Stopping ACL Injuries Before They Happen: A Framework for Prevention in Adolescent Athletes

Introduction

Approximately 200,000 to 250,000 anterior cruciate ligament (ACL) injuries occur in the United States each year, with nearly one quarter of these injuries occurring in children under the age of 18.¹ Adolescent athletes who sustain an ACL injury can face significant long-term consequences that extend well beyond the initial event. These injuries often result in substantial time away from sport, require months of intensive rehabilitation, and may ultimately limit opportunities to compete at higher levels, including collegiate athletics. Unfortunately, by the time these patients present to our office, the damage has already been done; we cannot go back in time. Therefore, the pressing question for addressing these injuries remains: How do we prevent ACL injuries in this vulnerable population before they happen? 

Identifying At-Risk Populations

It is well established that certain activities and populations are at a higher risk of ACL injury than the general population. For example, female adolescent athletes are notorious for suffering an ACL injury, with recent studies showing a 1.6-fold increase in ACL injury risk and incidence rate when compared to male counterparts of the same age. ^{2, 3, 4} As for the age of the athlete, the hazard for an ACL injury peaks around late adolescents, between ages 16 and 20 years old.⁵ Certain sports, such as soccer, football, and basketball, have higher incidence of ACL injuries as well, in both male and female athletes.^{2, 3, 6}  

Prevention Strategies

While identifying athletes at greatest risk is important, the real challenge lies in implementing effective, evidence-based strategies to prevent ACL injuries from occurring in the first place. Neuromuscular training (NMT) has been a widely studied method in preventing ACL injuries since the 1990’s.^{7, 8, 9, 10} The basis of NMT is improving neuromuscular control, leading to an increased reactivity and sensitivity of the central nervous system, leading to improved stability of functioning joints.¹¹ This is accomplished via a sport-specific strength and fitness training program focusing on balance, dynamic stability, plyometrics, and resistance training.¹¹ These interventions are not time-intensive, with meaningful reductions in injury risk demonstrated in sessions lasting less than 20 minutes when performed several times per week.¹² 

Many NMT-based ACL prevention programs, also known as injury prevention programs (IPPs), have been established and have shown excellent results. The first of its kind being the Prevention injury and Enhance Performance (PEP) Program, developed by Bert Mandelbaum, MD, with the Santa Monica Orthopaedic and Sports Medicine Group.¹⁰ Within the first year of implementing the PEP Program, there was an 88% decrease in the incidence of ACL injuries among adolescent female soccer players.¹⁰ As the season wears on, neuromuscular fatigue can lead to biomechanical laxity, adding yet another risk factor for ACL injury. However, evidence shows that collegiate female soccer players participating in the PEP Program had a significantly lower ACL rupture risk towards end of season.¹³ 

Another popular program is the FIFA 11+ injury prevention program. Introduced in 2009 for professional soccer players, the most recent study from 2019 revealed a 29% decrease in lower extremity injuries among all players, both male and female.¹⁴ There is also a FIFA 11+ Kids Program, targeting younger youth soccer players ages from 7 to 14 years old. This child-specific IPP focuses on coordination and balance, strengthening of leg muscles, and optimization of landing techniques, leading to a 50% reduction in all injuries, not only ACL injuries.¹⁵  

Does Neuromuscular Training Work?

The most important question for any medical intervention is “Does it work?”  A 2026 aggregate study by Watson et al found that neuromuscular training programs produce substantial reductions in ACL injury rates. Athletes who did not partake in a NMT-based ACL injury prevention program were nearly two times more likely to sustain an ACL rupture when compared to matched counterparts who participated in this prevention program.¹² These results not only took place in adolescent athletes younger than 18 years, but also remained true for athletes older than 18 years.¹² 

Compliance is a limiting factor when it comes to seeing results after implementing one of these programs. Of the studies examining compliance with the IPP protocol and the incidence of ACL injuries, it becomes clear that without consistent participation, the benefit becomes nonexistent. Findings across the literature consistently highlight the importance of program adherence. For example, Soligard et al demonstrated a 35% reduction in ACL injuries among athletes in the high-compliance group, despite averaging only 1.5 IPP sessions per week, compared to those with lower compliance.¹⁶ Similarly, Hägglund et al reported an 88% reduction in injury risk in the high-compliance group, while no significant difference was observed between the low-compliance group and controls.¹⁷ 

Implementation

With 20 years of data showing such promising and tangible results, in conjunction with consistent compliance of course, implementing a neuromuscular training regiment can significantly decrease the risk of ACL injuries. So why are these low cost, highly effective, and easily accessible injury prevention programs not widely used by adolescent athletes? The National ACL Injury Coalition set out to answer this question in 2023. At the annual National ACL Injury Coalition Meeting, the core challenges regarding ACL injury prevention in youth were brought forward, and four common goals were established: widespread implementation of interventions, high-quality education, equitable access, and aligning stakeholders.¹⁸  

Under the “widespread implementation” goal, it was determined that a comprehensive ACL Toolkit was needed. Within this toolkit that could be distributed to high school coaches and athletic trainers contained NMT programs, implementation guidance for coaches and trainers, warm-up programs, and the RIIP REPS app. The RIIP REPS app, designed by the Hospital for Special Surgery, is an app designed to facilitate the implementation of NMT programs for high school sports participants at minimum cost and effort with no special equipment needed. Coach or trainer-led IPPs are an easy and effective way to ensure consistent participation in the programs.  

To improve education and awareness, members suggested to promote ACL injury prevention in local and national news coverage, even establishing a “National ACL Awareness” month. To improve understanding of the effects of ACL injuries for parents, a visual roadmap describing how to navigate these injuries and the long-term health ramifications can be created and distributed to coaches, physicians, and trainers.  

Without equitable access to health resources and education, the implementation of NMT programs, and the resulting reduction of ACL injury rates, cannot be reliably achieved. Short-term goals to improve access included creating a national registry for reporting ACL injuries in the high school population, similar to the already established concussion registry. Shifting education into the classroom by increasing awareness among physical education teachers expands the reach beyond athletes to the broader adolescent population.  In the long term, the most effective strategy to achieve this goal is to strengthen and expand the athletic trainer workforce. Athletic trainers can improve early risk identification, ensure consistent implementation of neuromuscular training programs, and provide ongoing education and supervision to athletes, coaches, and school staff.  

At the base of the ACL injury prevention pyramid are the key stakeholders: schools, sports clubs, parents, physicians, and coaches, who collectively shape the environment in which prevention strategies are adopted and sustained. Open communication and the free flow of insights and information among these groups are critical to success. Effective collaboration allows stakeholders to identify and address barriers to implementation and adherence while ensuring each group fulfills its role within the injury prevention framework.¹⁸ 

Key Findings for ACL Injury Prevention Strategies

The encouraging news is that many ACL injuries may be preventable. Recent research points to several straightforward, scalable strategies that can be integrated into youth sports settings with minimal time and financial investment while producing meaningful reductions in injury risk:

• Neuromuscular training programs are widely studied and easily implementable ACL injury prevention strategies. 
• Consistent program compliance is paramount to successful ACL injury prevention, with results seen in sessions lasting less than 20 minutes when performed several times per week. 
• High-quality education for coaches, athletic trainers, and parents can lead to improved compliance, especially in younger patient populations. 
• Coach or trainer-led IPPs can be completed in 20 minutes before each game or practice, ensuring proper technique and consistent participation. 
• Utilizing an ACL Toolkit, which contains ACL prevention education, NMT programs, and the RIIP REPS app, is a low-cost and low-effort implementation strategy. 
• Effective collaboration among parents, coaches, schools, and athletic trainers can identify and address barriers to implementation and adherence. 

Looking Ahead

To advance ACL prevention, we must rigorously evaluate new toolkits and establish baseline injury metrics. A standardized national database is critical for making future research more accessible, consistent, and generalizable across demographics. Current leaders in this effort, such as the Multicenter Orthopaedic Outcomes Network (MOON) Knee Group and the AOSSM’s STOP Sports Injuries initiative, continue to provide vital insights into youth injury prevention. Ultimately, the combination of ongoing research and broad program implementation offers a clear path forward. With these strategies in place, we can reasonably mitigate the impact of ACL injuries, and their lasting consequences, on the adolescent population.

References

1. Arundale AJH, Silvers-Granelli HJ, Myklebust G. ACL injury prevention: Where have we come from and where are we going? J Orthop Res. 2022;40(1):43-54. doi:10.1002/jor.25058.
2. Justin Childers, Emma Eng, Benjamin Lack, Shu Lin, Derrick M. Knapik, Daniel J. Kaplan, Garrett R. Jackson, Jorge Chahla; Reported Anterior Cruciate Ligament Injury Incidence in Adolescent Athletes Is Greatest in Female Soccer Players and Athletes Participating in Club Sports: A Systematic Review and Meta-analysis.Arthroscopy. 2025;41(3):774-784.e2.doi:10.1016/j.arthro.2024.03.050.
3. Gornitzky AL, Lott A, Yellin JL, Fabricant PD, Lawrence JT, Ganley TJ. Sport-Specific Yearly Risk and Incidence of Anterior Cruciate Ligament Tears in High School Athletes: A Systematic Review and Meta-analysis: A Systematic Review and Meta-analysis. Am J Sports Med. 2016;44(10):2716-2723. doi:
4. Montalvo AM, Schneider DK, Yut L, Webster KE, Beynnon B, Kocher MS, Myer GD. "What's my risk of sustaining an ACL injury while playing sports?" A systematic review with meta-analysis.Br J Sports Med. 2019;53(16):1003-1012. doi: 10.1136/bjsports-2016-096274.
5. Magaña-Ramírez M, Gallardo-Gómez D, Álvarez-Barbosa F, Corral-Pernía JA. What exercise programme is the most appropriate to mitigate anterior cruciate ligament injury risk in football (soccer) players? A systematic review and network meta-analysis.J Sci Med Sport. 2024;27(4):234-242.doi: 10.1016/j.jsams.2024.02.001.
6. Bram JT, Magee LC, Mehta NN, Patel NM, Ganley TJ. Anterior Cruciate Ligament Injury Incidence in Adolescent Athletes: A Systematic Review and Meta-analysis.Am J Sports Med. 2021;49(7):1962-1972.doi:10.1177/0363546520959619
7. 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(1):19-21. doi:10.1007/BF01565992.
8. Beard DJ, Dodd CA, Trundle HR, Simpson AH. Proprioception enhancement for anterior cruciate ligament deficiency. A prospective randomised trial of two physiotherapy regimes.J Bone Joint Surg Br. 1994;76(4):654-659.
9. Cerulli G, Benoit DL, Caraffa A, Ponteggia F. Proprioceptive training and prevention of anterior cruciate ligament injuries in soccer.J Orthop Sports Phys Ther 2001;31(11):655-660; discussion 661. doi:10.2519/jospt.2001.31.11.655.
10. Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, Kirkendall DT, Garrett W Jr. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003-1010.doi:10.1177/0363546504272261.
11. Akbar S, Soh KG, Jazaily Mohd Nasiruddin N, Bashir M, Cao S, Soh KL. Effects of neuromuscular training on athletes physical fitness in sports: A systematic review.Front Physiol. 2022;13:939042. doi:10.3389/fphys.2022.939042.
12. Watson SL, Gohal C, Owen MM, Bajaj PM, Plantz MA, Tjong VK. A Systematic Review and Meta-analysis of Anterior Cruciate Ligament Injury Prevention Programs: Training to Stay in the Game. American J Sports Med. 2026;54(3):733-740.doi:.
13. Gilchrist J, Mandelbaum BR, Melancon H, et al. A Randomized Controlled Trial to Prevent Noncontact Anterior Cruciate Ligament Injury in Female Collegiate Soccer Players. Am J Sports Med. 2008;36(8):1476-1483. doi:10.1177/0363546508318188.
14. Al Attar WSA, Alshehri MA. A meta-analysis of meta-analyses of the effectiveness of FIFA injury prevention programs in soccer.Scand J Med Sci Sports. 2019;29(12):1846-1855.doi:10.1111/sms.13535.
15. Ramos AP, de Mesquita RS, Migliorini F, Maffulli N, Okubo R. FIFA 11+ KIDS in the prevention of soccer injuries in children: a systematic review.J Orthop Surg Res. 2024;19(1):413.doi:10.1186/s13018-024-04876-9.
16. Soligard T, Myklebust G, Steffen K, Holme I, Silvers H, Bizzini M, Junge A, Dvorak J, Bahr R, Andersen TE. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial.BMJ. 2008;337:a2469.doi:10.1136/bmj.a2469.
17. Hägglund M, Atroshi I, Wagner P, Waldén M. Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT. Br J Sports Med. 2013;47(15):974-979.doi:10.1136/bjsports-2013-092644.
18. Robbins L, Farrey T, Janosky J, Minjares V, Mandelbaum BR, Pearle A. Preventing Anterior Cruciate Ligament (ACL) Injuries in High School Sports Participants: An Executive Summary of the Inaugural Meeting of the National ACL Injury Coalition. HSS J. 2024;20(3):333-340.doi:10.1177/15563316231211320.