Arch Orthop Trauma Surg

DOI 10.1007/s00402-017-2809-5

ARTHROSCOPY AND SPORTS MEDICINE

Evidence‑based concepts for prevention of knee and ACL injuries.

2017 guidelines of the ligament committee of the German Knee
Society (DKG)
Julian Mehl1 · Theresa Diermeier1 · Elmar Herbst1 · Andreas B. Imhoff1 ·
Thomas Stoffels2 · Thore Zantop3 · Wolf Petersen4 · Andrea Achtnich1 

Received: 22 February 2017

© Springer-Verlag GmbH Germany 2017

Abstract  warm-up exercises and are focusing on muscle strength, bal-

Introduction  Knee injuries and especially anterior cruciate
ligament (ACL) tears are frequent in athletes. Therefore, pri-
mary and secondary prevention of sports-related lower limb
injuries is an ongoing topic of interest. The aim of present
study was to establish guidelines for the prevention of knee
and ACL injuries on the basis of evidence-based concepts
represented in current literature.
Methods  A comprehensive literature review regarding pre-
vention programs for knee and ACL injuries was conducted.
Results  Several modifiable and non-modifiable risk fac-
tors for knee injuries in athletes have been reported in lit-
erature. Referring to the ACL, specific injury mechanisms
have been identified and are well understood. In particular,
it has been demonstrated that dynamic valgus is one of the
most important modifiable risk factors. Simple tests like the
drop jump test have shown their efficacy in screening and
detecting athletes at risk. There is only few evidence for
the preventive effect on knee and ACL injuries by single
exercises. However, in order to prevent or correct endanger-
ing movement patterns including dynamic valgus, several
complex prevention programs have been developed in the
past. These prevention programs are included in standard
* Andrea Achtnich
a.achtnich@tum.de
1
Department of Orthopaedic Sports Medicine, Klinikum
Rechts der Isar, TU Munich, Ismaninger Str. 22,
81675 Munich, Germany
2
Department of Trauma and Orthopaedic Surgery,
Unfallkrankenhaus Marzahn, Berlin, Germany
3
Sporthopaedicum Straubing, Straubing, Germany
4
Department of Orthopaedic and Trauma Surgery,
Martin-Luther-Krankenhaus, Berlin, Germany
ance, and proprioception, as well as running and flexibility.
It is reported that these training programs can reduce the
incidence of knee injuries by up to 27% and ACL injuries
by up to 51%.
Conclusions  Screening, identification, and correction of
endangering movement patterns like the dynamic valgus
are the first crucial steps in order to prevent knee and ACL
injuries in athletes. Furthermore, jumping, running and flex-
ibility exercises as well as balance and strength training are
proven to reduce the incidence of these injuries and should,
therefore, be integrated into the regular warm up program.
Appropriate complete prevention programs are freely acces-
sible via the Internet and should be adapted to the specific
sport disciplines.
Keywords  Injury risk · Knee · ACL · Prevention ·
Screening · Valgus · Core stability · Proprioception
Introduction
Anterior cruciate ligament (ACL) tears are one of the most
frequent injuries of the knee with an estimated incidence of
1:3500 [34, 44]. Due to the typical jumping and stop-and-go
movements ACL tears are relatively common in ball sports.
However, knee injuries are also frequent in other sports like
alpine skiing, judo, and field hockey.
The ACL has an important function for knee kinematics,
and ACL tears result in serious consequences for the con-
cerned athlete. Instability of the knee joint might directly
reduce the athlete’s performance. In the long term chronic
instability might lead to repetitive subluxations with conse-
quently meniscal and cartilage lesions [51–53]. Therefore,

13
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the incidence of osteoarthritis in athletes with an ACL tear
is significantly increased [40].
Reconstruction of the ACL decreases the risk of osteoar-
thritis [2]; nevertheless, only 50% of athletes return to their
pre-injury activity level, which frequently leads to an early
end of the athlete’s career [6]. It is also alarming that 7–24%
of patients with ACL reconstruction suffer an ACL tear of
the contralateral knee [45, 55]. For these reasons primary
and secondary prevention of knee injuries is a topic of cur-
rent interest.
In the past years various strategies for prevention of ACL
tears have been developed including following key points
[18]:
1. Education about typical injury mechanisms and poten-
tial modifications of endangering movements,
2. exercises to improve balance and proprioception,
3. neuromuscular training for inter- and intramuscular
coordination,
4. invigoration of the ischiocrural and hip stabilizing mus-
cles, and
5. running exercises.
These strategies were summarized in special prevention
programs (e.g., Sportsmetrics, Prevent Injury and Enhance
Performance PEP, Knee Ligament Injury Prevention Pro-
gram, FIFA 11) [4]. A recent meta-analysis found a reduc-
tion of both knee injuries in general and ACL tears by 27
and 51%, respectively, for patients, who participate in such
programs [18].
The aim of this article was to summarize and analyze
evidence-based concepts for prevention of knee and ACL
injuries. On the basis of these data the ligament commit-
tee of the German Knee Society (DKG) wants to provide
guidelines in order to reduce the incidence of knee and ACL
injuries in athletes. These recommendations are directed to
clinicians, physical therapists, athletes’ coaches, and to the
athletes themselves.
Methods for guideline development
The present study was conducted on behalf of the ligament
committee of the German Knee Society (DKG). All above-
mentioned authors are members of the committee and were
involved in the development of the literature search strategy
according to a general consensus process as well as in the
internal review process.
The first part of this article gives a short overview of
current aspects of injury mechanisms and the assessment
of risk factors for knee and ACL injuries, while the main
part discusses different concepts for injury prevention.
For this purpose literature was searched for studies, which
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Arch Orthop Trauma Surg
present preventive exercises or programs and investigate
their influence on the incidence of knee and ACL injuries
in athletes.
The following were the key questions that should be
answered by present study:
1. What are the typical injury mechanisms and risk factors
for knee and ACL injuries in athletes?
2. Is there evidence for exercises or programs reducing the
incidence of knee and ACL injuries in athletes?
3. How can these programs be integrated in the regular
training?
The recommendations given at the end of this article
have been confirmed by all authors unanimously.
Injury mechanisms and assessment of risk factors
Injury mechanism
Video analyses of ACL tears revealed new details about
the injury mechanism [9, 63]. According to these studies,
in 72–95% of the cases, ACL ruptures occur during non-
contact situations [9, 45, 46]. The most dangerous situa-
tions for ball sports are as follows:
1. landing after a jump,
2. abrupt stopping, and
3. sudden direction change including rotary knee motion
[49, 63].
At the same time the knee is only slightly bended
(5°–25° knee flexion) and in a valgus position. In such sit-
uations, the in situ forces within the ACL increase remark-
ably. In addition it could also cause an impingement of the
ACL against the lateral femoral condyle. Most athletes
report from a planted foot at the moment of injury. Further,
usually the body’s center of gravity is behind of that of
the knee. In this position the associated contraction of the
quadriceps femoris muscle results in an anterior transla-
tion of the tibia with high tension to the ACL. Due to an
inappropriate lever arm, the ischiocrural muscles cannot
sufficiently protect the ACL against this anteriorly directed
force. In addition to that, the hip needs to be flexed in
order to maintain the balance, which forces the quadriceps
femoris muscle to further contract. By means of surface
EMG Colby et al. [12] could demonstrate that this move-
ment is connected with high activation of the quadriceps
femoris muscle, whereas the activity of the ischiocrural
muscles is lower [12].
Arch Orthop Trauma Surg
Athletes at risk
The risk factors for injuries of the knee and in particular
the ACL are summarized in Table 1 [3, 52, 57]. Common
non-modifiable risk factors ACL re-ruptures are age and
gender. Patients under 20 years and female patients have a
significantly higher risk for ACL re-ruptures [19, 39]. Also
generalized ligamentous laxity is mentioned as one risk fac-
tor [3]. Modifiable risk factors are kind of sports, hormone
status, and neuromuscular control.
Sports at risk are soccer, basketball, handball, and alpine
skiing [3]. Several studies could also show an elevated injury
risk for females without contraception in the pre-ovulatory
phase [3].
With regards to prevention programs, neuromuscular risk
factors are of major interest. Various studies could show
associated neuromuscular risk factors in athletes [3, 29, 30,
32]. Especially quadriceps femoris muscle dominance, weak
knee flexors, and the dynamic valgus-position with defi-
ciency in hip and core stability are of importance. It has been
observed that in athletes at risk, activation of the quadriceps
femoris muscle occurs earlier than for the protective flexors
(hamstring muscles) [32].
Furthermore, athletes at risk show general movement pat-
terns similar to the knee position identified during injury
mechanism analyses: knee valgus (frontal plane) and low
flexion angles with the center of gravity behind the knee
(sagittal plane). This valgus knee position is also termed as
dynamic valgus [3, 29, 57].
In principle, the harmful valgus drift right after a one-
legged landing- or stabilization phase- could occur due to
decreased hip and core muscle strength with consecutive
lateral tilting of the hip to the contralateral side, extended
eversion of the lower ankle, missing coordination, and pro-
prioceptive skills or by any combination of the aforemen-
tioned mechanisms. In athletes at risk proprioceptive defi-
ciencies in core control and strength deficits of the external
rotators and abductors of the hip could be verified [36, 70].
The dynamic valgus could also arise in the distal part of the
Table 1  Risk factors for knee and/or ACL injuries
Non-modifiable risk factors
Age: < 20 years
Gender: female
Hormone status: preovulatory phase without contraception
Sports: soccer, handball, basketball, alpine skiing
Narrow intercondylar notch
Generalized ligamentous laxity
Pes pronatus valgus
Synthetic floor or turf
History of muscle, tendon, knee or ankle injuries
Infectious disease
Poor weather conditions (outdoor sports)
ankle (eversion) and foot (external rotation) [56]. Another
risk factor in these athletes is an extended “one-leg-domi-
nance” [29].
These movement patterns are more common in female
athletes [29]. Micromotion studies could demonstrate that
landing position is more upright in women compared to men
with a less flexed knee and hip. “One-leg dominance” and
predominance of strength of the quadriceps femoris muscle
is also a typical female phenomenon. Moreover, female ath-
letes have an increased valgus position of their knees and
deficiencies in hip and core stability.
Screening tests
Prevention programs are expensive and, therefore, in the past
years several tests were developed to identify athletes at risk.
The main focus of these tests is to detect functional valgus
position of the knees.
The “Drop Jump Screening Test” is one of the most com-
mon tests [30, 47]. It consists of a vertical jump from a box,
in which the landing position is analyzed with a video cam-
era (Fig. 1). The frontal projection angle or the distances
between both knees and ankles could be measured (knee
distance < ankle distance = dynamic valgus). During such
landing situations the knee sustains the most uncontrolled
movement [47].
Minzner et  al. [43] demonstrated a good correlation
between the relation of the distances of knee and ankle and
two- or three-dimensional video analyses. Noyes et al. [47]
showed that this test is also useful to evaluate the success or
progression of training focused on the correction of dynamic
valgus knee position. In this study the distance between the
two knees in female athletes before training was 23 ± 8 cm.
After a neuromuscular prevention program the knee distance
was increased to 29 ± 8 cm was, therefore, able to reduce
the dynamic valgus.
Hewett et al. [30] evaluated the “Drop Jump Screen-
ing Test” in 205 female athletes (soccer, basketball,
Modifiable risk factors
Dynamic valgus
Low flexion of hip and knee during landing
Poor hip and trunk control
Weakness of knee flexors and hip abductors (relative to knee extensors)
Delayed activation of flexors
Proprioceptive deficits
Muscle fatigue
Poor general fitness
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 Arch Orthop Trauma Surg

Fig. 2  Another test for analyzing the dynamic valgus position is the

Fig. 1  “Drop Jump Screening Test” to detect risk athletes. It con-
sists of a vertical jump from a box, in which the landing position
is analyzed with a camera. The frontal projection angle or the dis-
tances between both knees and ankles could be measured (knee dis-
tance < ankle distance = dynamic valgus). During such landing situa-
tions the knee sustains the most uncontrolled movement
“Single Leg Squat” [16]. Therefore, the athlete should perform five
single-leg squats with maximum flexion (one squat in 2  s). These
squats are recorded by a video camera and graded as “good”, “mid-
dle” and “poor”

volleyball). This study verified a dynamic valgus position Table 2  Clinical assessment of single-leg squat according Crossley
et al. [16]
as one risk factor for sustaining an ACL tear. In female
athletes with an ACL tear the knee abduction angle was Criterion To be rated “Good”
increased by 8° when compared to healthy female controls.
(A) Overall impression
In this study, an abduction moment could predict an injury
 1. Ability to maintain balance 5. No loss of balance
to the ACL with a specificity of 73% and sensitivity of
 2. Perturbations of the person 6. Smooth performance
78%. In the sagittal plane, the authors found a decreased
 3. Depth of the squat 7. Squat with at least 60° of knee
maximum knee flexion angle of 10.5° during landing in flexion
athletes with ACL tear compared to healthy athletes (flex-  4. Speed of the squat 8. 1 Squat per 2 seconds
ion angle in athletes with ACL tear: 71.9° ± 12°; flexion (B) Trunk posture
angle in athletes without ACL tear: 82.4° ± 8°).  9. Lateral deviation 13. No lateral deviation
Another test for analyzing the dynamic valgus position  10. Rotation 14. No rotation
is the “Single Leg Squat” (Fig. 2) [16]. In the original  11. Lateral flexion 15. No lateral flexion
version of the test the athlete is positioned on a 20-cm  12. Forward flexion 16. No forward flexion
box with folded arms: In this position the athlete should (C) Pelvic posture
perform five single-leg squats with maximum flexion (one  17. Shunt or lateral deviation 20. No shunt or lateral deviation
squat in 2 s). These squats are recorded by a video cam-  18. Rotation 21. No rotation
era. With different qualitative criteria the performance of  19. Tilt 22. No tilt
the squats is graded in “good”, “middle” and “poor”. The (D) Hip
criteria are listed in Table 2. Further, it is also possible to  23. Adduction 25. No adduction
determine the frontal projection angle. Originally this test  24. Internal rotation 26. No internal rotation
was designed to evaluate the dynamic valgus position in (E) Knee
patients with patellofemoral pain syndrome. Ortiz et al.  27. Valgus 29. No valgus
[48] also used “single leg squats” to assess the effect of a  28. Knee to foot position 30. Center of knee over center
6 weeks’ ACL prevention program in female soccer play- of foot
ers. The authors found a successful reduction of functional
To be classified as “good” in the overall assessment, 4 of 5 criteria
valgus during “single leg squats” after performing that have to be fulfilled. Athletes, who fulfill only one criterion, are clas-
sified as “poor”

13
Arch Orthop Trauma Surg
prevention program. In these tests a valgus position of the
knee was correlated with a reduced hip abduction [1, 16].
The “Functional Movement Screen” (FMS) is another
test known in sports science to evaluate the risk of injury
[10, 13, 42, 58]. The aim of the FMS is to detect functional
asymmetries and disbalances [58]. The athletes have to
complete seven different exercises, which are scored with a
maximum of three points (three points: perfect performance,
two points: evasive movements, one point: exercise is not
possible, no point: pain). 14 points and more are associated
with an increased risk of injury. Until now this test has been
used only rarely for knee injury prevention since the main
aim of the test is limited to injury risk assessment [10, 42].
A systematic review demonstrated a specificity of 86% for
the FSM, but also a low sensitivity of 25% [18]. The predic-
tive value for risk assessment is also low [18]. Therefore, at
the moment FSM is not recommended for ACL injury risk
assessment.
Prevention program
Education about mechanism of injury and modification
of endangering movement patterns
Concluding from the data regarding the genesis of an ACL
tear, education about mechanism of injury could be part of
prevention. Various studies are supporting this hypothesis.
Lephardt et  al. [38] using three-dimensional motion
analysis demonstrated that endangering movement patterns
could be modified with appropriate training. According to
Cowling et al. [15], verbal instructions are already suffi-
cient to increase the knee flexion angle significantly during
landing.
The approach for prevention of knee injuries was first
described in the “Henning program”, a prevention program
for ACL tears in basketball player [22]. The aim of this pro-
gram was to modify movement patterns to avoid endanger-
ing joint positions. The so-called “plant and cut” maneu-
ver should be performed smoothly in single small steps to
Table 3  Avoidance of Frontal plane
endangering movements
Avoidance of dynamic valgus
 Centers of hip, knee, and ankle are aligned
 Knee pointing externally
 Hips are horizontal
 Trunk is upright
Rotation as a smooth movement in single steps
Stopping with several small steps and without extended knees
avoid abrupt motions. During landing, after a jump the knee
should be flexed and stopping should also be performed in
several small steps and with avoidance of low knee flexion
angles. This prevention strategy was educated to the sports-
men by means of a video film. With this approach of preven-
tion the injury rate was reduced by 89% [23].
Moreover, a study from alpine skiing demonstrated a pre-
ventive effect by education regarding injury mechanisms.
Within the “Vermont ACL prevention program” athletes
were confronted with videos of typical ACL injury situations
during skiing. These videos should stimulate the athletes
to develop individual prevention strategies [20]. Further-
more, the videos should help to detect endangering situa-
tions and to develop strategies as a response to the injury
stimulus in “almost injury” situations. In the winter season
of 1993/94 4700 ski instructors and ski slope patrols took
part in this program. Hereby the rate of severe knee injuries
was reduced by 62% [20].
In summary, there are certain indications that education
about injury mechanism and modification of endangering
knee movement patterns could avoid ACL tears (Table 3).
The avoidance of dynamic valgus position and landing
with flexed knee are the basis for exercises and warm-up
programs with the aim to prevent knee and ankle injuries.
Balance training
Proprioception (afferent information on joint position) rep-
resents the sensorial source of information that enables neu-
romuscular control of the joint [37]. Proprioceptive informa-
tion is given by different mechanoreceptors that are located
in muscles, joints (ligaments and capsule), and the skin.
In the knee joint this mechanism regulates the interaction
between the extensor and flexor muscles, which is crucial
for balancing the stress on the ACL but can be practiced by
balance training (Fig. 3).
It has been shown that exercises on a balance board
decrease the incidence of primary and secondary ankle joint
injuries [7, 64, 66]. However, current literature is lacking
consistent data regarding the benefits of such exercises on
Sagittal plane
During landing after jumping the hip and the knee
should be flexed (if possible 90°) and should not be
straight
Body’s center of gravity over the foot
13

Fig. 3  Proprioception exercises on a balance board; leg position has
to be noted and a dynamic valgus position has to be avoided
the incidence of ACL injuries. Caraffa et al. [11] conducted
a study with 300 male soccer players and found a significant
reduction of ACL injuries due to exercises on the balance
board [10 ACL injuries in the study group (n = 300) versus
70 ACL tears in the control group (n = 300)].
Wedderkopp et al. [67] analyzed an intervention program
including exercises on balance boards as well as muscle
strengthening on juvenile female handball players. In this
study a decrease of the injury rate by 78% was shown by
applying this prevention program. In order to investigate the
preventive effect of balance training, another study com-
pared two different prevention programs on 16 female hand-
ball teams: (1) Standardized strengthening exercises (control
group) versus (2) Combination of strengthening exercises
and balance board training (study group) [68]. It was found
that the incidence of injuries was reduced from 6.9 per 1000
playing hours in the control group to 2.4 injuries per 1000
playing hours in the study group. However, on the basis of
the given data a statement regarding knee injuries was not
possible.
Contrary results were reported by Soderman et al., who
conducted a balance board training with 121 juvenile female
soccer players [59], while further 100 players served as con-
trol group. After one season of observation there was no
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Arch Orthop Trauma Surg
Fig. 4  Combination of balance exercises with sport-specific exer-
cises
significant difference between both groups regarding fre-
quency of injuries. The incidence of severe injuries was even
higher in the intervention group (8 versus 1) with four out of
five ACL ruptures in this group. Only in patients, who have
had injuries within the past 3 months prior to the beginning
of the study, a significant lower injury rate was observed in
the intervention group.
In summary, on the basis of current data, the usage of
balance boards should be recommended as the general inci-
dence of injuries can hereby be reduced. In several studies,
which demonstrate a positive effect of preventive warm up
programs, balance training is included in these programs
[41, 46, 49, 50, 54]. Especially the combination of balance
exercises with sport-specific exercises is an appropriate sup-
plement to warm up programs (Fig. 4).
Neuromuscular training
Athletes at high risk for ACL injuries are characterized by
a dominance of the quadriceps muscle, as on an experimen-
tal anterior tibial translation (injury stimulus) these athletes
react with quadriceps activation. By contrast, several studies
have demonstrated that a rapid activation of the hamstring
muscles as a reaction on an injury stimulus helps to protect
the knee joint [5, 8, 26, 33, 60].
Arch Orthop Trauma Surg

Hewett et al. [27] could show that by means of a specific

jump training, activation of the hamstring and gluteal mus-
cles can be increased and, therefore, also a possible imbal-
ance between the quadriceps and the hamstring muscles can
be reduced. In this context, it is important that during land-
ing, both the athletes knees and hips are flexed by 90°. On
the basis of this knowledge the “Cincinnati Sportsmetric
Training Program” has been introduced. This prevention
program has been tested on 1263 athletes (football, volley-
ball, basketball) [28]. It consists of different jumping exer-
cises with increasing complexity. In this regard, too, move-
ment control based on the principles proposed by Henning
[23] is very important in order to avoid endangering move-
ment patterns. In the study by Hewett et al. only two athletes
of the training group suffered severe injuries compared to Fig. 5  Muscle strength training: typical exercises for ACL prevention
are the “Russian hamstrings”, which activate the posterior muscle
ten athletes of the control group. The relative incidence for chain both concentrically (upwards) and eccentrically (downwards)
injuries was 0.12 in the training group and 0.43 in the con-
trol group. Summarized, the studies by Hewett et al. [27,
28] show that specific jumping exercises can improve the
balance between flexor and extensor muscles at the knee
joint; however, consideration of Henning’s principles for
movement modifications is crucial [23].
Therefore, jumping exercises have been included in sev-
eral warm up programs [41, 46, 49, 50, 54] and are par-
ticularly suited for sport disciplines with repetitive jumping
tasks.

Strength training

Because of the crucial role of muscle imbalance in the

occurrence of dynamic valgus alignment and the associated
risk of ACL tears, strength exercises have been integrated in
many prevention programs [17]. These are primarily focus-
ing on the knee flexors, hip abductors, and trunk stabilizers
[29].
Muscle strength training can be performed using basic
training devices at the gym. However, for a better integration
of muscle strength training into warm up programs, dynamic Fig. 6  Flexor training on the exercise ball represents a possibility to
exercises have been developed that can be performed by strengthen the posterior thigh muscles as well as the abdominal mus-
means of simple training tools [29]. cles and the stabilizers of the hip
Typical strength exercises for ACL prevention are the
“Russian hamstrings” [29], which activate the posterior their warm up programs [21, 35, 41]. Individual strength
muscle chain both concentrically (upwards) and eccentri- exercises, however, have not been tested separately so far.
cally (downwards) (Fig. 5).
The flexor training on the exercise ball represents a fur- Running und flexibility training
ther possibility to strengthen the posterior thigh muscles as
well as the abdominal muscles and the stabilizers of the hip. Running exercises are suitable for injury prevention as they
In addition to that, exercises that strengthen the hip abduc- are a classical part of every warm up program.
tors and the hip rotators are included in ACL prevention Running and flexibility exercises have been integrated
programs (Fig. 6) [29]. into the “Prevent Injury and Enhance Performance Program”
Several studies that could show a positive effect of pre- (PEP), which was developed especially for the prevention
ventive warm up programs include strength exercises in of ACL injuries in football [21, 41]. It includes different

13

running exercises (e.g., straight ahead running, side steps,
running with hip rotation). It is important that the instructors
pay special attention to the correct execution of these exer-
cises. Above all, a dynamic valgus has to be avoided. Several
studies have shown that the PEP can significantly decrease
the prevalence of ACL injuries in football players [21, 41].
However, there are no studies, which have investigated the
effect of individual running exercises separately.
The effect of specific warm up programs
on the prevention of ACL ruptures and knee injuries
Several systematic reviews and meta-analyses have shown
that the risk of knee injuries and ACL ruptures can be sig-
nificantly reduced by specific warm up programs [17, 24,
31, 61, 62, 69].
In a meta-analysis of 24 studies, published in 2015, a
preventive warm up program could reduce knee injuries
by 26.9% and ACL ruptures by 50.7% [17]. Nine of these
studies reported additional prevention of musculoskeletal
injuries in general. Although the majority of these studies
focused on female athletes, a preventive effect could also
be demonstrated for male athletes [17]. Most studies have
investigated programs that have combined multiple preven-
tive concepts: balance training, jumping exercises, strength
exercises, running, flexibility exercises, and stretching [17].
However, a meta-regression analysis did not show a signifi-
cant effect on the results by any of these individual proce-
dures [17]. Only for stretching a little evidence could be
shown that it has no effect on the result [25, 65]. Probably
the effect of the different preventive procedures is based on
modifications of dangerous movement patterns (dynamic
Table 4  Overview of established warm up programs for injury prevention
Name Discipline Exercises
FIFA 11+ Football R, P, S, B 20 min
Prevent injury and enhance Football R, P, S, F
performance (PEP)
Sportsmetrics Football, basketball, P, S 60 min
tennis, volleyball
Harmo Knee Prevention Football, basketball R, P, B, F 20–25 min
Program
“Sei kein Dummy” (prevention Football R, P, S, F
program of VBG)
R running exercises, P plyometrics (jumping exercises), S strengthening exercises, B balance training, F flexibility training/stretching
13
Arch Orthop Trauma Surg
valgus, low knee and hip flexion). Therefore, the individual
preventive exercises, which are presented in this article, can
be combined in such a way that the warm up programs are
suitable for the specific sports discipline. Hence, running
exercises are suitable for football, jumping exercises for
handball or basketball, and strength exercises for skiing. It
seems reasonable that these exercises are combined with
sport-specific exercises as this can increase the compliance.
Furthermore, it could be demonstrated that movements of
the upper extremities can influence movement patterns of
the lower extremities [14].
There is also evidence that the timing of preventive pro-
grams has an influence on the efficacy of risk reduction. Per-
forming the preventive training during the pre-season period
shows a significantly higher effect than performing it only
during the competitive period [17]. Further effects on the
efficacy of preventive programs could be shown for duration,
frequency, and compliance. The longer the duration of the
program (> 20 min) and the more frequent it is conducted
(> three times per week), the greater is the effect [61, 62].
Established prevention programs
Table 4 gives a summary of different established warm up
programs for prevention of knee injuries and ACL ruptures.
The preventive effect on primary ACL injuries is scien-
tifically proven for most of these programs; however, their
effects on the secondary prevention of a re-rupture after
ACL reconstruction are still to be investigated.
All of these programs are available via Internet. They
have been developed specifically for ball sports (football,
handball, basketball) and include balance, strength, jumping,
Duration (approx.) Scientific evidence Web address
Soligard et al. [61] www.dfb.de/trainer/b-juniorin/
artikel/fifa-11-310/
www.fmarc.com/downloads/
cards/11pluscards_d.pdf
www.f-marc.com/1lplus/
startseite/
20 min Mandelbaui et al. [41] smsmf.org/files/PEP_
program_0412201l.pdf
Hewett et al. [27, 28] http://sportsmetrics.org/
Kiani et al. [35] harmoknee.com
20–30 min – http://www.vbg.de/Shared-
Docs/Medien-Center/DE/
Broschuere/Branchen/Sport/
Trainingsuebungen_fuer_
ein_starkes_FuBballteam.
pdf?_b
Arch Orthop Trauma Surg
running, and flexibility exercises. The aim of these exercises
is to reduce the dynamic valgus and to strengthen the poste-
rior muscle chain (flexor muscles of the knee and abductor
muscles of the hip). These exercises can be modified and
integrated into specific warm up programs of other sports
disciplines of high risk (e.g. judo, hockey, skiing). This inte-
gration is very useful in order to increase the athletes’ com-
pliance. The duration of most of the warm up programs is
20 min. The application of preventive procedures is intensi-
fied during the pre-season period, while it is reduced during
the competition period.
Conclusion and recommendations
Especially in non-contact situations there are typical move-
ment patterns with increased risk of ACL injuries in ath-
letes. Dynamic knee valgus with only slight flexion in the
knee and hip joints after landing or during sudden direction
change seems to be particularly predisposing. In this respect,
several “screening” tests like single-leg squats or jumping
tests have been developed, that can help to detect athletes
at risk.
There is significant evidence that the incidence of knee
injuries and ACL ruptures can be reduced by appropriate
modifications of the athletes’ training. In this regard preven-
tion programs should be based on the following aspects:
1. Information about injury mechanisms,
2. jumping exercises for muscle strengthening and correc-
tion of movement patterns,
3. balance training,
4. strength training,
5. running/flexibility exercises.
These preventive exercises should be integrated into the
usual warm up program in combination with sport-specific
exercises. Thus the athlete’s motivation and compliance can
be kept high and no further resources are needed. Corre-
spondingly several complete warm up programs have already
been developed, which are freely accessible via the Internet.
However, to date the effectiveness of these programs is
only evident for ball sports, while their influence in other
sports with higher rates of contact injuries like Judo has not
been investigated so far. So, further research is needed in
this field. Nevertheless, until further data are available we
recommend the same exercises adjusted to the specific warm
up programs also for these sports.
Acknowledgements  The ligament committee of the German Knee
Society (DKG) developed this study to provide guidelines regarding
the topic prevention of knee and ACL injuries. Members are listed
below. Petersen W, Zantop T, Imhoff A, Müller P, Patt T, Scheffler S,
Höher J, Stöhr A, Ellermann A, Stoffels T, Jung T, Herbort M, Akoto
R, Achtnich A, Diermeier T, Mehl J, Herbst E, Stein T.
Compliance with ethical standards 
Conflict of interest  The authors declare that they have no conflict
of interest.
Funding  There is no funding source.
Ethical approval  This article does not contain any studies with
human participants or animals performed by any of the authors.
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