In order to understand the function of the ACL and what causes injury to this

ligament, one must know the general anatomy of the knee. Four major bones join at the

knee: the femur, commonly known as the thigh bone, the tibia, the collateral shin bone,

the fibula, the shin bone on the lateral side, and the patella which is the kneecap. The

patella rests in the intercondylar groove, which is located at the base of the femur. This

groove is also an important part of ACL injury because the ACL runs through this groove.

Another key part of knee function are the four ligaments used for stabilization: the

Medial Collateral, the Lateral Collateral, The Posterior Cruciate and the Anterior

Cruciate. The Medial Collateral ligament runs on the inside of the knee and the Lateral

Collateral Ligament runs on the outside of the knee. Both are used for stabilization in

sideways motions. The Posterior Cruciate Ligament runs from the posterior of the tibia to

the anterior of the femur. This ligament prevents dislocation of the femur. The final

ligament in the knee is the Anterior Cruciate Ligament. This ligament runs from the

anterior side of the tibia to the posterior side of the femur and is primarily responsible for

stabilizing the shin and preventing it from moving forward (AAOS 2014). For more

details about the anatomy of the knee view the diagram below. The overall structure of
the knee as well as the functions of the individual components of the knee is essential to

the study of ACL injury.

The next important research area related to ACL tears is the risk factors that make

this injury more likely to occur. Over eighty percent of ACL tears occur in non-contact

situations and are heavily influenced by several factors. The first factor is fatigue. In a

study conducted by the Journal of Athletic Training a group of female and male athletes

had their Landing Error Scoring System (LESS) numbers taken, then completed a

functional training program to the point of fatigue which was characterized by

participants demonstrated a decrease in vertical-jump height of at least 5 cm (2 in) on 2

consecutive course repetitions, and then had their LESS scores recorded again. The

LESS score is an indicator of the number of errors made by an athlete in a depth jump

that is followed immediately by a vertical jump. I. The results were that, Overall,

postexercise scores were significantly higher than pre exercise scores (mean difference =

1.3, 95% CI = 0.8, 1.8). The increase in LESS scores indicates that as athletes become

fatigued they commit more errors in their landing and jumping movements; this can

contribute to ACL injury (Wesley et. all, 2014). Another risk factor is footstrike. Forefoot

contact is better than rearfoot contact because it gives a more even distribution of force.

Rear-foot contact causes a large spike in force on the knee. The graphs below show the

difference in force distribution in a rearfoot strike versus a forefoot strike and indicates

that a rearfoot strike is much more damaging to the knee because of the pressure shock it

causes.
 Another movement that has a high association with ACL injury is change of

direction movements. Often the reason that these movements are risky is because they are

usually accompanied by valgus knee movement (inward twist of the knee) and low knee

flexion. One study found that, jumping to the left had the smallest maximum flexion

angle and was significantly less than jumping vertically (P= .003) or to the right (P < .
001). The maximum knee flexion angle at PPGRF was also significantly less when

jumping to the left compared with vertical jumps (P = .008) (Timothy et. all). The

decreased knee flexion in change of direction movements was prevalent in both right and

left cuts; however this study found left movements to be the most dangerous (Sell et. all

2006). Having a low knee flexion is dangerous because it relies mainly on the hamstrings

to control the knee, which in turn leads to muscle imbalances and a high risk of injury.

In addition to these risk factors females are also at risk of ACL injury for even

more reasons. Why females are different than males at movements (Yu et. all, 2014) The

first is joint laxity. Females joints are more flexible and looser overall. This can increase

the likelihood of hyperextension and causes general joint weakness. Other neuromuscular

factors also affect females. For one they tend to rely more on their quadriceps and as a

result have underdeveloped hamstring muscles. In addition females frequently have one

leg that is stronger than the other. A very dangerous risk that females face is that most

rely on their bones and ligaments to bring their body to a halt. This puts extreme stress on

ligaments instead of putting the force more safely on the quadricep, hamstring, and

gluteal muscles (Smith, 2012). Females also have physical factors that increase their

chances of ACL injury. This is because they tend to have a smaller intercondylar groove.

The ACL runs through the intercondylar groove, so the smaller this groove is the smaller

and weaker ACL. Overall there are many risk factors for all people that make them likely

to injure their ACLs; in addition, there are also many more factors that pertain

specifically to women and cause them to have a much higher risk of injury than men.

Another portion of background research consisted of identifying current

assessment methods that are meant to determine a persons risk of ACL tear. One method
that is used to determine the movement of the tibia bone is the Navicular Drop Test. The

movement of the tibia directly translate to the risk of ACL injury because the tibia is on

stabilized by the ACL. For this test the distance between the subtalar bone and the ground

is measured. Then the test subject rocks side to side while keeping their feet planted.

During this rocking the maximum distance between the subtalar bone from the ground is

recorded. The difference between these two scores is recorded as the navicular drop score

and the higher the score the more the tibia has shifted. High scores indicates a weak ACL.

Another test is the Landing Error Scoring System (LESS) score. In this predictor

test the test subject performs a depth jump from half of their height and immediately after

landing they complete a vertical jump as high as possible. A reviewer has a checklist and

if something is done incorrectly the test subject gets a point. A higher score is bad and

indicates that more errors were committed during the test. These errors such as low knee

flexion and lack of hip flexion put increased stress on the knee and specifically on the

ACL which can cause injury.

A final test used to determine risk of ACL injury is the single leg squat. The single

leg squat is used to evaluate knee and hip flexion during movement. In a clinical study

done by (Weeks et. all, 2012) a sample of twenty two participants performed single leg

squats and were evaluated for hip flexion, hip adduction and abduction, and the degree of

knee flexion and rotation. Internal and external rotation of the knee and the hip is best as

a minimum. This test worked best for evaluating peak knee flexion, the degree to which

the knee bends. This test only somewhat reliable for the other test areas, but overall it can

be used to evaluate the general movement patterns and errors committed. It is not the

most useful assessment method.

A final part of the background research was to analyze a few current training techniques

to help people recovering from ACL reconstruction (ACLr) regain knee strength. Many

sources mentioned this type of training as essential to strengthening the entire knee

region. Eccentric training is described as movements in which a muscle is contracted

while bearing a load. It causes a prolonged contraction that in turn leads to a boost in

muscle development and strength of the targeted region. Nick Campanaro, a gym owner,

explained in an interview that, eccentric strength is basically just your ability to resist

weight and control it... The eccentric strength is the most important aspect of

rehabilitating someone from the ACL (2017). This statement was supported with data

from a clinical trial that analyzed the effects of eccentric exercises after two to three

weeks. The results, improvements in quadriceps femoris and gluteus maximus muscle

volume were 23.3% (SD=14.1%) and 20.6% (SD=12.9%), respectively, in the eccentric

exercise group and 13.4% (SD= 10.3%) and 11.6% (SD=10.4%), respectively (Herman

2009) indicated that the usage of eccentric training was particularly beneficial in

generating muscle development. In all areas of measure the participants who had used

eccentric training were always more than one standard deviation above the mean in each

category of muscle development (ACSM, 2013). This is a strong indicator that eccentric

training can be used as an effective part of an ACL prevention and and an ACLr recovery

program.