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Female Athletes and ACL Injuries: Why the Warm-Up Matters

The anterior cruciate ligament (ACL) is one of four main ligaments within the knee. It crosses the center of the joint and plays an important role in providing knee stability. Unfortunately, it is also a common injury site in many popular sports, such as soccer, skiing, basketball, and football. An estimated 200,000 ACL injuries occur every year in the United States. Of these injuries, 70% are non-contact in nature and tend to occur in two types of scenarios. The first scenario occurs during changes of direction when an individual’s knee collapses down and in. The second risky position happens when a person lands with his or her knees hyperextended after a jump.

While anyone can sustain an ACL tear, the highest injury rates occur among female athletes. In fact, high school and collegiate female athletes are up to 3 times more susceptible to this type of injury than male athletes who play the same sport. Extensive research on this difference in injury rates reveals a variety of contributing factors. Anatomical differences, such as knee position relative to a wider pelvis or having a narrow ACL can both contribute to higher injury risk. Researchers have also found that females tend to be more quadriceps dominant when jumping and landing. This places the knee in a vulnerable, extended position when athletes land.

While some risk factors cannot be modified, it’s not all doom and gloom in the world of ACL injury research. Researchers have found that female athletes demonstrate a 41% reduction in ACL injury rate after participating in a specific warm-up known as the Prevent Injury, Enhance Performance (PEP) program. This warm-up was designed by physical therapists at the Santa Monica Orthopedic and Sports Medicine Group. It includes agility and sport-specific exercises that address deficits in movement coordination, as well as hip and core strength. A separate study conducted by LaBella and colleagues in 2011 found that a neuromuscular warm-up led to a 56% reduction in non-contact ACL injuries, as well as a 66% reduction in non-contact ankle sprains.

Anterior cruciate ligament injuries are all too common in today’s sports landscape. While certain risk factors are difficult to address, we are not completely powerless in improving the safety of our athletes. Physical therapists, athletic trainers, coaches, and parents can all play a vital role in understanding and identifying risk factors for ACL tears. Simple changes in how we warm up and prepare for athletics activities can not only enhance our performance, it can keep our bodies healthy and participating for years to come.


1. Ahmad CS, Clark AM, Heilmann N, Schoeb JS, Gardner TR, Levine WN. Effect of
gender and maturity on quadriceps-to-hamstring strength ratio and anterior
cruciate ligament laxity. Am J Sports Med. 2006 Mar;34(3):370-4.
2. LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled