Minimizing the Risk of ACL Injuries in Athletes

By Leython Williams, PT, DPT for Athletico Physical Therapy

One of the most feared injuries in all of sports is injury to the Anterior Cruciate Ligament (ACL), yet this continues to be among the most common injuries in active individuals. Even as the latest evidence in injury prevention has decreased the prevalence of some other injuries, ACL tears have continued to be an issue over the years. Many of our friends, family members, and/or favorite athletes have suffered from ACL tears. Thus there have been several studies conducted to get to the core of what actually causes the ACL to tear.

As with any injury, there is not one thing that we can point to and say “Alas! This is what I can do to make certain that my ACL remains intact…forever!” Injuries are multi-factorial and despite the term “injury prevention,” they cannot be completely prevented. As long as people are active, injuries will occur. However, with much thought and intentionality in our workout regimens and treatment planning, we can certainly decrease the frequency of these traumatic injuries. I’m confident that as the field of physical therapy continues to evolve and we continue to uncover various aspects of mechanisms of injury in an ACL tear, clinicians and researchers will develop more and more strategies to decrease the likelihood of ACL injury. Here are some things to consider in your injury prevention efforts:

1. Strong Core = More

“The core” is a complex series of muscles that are responsible for providing proximal stability for the pelvis, hips, knees, ankles, etc. to establish and maintain proper function in sport (and in activities of daily living). Without a stable base (strong core), injury is more likely up and down the kinetic chain.

Decreased core stability can cause:

  • Pelvic Drop
  • Hip Internal Rotation
  • Knee Valgus
  • Tibial External Rotation
  • Excessive Ankle Pronation

*All of the above are associated with increased risk for ACL injury.  

2. Mobility

Hip Internal Rotation (IR): Although Hip IR in itself can contribute to an ACL injury, being deficient in available Hip IR can also put an athlete at greater risk for injury. When our bodies don’t have certain available ranges of motion, our brains and central nervous systems are not able to prevent us from going into those ranges. Therefore, if an athlete does not have adequate Hip IR, they are unable to prevent this motion from occurring during functional activity.

Hip External Rotation (ER): This motion is important in helping athletes avoid knee valgus, which is crucial in avoiding ACL injury. Adequate Hip ER mobility will allow the athlete to establish and maintain athletic positions during their performance without harmful valgus stresses to their knee joints.

Hip Extension: It is necessary to be able to activate the posterior musculature to decrease the likelihood of knee collapse with dynamic activity. Inadequate hip extension leads to poor muscular compensatory patterns that could lead to injury.

Dorsiflexion: Dorsiflexion is one’s ability to bring their toes upward toward their shin. Dorsiflexion range of motion is very important in absorbing forces during a landing from a jump, deceleration and sudden changes of direction. The force absorbed at the ankle joint with full dorsiflexion motion decreases stress to knee joint. 

3. The Separation in Deceleration

Most competitive athletes develop some level of speed, quickness and agility as it relates to their respective sport. The elite athletes can speed up and slow down better than anyone! One common risk factor we see with ACL injuries is a subpar ability to decelerate. If an athlete is going to stop or change direction, they need to have the necessary skills to control their body in space when going from accelerating, to decelerating, and then back to accelerating again.

In order to assess an athlete’s ability to decelerate, it is important to observe how they do with the following change of direction drills:

Linear Cone Drill: Set up cones 3 yards apart, sprint to the cones, decelerate into a lunge, backpedal to cones. Continue for designated sets/reps.

Lateral Hurdle Run w/ Pause: Set up 3-5 hurdles, laterally run over the hurdles, focus on a deep pause for about 2 seconds when changing direction.

Ickey Shuffle: Set up a ladder, run diagonally across the ladder, 2 feet in, 1 foot out. Focus on proper hip/knee angles on outside of ladder.

*Emphasize the end of the drills –Athletes should come to a complete stop abruptly when ending the drill instead of jogging or coasting. To decelerate, lower the hips and slightly overreach by contacting the ground in front of the hips. This will help enhance deceleration over time.

*Focus on force reduction deceleration technique – Start deceleration drills off with an agility ladder and only perform the drills around 70 percent.  Focus on digging the foot into the ground, coming to a complete stop, and maintaining low hips and proper body angle. Progress by increasing speed and more complex agility/plyometric drills.

*Add tempo into strength training – Emphasize the eccentric phase (muscle lengthening phase) of exercise. For example, instead of doing regular squats, descend down into the squat very slowly to work on controlling the load. Isometrics can also improve deceleration. Descend down into the bottom of the squat and hold for 5-10 seconds before exploding back upward. 

4. Prepare For Your Landing

Tune in to any football game on any level, it won’t take long for you see a wide receiver jumping up to make a catch or a running back attempting to hurdle a defender. Some level of jumping or hopping is part and parcel to most competitive sports. However, most ACL tears don’t occur in the jumping motion, but in the landing! An athlete absorbs up to 7-10x their own body weight in ground reaction forces upon their landing from a single jump. It is imperative that we are working with athletes to ensure that their landing mechanics and patterns are solid in effort to avoid repetitive stress and traumatic injury.

A quick way to determine an athlete’s susceptibility to injury is to evaluate their ability to absorb eccentric stresses in their landing from a “Depth Drop” or “Step Down Test.”

Depth Drop: The athlete steps down from (or drops) from a 6-18 inch plyobox or step. The athlete is then instructed to land simultaneously with both feet. We’d like to see the pelvis, hip, knee and ankle remain in alignment with very little to no hip drop, hips back and knees bent. Ask the athlete to hold the landing for 3 seconds.

*If the athlete steps down and the hip internally rotates and/or their knee collapses into valgus, this is something that must be corrected to decrease risk for injury.

Please note that this blog is not intended to be an exhaustive list of injury prevention tools. Instead, it is my hope that the reader will be able to gain some insights into ACL injury prevention that aren’t regularly discussed.

To learn more about ACL injury prevention and Athletico’s ACL 3P Program, please email Or find an Athletico ACL expert near you!

Read more health resources related to these topics:

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3 Reasons to Attend the Chicago Sports Summit

By Athletico Physical Therapy

We are proud to be the title sponsor of the third annual Chicago Sports Summit!   What better way to spend a morning than meeting pro athletes, Olympians and general managers of Chicago’s pro teams?

There are a lot of reasons to join us at the Chicago Sports Summit on October 3, but here are three of the best:

  1. Amazing panelists. Listen to Olympic medalists, professional athletes, Chicago pro team general managers and our very own Performing Arts Program Manager Julie O’Connell, PT, DPT, OCS, ATC, as they get together to discuss hot topics affecting sports and sports business.
  1. Great networking. The Hyatt Crystal Ballroom will be full of 400 people you’ll want to meet, including Midwest Orthopaedics at Rush physicians, sports medicine industry reps and other valuable business connections.
  1. Support a good cause. Last, but certainly not least, the Summit benefits some amazing causes that support Chicago’s youth: After School Matters and Girls in the Game. Both organizations help students reach their academic potential and learn life skills through participation in after school programs.

For more information or to purchase a ticket or table, visit See you on October 3rd!

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Back to Basics: 3 Injury Prevention Tips for Dancers

By Athletico Physical Therapy

As summer starts winding down, dancers are getting ready to transition to the fall program season. Preparing for the season’s big shows means long hours spent at rehearsals on top of other responsibilities, such as academics, work and household duties.

During this time of year, it can be easy to overlook some of the fundamentals of injury prevention when trying to fit in a rehearsal into a busy schedule. However, this is the time when the basics like proper warm up and nutrition matter the most. To help dancers minimize the risk of injury and stay ready for their big shows, we are highlighting three basic injury prevention tips below:

1. Warm Up

To minimize the risk of injury during practices and performances, dancers should incorporate dynamic warm-ups into their training routine. Dynamic warm-ups increase heart rate and get the blood flowing so that the muscles become more pliable and able to stretch. This helps prime the body for physical exertion and minimizes the risk of injury to muscles or joints. A few examples of dynamic warm-ups include body weight squats, jumping jacks, and forward and backward lunges.

Learn more about dynamic warm-ups, as well as cooling down after activity, by reading “Warming Up vs Cooling Down: Things to Know.

2. Cross Train

Although technique training is important, dancers should also consider adding cross training into their routine to improve endurance, strength and flexibility. Swimming or biking are activities that can help improve endurance, while strength training can improve muscular fitness. Additionally, incorporating exercises like Pilates into training can help dancers improve flexibility, balance and core stability.

3. Maintain Healthy Habits

In order to be in peak condition, dancers should focus on their general health in addition to their training. This includes maintaining a healthy diet, staying hydrated and getting enough sleep. Since dancers don’t typically have an off-season, they are more likely to experience altered sleep-wake rhythms, which can increase the risk of illness and musculoskeletal injuries. For tips on how to get better sleep, read “Eat, Sleep, Dance, Repeat: The Importance of Sleep for Dancers.

These three tips can help both experienced and novice dancers keep their bodies healthy to minimize the risk of injury during practices and performances. Should an injury occur, make sure to schedule an appointment at a nearby Athletico location so our team can help you heal.

If you are a dancer who would like to learn more about our Performing Arts Rehabilitation program, please email

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Treating a Different Kind of Achilles Tendon Pain

By Sarah Ryerson, PT, ATC, CSCS for Athletico Physical Therapy

Calf stretching, ice and activity modification are commonly used as treatment for those who suffer from Achilles tendinosis. However, when traditional treatment fails to relieve symptoms, the problem may be in the diagnosis.

Achilles tendon pain localized in the heel (known as insertional Achilles tendinopathy), can benefit from different treatment than when Achilles pain is present in the mid-portion of the Achilles tendon (known as intertendendinous Achilles tendinopathy). Mid-portion Achilles tendinopathy is primarily a tensile loading problem involving the ability of the Achilles to resist stretching, while insertional Achilles tendinopathy is a compression issue.

When the ankle is loaded, which occurs when placing full weight on the foot during walking, the Achilles tendon is stretched and becomes compressed against its attachment site on the heel. This flat foot loaded position, placing the ankle in a position of maximal dorsiflexion, is also the position for stretching the calf. It is easy to understand why calf stretching would only compress the tendon and exacerbate the condition further. Therefore the best treatment includes avoiding stretching the Achilles. Other helpful treatment strategies include:

  • Discontinue running, especially if symptoms are provoked for more than three hours following a run
  • Avoid running uphill or extensive stair climbing
  • Avoid wearing minimalist running shoes, flat shoes such as flip-flops or walking barefoot
  • Use a heel lift in shoes, wear shoes with a heel (wide sole tennis shoe or wedge < 2″), or tape the Achilles or ankle to avoid excessive stretch on the Achilles
  • Use ice as needed to manage symptoms
  • Strengthen the calf in a protected position

Once the symptoms have resolved during general walking and stairs, calf strengthening can be initiated. Begin with calf raises in a shorted position (small book placed under heel) and progress to single leg calf raises from the floor. Avoid calf raises incorporating a heel drop off the edge of a step. Instead work to develop the amount of load the tendon can withstand by adding weight using a weighted backpack or weight vest. Pain should always be a guide with avoidance of soreness for greater than 2-3 hours following exercise.

It is important to note that these guidelines provide a basic recommendation for treatment and all conditions are unique, so always seek a comprehensive examination should self-management fail to resolve the symptoms. The entire lower extremity often contributes to the cause of the pain and the tendinopathy may return if the source of the problem is not properly addressed. Therefore, an evaluation or free injury screening by an experienced physical therapist at Athletico Physical Therapy can help you target the source of the problem and get you back on your feet and running.


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