Knee Injury Prevention

Original Editor - Aimee Tow

Top Contributors - Angeliki Chorti, Aimee Tow, Kim Jackson, Wanda van Niekerk and Temitope Olowoyeye  

Introduction[edit | edit source]

Knee injuries are common among people who play sports or do activities in competitive and non-competitive settings. Donnell- Fink et al.[1] reported that these injuries are responsible for about 10–25% of all sports-related injuries.

Knee injuries refer to a range of knee conditions which may involve different mechanisms of pathology and thus, result in the selection of different exercise regimes for their prevention. Recommendations to support exercise-based knee injury prevention programmes and guidance on their implementation have been provided in 2018 [2] and updated in 2023. [3] These guidelines provide evidence on exercises, their components, dosage, and delivery that have been shown to help prevent anterior cruciate ligament injuries and other knee injuries.

Exercise-based Prevention Programmes[edit | edit source]

The following programmes are recommended for reducing all knee injuries: 11+ and FIFA, HarmoKnee, and Knäkontroll, and those used by Emery and Meeuwisse, [4] Goodall et al, [5] Junge et al, [6] LaBella et al, [7] Malliou et al, [8] Olsen et al, [9] Pasanen et al, [10] Petersen et al, [11] and Wedderkopp et al. [12]

For reducing ACL injuries, exercise-based programmes include HarmoKnee, Knäkontroll, Prevent Injury and Enhance Performance (PEP), and Sportsmetrics™, and those used by Caraffa et al, [13] Heidt et al, [14] LaBella et al, [7] Myklebust et al, [15] Olsen et al, [9] and Petersen et al.[11]

Exercise Recommendations[edit | edit source]

Exercise programmes for knee injury prevention should incorporate multiple types of training including strength, plyometric, and core conditioning. [3] Prevention exercises should be performed for at least 20 minutes multiple times a week and sport specific training should occur for >30 minutes, multiple times per week. [3] Prevention exercises should start in the "pre-season" before the athletic sport commences and should continue throughout the regular season; high compliance with exercise-based knee injury prevention programmes must be ensured, particularly in women athletes. [3]

Clinicians may also use exercise-based neuromuscular training programmes in the late phase of ACL reconstruction rehabilitation for the secondary prevention of ACL injuries. [3]

Exercise-based knee injury prevention programmes should target all young athletes, not just individuals identified through screening as being at high risk for ACL injury, to optimally avoid injuries and reduce cost. [3] Implementation of exercise-based ACL injury prevention programmes should include athletes 12 to 25 years of age involved in sports with a high risk of ACL injury. [3]

ICF Classification Category[edit | edit source]

Exercise-based knee injury prevention programmes relate to the following ICF activities and participation codes: “d410 Changing basic body positions,” “d450 Walking,” “d4552 Running,” “d4553 Jumping,” “d4559 Moving around,” “specified as direction changes while walking or running,” “d9200 Play,” “d9201 Sports,” and “d9202 Arts and culture.” [3]

Sample Exercises for Field Sports[edit | edit source]

Field sports include sports such as soccer, field hockey and ultimate frisbee, to mention a few.[2] Athletes should perform Phase I, II, III before training and practice. Before games, Phase I and II should be performed.

Phase I (Warm up prior to game and practice)[edit | edit source]

  • Jog forward
  • Airplanes dynamic
  • Jog backwards
  • Lunge with opposite arm sky reach
  • High skips/bounding skips
  • Dynamic thigh/quad stretch with opposite arm sky reach and heel raise
  • Skips with front kick
  • Lateral lunge both sides with 180 pivot
  • Karaoke
  • Open gate (hip flex ER) with side shuffle
  • Circle drill side shuffle
  • Close Gate (hip flex IR) with forward shuffle

Phase II Functional movement (prior to training/practice only)[edit | edit source]

Participant should be able to perform Tier 1 exercises for 45 seconds x 2 with good form before progressing to the next tier.

2x45 sec (a, b) or 2x30 sec (c, d, e)

Tier 1 Tier 2 Tier 3 Tier 4
a. Forward ½ plank Forward full plank Plank hands on ball Plank feet on ball
b. Side plank ½ Side plank full Side plank ½ leg lifts Side plank full left lift
c. Single leg bridge alternating Double leg roll outs on ball Single leg roll outs on ball Eccentric hamstring curl
d. Lunge holds Alternating lunges Scissor/switch lunges 180 scissor lunges
e. Squat lateral weight shift Squat heel raise Squat jumps 4-square squat jumps
f. Single leg ball dribble around standing leg Single leg passing Single leg volley Skater hop passing

Phase III Coordination/alignment/cutting/reaction/plyometrics[edit | edit source]

Landing alignment[edit | edit source]

Tier 1 Tier 2 Tier 3
Squat heel raise arm swing Clock hops Single leg diagonal forward hops
Diagonal single leg hops V 90 degrees single leg hops Skater hips pause forward

Cutting[edit | edit source]

Tier 1 Tier 2 Tier 3
3-6 step deceleration outside leg cutting 1 step deceleration outside leg Diagonal cut with ball
3-6 step deceleration inside leg cutting 1 step deceleration inside leg Scissors lateral leap diagonal

Reaction[edit | edit source]

Tier 1 Tier 2 Tier 3
Lateral jump with side contact 3 step deceleration with 90-180 degree pivot (with cuing on when to cut) 1 step deceleration with 90-180 degree pivot (with cuing on when to cut)
Squat jump with lateral cut 3-6 feet with cuing on which way to cut 3 step deceleration with diagonal cut (with cuing on when to cut) 1 step deceleration with diagonal cut (with cuing on when to cut)

Sample Exercises for Court Sports[edit | edit source]

Court sports include sports such as volleyball, basketball, tennis, netbal, etc.[2] Athletes should perform Phase I, II, III before training and practice. Before games, Phase I and II should be performed.

Phase I Dynamic Warm up[edit | edit source]

  • Jog
  • Bear crawl
  • Backwards Jog
  • Lunge with side reach
  • Lateral shuffle
  • Thigh/quad stretch with heel raise and overhead reach dynamic
  • Karaoke
  • Lateral lunge
  • High Skips
  • Open Gate
  • Forward Skips
  • Close Gate

Phase II Foundational Movements trunk and hip strengthening[edit | edit source]

Participants can progress to higher tiers when they have appropriate form and endurance.

2x45 seconds or 2x30 seconds

Tier 1 Tier 2 Tier 3 Tier 4
Forward ½ plank Forward full plank Plank hands on ball Plank feet on ball
½ side plank Full side plank Full side plank with leg hold Full side plank with repeated left lifts
Lunge holds Alternating step back lunges Jumping scissor lunge Jumping scissor lunge with 180 degree turn
Double leg bridge Double leg bridge with roll out Single leg bridge with top leg straight Single leg bridge ball rollout
Squat holds with lunges Double leg squat with toe raise Double leg squat jumps Squat jump square both directions
Single leg balance arm swing/dribbling ball Single leg balance passing Single leg squat Single leg squat clocks

Phase III: Movement, coordination, deceleration, cutting, and plyometric training[edit | edit source]

Tier 1 Tier 2 Tier 3 Tier 4
Broad jumps Forward/lateral jumps Jump with single leg landings Forward and lateral single leg landings
3 step deceleration 3 step deceleration and lateral shuffle 1 step deceleration 1 step deceleration and lateral shuffle
Lateral cuts Diagonal cuts Skater hops with pause Skate Hops

Clinical Implications and Future Research Directions[edit | edit source]

The use of exercise-based knee and ACL injury prevention is currently strongly suggested due to evidence for primary benefits as well as some preliminary support on secondary ACL injury prevention.[3] All athletes are recommended to perform prevention programmes instead of high risk athletes only, and guidelines report no harm in performing prevention programmes. [3] However, greater diversity in the athlete populations studied is needed to represent communities currently underrepresented in the literature, as well as those underserved or overlooked by current health care systems. [3]

There is still scarce evidence regarding components, dosage and delivery, as well as compliance of exercise-based knee and ACL injury prevention programmes. More research is still needed on the dose-response relationship and around improving compliance and adherence. [3] Alternative implementation models and models that look beyond the physical aspects of injury prevention may also need to be considered in future research. [3]

References[edit | edit source]

  1. ↑ Donnell-Fink L., Klara K., Collins J., Yang H., Goczalk M., Katz J., Losina E. Effectiveness of knee injury and anterior cruciate ligament tear prevention programs: a meta-analysis. PloS one. 2015 Dec 4;10(12):e0144063.
  2. ↑ 2.0 2.1 2.2 Arundale A., Bizzini M., Giordano A., Hewett T., Logerstedt D., Mandelbaum B., et al. Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy. JOSPT 2018 Sep;48(9):A1-42.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 Arundale A., Bizzini M., Dix C., Giordano A., Kelly R., Logerstedt D., et al. Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. JOSPT 2023, Jan 1; 53(1): CPG1-34.
  4. ↑ Emery C., , Meeuwisse W. The effectiveness of a neuromuscular prevention strategy to reduce injuries in youth soccer: a cluster-randomised controlled trial. Br J Sports Med. 2010; 44: 555– 562.
  5. ↑ Goodall R., Pope R., Coyle J., Neumayer R. Balance and agility training does not always decrease lower limb injury risks: a cluster-randomised controlled trial. Int J Inj Contr Saf Promot. 2013; 20: 271– 281.
  6. ↑ Junge A., Rösch D., Peterson L., Graf-Baumann T., Dvorak J. Prevention of soccer injuries: a prospective intervention study in youth amateur players. Am J Sports Med. 2002; 30: 652– 659. https://doi.org/10.1177/03635465020300050401
  7. ↑ 7.0 7.1 LaBella C., Huxford M., Grissom J., Kim K-Y., Peng J., Christoffel K. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. Arch Pediatr Adolesc Med. 2011; 165: 1033– 1040.
  8. ↑ Malliou P., Amoutzas K., Theodosiou A., Gioftsidou A., Mantis K., Pylianidis T., Kioumourtzoglou E. Proprioceptive training for learning downhill skiing. Percept Mot Skills. 2004; 99: 149– 154.
  9. ↑ 9.0 9.1 Olsen O-E., Myklebust G., Engebretsen L., Holme I., Bahr R. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ. 2005; 330: 449.
  10. ↑ Pasanen K., Parkkari J., Pasanen M., Neuromuscular training and the risk of leg injuries in female floorball players: cluster randomised controlled study. BMJ. 2008; 42: 502– 505.
  11. ↑ 11.0 11.1 Petersen W., Braun C., Bock W., Schmidt K., Weimann A., Drescher W., et al. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg. 2005; 125: 614– 621.
  12. ↑ Wedderkopp N., Kaltoft M., Lundgaard B., Rosendahl M., Froberg K. Prevention of injuries in young female players in European team handball. A prospective intervention study. Scand J Med Sci Sports. 1999; 9: 41– 47.
  13. ↑ Caraffa A., Cerulli G., Projetti M., Aisa G., Rizzo A. Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc. 1996; 4: 19– 21.
  14. ↑ Heidt R., Sweeterman L., Carlonas R., Traub J., Tekulve F. Avoidance of soccer injuries with preseason conditioning. Am J Sports Med. 2000; 28: 659– 662.
  15. ↑ Myklebust G., Engebretsen L., Brækken I., Skjølberg A., Olsen O., Bahr R. Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med. 2003; 13: 71– 78.
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