image of 4 adolescent soccer players in yellow and blue jerseys playing on the field. 2 opposing players are falling, at a risk for injury, such as an ACL tear

Preventing ACL Tears: What Does the Evidence Say?

If you talk long enough with most athletes, especially basketball and soccer players, the topic of ACL tears comes up. It’s a far too common injury and many wonder if it can be prevented. Good news: There are ways to lower the risk of ACL injuries.

Preventing ACL Tears

There are several muscles and ligaments that work together to help a knee work and keep it stable. The anterior cruciate ligament (ACL) is often considered the main structure that keeps a knee stable.

Because an ACL tear often leads to surgery and significant time off the field, most athletes (and their coaches) want to know how to prevent an ACL injury from happening. 

While there is a lot of good general advice, one study found that a specific regimen lowered risk of ACL injuries by up to 88%.


This study was done in female soccer players aged 14-18 years.

This is a huge deal. The exercises are many that athletes routinely perform anyway, but it’s specific ones on a specific schedule that lowered the risk. They include things that warm up the muscles, stretching, coordination and agility exercises, and strengthening of the muscles that also help stabilize the knee.

Some people ask if strong legs help prevent ACL tears. So, of course strength is part of the equation, but it’s more than strength alone. These exercises help with strength, stability, and coordination. 

The PEP Program

Here is a link to the program, called The PEP Program: Prevent Injury and Enhance Performance. It’s meant to be free for athletes and coaches.

The protocol is to be done three times a week. Each session lasts about 20 minutes and it needs to be done prior to the rest of practice or conditioning exercises. This way muscles aren’t tired and the athlete can focus on proper form, which is key. 

Please note it is designed for athletes over age 12, but it does provide modifications for younger kids. 

Why does the PEP Program help prevent ACL tears?

To see why it’s effective, let’s review a bit more about when ACL injuries happen. 

ACL injuries in athletes can happen in a few ways. 

A common one starts when someone has their foot planted on the ground. Then, a quick forceful movement or impact puts too much sudden stress on the knee, causing the ACL to tear.

Another way, more common is basketball, happens when an athlete lands on their leg at a specific angle without flexing their knees enough. 

ACL injuries can also happen with snowboarders, skiers, and in car accidents. 

These injuries can feel like terrible luck (and sometimes it is). However, many ACL tears are related to how an athlete moves, jumps, and maneuvers on the ground. This is where there is a huge opportunity for preventing ACL injury. Practicing proper form and strengthening all the muscles that help stabilize the knee (therefore taking some pressure off the ACL itself) can help reduce some of these types of injuries. This is part of what the PEP Program offers.

Who is at risk for ACL tears?

Generally speaking, female athletes are at greater risk for knee injuries (including ACL tears) than their male counterparts. This may be due to a variety of reasons. Some of the factors are not under an athlete’s control, like menstrual cycle or specific joint angles. And many other factors haven’t been studied well, like playing surface or sporting equipment.

It’s also worth noting that a lot of the research is on adolescent (high school and college) athletes. So, we have a lot to learn about younger and older people at risk for ACL tears.

After an ACL Tear

Even if someone takes all precautions and does everything they can to prevent an injury, ACL tears still happen. The next steps after the injury depends on each athlete and their physician.

Generally speaking, it often comes down to having surgery or not. There is some data that shows early surgical repair (soon after the injury) may lower risk for knee instability and other injuries in the future. Statistically, athletes who don’t get surgery are less likely to return to full activity in their sport. Surgeons consider each athlete individually, though. They think about individual risks and how old the athlete is (how mature their bones and joints are). They also consider how severe the injury is, as well as many other factors.

Long-Term Issues of ACL Tears

Surgery, a long recovery, and high medical costs are some of the immediate aftereffects of an ACL tear. These alone are enough reason for many to want to do everything to prevent such an injury.

However, one of the more long terms outcomes of an ACL tear is osteoarthritis. That’s the same classic arthritis usually more common in elderly people. For these former athletes, it means knee pain and sometimes a knee that just doesn’t “work” as well as expected. One study found that half of people who had ACL tears ended up with osteoarthritis just 10-20 years after their injury.

Summary: Athletes can lower their risk of ACL tears

Preventing all ACL tears might be impossible, but the PEP Program is about as hopeful as it gets for lowering risk. I encourage families to discuss the listed exercises with their coaches or with their doctors, as part of the sports physical.

If you are currently an athlete or a coach, I’d love to hear your thoughts. Do you think the PEP program regimen of 20 minutes three times a week is feasible? Are the specific exercises something that would be easy to incorporate into your routine? Have you or your teammates had an ACL injury? Let me know in the comments below!

Maya M. Mahmood, D.O., FAAP is a board-certified pediatrician and mom. She is passionate about parents having evidence-based information to help their families be healthier.  Subscribe to the newsletter for regular updates.


This is for information only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this websitePlease see the complete disclaimer.

Photo by Omar Ram on Unsplash

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