Save the Knees: Beating ACL Injuries with Prevention

On July 10, 2011, Ali Krieger pounded home the penalty kick that advanced the U.S. Women’s National Team past Marta and the Brazilians in the 2011 Women’s World Cup quarterfinals. Remember? We couldn’t stop watching the replays. Now, it’s 2012 and time for Olympic gold, but where is Ali? Out with an ACL, an anterior cruciate ligament tear. I don’t need to spell it out, though, because if you know soccer, you know ACLs, probably better than you know Ali. How did this happen?

Actually, it’s a shadow that’s been looming for a while. In 1989, the NCAA started tracking knee ligament injuries. By 1995, anterior cruciate ligament injuries were termed “a crisis.” In 1996, it was an epidemic. Tim Hewitt at the Sport Medicine Research Center in Cincinnati, Ohio, showed that the knees of girls who participate in jumping and cutting sports are at particular risk. He designs a comprehensive plyometric training program which considerably reduces the risk.

Based on Hewitt’s research, injury prevention programs take shape in soccer hot spots across the country. They require only 15 minutes per training session to complete. Ongoing studies show that these programs, performed correctly, can significantly reduce the risk of ACL injury to women soccer players’ knees. So we can put that injury aside, right?

Wrong. If you google ‘injuries in youth athletes’ in 2012 this is what you get:

  • “Teen knee Injuries Dramatically Rising in Youth Athletes”
  • “Serious Knee Injuries in Younger Kids”
  • “Injury Prevention Programs are A Must”
  • “New Surgeries Attempted to Preserve the Growth Plate in Youngest ACL Victims”
  • “ACL injuries Predispose to Early Onset Osteoarthritis.”

We knew this was on the way in the mid 90s. We developed injury prevention programs shown to be protective at the millennium. So why do we still have a crisis?

In the years I have been working in this field here are some of the reasons and how I would respond. See if you agree:

  1.      Coaches don’t care; there is always another player ready to step in. Survival of the fittest. Certainly not among The Soccer Wire readers, but there are still some callous coaches who take this approach. I hope parents are making them a very rare breed.
  2.      Coaches believe injury prevention programs take up too much practice time so they discontinue them. ACL prevention practices only work if you do them consistently, but they require only 15 minutes, time you may already be using for your warm-up, and their principles can be blended into the field work you are already doing.
  3.      Coaches have players perform injury prevention-type warm ups but don’t insist on (or don’t know) proper form. This training is only effective if it’s done well. A qualified sports professional can and should, as they work with the athletes, introduce the principles to the coaches. Then, coaches must treat these warm ups as an important part of practice.
  4.      Parents insist their kids play even when they are injured. We’ve got to stop celebrating the warrior instinct and help kids recognize when they need to step out of the action and insist they do so. We also need to help them work their way back into the line-up after time off. Be sure your parents know you will be making line-up decisions with safety for long-term health in mind.
  5.       Injury prevention doesn’t start early enough to pre-empt bad habits. The “new” injury epidemic is among pre-teen athletes — overtraining, pushed to perform and rarely resting. Injury prevention needs to start here. With fun fitness, not professional pounding. The youngest kids at all levels of play need to start with games that build body control, coordination and endurance. Older elementary kids need “pre-injury prevention” movement training, building a foundation of balance and basic strength for the plyometrics that come next.

So, am I completely biased? Yes. I have seen this training work and have coaches who testify to its effectiveness. Injuries are not inevitable and many, some say up to 70 percent, are preventable with the proper approach to training. (And if you thought boys were safe, think again. It looks like the epidemic in our teen girls just comes to young men in their 20s.)

Will proper training knock out all the injuries? Unfortunately, we know it won’t. This was particularly well illuminated in Michael Sokolove’s Warrior Girls. The competitive environment of youth soccer is often not a healthy one. They play too many hard-fought minutes on too many days all year round. And this is starting younger and younger. Does it bother you, like it does me, that surgeons are trying out new surgeries on eight-year-old knees in hopes of preserving the cartilage in their growth plates?

Our kids are resilient, but they’re also fragile, and they are desperately trying to meet expectations — just like it says on their elementary school report cards. Yes, the problem’s been around since the mid-90s. We didn’t start the fire…but who’s gonna put it out? We must honestly address the age at which kids play select soccer, what is demanded of them and how much rest they get from competition and play. We must also consider whether they are prepared for the faster, more competitive, physically demanding game that comes at them.

So, you’re a good coach who really cares about his players. What can you do to keep them healthy and grow their soccer? Here is what you want to work on with them:

  1. Bending at the knees and not from the waist
  2. Keeping knees from bowing inwards on cuts and landings
  3. Being agile and light on their feet
  4. Being in control of their bodies


  1. Building a strong core and good endurance
  2. Maintaining supple muscles and full range of motion at joints

If you’ve read the knee injury articles, you probably know these recommendations. But do you know how to build them into your practice and their game? Do you know how to teach the kids this?

If you’re the “self-check-out line” kind of person (which most of us are these days) you may want to see what this training looks like. At Sportsmetrics you can be certified to offer their program.

The Santa Monica sports medicine foundation puts its “PEP” program description entirely online. You can find many versions of it on Youtube.

On my Fit2Finish page you’ll find some of the kinds of training I use.

But if you are really dedicated to beating ACLs with your players nothing tops bringing a sports medicine professional in to work directly on the field with the players — answering their questions, correcting their form, applying proper intensity at the level of their ability AND making sure they take those changes to the field. Numbers 1-4 above are what coaches should be looking for and parents should expect from their kids’ coaches.

A high school friend and fellow soccer parent contacted me after reading some of my articles on The Soccer Wire. She said, “I wish we had talked to you before our daughter tore her ACL. Her club coach was doing all the injury prevention training but apparently they weren’t aware of it on the high school team.” These parents had just assumed that all coaches knew to do this. Now, four months post-surgery, it’s a tough admission.

Fifteen minutes of a well-designed, well-executed training program really is worth our time. Coaches can learn how to run these programs and kids enjoy performing them. When injury prevention training done right is the rule rather than the exception, there will be no more need for professionals like me who market injury prevention. In the meantime, it gives kids a fighting chance to keep playing the game they love, in the spirit and with the intensity it deserves.

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