Fit to Play with Jim Johnson: The ACL tear: Cause and prevention

  • Jim Johnson

Published: 3/14/2022 2:38:35 PM
Modified: 3/14/2022 2:51:30 PM

Jessie, a top soccer prospect from Michigan, received a scholarship from a top Division 1 school. Jessie was what Michael Sokolove called a “Warrior Girl,” tough, relentless in training, bonded to her teammates, and unwilling to leave the field of play. I met Jessie when she entered graduate school at Smith College. She already had three ACL tears and three surgeries on her right knee.

Following graduation she took a high school teaching and coaching job in Florida. One day during recess, she was goofing around with some of the kids and jumped on a skateboard. The result? A fourth ACL surgery. Her surgeon warned that the fourth surgery might not work and it didn’t. Today, she walks painfully, slowly. Her knee is constantly swollen. She cannot play anymore.

How many ACL surgeries is enough? Should athletes be encouraged to put themselves at risk time and again? Should she have been encouraged to continue to play after her second surgery?

Injuries tend to reoccur, but when the same injury has occurred twice during the same activity, the chances of another incidence goes way up. Another season of soccer may have seemed worth it to a 20-year-old, but Jessie faced the likelihood of a reduced quality of life for years to come. She now waits for her first knee replacement.

The anterior cruciate ligament (ACL) is a small ligament located inside the knee that helps prevent the tibia from sliding forward, particularly when stopping or turning. You can tear your ACL and walk around, but you cannot play at a high level without an ACL reconstruction and intensive rehabilitation. Many return to play at the top level, but often not. For some, it is career ending. ACL reconstruction is now one of the most common surgeries in athletes.

When Title IX passed in 1972, the number of women participating in athletics bloomed, but so did ACL tears. Some questioned whether females should play competitive sports. Actually, with the exception of knee injuries, males and females are injured at about the same rate, but when playing the same sport, such as soccer or basketball, women suffered knee injuries far more frequently. What was the reason? Studies have examined gender differences such as hip width and hormonal changes, but no clear answer has stood out.

About 70-percent of ACL injuries for males and females are non-contact, occurring when the athlete is decelerating. Landing (especially on one foot), stopping, and turning result in considerable stress on the knee. Ligaments are only partially responsible for joint stability, as muscles also provide significant stability to joints. Males have stronger legs and studies suggest that females have relatively weaker hamstrings. Good hamstrings are critical as they work in unison with the ACL to stabilize the knee when decelerating. Neuromuscular evidence also indicates that males activate their hamstrings earlier than females, thereby increasing support. Landing mechanics appears to be the male/female difference.


The good news is that the hamstrings can be strengthened and neuromuscular control can be improved for males and females. Responding to the high prevalence of ACL injuries in soccer, FIFA, the world soccer organization, created a three-part warm-up and training program (FIFA 11+) to reduce ACL injury. Early research has shown a 30-50 percent reduction in lower body injuries when done properly. The FIFA program is designed for soccer but it works in all sports. Football, basketball, and lacrosse players should all be using this program to reduce injury.

The FIFA program is on the web, but that’s the easy part. The difficulty is administration. I have administered this program to hundreds of athletes and it only works if performed correctly and usually twice a week. This requires supervision by coaches or other trained personnel. Unfortunately, since practice time is often limited, many coaches are reluctant to take time away from sport specific practice. Healthy teams win and coaches need to invest in injury prevention.

Injuries are going to occur to all athletes, regardless of preparation. Jessie had a very active childhood, playing soccer almost daily with her three brothers, and she still got hurt. But so many children today sign up to play a sport and are physically unprepared and vulnerable. In particular, numerous studies have identified the lack of physical activity among girls. Children need vigorous free play, not just on teams. Jumping rope teaches you to land and you learn to change directions when you play tag. Want to learn to land on one foot? Play hopscotch.

Jim Johnson is a retired professor of exercise and sport science after teaching 52 years at Smith College and Washington University in St. Louis. He comments about sport, exercise, and sports medicine. He can be reached at

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