ACL reconstruction in high risk patients

ACL Injury Prevention Programs

ACL tears are a common sporting injury. I’ve discussed many aspects of ACL injury and treatment on my website and in blogs hereherehereherehere and here.


There is an adage in medicine “Prevention is better than cure”. It turns out this saying also applies to ACL injuries. Many studies have looked at the benefits of ACL injury prevention programs. Webster1 pulled many of these studies together in a systematic review. They said there is “conclusive evidence” that ACL injury prevention programs lessen the risk of all ACL injuries by 50%. This effect is even more significant in female athletes, reducing non-contact ACL injuries by two-thirds.


ACL injury prevention programs are specific programs that replace the traditional training warm-up. One such program is the PEP program (Prevent injury and Enhance Performance Program), developed by the Santa Monica Orthopaedic and Sports Medicine Research Foundation. The program includes a warm-up, stretching, strengthening, plyometrics, and sport-specific agility training. These drills improve balance, power and agility. Plyometrics, consisting of jumping exercises, improve neuromuscular conditioning and muscular reactions. 


The PEP program consists of:

1.     Warm-up (50 metres each):

a.     Jog 50m

b.     Shuttle run (side-to-side)

c.     Backward running 

2.     Stretching (30 seconds; × 2 reps each): 

a.     Calf stretch

b.     Quadriceps stretch

c.     Figure-4 hamstring stretch 

d.     Inner thigh stretch

e.     Hip flexor stretch

3.     Strengthening: 

a.     Walking lunges (20 metres × 2 sets)

b.     Russian hamstring (3 sets × 10 reps)

c.     Single toe-raises (30 reps on each side)

4.     Plyometrics (20 reps each):

a.     Lateral hops over 5 to 30 cm cone

b.     Forward/backward hops over 5 to 30 cm cone

c.     Single leg hops over 5 to 30 cm cone

d.     Vertical jumps with headers

e.     Scissor jump

5.     Agilities:

a.     Shuttle run with forward/backward running (40 metres)

b.     Diagonal runs (40 metres)

c.     Bounding runs (50 metres)

Other similar programs also exist. For example, for the local setting, an Australian soccer modification of the FIFA 11+ program that also targets hip and groin injury prevention can be found here. In addition, Netball Australia has produced “The Knee Program”, which can be found here.


As mentioned, programs such as these, performed two to three times per week, have been shown to decrease the incidence of non-contact ACL tears, especially in females. Importantly, these programs have also been shown to reduce ACL injuries after reconstruction, an essential part of the rehabilitation program.  


1. Meta-Analysis of Meta-Analyses of Anterior Cruciate Ligament Injury Reduction Training Programs. KE Webster and TE Hewett .  Journal of Orthopaedic Research, October 2018