Please ensure Javascript is enabled for purposes of website accessibility

New Trends in ACL Tears and How to Prevent One

Dr. Rick Cunningham | Vail-Summit Orthopaedics

There are 200000 injuries to the Anterior Cruciate Ligament (ACL) per year in the United States representing a cost of $3 billion.

Three-fourths of all ACL tears are non-contact injuries (think skiing) and typically occur during deceleration lateral pivoting or landing. Most people who tear an ACL will hear a pop feel their knee “giving way” and notice immediate pain and swelling.

Female athletes are three to four times more likely to tear an ACL than male athletes playing at similar levels in the same sport. Since passage of Title IX in 1972 female participation in high school sports has increased nine-fold to 2.8 million while male participation has been steady at 3.8 million. Indeed there is an epidemic of female athletes tearing their ACLs.

I have also recently seen an increase in young teenagers (12-14 year olds) tearing their ACL which is concerning. In these young patients I still recommend fixing their ACLs. Orthopedic knee surgeons used to wait on these kids and try to have them modify their activities but as kids they don't and then they come back when they are done growing at 16-17 and their knees are much worse with bad cartilage injuries and even arthritis.

Why are women more at risk?
There are several factors at play but they are mostly neuromuscular. Women tend to land in a knock-need alignment. They also land with their center of gravity being posterior or behind their knee (ie. “landing in the back seat”) and these positions place increased forces on the ACL and can cause it to tear. Women's ACLs are also generally smaller in diameter than males and their tissues are generally more lax and these factors predispose to tearing the ACL. Women's intercondylar notch at the end of the femur (kind of like the valley through which the ACL passes) is narrower and can more easily pinch the ACL in sports and predispose it to tear. Some experts question whether there are hormonal factors at play but this is unproven.

How do professional female athletes train to help avoid ACL tears?
Most professional female athletes work hard to keep strong but more importantly they prevent imbalances in their musculature. Numerous studies comparing athletes who went through neuromuscular training and those who did not demonstrated lower rates of ACL tears in those who participated.

Gluteal (buttock) strengthening is critical as these muscles prevent your knee from falling into that knock-need alignment which places increases stresses across the ACL. Core strengthening is also critical so that athletes land directly over their feet and not land in the back seat which again stresses the ACL.

I recommend preseason and in-season plyometric strengthening and balance training to reduce the risk of ACL tears. Even 15 minutes of neuromuscular training done once a week for six weeks has shown to help.

Dr. Rick Cunningham is an orthopaedic specialist with Vail Summit Orthopaedics. He specializes in ACL reconstruction sports injuries to knee and shoulder partial and total knee replacement. For more information visit or