1149405

research-article2023
HSSXXX10.1177/15563316221149405HSS Journal(R): The Musculoskeletal Journal of Hospital for Special SurgeryJosse

Football Sports Medicine

HSS Journal ®: The Musculoskeletal

Gym-Based Training Interventions

Journal of Hospital for Special Surgery
2023, Vol. 19(3) 285­–291
© The Author(s) 2023
for Anterior Cruciate Ligament Injury Article reuse guidelines:
sagepub.com/journals-permissions

Reduction in American Football Players DOI: 10.1177/15563316221149405

https://doi.org/10.1177/15563316221149405
journals.sagepub.com/home/hss

Cameron M. Josse, MS1

Abstract
Injuries to the anterior cruciate ligament (ACL) of the knee are one of the most prominent injuries affecting players in
American football. One primary aim of training to reduce injury risk is to provide exercises for players on attaining the
highest athletic performance with the least orthopedic stress. This review article on ACL injury reduction protocols
focuses on the protective and performance-enhancing biomechanical patterns during simple exercises used in a gym-based
setting, in the following areas: single-leg balance and trunk stability, single-leg jumping/plyometrics, and reflexive strength
training. This supplementary training, as part of a sports performance program, might include training to develop maximum
strength, explosive power, acceleration, maximum velocity, bioenergetic endurance qualities, mobility/flexibility, agility, and
sport skill acquisition.

Keywords
ACL injury, injury reduction, stability, attractor, intervention

Received July 1, 2022. Accepted September 23, 2022.

Introduction the system that may be used in a variety of circumstances,

although not all attractors are helpful. The system will
Injuries to the anterior cruciate ligament (ACL) of the knee search for stable end-points when forming movement solu-
are one of the most prominent injury-related issues in tions to sport-related problems, but some of these solutions
American football. In the 2015–2019 seasons of the may not be ideal for the reduction of injury.
National Football League (NFL), 314 ACL injuries Three broad categories of attractors are the following
occurred, at an average of 62 injuries per year, with consis- [2]:
tency in the number of injuries reported annually [23]. In a Passive attractors reduce performance and do not pro-
sport in which each team consists of 53 players, this rate of tect against injury. The system finds stability through pas-
ACL injury is comparable to losing an entire NFL team sive tissues, such as ligaments or tendons, without the
each year. Much research has been conducted on best prac- benefits of intermuscular and intramuscular coordination.
tices to reduce these injuries, as they appear to be statisti- Perhaps no example is better in relation to ACL injury than
cally consistent each year, according to NFL Player Health excessive knee valgus on ground contact when a person is
and Safety data. running, landing, or changing direction. This pattern is
A primary aim of training is to reduce injury risk by pro- characteristic of what has been termed “ligament domi-
viding exercises that allow players to attain the highest level nance,” a condition of imbalance in which muscles do not
of athletic performance with the least amount of orthopedic sufficiently absorb ground reaction forces (GRF), so the
stress. Efficient biomechanical movement patterns must joint and the ligaments must absorb high amounts of force
exist not only in isolated, controlled settings but also in over a brief period [15]. While ligament dominance can
team play, where the very nature of participation is complex
and chaotic. This search for stability within chaos leads to
the concept of attractors. 1
Indiana University Athletics, Bloomington, IN, USA
Attractors may be understood as stable functional coor-
Corresponding Author:
dination patterns into which the human movement system Cameron M. Josse, MS, Indiana University Athletics, 1001 East 17th
can settle during activity [6]. These are not joint positions Street, Bloomington, IN 47408, USA.
but rather abstract principles associated with the stability of Email: [email protected]
286 HSS Journal ®: The Musculoskeletal Journal of Hospital for Special Surgery 19(3)

provide stability, the cost is a lack of protective or perfor- gym-based setting: single-leg balance and trunk stability,
mance-enhancing features and should be avoided in train- single-leg jumping/plyometrics, and reflexive strength
ing or competition. training. A holistic program would strike a balance between
Active, protective, performance-reducing attractors pro- isolated exercises in a closed, controlled setting and sport-
tect against injury but may reduce performance. These are specific skills in the context of a football game by also
emergency measures taken by the system to achieve stabil- including neuromuscular strength (particularly in the eccen-
ity. In team sports, quadriceps-dominant players may attempt tric and isometric regimens) [8,9,12,19,22], visuospatial
to decelerate their momentum by contacting the ground with attention [5,20], and neurocognitive performance, including
the foot far outside of the center of mass (COM), with the perception-action coupling [1,10,26].
knee joint extended. This can result in excessive shear stress
to the ACL, especially if the trunk is upright, leaning back-
ward, and/or rotating away from the planted foot. In this sce-
Developing Stable Positions in
nario, the muscles of the posterior chain are unable to Training for ACL Injury Reduction
contribute to the load distribution of the GRF, so the quadri- High-velocity braking, where the foot is planted far outside
ceps take on potentially damaging anterior shear forces. One the COM, is potentially one of the most injurious move-
way to mitigate stress to the knee when the foot is planted far ments for the ACL. It has been reported that peak GRF can
out in front of the COM is to add internal rotation at the hip exceed 5 times body mass within 50 ms during a penulti-
where the trunk rotates toward the stance leg on impact. The mate foot contact of a severe 135° change of direction [14].
eccentric tensioning of muscles around the hip (biceps femo- When the body stops forward momentum in the sagittal
ris, gluteus maximus, contralateral latissimus dorsi), plus the plane, a hinging motion at the hip with neutral spine can
ligaments crossing the sacroiliac (SI) joint, can increase fric- activate the posterior chain through eccentric lengthening.
tion and stiffness and reduce shear on the knee through acti- This co-contraction with the quadriceps may reduce the risk
vating the posterior chain muscles [2,27]. These activated of anterior tibial shift [11]. With a rounded spine, the poste-
structures may share in accepting load from the GRF, help- rior chain may not be properly tensed and the anterior mus-
ing to translate the tibia posteriorly, as the base of support is cles may take too much of the load, leading to shearing
in front of the COM with an extended knee. Another protec- forces that may rupture the ACL. Therefore, proper hinge
tive strategy in this circumstance is continuing to run, taking patterns may be built into sports performance training, from
multiple braking steps, each with significantly less GRF, slow, high-force movements (such as single-leg Romanian
until a stable, powerful plant step can be performed. deadlift) to faster, more-explosive movements (such as
Active, protective, performance-enhancing attractors landing from a single-leg depth drop).
both enhance performance and protect against injury. These In American football, movements are multiplanar, with a
are most desirable for enforcing safe movement. For exam- player’s motion inevitably occurring in the transverse
ple, maintaining the spine and pelvis in neutral alignment plane—for example, turning the head and upper body to
keeps the postural muscles at or near their optimum length locate the ball in the air or keeping an eye on an opponent’s
(the muscle length at which the maximum muscle force can cues. Such movements may increase the risk of dynamic
be generated [4]); this enhances neural communication and lower extremity valgus resulting from a combination of
force expression through the trunk. Optimum muscle length rotation at the hip, knee, and ankle, including hip adduction
is also associated with reflexes and preflexes, the latter with internal rotation, tibial abduction, tibial external rota-
referring to the immediate muscle responses to disruptive tion with anterior translation, and ankle eversion—all asso-
external influences, where perturbations of length and ciated with increased ACL injury risk [17]. A “chest out”
velocity produce changes in contractile force with zero spinal posture when rotating may reduce the risk of these
delay [13,18]. A neutral spine has a positive impact on pel- dangerous positions [2]. This may also ensure that the pos-
vis position, which allows for self-organization of the lower tural muscles are kept close to their optimum length, with
limb muscles as they activate favorable positioning, achieve appropriate isometric and eccentric tension distributed over
optimum length, and withstand high forces. This aids in dis- several joints. Exercises may be built into a training pro-
tributing the force of ground contact and the range of motion gram to enforce this protective attractor, such as a forward
associated with movement expression across several joints. lunge with internal rotation toward the lead leg while hold-
This may dramatically reduce the risk of imbalance condi- ing a weighted plate and rapidly extending the arms during
tions such as quadriceps dominance and trunk dominance, the rotation. The player must resist the temptation to go
the latter involving poor pelvic control leading to excessive with the momentum of the plate punch, thereby avoiding a
lateral or anterior trunk flexion upon foot plant when brak- flexed spinal position, and instead maintain an upright,
ing, another posture associated with ACL rupture [15]. chest out position as the arms are extended.
This review article focuses on protocols for reducing To avoid quadriceps dominance when changing direc-
ACL injury involving active, protective, and performance- tion on the football field, a player should activate the mus-
enhancing attractors with simple movements used in a culature around the hip and posterior chain. During sprint
Josse 287

Fig. 1. Single-leg balance with plate halo.

acceleration, the gluteal and hamstring muscles provide lin- as a roadmap and developing global neuromuscular strength
ear propulsion. Applying horizontal force requires the ham- may address most of the neuromuscular imbalance associ-
string muscle group during the swing phase to push into the ated with ACL injury risk.
ground with each step [21]. Greater transmission of force Balance/trunk stability exercises, single-leg jump train-
into the ground is accomplished by initiating the effort at ing, and reflexive strength training may be carefully con-
the hip, through retraction of the swing leg, leading to a structed to challenge the system in activities of greater
“whip from the hip” that results in a coordinated sequencing balance, speed, and complexity.
among the muscles of the hip, knee, and lower leg [7].
When changing direction, these same attractors apply, even
Balance and Trunk Stability Exercises
if the movement plane differs. Effective change of direction
occurs with the pelvis in a neutral position, the swing leg Incorporating variations of balancing on 1 limb, especially
retraction initiated at the hip, the foot planted beneath the with added perturbations to disrupt stability, has been
COM, and force transmitted through the ground. shown to aid in decreasing asymmetry between legs. The
Thus, an ACL injury risk reduction program can guide exercises achieve this by activating neuromuscular feed-
players to align their motor control strategies with active, back loops and bilateral neurologic systems to influence
protective, performance-enhancing attractors. These attrac- symmetry when balancing on 1 limb [15]. Perturbations
tors ideally exist during complex activities, such as repre- may involve closing the eyes to remove the benefit of visual
sentative learning where dynamic training interventions are focus or taking a weight plate and circling it around the
designed in consideration of the interacting constraints on head swiftly to challenge the trunk to remain stable against
movement behaviors, adequately sampled informational varying lever arms of resistance (see Fig. 1). In addition,
variables from specific performance environments, and moving the head from left to right while balancing on 1 leg
functional coupling between perception and action pro- can provide natural perturbation and challenge the core
cesses [25]. musculature, especially the pelvic and hip stabilizers.
Strength and stability in the hip external rotators are predic-
Training Interventions for Reducing tors of future ACL injury risk, with an 8-fold greater chance
of sustaining repeated ACL injury in those with reduced hip
ACL Risk in Football Players external rotation strength following ACL reconstruction
Implementing ACL injury risk reduction programs aimed at [24]. Keeping a slight bend in the knee while performing
making small improvements in biomechanical movement these exercises is encouraged for hip and knee muscle
patterns can have a dramatic effect. For example, neuro- activation.
muscular training interventions to alleviate imbalances such An isometric split squat hold with perturbation simulates
as ligament dominance, quadriceps dominance, trunk domi- a braking step with the lead leg and is less stable than a
nance, and leg asymmetries have been shown to reduce traditional bilateral squat position; added perturbations such
ACL injury risk by 30% to 80% (average 50% reduction in as lateral band resistance around the lead knee, pulling the
relative risk) [15,16]. Training in using protective attractors knee into valgus requires the player to resist and maintain
288 HSS Journal ®: The Musculoskeletal Journal of Hospital for Special Surgery 19(3)

Fig. 2. Split squat variations.

Fig. 3. Single-leg depth drop variations.

neutral knee position. Other perturbations may include in lateral flexion toward the lead leg, requiring the player to
manipulation of the trunk through a lateral band resistance resist these forces to maintain neutral posture (see Fig. 2).
pulling the body along the transverse plane away from the These balance and stability exercises may be performed
lead leg or a band pulling the body along the frontal plane for 1 to 2 sets of 30 to 60 seconds of balancing on each leg.
Josse 289

Fig. 4. Jump with partner perturbations.

Fig. 5. Lunge with plate punch.

Single-Leg Jump Training of unpredictability, a player may perform a bilateral vertical

jump on a flat surface and have a partner provide a push as
Performing jumping and plyometric exercises on 1 limb has the player leaves the ground so that perturbation is applied
been described as useful in addressing asymmetry and in the air, after which the player must find stability and stick
quadriceps dominance by influencing synergistic recruit- the landing on 1 limb (see Fig. 4).
ment of the posterior chain [15]. Accentuated single-leg These single-leg jumping exercises may be performed
landings, such as a depth drop from a high box (eg 24 in.), for 2 to 4 total sets of 2 to 4 repetitions on each leg.
may expose players who are quadriceps-dominant and liga-
ment-dominant to medial collapse. Constant exposure to
Reflexive Strength Training
this lower extremity valgus can dramatically increase the
risk of ACL injury for athletes, and so it is important to Reflexive training, recently popularized by Dutch professor
assess for and mitigate this risk. and coach Frans Bosch, is used for coordination and stabil-
Depth drops performed to the side may challenge the ity by performing more complicated variations of basic
athlete to stabilize a lateral force when jumping in the same strength training patterns [3]. An example is performing an
direction as the working leg or a medial force when jump- explosive forward-lunge pattern while holding a weight
ing in the opposite direction. This will challenge trunk and plate and, as soon as the front foot hits the ground, rotating
pelvic control in the frontal plane under time pressure. To the trunk toward the lead leg and explosively extending the
challenge the transverse plane, the player may perform a arms in a “punch” motion (see Fig. 5). This develops mul-
90° turn in midair after jumping from the box and attempt to tiple protective attractors simultaneously, such as upright
stick the landing on impact (see Fig. 3). To add an element trunk position, extended force closure around the pelvis,
290 HSS Journal ®: The Musculoskeletal Journal of Hospital for Special Surgery 19(3)

Fig. 6. Lunge with partner perturbations.

and chest out when rotating, all in a single swift motion. Declaration of Conflicting Interests
Variations may include a lateral lunge pattern, where a part- The author(s) declared no potential conflicts of interest with respect
ner provides an unpredictable lateral push, causing the to the research, authorship, and/or publication of this article.
player to reflexively activate the proper structures to stabi-
lize into the lateral lunge movement (see Fig. 6). The goal Funding
for reflexive strength training is to develop coordinative The author(s) received no financial support for the research,
structures with speed and perturbation, not necessarily to authorship, and/or publication of this article.
progressively increase the overload used.
Reflexive strength training exercises may be performed Human/Animal Rights
for 2 to 4 sets of 3 to 6 repetitions on each leg. All procedures followed were in accordance with the ethical stan-
dards of the responsible committee on human experimentation
(institutional and national) and with the Helsinki Declaration of
Conclusion 1975, as revised in 2013.
These exercises and training interventions for American
Informed Consent
football players have the primary goal of working toward
active, protective, performance-enhancing attractors of Informed consent was not required for this review article.
movement. Exercises in balance/trunk stability, single-leg
jumping, and reflexive strength may supplement an existing Required Author Forms
sports performance program. Such a regimen might involve Disclosure forms provided by the authors are available with the
developing maximum strength, explosive power, accelera- online version of this article as supplemental material.
tion, maximum velocity, bioenergetic endurance qualities,
mobility/flexibility, agility, and sport skill acquisition. References
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