career to help avoid injury,” notes Dr. Matzkin.

ACL injury prevention with neuromuscular training

Neuromuscular training incorporates general and sports-specific strength and conditioning activities, including:

• Resistance
• Dynamic stability (exercises that help you maintain balance while moving)
• Plyometric (quick, explosive exercises to improve and strengthen muscles involved in quick turns, landing, jumping, and other sport-specific movements)
• Core strength
• Balance
• Agility exercises

"The exercises train the nerves and muscles to react and work together for best performance," Dr. Matzkin says.

A sports medicine specialist, physical therapist, or a trained coach teaches you neuromuscular training exercises and can customize them to your specific sport and goals.

For female athletes at higher risk for ACL injuries, the training strengthens the muscles around the knee and hip so the hip flexors, abductors and quadriceps can work well together. "It's really working on strength and awareness, so athletes have good balance, form and technique," Dr. Matzkin says. "In fact, maintaining excellent strength of the hip flexors, abductors and quads is one of the only things we can control to help prevent knee injuries.”

Having a coach or specialist give verbal feedback while you practice neuromuscular training can help you improve your form, increase strength, and reduce the likelihood of injury. “While you may not be able to practice with a coach every session,” Dr. Matzkin says, “it can be helpful to get guidance to establish a solid foundation for your neuromuscular training habits.”

Adding neuromuscular activities to training

Neuromuscular training protects against ACL injuries when performed early and often. Because ACL injuries peak during the middle teenage years, many experts recommend that female athletes begin practicing neuromuscular exercises in their early teens. This can lay the foundation for stronger proximal muscles before they're most vulnerable to injury.

Some of the most beneficial exercises include:

• Core strengthening such as planks, side planks and abdominal crunches
• Resistance training such as squats, lunges and deadlifts
• Speed training such as ladder drills, side shuffles and sprints

Research shows that athletes reap the biggest benefits when they engage in neuromuscular training for 20 minutes at least twice a week and receive verbal feedback on their performance from a coach or trainer.

Should you train with a physical therapist?

Performing neuromuscular training as part of warm-ups or scheduled team practices may be enough for some young female athletes, especially those who only plan to play recreationally. Those who plan to play competitively in high school, college, or beyond may benefit from sessions with a physical therapist. Mass General Brigham Women’s Sports Medicine Program and the Center for Sports Performance and Research (CSPAR) offers preventative training for female athletes, including an individual assessment and tailored training plan.

“With an integrative approach, we care for the whole athlete—offering primary and preventive care, mental health, and sport psychology for female athletes, care for pregnant athletes, and sports nutrition coaching,” says Dr. Matzkin. “We partner with you at each stage in your journey—from prevention to treatment and recovery to get back to sport safely.”