November 2007

Preventing ACL Injuries in Women

Anthony Luke M.D., M.P.H.
Primary Care Sports Medicine Specialist
UCSF Sports Medicine Center

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee, with women more prone to ACL tears than men.

As early as the 1990s, higher rates of injuries to the ACL in women vs. men have been observed (6:1 in basketball and 2:1 in soccer).i Researchers have speculated that the greater risk to women is due to various factors, including hormonal causes, anatomical variations between men and women and differences in neuromuscular control. The most promising explanation is a female athlete's ability to balance (proprioception) and control her knee with her muscles (neuromuscular control). Because of anatomical and muscle strength differences between average men and women, females have less stability and upper body control, which can lead to an awkward fall and subsequent ACL injury.

ACL Tear Prevention

Research has shown that proprioception and neuromuscular training are effective in reducing the risk of ACL injury in women. The following are recommended exercises for ACL injury prevention:

  • Use of balance equipment, such as wobble board and therapeutic exercise balls. A study of a weekly six-month, home-based balance-training program using a wobble board showed improvements in static and dynamic balance for the intervention group, but not in the control group (Emery et al., 2005). The protective effect of balance training in over six months decreased the number of self-reported injuries (relative risk of injury 0.2, 95 percent CI 0.05 to 0.88), with the number needed to treat to avoid one injury over six months being 8 (95 percent CI 4 to 35).
  • Careful work on coordination, balance and hamstring strength. In one study, female soccer players, ages 14 to 18, who underwent a neuromuscular training program — Preventative Injury and Enhancement Program (PEP) — consisting of basic warm-up activities, stretching techniques for the trunk and lower extremity, strengthening exercises, plyometric activities and soccer-specific agility drills had 88 percent less ACL injuries in the first year and 74 percent less injuries in the second year (Mandelbaum et al, 2005).

Referring patients to a health professional familiar with similar proprioception programs may be the best measure to help athletes reduce their chances of an ACL tear.

To contact Dr. Anthony Luke or Dr. Christina Allen who specializes in ACL surgery for women, call the UCSF Sports Medicine Center at (415) 353-7566. Appointments can be requested online.

For more information, contact the Physician Referral Service at UCSF Medical Center:

Phone (888) 689-UCSF or (888) 689-8273

Other Resources

UCSF Sports Medicine Center
A Female's Aching Knees
ACL Reconstruction Surgery
Patient Profile — Knee Surgery Doesn't Slow Down Soccer Player


Caraffa, A., Cerulli, G., Projetti, M., Aisa, G., Rizzo, A. (1996) Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 4,19-21.

Dick RW, Arendt E. Gender specific knee injury patterns in collegiate basketball and soccer athletes. Med Sci Sports Exerc 25:S159, 1993.

Emery , C.A., Cassidy, J.D., Klassen, T.P., Rosychuk, R.J., Rowe, B.H. (2005) Effectiveness of a home-based balance-training program in reducing sports-related injuries among healthy adolescents: a cluster randomized controlled trial. CMAJ. 172: 749-54.

Hewett, T.E., Myer, G.D., Ford, K.R., Heidt, R.S. Jr, Colosimo, A.J., McLean, S.G., van den Bogert, A.J., Paterno, M.V., Succop, P. (2005) Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 33, 492-501.

Mandelbaum, B.R., Silvers, H.J., Watanabe, D.S., Knarr, J.F., Thomas, S.D., Griffin, L.Y., Kirkendall, D.T., Garrett, W. Jr. (2005) Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2 year follow up. Am J Sport Med 33, 1003-1011.

Myklebust, G., Engebretsen, L., Braekken, I.H., Skulberg, A., Olsen, O.E., Bahr, R. (2003) Prevention of ACL injuries in female handball players: a prospective intervention study over 3 seasons. Clin J Sports Med. 13, 71-78.