What if I told you ACL injury is more than wide hips?

What if I told you it is more than weak glute muscles?

What if I told you it is more than poor landing mechanics?

The physical side of ACL injury reduction is important, and it should be something coaches, and players understand, as well as implement year-round with a comprehensive resistance training program. It is worth mentioning that the “I don’t have time” argument is a lazy and apathetic one. Female athletes are five times more likely chance to get a non-contact ACL injury than males, so our role in setting them up for success needs to be a priority.

First and foremost, they need to strength train with a qualified strength coach, who has committed their entire career to study biomechanics, exercises physiology, and sports performance programming. Beware of charlatan coaches who look legitimate on social media and preach female empowerment yet have no body of work with young girls. Too, be on the lookout for social media influencers who look beautiful and skinny to a young girl, yet their bodyweight movements, a plethora of ab crunches, and hundreds of ground contacts for plyometric workouts aren’t going to suffice for a female athlete.

We have to remember our girls are humans who need to be treated with great care, trained with meticulous programming, and coached to execute the quality form. Worst case, if they do not have a strength coach, team coaches have the opportunity to sprinkle in exercises on the field or on the court for ten minutes, touch on every muscle group, and move on.

There are several physical training non-negotiables that need to occur year-round. For starters, girls need to strengthen the entirety of their system, from the feet to calves, to quadriceps, to hamstrings, to gluteals, to the trunk and upper body.

I do not care if the knee is lower extremity. This is an argument I hear a lot; to strengthen the hamstrings and quadriceps. It is tantamount to saying a car does not need all its pieces to function – the gas, the oil, the braking system, the engine, the steering wheel, and so forth.

Think of the female athlete’s body as one interconnected system, in which if it has one leak, it collapses.

If the shoulders are weak, this impacts the hips. If the core and hip flexors are over-activated, the glutes are under-activated. If the glutes are inhibited, the hamstrings are taking on the load. If the foot is pronated, the pelvis is internally rotated. If the pelvis is internally rotated, the knee goes into the valgus. If the knee goes into valgus, the torque is increased. And then what happens? I think you can guess.

Here is a visual demonstration of this messy chain reaction:

Reducing ACL Injury in Female Athletes

Of course, I could write a dissertation on the physical side of ACL reduction, but this isn’t the focus of this article, so here is what you need to know:

Total body strength train year-round

Dumbbell Floor Presses

Foot Elevated SL Bridge Hold

Female Athlete Hamstring Strength

Work on jumping and landing mechanics (ankle dorsiflexion, stable trunk and pelvis, hip flexion with hip hinge position, and hamstring recruitment)

Female Athlete Single Leg Landing Progression

Tornado Jumps for Female Athletes

Reinforce speed technique (posture, rhythm, coordination, ball of foot strike)

Rhythmic Skips Remote Training

Lateral March

Teach proper deceleration and change of direction, then expose them to a chaotic and competitive environment

2v2 Hip Turn Race

2v2 Curved Sprint

Okay, I just warmed up. That is the physical training piece, and if you are not doing this, start now because ACL injury reduction has many more layers, and there are several risk factors that also need to be addressed. Proper physical training in a practical setting is the bare minimum. In fact, it should be a standard set by all youth female athlete teams.

With the drills listed above, it is easy and quick to incorporate them into practice, whether it means adding the strength and plyometric drills into the warm-up or setting aside ten minutes to work on speed and agility. Too, you can encourage your female athletes to do

Now that the physical training is nailed down buckle up for the other pieces to ACL reduction. These start with understanding how they impact the nervous system and cause a potential breakdown in mechanics, then having open conversations with your female athletes about their lifestyles.

Let’s do this:

Sleep Quality

If a female athlete is not getting enough sleep, the Central Nervous System cannot do its job to execute the dynamic actions in the game, from the physical actions of cutting, changing direction, and running at maximum velocity, to making spontaneous decisions, being creative, and maintaining focus.

I do not care if a girl is doing all the balance and jumping exercises, nor do I care if she can Deadlift two times her body weight. Of course, these are a must to reduce her chance of blowing out a knee, but sleep is what allows her to train at her best, as well as recover her muscles with growth hormone production, and feel sharp for a game the next day.

One study examined young athletes who got less than 6 hours of sleep a night and concluded that injuries increased due to decreased muscle recovery, cognition, motor function, and focus (Milewski et al 2014). Another study was done in the Orthopaedic Journal of Sports Medicine also notes that young athletes who sleep for less than 8 hours a night chronically are at a much higher risk for musculoskeletal injuries. It is important to take into consideration sleep quality, as well. The same study suggests that frequent night awakenings can increase injury risk (Gao et al 2019).

Stress

Homework, standardized tests, projects, friend drama, and so much more stress in a female athlete’s life can hinder performance. Time and time again, I have seen athletes come into my gym and half-focused during a workout or not hitting new records like I thought they would.

The more I dug for what was going on, the more I realized what is going on in their personal life can be a bomb to their nervous system, so by the time they get to me or step on the pitch to play a championship game, they have exhausted their CNS and are unable to focus, make decisions and stay energized.

Some of the best ways to manage stress are through breathing and meditation. This can be done by simply going for a walk with no mobile device or lying down and staring at the sky or ceiling and focusing on belly breathing into a parasympathetic nervous system state.

Nourishment and Hydration

A banana for breakfast is not enough, nor is half a bottle of water.

Oh, and “forgot to hydrate” are three words I never want to hear again. Food and water are what keep us alive, functioning, and flourishing as humans and athletes.

A young female athlete’s body thrives off of proper nourishment with all the macronutrients, vitamins, and minerals she needs for energy and muscle recovery. Not enough calories are detrimental because this can lead to hormonal disruptions, fatigue, irregular periods, muscle soreness, and nervous system function.

According to Sports Medicine, the majority of young female athletes fall vastly short of their caloric needs, especially their carbohydrate intake. Carbohydrates are crucial for mental function and alertness, as well as optimizing muscle glycogen stores. Reduced glycogen leads to muscular weakness and reduced joint stability, as well as a breakdown in balance and landing mechanics (Elliot et al 2010).

As long as a female athlete is consuming adequate calories and hydration, she will be able to train, play and recover at her best with optimal neural function and control of her joints.

Menstrual Cycle

While studies still need to be conducted on whether or not a female is more susceptible to an ACL injury during the menstrual cycle, it is critical to alleviating possible performance hindering symptoms.

Some girls will say they experience more fatigue, brain fog, and bloating during the Luteal Phase (just before menstruation), and this can impact how they exert themselves during a workout. Instead of changing the workout, a female athlete’s best bet is to mitigate these symptoms by improving the factors above, such as sleep, stress management, and proper nutrition with enough carbohydrates for sustained energy, as well as protein for up building the muscles. During the menstrual “bleed” phase, some also report fatigue, which could be due to a loss in iron.

A great phone app that helps female athletes understand the unique symptoms of each phase is FitrWoman. It is important to gather data and journal symptoms over a long period of time to track consistencies and be able to take action in their sleep, recovery, and nutrition.

The ACL epidemic in young females involved in sports is an immense one, so we need to approach it with actionable solutions that look at injury reduction through a holistic lens. Physical training with proper stability, total body strength, and deceleration training is just glossing over the tip of the iceberg, with the other components of sleep, stress, nutrition, and menstrual cycle be other factors that need to be deeply examined and tweaked to set a female athlete up for good health.

REFERENCES

Elliot, D.L., Goldberg, L. & Kuehl, K.S. Young Women’s Anterior Cruciate Ligament Injuries. Sports Med 40, 367–376 (2010). https://doi.org/10.2165/11531340-000000000-00000

Milewski, M. D., Skaggs, D. L., Bishop, G. A., Pace, J. L., Ibrahim, D. A., Wren, T. A., & Barzdukas, A. (2014). Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. Journal of pediatric orthopedics, 34(2), 129–133. https://doi.org/10.1097/BPO.0000000000000151