Female athletes have a higher risk of anterior cruciate ligament (ACL) injury than males. Combining exercises, such as strength, balance, and flexibility, in a preventive training program may help reduce this risk.

ACL is a ligament in the knee. Most ACL injuries do not occur through direct contact, which means that prevention exercises may help reduce injury risk.

A person may wish to incorporate a combination of exercise categories into a preventive training program. They may consider including exercises that improve strength, mobility, and flexibility.

This article discusses ACL injury prevention exercises, why female athletes face a higher risk of ACL injury, and appropriate post-injury activity.

A note about sex and gender

Sex and gender exist on spectrums. This article will use the terms “male,” “female,” or both to refer to sex assigned at birth. Click here to learn more.

Was this helpful?
A person performing a squat with a kettlebell.Share on Pinterest
Oleg Breslavtsev/Getty Images

Females are more likely to experience ACL injuries than males.

Most ACL injuries are noncontact. These typically occur during deceleration, landing movements, or a change in direction.

ACL injuries can range from mild to severe, but most ACL injuries are nearly or fully complete tears.

Evidence supports that preventive training programs can help reduce ACL injury risk. Experts have not determined a single best training program for ACL injury. However, a position statement by the National Athletic Trainers’ Association suggests that training programs should have multiple components and involve at least three of the following:

  • strength
  • plyometrics
  • agility
  • balance
  • flexibility

Experts recommend that professionals supervise and implement training programs to ensure proper feedback and quality movement patterns.

Preventive training programs can incorporate a variety of different exercises.

Some options that may help prevent ACL injury include:

  • Leg exercises: For instance, single- and double-legged squats, lunges, Nordic hamstring exercises, and similar strength training.
  • Core exercises: Examples include planks and bridges.
  • Plyometric exercises: For instance, skaters, single-leg forward and backward hopping, and sport-specific drills.
  • Running drills: Examples include zigzag running, bounding, and backward running.
  • Flexibility exercises: For instance, dynamic stretches for the hamstrings, quadriceps, hip adductors, hip flexors, and calf muscles.

According to a 2017 study, specifically training the hamstring muscles may decrease the risk of ACL injury in females by improving the hamstring-to-quadriceps co-activation ratio. A co-activation ratio describes how two muscles activate simultaneously, and a relatively equal ratio is considered ideal.

Research shows that females are more likely to experience ACL injury — in fact, female athletes injure their ACLs 2–8 times more often than males.

Several factors may be responsible for this. Some examples include:

  • joint morphology, or how a person’s joints have formed
  • family history
  • hormones
  • neuromuscular control and patterns, which is the body’s unconscious ability to create controlled movement

Specifically, females tend to activate their quadriceps more than their hamstrings during functional movements. As a result, their ACL experiences more force, elevating injury risk.

Having an ACL injury can be frustrating for people who are used to being very active. While it may be possible to maintain some level of activity level with an ACL injury, it depends on factors such as:

  • whether or not surgery is needed
  • the degree of the injury
  • if there is any injury to the surrounding area

It is important for people to follow a doctor’s prescribed recovery and rehabilitation protocol.

Mild ACL tears usually have a rehabilitation period of several months, but partial or complete tears may be surgically repaired and require a longer rehabilitation period. Physical therapy also plays an important role in ACL injury recovery.

There is currently no consensus regarding a post-injury rehabilitation program’s specific details and progression, including a return to exercise.

Rehabilitation after ACL repair may include:

  • bracing and weight-bearing progression using assistive devices such as crutches
  • range-of-motion training
  • neuromuscular and proprioceptive training, such as the use of a balance board
  • exercises that reestablish muscle strength, power, and endurance
  • running

Return to sport depends on someone’s specific readiness and test outcomes.

Female athletes are more likely to experience ACL injuries than males. This may be due to family history, hormones, neuromuscular control, and joint morphology, which is how a person’s joints have formed.

However, most ACL injuries do not involve direct contact, which suggests that prevention training programs can help decrease injury risk.

While there is no optimal prevention training program, research notes that programs should combine at least three of the following categories: strength, plyometrics, agility, balance, and flexibility. Specifically, improving hamstring strength may also reduce injury risk.