The grandeur of the World Cup is upon us. The world’s most popular sport has its chance to shine. As soccer gets its much deserved pedestal, summer camps fill. High school and collegiate soccer athletes become inspired. Training begins and with that begins the season of the ACL. With approximately a quarter-million ACL injuries per year, it is safe to say the injury is common in sport. Though most common in female athletes, ACL injuries happen to anyone anywhere, with soccer, basketball, and gymnastics athletes being at most risk.
While an ACL injury is traumatic in nature, the injury is rarely due to direct trauma. More than 75% of ACL injuries are non-contact in nature (1). Non-contact ACL injuries stem from a complex interaction of anatomical, hormonal and neuromuscular factors. Recent studies suggest that ACL injuries are caused by both neuromuscular fatigue and unanticipated movements commonly found in athletics, such as evasive maneuvers that involve some form of deceleration, change of direction, or landing. The coupling of these movements with modifiable risk factors (see graphic) is what leads to non-contact ACL injury. The good news is that non-contact ACL injury can be prevented by addressing these modifiable risk factors.
Through appropriate neuromuscular training, we can improve lower extremity arthrokinematics and allow for proper muscular firing that allows our bodies to control forces that lead to ACL injury. All it takes is an understanding of mechanics and ability to correct dysfunctional movement.
The Evidence of ACL injury Prevention Programming:
Last year, Bell, Clark, and Padua had an article published in the Journal of Athletic Training. This team has done a lot of work on knee displacement and correlating the findings with ankle hypomobility and hip underactivity. This particular model used the NASM Corrective Exercise Model as the intervention procedure. This method systematically turns off hyperactive tissue and activates hypotonic tissues. The data revealed that following intervention, the ankle and hip mechanics improved and medial knee displacement of the knee was significantly reduced (2).
A systematic literature review compared postural control in those with and without ACL injury. The authors found that ACL injury was highly associated with global deficits in postural control. The authors concluded that proprioception exercises should be emphasized during rehabilitation (3). Another systematic literature review published in the Journal of Bone and Joint Surgery demonstrated ACL injury prevention programming provides a significant reduction in ACL injury, 52% in females and 85% in males (4). There are many more studies, but despite the flood of evidence showing the effectiveness of ACL injury prevention programming, the majority of athletes and/or teams do not regularly incorporate prevention programming. What follows is a program that is easy for athletes, coaches, and athletic trainers to adopt as part of their training regimen.
RIDS Program – A New Paradigm for ACL Prevention
You may have read my anti-ice and no more RICE articles. Forget RICE and let’s fix with RIDS. The primary goal of the RIDS ACL injury prevention program are 1 – to correct dysfunction and 2 – to optimize the neuromuscular system. The program outlined below should serve as the warm-up for all training sessions. This program, if done properly will aid in the prevention of ACL injury and can be done in as little as 15- 20 minutes per session.
Step 1: ROM – 7.5 minutes
Improving ROM (range of motion) is step one and vital. Without appropriate motion, joints will have excessive compensatory movement that lead to ACL injury. Below are two methods to improve ROM. These are for an individual or team. If you are a clinician and are appropriately trained, you can add manual therapy techniques, such as myofascial release, ART, PRT, Muscle energy, Mulligan, joint mobilization, and the like to this group. Here are the techniques and muscles you will focus on in this step.
Foam rolling or self myofascial release is designed to inhibit overactive neurological drive to hypertonic tissue. Target these muscles and roll each muscle for 30 seconds.
Now that the neurological drive to the muscles has been inhibited with foam rolling, we can now elongate the tissue by static stretching the same muscles. Stretch each muscle for 20 seconds.
- Lateral Gastrocnemius
- Anterior Adductors
- Tensor Fascia Latae (TFL) / IT Band
- Biceps femoris
Step 2: Isolated Strengthening – 4 minutes
Much like foam rolling inhibits neurological drive to hypertonic muscles, isolated strengthening will activate or increase neurological drive to hypotonic or phasic muscles. Those who are susceptible to non-contact ACL injury and demonstrate poor movement patterns will commonly have weakness of certain muscles. Below is a list of muscles to strengthen. Perform the following exercises for 1 set of 15-20 repetitions:
- Medial Gastrocnemius – single leg calf raises (slightly turn foot inward)
- Gluteus Medius – Side lying hip abduction, with extension
- Gluteus Maximus – Floor Bridge
- Medial Hamstrings – Ball hamstring curls
Step 3: Dynamic Strengthening – 2.5 minutes
Once ROM and isolated strengthening are complete, dynamic strengthening can begin. Dynamic strengthening is a total body exercise that is multiplanar in nature and mimics functional activity. The goal of dynamic strengthening is to bring the above two components of ROM and isolated strengthening in to one harmoniously working unit. Below are a few examples of dynamics strengthening exercises. Choose one exercise and perform 2 sets of 15 repetitions:
- Squat to row
- Lunge with a dumbbell curl and press
- Single leg RDL with dumbbell press
- Box step-up with a dumbbell press
Step 4: Sport Specific Activity – 3 minutes
The purpose here is to mimic sport activity in terms of movement and intensity. These activities include speed, agility, and power or reactive exercise. These exercises are designed to improve dynamic stability of the lower extremity, dynamic postural control, and prep the body to move at high intensity without biomechanical breakdown. Exercises are explained below.
Speed and Agility:
These drills are designed to train for dynamic stability and postural control while increasing foot speed and change of direction. Choose 2 exercises and perform each exercise 2 times.
- Speed Ladder – two-ins
- Speed Ladder – Zig- zag
- Speed ladder – W-weave
- Cone drill – T-drill
- Cone drill – Box Drill
These exercises are explosive and vital to performance in most athletes. Power and reactive neuromuscular control makes use of the stretch shortening cycle to produce the greatest force in a short time. The most important element when considering performance is technique is that one must demonstrate proper mechanics during take-off and landing. If movement compensation is identified, the intensity must be decreased. Below are sample exercises (ranked in order of easy to hard). Choose 2 exercises and perform 1 set of 10 repetitions of each.
- Lateral cone hops
- Box jumps
- Tuck jumps
- Power step-ups
- Lunge jumps
ACL injuries can end an athlete’s career or significantly alter their future abilities. Oftentimes the injury is non-contact and is a result of the body’s inability to control the high-intensity movements, such as deceleration, cutting and jumping, common in athletics. Evidence has shown that a comprehensive neuromuscular training program can significantly reduce the risk of non-contact ACL injury.
Designed and conceptualized around current evidence, the RIDS program introduced here is a comprehensive program that I created. The components of the RIDS program are a systematic progression to enhancing neuromuscular control during sport specific activity. Performing the RIDS program components, as outlined above, before training sessions will go a long way in reducing the risk of ACL injury in your athletes.
If you are a parent, coach, or athlete looking to reduce the risk of ACL injury, please free to contact me for a comprehensive, individualized, sport specific program.
- J. Agel, E.A. Arendt, B. Bershadsky. Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. Am J Sports Med. 2005. 33; 524–530.
- Bell, DR, Clark, MA, Padua, DA, et al., Two- and 3-Dimensional Knee Valgus Are Reduced After an Exercise Intervention in Young Adults With Demonstrable Valgus During Squatting. Journal of Athletic Training published online first, 2013.
- Negahban, Et al. A systematic review of postural control during single-leg stance in patients with untreated anterior cruciate ligament injury. Knee Surgery Sports Traumatology and Arthroscopy, May, 2013.
- Sadoghi, P, von Keudell, A, and Vavken, P. J Bone Joint Surg Am, 2012 May 02;94(9):769-776.