151 N. Sunrise Avenue
Suite 1005
Roseville, CA 95661

Phone 916-782-1217
Fax 916-782-7630

Our Physicians

Thomas C. Merchant, M.D.
Tyler G. Smith, M.D.
Kevin P. Hansen, M.D.
Annie L. Nguyentat, DPM
Robert D. Jamieson, D.O.

Thomas C. Merchant, MD
January 2009, Modified June 2011

INTRODUCTION: Tear or rupture of the anterior cruciate ligament (ACL) has become a serious problem for today’s athletes, reaching near epidemic rates among women in certain sports. It is estimated that 75,000 ACL tears occur each year in the US and that 50,000 surgical ACL reconstructions are performed each year.

There are many important reasons to prevent ACL tears. It appears that a high percentage (up to 50%) of knees having an ACL tear, whether reconstructed or not, may go on to develop degenerative joint disease (“arthritis”) within 12 years of injury. Additionally, when the ACL is torn, the athlete suffers lost time from sport which may compromise scholarship opportunity and social life (often centered around sport in competitive athletes). Surgery for this injury is costly and, of course, is not 100% successful. Women are most at risk for non-contact ACL tear (the incidence is four to six times higher in females than males in certain sports) but it occurs frequently in men too. Basketball and soccer are the most problematic in regard to non-contact ACL tears in the U.S., but they occur in multiple other sports including football, volleyball, field hockey, cheer, lacrosse, baseball, softball, gymnastics and tennis.

There is increasingly good evidence that preventive programs can reduce the risk of non-contact ACL tear. 70% – 80% of ACL tears occur without direct contact by another player. Studies involving girl’s soccer in Southern California (Dr. Mandelbaum, et. al., Santa Monica), elite level men’s soccer in Italy (Dr. Caraffa, et. al.), women’s high school sports in Cincinnati (Dr. Hewett, et. al.) and team indoor handball in Norway (Dr. Myklebust, et. al.) have each shown significant reduction in the rate of ACL tears using different exercise programs.

Programs such as those mentioned above focus on proper leg position when cutting or landing jumps, avoidance of at risk situations, flexibility, strength, plyometrics, agility and balance.

I have produced the following program by reviewing multiple published programs and pulling from them (particularly those noted above) the common and most useful appearing elements. The following program takes about twenty minutes and is meant to replace the normal warm-up. At the very least, it should improve athlete performance. It is my sincere hope that by instituting this program, you will keep more athletes on the field and out of the doctor’s office. Please understand that this program certainly can’t prevent all ACL tears and that there are no guarantees that it will be successful.

As an alternative, the PEP (Prevent Injury and Enhance Performance) program, by the Santa Monica Orthopaedic and Sports Medicine Group can be found online at www.aclprevent.com/pepprogram.htm. This program is somewhat less strenuous, includes stretching and has been shown to be effective in published studies.

This is a 20 minute program designed to reduce the risk of tears of the Anterior Cruciate Ligament. It is meant to take the place of the warm up period and should improve athlete performance.

This program must be done faithfully to be effective. It is appropriate to remove or add exercises to adjust the difficulty or time of the workout.

It should be started at least four and preferably six weeks prior to start of competition. Ideally it is done five times per week preseason and three times per week in season. The coach or trainer must constantly observe athletes during these exercises to correct and maintain proper technique. Once the athletes understand the principles, they can monitor and coach each other.

Four phases: Warm-up, Strengthening, Plyometrics, Agility and Balance.
I. Warm-up.
   1. Light jog
   2. Backward run
   3. Sideways run

30 seconds
30 sec
30 sec: 5 steps w/ R
   foot fwd, 5
   w/L fwd, 5
II. Strengthening.
   1. Crunches
   2. Side to side ab (obliques) work (touch ball R and L)
   3. Reverse sit-ups
   4. Walking lunges
   5. Russian hamstrings

   6. Single leg squats – put opposite toe down if need
   7. Single leg heel raises
   8. Step-ups (onto a step, bleacher or, with caution, a ball)
   9. Walking leg cradle with heel raise (alternate legs)

30 Reps
Paired athletes: 15 ea.
If alone do standing
hamstring curls with
ankle weights, 20 reps
each leg

20 each leg
15 each leg
20 each leg
7 each leg
III. Plyometrics – continuously coach/observe technique: knee over ankle, balanced soft landing, weight on balls of feet and knees and hips flexed at landing, upright body position. Gradually increase height, speed. Rest as needed during exercises, ultimate goal is to do them continuously with good balance and proper position..
   1. Wall jumps/ankle bounces
   2. Lateral hops
   3. Forward and backward hops
   4. Single leg lateral hops
   5. Single leg diagonal hops: diagonal forward, backward,
       diagonal fwd, bwd, repeat.
   6. 180 degree jumps (alternate directions)
   7. Scissor jumps
   8. Single leg hop, hop, “stick” (land on both feet,
        change “hopping leg” every two sets).
   9. Vertical jumps with sport specific end at peak of
         jump: pass volleyball, catch or throw softball
         pass or catch basketball, head soccer ball, volley
         tennis ball. Jump with good landing technique is always
         first priority.
   10. Squat, tuck and broad jumps can be added or number of
         reps increased for more intensity

20 reps
10 each leg
4 each leg

20 reps
4 each leg

1 min (30 sec per
paired athlete)
IV. Agility and Balance
   1. Shuttle run: forward sprint 10 –20 yards, backward jog
   2. Slalom run: emphasis on good knee position for
       cut/direction change (knee flexed and over ankle).
       Progress to jump and cut if athlete doing well.
   3. One legged balance drills: While standing on one leg
       pass ball back and forth to teammate (throw in soccer
       ball, volley tennis ball, etc.). Consider use of balance board
       if available when athlete is proficient on ground.

1 minute
1 min

1 min: 30 sec ea leg
V. Cool down/stretch
Notes: If the program is running longer than 20 minutes, reduce reps from 20 to 15 where appropriate and single leg diagonal hops could be removed as they are similar to other exercises in the program. (This program should be adjusted to your needs as you see fit and should still be effective if strategically reduced to 15 minutes). If there are questions, call me at 782-1217.

Download ACL Tear Prevention Program as PDF