How to

reduce the risk
of acl tears in athletes.

Maria Mountain,
MSc,CSCS,CEP

www.revolutionconditioning.com

Section One - Introduction 1. Introduction 2. What is the ACL? 3. How does it get injured? 4. What happens when it does get injured? section Two Risk evaluation 1. Evaluating risks. 2. Understanding proper mechanics. Section three building smart strong muscles 1. Building 3D glute strength 2. Developing the hamstrings. 3. Jumping with better mechanics. developing functional movement patterns 1. Hitting the brakes – Learning to Stop 2. Movement with Transitions. 3. Movement Complexes

Section four

Section five The workout 1. Level One Program – weeks 1-3 2. Level Two Program – weeks 4-6 3. Level Three Program – weeks 7-9

www.revolutionconditioning.com ©2008

2

“numbers do not lie” and the numbers surrounding the incidence of ACL (Anterior Cruciate Ligament) tears in recent years is staggering! • NCAA • 2. • athletes will injure her ACL.200 ACL Injuries every year in the Female Athletes have a 4-8 times higher Predicted that 1:100 female high school Predicted that 1:10 female college incidence of ACL injury • athletes will injure her ACL.revolutionconditioning. then there may be an opportunity to train the athlete to use their muscles in a way that reduces the risk. www. rather it’s a structural breakdown that comes when the force produced by the muscles which cross the knee joint are not attenuated by appropriate reflex motor patterns. meaning. As they say. What is the ACL? The ACL is one of the four major ligaments in the knee. Before we get into the nuts and bolts of injury prevention let’s take a look at what the ACL is and what it does in the body.Section one introduction Welcome to the Revolution Sport Conditioning special report on reducing the risk of ACL tears in athletes. it is not force or impact from another player which causes the injury. Ligaments on their own provide structural stability but no dynamic stability as they are non-contractile.com ©2008 3 . If the statistics above have an upside it is the fact that most of these injuries are non-contact mechanisms. since the mechanism which causes the injury comes purely from within the body. What does this mean for athletes? Well.

The giving way or shifting episode is accompanied by pain and often a popping sound. On the outside of the knee are the medial and lateral collateral ligaments which provide side to side stability for the knee.revolutionconditioning. The key point is the presence of an external force. The second mechanism in the one that we are concerned with.com ©2008 4 .The role of the ACL is to prevent anterior translation of the tibia with respect to the femur. it is the active mechanism which occurs when a co-contraction of the muscles crossing the knee fail to provide dynamic stability. Often the athlete will hear it and sometimes even bystanders will hear the sound. So if www. This is often the mechanism when you see athletes collide knee on knee. collides with the athletes knee forcing it into a position where the ACL is ruptured. The ACL and its partner in the PCL (posterior cruciate ligament) are found deep in the center of the knee joint. Gray’s Anatomy Illustration of the knee as seen from the front. in layman’s terms this means that it prevents the shin bone from sliding forward underneath the thigh bone. How does it get injured? There are two mechanisms of ACL injury. What happens when it does get injured? When you hear an athlete say that they were just running or changing direction or jumping when their knee gave way this is an active mechanism of injury. ACL indicated with red arrow. the first is a passive mechanism which would occur when another player or an object.

they will probably want to have the ACL reconstructed to regain the anatomical structural stability. This procedure is performed as a day surgery usually requiring no overnight stay in the hospital.revolutionconditioning. The athlete should expect to participate in physiotherapy for approximately six months before considering a return to Sport. Following surgery – the athlete is on crutches and will be sent to follow up with a sport physiotherapist. In the five years I worked at the Fowler Kennedy Sport Medicine Clinic as the exercise specialist one thing became clear.. If an athlete has torn their ACL and they are involved in a sport that requires dynamic movement as most team sports and individual sports do. these are signs that you need to go visit your sport medicine specialist to get it evaluated. In London. Ontario where Revolution Sport Conditioning is located surgeons typically harvested the graft using a portion of the hamstrings tendon. the knee will often puff up like a balloon.you experience a shifting episode accompanied by pain and acute swelling.com ©2008 5 . www. A reconstruction it is a routine operation for the orthopaedic surgeon who will use different tissues to create a new ACL and position it in the knee. the athletes that put the most into their rehabilitation had the most successful return to sport.

Alignment at the hip. you may be exhibiting some quadriceps dominance. knees and ankles stay in alignment during both jumping and landing.com ©2008 6 . Understanding Proper Mechanics. stand sideways to that full length mirror. www. I want to make sure that you have a clear picture of proper alignment and mechanics.revolutionconditioning. increases the force on the quadriceps and suggests that the athlete is not effectively recruiting his/her glute muscles. Landing without the transition to full foot contact. Absorb the landing with your legs such that you finish in a half squat position.section Two Risk evaluation There is evidence to suggest that faulty muscle recruitment patterns may contribute to these non-contact injuries. but here are two tests you can try at home: • Stand facing a full length mirror and jump straight up in the air. Are your knees pointing inward? If yes. Mainly an over utilization of the quadriceps and an under utilization of the glutes and hamstrings may help set up the right environment for ACL tears. Are your heels off the floor or is your weight shifted toward the balls of your feet after you have landed? If yes. Jump up in the air and absorb the landing with your legs such that you finish in a half squat position. knee and ankle may also play a key role. Now that you have used the evaluations outlined above to evaluate your movement patterns. you need to work on your dynamic alignment. We are also looking to see if the athlete lands on the forefoot (ball of the foot) and then quickly transitions to full foot contact. Evaluating Risks How do you know if you have poor alignment or a faulty recruitment pattern? You can always get a thorough assessment from your sport physiotherapist. What we’re looking for in athletes is that their hips. • Now.

but make sure your technique is perfect. This exercise will help teach proper squatting technique and correct movement patterns for landing jumps. you will feel that you are ‘pulling’ your knees outward slightly. while activating the Gluteus medius muscle which helps one maintain proper knee alignment.Section three Building 3D Glutes building smart. Count to four as you lower yourself to the chair. simply tap and return to the standing position. To begin the movement. Do not sit down. Position a resistance band (tie the ends of a 50cm piece of rubber tubing together to create a loop approximately 30cm in diameter) above the knees and maintain a slight outward pull. To begin the movement reach back with your buttocks you should feel pressure toward the heels of your feet not the balls. To perform this exercise stand approximately 20cm away from the front edge of a chair or bench. reach back with your buttocks. strong muscles Squat with Tubing above the knees.com ©2008 7 . Sumo squat Take a double hip width stance and point your toes outward slightly. Remember www. As you lower into the squat remember to keep your knees in alignment with your feet. You may use a weight to overload this exercise. again the pressure will be on your heels.revolutionconditioning. Remember to keep your chest up and squat down until you just lightly make contact with the bench or chair.

revolutionconditioning. Push your heels straight down into the floor and squeeze your glutes (buttocks). Efficient timing of the co-contraction between the quadriceps and the hamstrings can reduce the risk of noncontact ACL tears.to keep your chest up throughout the exercise. The hamstrings must fire at the proper time and with adequate www. You will brace lightly with your abdominals (as if you are going to receive a light punch in the stomach) and lift your hips and back off the floor all at once. You should feel this exercise working the fronts of your thighs (quadriceps) and your outer glutes. Developing the Hamstrings The hamstrings are a critical dynamic stabilizer of the knee. Supine Glute Bridge and Hold Lie face up with your knees bent and feet flat on the floor.com ©2008 8 .

Basic Isometric Hamstring Curl www.” “female athletes after menarche increase their quadriceps strength greater than their hamstring strength.com ©2008 9 . A 2006 article published in the American Journal of Sports Medicine also found that “female athletes after menarche increase their quadriceps strength greater than their hamstring strength. with the hamstrings appearing much weaker relative to the quadriceps. Lift your hips off the floor into a bridge position. AJSM 34:370-374 The following exercises are intended to improve the functional strength of the hamstrings. putting them at risk for anterior cruciate ligament injury. but you will learn to maintain a nice contraction over the full range of motion. Maintain this perfect position with your body as you bring your knees in toward your chest.revolutionconditioning. During this exercise there is little to no overall change in the length of your hamstrings. Hamstring Curl Progression using the Stability Ball Lie face up on the floor with your heels on a stability ball. putting them at risk for anterior cruciate ligament injury. Testing of athletes often shows an imbalance between the strength of the quadriceps and hamstrings.force to stabilize the tibia under the femur.” Ahmad et al. thus preventing the shear mechanism that results in an ACL tear.

You should not bend at your hips as you did in the previous exercise.revolutionconditioning. To add resistance.Advanced Hamstring Curl Lie face up on the floor with your heels on the stability ball (exactly the same as the previous exercise). through your hips. Do not set your hips down until you have finished the entire set. Slowly straighten your knees back to the starting position. Butt Kickers This exercise can be completed with or without resistance. Brace lightly with your abdominals and lift your hips up off the floor to make a straight line from your shoulders.com ©2008 10 . Maintain the straight line position from your shoulders to your knees as you curl your heels toward your butt. fix the middle portion of a 6’resistance tube and loop the other ends around your ankles. Use a light resistance (similar to a red band in the Theratube brand). www. to your ankles.

make sure you are maintaining good knee alignment.revolutionconditioning. do not let your feet flare out. A useful cue is to think about smashing your calf into your hamstring. Remember to keep your hips up and level throughout the entire movement. www. Also. do not allow your toes to point. Once the technique is perfect the tempo of the exercise should be at a sprinting pace.Stand with a tall torso position and perform a running buttkicker motion as you quickly bring your heels to your buttocks. Focus on pulling with your hamstrings through a full range of motion.com ©2008 11 . Perform the crab walk feet first so you have to pull yourself forward using your hamstrings. Remember to keep your toes pulled up throughout the drill. Get into your ‘crab walk’ position. Crab Walks You will need 10-15 metres of space to perform this next exercise.

Hold this position for 3 seconds – try to imprint the ‘feel’ of this position. Make sure you can do this exercise with perfect alignment before moving on to the next exercise.revolutionconditioning. If possible. go by what looks right. Keep your hips knees and ankles in a line on both take off and landing. Upon landing. The acceleration movement is also referred to as “Triple Extension” as this describes the extension at the hip. Developing this skill will lay the foundation for efficient deceleration. Return to the standing position. you will contact with the www.Jumping with Better Mechanics Now that we have taught your glutes to fire and built some functional strength in your hamstrings. Make sure your hips. a grassy surface is ideal for this type of exercise. Jumping is a great pattern to start with because it allows the athlete to fine tune both acceleration (take-off) and deceleration (landing) mechanics. it is time to use these muscle groups to perform a complex functional pattern. knees and ankles flex (or bend) to absorb the landing. Squat Jump & Hold Do this exercise in front of a mirror so you can observe and correct your form. Do not go by what feels right.com ©2008 12 . knee and ankle. knees and ankles are in proper alignment with your heels on the floor. It makes sense then that the deceleration movement is often referred to as ‘Triple Flexion” as the hips. Stand with your feet hip width apart and quickly ‘drop’ down into a squat position. Drop Squat & Hold The emphasis here is on triple extension. Strive for a quick but quiet landing where you absorb the impact by using your legs as shock absorbers.

www.com ©2008 13 . Make sure the barrier you chose is not an immovable object such as a bench. Focus on linking your jumps and maintaining quick and quiet landings. Hold the landing for 3 seconds before beginning your next three jumps. followed quickly by a lowering of the heels. You will use triple flexion/extension to absorb and explode. Choosing an immovable object exposes the athlete to a risk of injury if they miss a jump. Perform 3 squat jumps then stick the landing on the third repetition using your triple flexion as you decelerate. Lateral Hop Over Barrier For this exercise you will perform a lateral hop over a barrier (such as a shoe or micro hurdle). rather than driving your knees forward.balls of your feet first. As you absorb the impact you will reach back with your buttocks into a squatting position.revolutionconditioning.

but the fact remains that the energy from running forward must be harnessed and dissipated to facilitate the change of direction. so the best option is to learn how to absorb these forces using the proper muscles. I must first stop running straight ahead. As your feet make contact bend your knees and drop your butt. • Run forward over approximately 5-10 metres. make contact with your heel first and then let your full foot contact the floor. How do you use your legs to absorb energy? Well first you need to have strong legs. www. an external object like a brick wall or my muscles to absorb this energy. I can use my connective tissue. The brick wall is clearly not a great choice. If you think about it. If you cannot produce enough force with your legs to decelerate. This will happen quickly and seamlessly in a trained athlete. • Without hesitation decelerate over 1-2 metres by using your legs.Section four developing functional movement patterns Hitting the brakes – Learning to Stop Many sport coaches and trainers are consumed by acceleration and first step quickness. after all who is going to scrape you off the brick wall every time you want to change direction? Using your connective tissue can be a definite problem as we already discussed in the mechanism for ACL tears.revolutionconditioning.com ©2008 14 . You should be balanced over your feet rather than forcing the pressure to the ball of your foot. Using the Legs to Absorb Energy If I am running straight down a field and wish to make a cut right. then you will end up ‘jamming’ on the brakes and sending the stress to your connective tissue and bony structures rather than using your muscles like shock absorbers. then you can increase your speed. any change in direction must be preceded by a quick and efficient deceleration. • Walk back to your starting point and repeat. but the foundation should really begin with deceleration training. To use your legs. To practice deceleration try this exercise: • Run at approximately 75% of your top speed to begin with. injuries often occur during the lengthening contractions of deceleration and from a sport perspective.

• Gradually increase the speed until you can complete this skill at game speed. Upon landing the third jump. Walk back to the starting point and repeat. Squat Jump to Run to Decelerate This exercise will help you learn to accelerate and decelerate from transitions.revolutionconditioning. www. Begin with three squat jumps using perfect technique. you will immediately accelerate over 10 metres and then come to a quick stop using the technique described above.com ©2008 15 .

When you backpedal. practice decelerating with the legs and quickly exploding back in the opposite direction. Learning to move with powerful execution and without ‘wasting steps’ will improve your noticeable speed on the field of play. Use your hip. make sure you do not lean backwards with your torso. To complete this exercise.Movement with Transitions Now that you can use the strength of your legs to decelerate your body. This is what I call ‘shifting into reverse’. you need to learn the skill of changing direction. Run Forward to Backpedal Accelerate over 10 metres – use your legs to brake and without hesitation begin your backpedal. place two small markers on the floor/field approximately 10 metres apart. Stay low and practice shuffling side to side over the 10 metre distance. knee and ankle to move laterally rather than rotating at the hip alone.revolutionconditioning. Your head should stay level. The other technique I want you to learn when moving laterally is keeping your toes pointing straight ahead – resist the temptation to point your lead toe outward as this telegraphs your movement to your opponent and it requires an additional step when the direction of play changes. Keep your arms under control – do not let them swing around. Efficient change of direction is what makes an athlete agile. If you are playing a multi-directional sport where there is an offense and defense you are automatically putting yourself ½ a step behind your opponent by doing this. Shuffle with Change of Direction The key to efficient lateral movement is to stay low and reactive in the legs. Your coaches will notice and so will your opponents. there should not be much up and down movement at all. Remember to stay balanced over your feet with your knees bent in a great athletic/reactive position. If you are getting most of your movement from hip rotation you will see your knees angling inward with each step. ◘ 10 metres ◘ www.com ©2008 16 . At each end.

Try to maintain your speed throughout the drill by using your legs to decelerate the forward movement and initiate a quick and explosive shuffle.revolutionconditioning.Angle Runs This drill allows the athlete to practice transition from a lateral movement to a sprint. ◘ ◘ ◘ ◘ ◘ ◘ ◘ ◘ ◘ www. Also try repeating the drill in reverse with a backpedal to a shuffle.com ©2008 17 .

Box drills are a great way to improve your reactivity which will play a role in both injury prevention and improved performance by training you to be more agile.revolutionconditioning. Place a marker in each corner. Use your legs to decelerate and without hesitation perform three squat jumps. Just make sure that it is not something that you could trip over.com ©2008 18 . Here are a few of my favourite patterns: Box 1: Run-Shuffle-Backpedal S◘ ◘ S Run Shuffle Backpedal Start ◘ ◘ www. You can make the patterns as easy or difficult as you wish.Movement Complexes Jump to Run – STOP – Jump to Backpedal Begin with three squat jumps and upon landing the third jump. but always keep in mind the purpose of the drill is to teach you to use optimal movement mechanics while executing complex movement patterns. Box Drills Set out a box pattern measuring 5-10 metres square. The marker can be a small pylon or just something you find around the house like a rolled up pair of socks. Repeat. immediately accelerate over 10 metres. Immediately upon landing the third jump push off into a quick tempo backpedal.

revolutionconditioning.com ©2008 19 .Box 2: Run-Shuffle-Backpedal with Jump S◘ ◘J S J Run Shuffle Backpedal Start Jump J◘ Box 3: Run – Shuffle-Backpedal with Zig Zag ◘J ◘ S S◘ Run Shuffle Backpedal Start ◘ ◘ www.

com ©2008 20 .Box 4 – Hour Glass Run S◘ ◘ S Run Shuffle Backpedal Start ◘ ◘ www.revolutionconditioning.

Exercise Sumo Squat Isometric Hamstring Curl with Ball Lateral Hop Over Barrier Butt Kickers Decelerations Shuffle with Change of Direction Squat Jump to Run & Decelerate Week 4 3x10 3x5-10 3x10 3x15s 3x3 3x15s Week 5 3x15 3x10 3x10 4x15s 3x4 6x15s 3x3 Week 6 3x20 4x10 3x10 5x15s 10x15s 3x5 www. To be safe you should get a thorough musculoskeletal evaluation from your preferred sport medicine practitioner. If you do not have perfect jumping mechanics by the end of this three week phase despite your best efforts.hold 3s Week 2 3x15 5x20s hold 3x10.revolutionconditioning.Section five The workout Level One – Weeks 1-3 Complete these exercises three times per week on non-consecutive days.hold 5s 5x5 – hold 5s 5x10 – hold 5s Week 3 3x20 5x30s hold Level Two – Weeks 4-6 Complete these exercises three times per week on non-consecutive days. In my opinion physiotherapists have great hands on evaluation skills and they are fantastic at figuring out movement mysteries. such as “why can’t I squat without pinching my knees in?” Exercise Squat w Tubing Above Knees Glute Bridge & Hold Drop Squat & Hold Squat Jump & Hold Week 1 3x10 5x15s hold 3x10. then there may be some more complex issues affecting your movement.com ©2008 21 . You must have perfect squatting mechanics and perfect ‘drop & stick’ mechanics before you move on to this phase.

Following the exercise program outlined in this special report will not guarantee an injury free season. Exercise Advanced Hamstring Curl Single Leg Squat Jump & Hold (small jump) Crab Walk Angle Runs Box Drills Shuffle with Change of Direction Single Leg Squat w Band Above Knees Week 7 2x8 Week 8 3x10 4x5ea 3x10m 3x10s each 3x2 each 3x15s 3x5 4x10m 4x10s each 3x3 each 3x8 Week 9 3x15 5x5ea 5x10m 5x10s each 3x4each 3x10 The preceding exercises are intended for healthy.revolutionconditioning. If you experience discomfort during any of the exercises. Gradually increase the speed of the multi-directional exercises. uninjured athletes. stop immediately and consult your preferred sport medicine professional. such as Angle Runs. Box Drills and Shuffles with change of direction until you are up to game speed and maintaining perfect mechanics. www. You will incorporate some single leg training in this phase – make sure you maintain your perfect alignment during the single leg exercises.Level Three – Weeks 7-9 Complete these exercises three times per week on non-consecutive days.com ©2008 22 . They are not intended to treat injury. but it may help reduce the risks.

with more strength.com ©2008 23 .revolutionconditioning.com www. She helps athletes of all ages by providing the quality training that not only improves performance. The art and science of the Revolution methodology is backed by Maria’s academic preparation having earned both an honors and Master’s degree in Kinesiology. more speed and more stability. In addition to her specialization in sport conditioning.About the author Strength coach Maria Mountain is the owner of Revolution Sport Conditioning. but reduces the risk of injury.revolutionconditioning. The goal of Maria’s post-rehabilitation conditioning is to return athletes to competition not only as adept as they were before the injury. Learn more and download FREE workouts by visiting: www. Maria applies her 5-years of experience from the Fowler Kennedy Sport Medicine Clinic to get injured athletes back to the top of the podium. but surpassing their pre-injury performance level.

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