Prevention, Treatment, Performance

ACL Injury – Prevention, rehabilitation and reducing the risk of re-injury when return to play

If you play a sport that involves a lot of cutting, turning or change of direction then there is a risk of sustaining an injury to an important ligament in your knee called the Anterior Cruciate Ligament (ACL).  This can happen in contact and non contact situations. During football (soccer) the most common way to injure your ACL is during non contact situations.  These injuries happen when the body is unable to control the forces that come through the knee, either because of poor technique in the way you change direction, weakness in the muscles around the knee and hip, wearing the wrong type of footwear for the field you are playing on, or fatigue.

Females tend to injure their ACL’s more commonly than males in football.

ACL’s can be stretched (a grade 1 or grade 2 injury) or if there is enough force ruptured (grade 3 injury). Once an ACL has ruptured it does not rejoin or regrow.

What are the symptoms of an ACL injury?

Every incident is different and the ACL can be injured in contact and non contact situations.  The ligament can also be injured in isolation, or there can be damage to other structures within the knee joint and to the ligaments that stabilise the knee.  The ‘text book’ story of an ACL injury is when the athlete changes direction, the knee callapses and they hear a ‘pop’ from within the knee, and the knee subsequently swells up.  Other symptoms can include:

  • pain in the knee when you put weight through it
  • pain and loss of movement at end range of knee flexion or extension
  • feeling of instability or giving way

Can you prevent ACL injuries from happening?

Yes, it appears that we can reduce the risk of getting an ACL injury.  There have been a number of studies that have shown that by doing a consistent warm up such as the FIFA 11+ or the PEP programme a couple off times a week reduces the risk of injuring your ACL.  This is because they include strengthening exercises and neuromuscular control exercises as part of the warm up.  Increasing your knee flexion angle (bending your knee more) when changing direction appears to reduce the risk of non-contact ACL injuries.  Wearing the correct shoes for the field you are playing on can make a difference because if you are using shoes that have too much traction or grip then your foot can get stuck and the forces can go up to the knee.   Practicing change of direction and agility exercises when fatigued may reduce ACL injuries.

What should you do if you suspect you have injured your ACL?

In the acute situation the current recommendation is to apply RICED management:

Rest (from running / sport etc… if you can take weight comfortably through the leg then you can walk on it) but crutches can be useful to make it more comfortable to weight bear.

Ice (you can use crushed ice in a bag for 10-15 minutes at a time, with something like a food cling wrap or a damp tea cloth between the ice and your skin to reduce the risk of ice burns). Repeat every couple of hours.

Compression: Use tubigrip or an elastic bandage

Elevation: Keep the knee elevated to try and reduce swelling

Diagnosis: It is important to see a physio or your GP to get an accurate diagnosis and so you can start your management plan as soon as possible.

You can book an appointment with one of our therapists by clicking here.

What can your Physio do in the acute period after an ACL injury?

Physiotherapists are trained in the diagnosis an management of ACL injuries.  They can refer you for an X-ray and to Sport and Exercise Medicine Specialists or Orthopedic Surgeons to get an MRI to confirm the ACL rupture and to investigate the extent of damage to other structures in the knee such as articular cartlidge, meniscus, ligaments, tendons and muscles.

Make an appointment with your physio as soon as possible.  They can help you improve and maintain the movement in your knee, reduce your pain and safely get you moving.  They can provide crutches, education and advice and give you strategies to reduce muscle wasting that can happen if you don’t keep exercising and using your leg.

Should you have surgery if you have ruptured your ACL?

There is a trend in sports medicine to try conservative rehabilitation for an ACL injury rather than immediately have an ACL reconstruction surgery.  It is important to start your rehabilitation straight away to reduce muscle wasting and There are a number of factors that can affect your decision to have an operation and an open and honest dialogue with your physiotherapist and orthopaedic surgeon is important to make the right decision for you.  The indication for surgery is usually failed conservative management (where you have gradually tried to return to change of direction sports but the knee gives way or is unstable).

Allowing the inflammation and swelling on your knee to go down and getting full range of movement before having an operation is important.

Post surgical rehabilitation for ACL injuries

After surgery your physiotherapist can guide you through the different phases of your surgeons protocol.  Progression  through the different phases can take different times for different people so we use a criteria based progression rather than time as a means of knowing when you should progress to the next stage.

Rehabilitation initially is targeted at getting your range of movement back, getting you walking without a limp and using strengthening and balancing exercises to get your muscles working again.

Progressively challangeing your muscles to get stronger, retraining your running movement pattern, improving your balance and getting confident to hop and stop and change direction is all started once you have been cleared to do so by your surgeon.

We use video feedback to help give our clients information on how they are moving and to help retrain them to move in a more biomechanically advantageous way. We also train our athletes to be able to pass a return to function test before we progress to any high tempo change of direction activities.  This includes but is not limited to:

  • Single leg hop test
  • Single leg triple hop test
  • Single leg triple cross over hop test
  • Single leg drop and vertical hop test
  • Single leg leg press exercise 3 Rep Max test

Our sessions are one on one and we take our athletes out onto the field to help improve their technique and confidence in running in straight lines, changing direction, gradually progressing their on field movement patterns through speed and introducing perturbations and ballwork before clearing them to return to team training.

We also offer a group based Balance And Strength Exercise Training (BASE Training) bootcamp a couple of mornings a week to help build fitness, strength and to improve biomechanics.

BASE Training – an example of functional rehabilitation in a group setting

If you would like an assessment or help on the way to restoring the functional stability of your knee get in touch. We will get you Back To Your Feet!!


Bizzini, M., Hancock, D., Impellizerri, F. Suggestions From the Field for Return  to Sports Participation Following Anterior Cruciate Ligament Reconstruction: Soccer. J Orthop Sports Phys Ther 2012;42(4):304-312. doi:10.2519/jospt.2012.4005

Meierbachtol, A., Rohman, E., Paur, E., Bottoms, J., & Tompkins, M. (2017). Quantitative Improvements in Hop Test Scores After a 6-Week Neuromuscular Training Program. Sports Health9(1), 22–29.

First Aid kits for football

Looking after athletes on the sideline is a challenge, and at lower levels of competition when funding is limited, is often provided by sports medics or trained First Aiders. I recommend you find a local physio that can help provide services for your team, and who you can contact if you have an injury on the field. If you are unable to source a professional then doing a Sideline Sports Medic First Aid course or a First Aid and CPR course will help give you the confidence to make good decisions when someone does get injured. Making sure you plan for all the eventualities and source a good ‘kit’ so you have what you need when an injury happens.

Sideline Kit

I think a good basic kit should contain:

  • CPR mask and resuscitation card x 1
  • Survival blanket x 1
  • Scissors stainless x 1
  • Gloves x multiple
  • Management of blood products
    Plasters Assorted water proof x 25 / gauze swab 7.5cm x 7.5cm / Sterile island dressings 7.2cm x 5 cm / Steristrips / non adherent wound pads 5cm x 7.5cm / swimming cap for head wounds / sealable bag to dispose of items with blood on
  • Wound cleansing wipes x2
  • Saline solution x 3
  • Antiseptic cream
  • Strapping materials
    38mm Rigid tape / 25mm rigid tape /50mm EAB / 75mm EAB
  • Compression bandages
    Coban 75mm / coban 50mm /tubigrip
  • Blister management materials
    Second skin / blister plasters assorted sizes
  • Vaseline / sports lube
  • Massage Lotion / massage wax / warm up rub
  • Cold spray / magic water
  • Sunscreen
  • Triangular bandage / Sling
  • Instant ice packs
  • ?Players medications / panadol
  • Sport specific tools
    Laces / studs / stud tightener / spare shinpads
  • Pocket Concussion Recognition Tool
  • Business cards for BTYF Physio

It takes a while to get a good kit together, and once you have created a good kit you need to remember to replace items you use.  Every team or athletes requirements are often slightly different so make a kit that suits your team perfectly and encourage athletes to take responsibility to bring the things they may need.