Raise your hand if you or someone you know has suffered an injury to their ACL. Maybe it was you. Maybe it was your best friend. Or maybe it was your favorite NFL player. If you’ve been involved in athletics for any extended period of time, odds are you or someone you know has been tattooed with the infamous scar left behind after an ACL reconstruction.
ACL tears in sport have been a hot topic for some time now, likely due to the significant increase we’ve seen in the last three decades. As the incidence of ACL tears has ascended, we’ve grown accustomed to associating the words “non-contact injury” with “out for the season.” This may be due to 55% of all ACL injuries being the result of non-contact events, with 68% of all adolescent ACL injuries being non-contact (2). Peak incidence of ACL tear is between the ages of 14-18 in females and 19-25 years in males (4), with females being anywhere from 2-8x more likely to suffer an ACL injury than their male counterparts (2). Currently, the typical time to return to sport after ACL reconstruction is 8-9 months, and once we’ve suffered an ACL tear, our risk of subsequent ACL injury on the contralateral limb is significantly increased (1).
Now that we’ve gotten all the bad news out of the way, let’s talk about the good news: There’s still hope! While preventing an ACL injury that is the direct result of contact, such as a slide tackle in soccer, may be a tall task, the strength and conditioning field has had decent success at limiting the number of non-contact injuries that occur by implementing preventative programs. These programs aim to reduce excessive knee compressive loads as well as internal torque, or twisting forces, which have both been shown to be contributors to ACL injuries (1).
One possible reason for the success of these prevention programs is that they shift the stress from the unforgiving ligaments back to the more compliant muscles and tendons. We have shared Loren Landow’s guard rails analogy in the past, but we believe it’s worth repeating. Imagine we are driving on a mountain road with guard rails in place to prevent our car from tumbling into a ravine. Our cars don’t rely on these guard rails to stay on the road, rather, they are a last resort in case we lose control of our car. The guard rails are representative of our ligaments in this analogy. Our ligaments are our last line of defense against instability, but we should make every attempt to avoid using them. Teaching athletes to move efficiently can help an athlete shift the forces from the ligaments back to the muscles and tendons to both improve athletic performance and decrease the risk of a catastrophic injury.
In previous blogs we discussed how to reintroduce plyometrics after an ACL reconstruction (start here), but only focusing on one small component of our athletes’ athletic endeavors isn’t sufficient for returning our athletes back to their sport and preventing future injury. In fact, research shows that neuromuscular training programs which consist of balance training, strengthening, plyometrics, AND change of direction can reduce the risk of ACL injury by up to 45%, with longer and more frequent programs consisting of a larger number of training components yielding greater results (3). Today we’ll cover how to reintroduce change of direction after ACL reconstruction.
As we begin to reintroduce change of direction training, there are two movement patterns we will focus on:
The Crossover Run
The shuffle/cut is critical to deceleration and initiating the act of changing directions. This pattern is typically utilized when an athlete is already in motion and the degree of the cut is greater than 90 degrees. A classic example of the shuffle/cut is a basketball player who is performing a crossover. The athlete plants on their outside leg prior to alternating course in the opposite direction.
The crossover run is also utilized to change directions when an athlete is already in motion, however, unlike the shuffle/cut, the crossover run is typically employed when the degree of the cut is less than 90 degrees. During the crossover run, the outside leg crosses the midline while the athlete drives through their inside leg. In addition to changing directions, this maneuver is also utilized to transition an athlete from the frontal plane to the sagittal plane in order to accelerate in a more linear fashion.
As we begin the process of introducing change of direction tasks back into our athletes’ training, we will follow a set of principles as we progress towards return to play.
First, we will progress from non-impact to impact activities. Beginning with non-impact activities allows us to teach our athletes how to own positions in space prior to progressing them to more violent movements. Next, we will progress from closed drills to open drills. A closed drill is one that is predetermined, such as the pro agility drill that is performed at the NFL Combine. An open drill, however, has a reactive component to it. It is important that we employ both types of drills throughout the return to play process, as closed drills give us an opportunity to focus more on technique while open drills allow us to prepare our athletes for the demands of their sport. This brings us to our third guiding principle: we will progress from general to specific. As we progress an athlete back into their sport, the session should look more individualized to that specific athlete and will begin to resemble what they can expect to see on the field or court.
As we begin to reintroduce change of direction to an athlete’s program following an ACL reconstruction, we will utilize the performance pyramid. At the base of this pyramid is position. Position drills give us an opportunity to teach athletes how to own positions in space while coaching angles at slower speeds. This is an important step in the change of direction process as helping an athlete to feel the positions necessary to achieve efficient movement will help with carryover as the speed of the movement increases.
Wall drills are a great option for teaching posture prior to introducing impact. We can start by performing posture holds. To perform a Shuffle/Cut Posture Hold, start by standing perpendicular to a wall about an arm’s length away. While keeping one arm in contact with the wall for support, take one step away from the wall, angle the outside foot towards the wall slightly, and raise the inside leg. In this position we want the athlete to feel themselves getting long through their outside leg while driving through the inside of their foot. This exercise can be performed for 2-4 repetitions with a 10-15 second hold.
A Crossover Run Posture Hold can be performed in a similar fashion with a couple of small changes. Once again, we will start perpendicular to the wall with one arm in contact with the wall for support. Take one step away from the wall but this time angle the inside foot towards the wall while lifting the outside leg up and across the midline. While performing this exercise, we want the athlete to feel themselves getting long through their inside leg this time while driving through the outside of their foot.
Posture holds can be progressed to a load and lift in order to teach the athlete to undulate between the absorption and propulsion phases of the change of direction pattern. To perform a Shuffle/Cut Load and Lift, begin in the posture hold position. Next, drive the inside leg down and back in order to load the outside leg into a flexed position. Return to the starting position by pushing through the inside of the foot while getting long through the outside leg. This exercise can be performed for 2 sets of 5-8 repetitions.
During the Load and Lift, you’ll notice that we load into our forefoot, or the front part of our foot. This is not an accident. Video analysis has shown that athletes who suffer an ACL rupture tend to initially come into contact with the ground more towards their rearfoot compared to those who don’t rupture their ACL (1). Landing towards the rearfoot decreases the amount of time the ankle complex has to absorb force, which leads to these forces being transmitted to the knee. This subtle change increases the compressive forces experienced at the knee which, as we mentioned earlier, is a contributor to ACL injury. By landing on our forefoot, we place our ankle complex in a better position to absorb force, thus decreasing the amount of compressive force experienced at the knee.
A Crossover Run Load and Lift can be performed in a similar fashion, except this time we will load through our inside leg before punching our outside leg up and across the midline.
Next, we can teach the athlete to achieve proper shin angles as they change directions. Shin angle is exactly what it sounds like; the angle the shin is pointing while performing a movement. In the photo below, the outside leg is the one we will focus on. If we were to draw an arrow from the foot to the knee, it should point in the direction the athlete intends to go next. Below, the left shin is pointed to the right. This position sets the athlete up to efficiently absorb force before applying force back into the ground as they cut from left to right. As we mentioned earlier, moving efficiently improves our ability to use muscles and tendons, improving performance and reducing our risk of injury.
Skier cuts are a great exercise to introduce impact while also teaching proper shin angles. To perform a Skier Cut, start with one foot on a slightly elevated surface, such as a bumper plate. Next, place the majority of your weight over the plate. This will angle the outside leg inward; remember, the outside leg should always be angled in the direction we intend to go next. Finally, quickly switch your outside foot with the inside one. During the final step, it is very important to keep your weight over the plate. Maintaining a relatively stable torso position helps the athlete to feel their center of mass over their inside leg. This is another helpful strategy for creating a proper shin angle and changing directions more efficiently. 2 sets of 5-8 repetitions is the typical repetition scheme we'll choose for this exercise.
Resistance bands are a great implement that can be used for manipulating the angles our athletes are achieving. This gives us a medium to help the athlete achieve the position we are looking for without bombarding them with verbal cues. An Assisted Skier Cut pulls the athlete into the cut. This position assists the athletes with the propulsive phase of the cut while accentuating the forces experienced in the absorption phase.
A Resisted Skier Cut does the opposite. This setup will accentuate the propulsion phase while reducing the amount of force the athlete must absorb upon landing.
Skier cuts can next be progressed to include change of direction. Just like before, we can use a resistance band to manipulate the exercise. When initiating change of direction, using a band to assist the movement can be a great way to get an athlete comfortable with cutting again. We can start with an Assisted COD Skier Cut. To perform this exercise, set up like before but this time perform the movement over and back. During this variation, the band will assist the athlete out of the cut to limit the amount of force they must absorb and produce while changing directions. Once again, we want to cue the athlete to keep their weight over the plate to ensure the outside leg’s shin is angled in the direction they intend to go next. We will typically program this exercise for 2 sets of 3-5 repetitions.
We can progress the athlete by performing this exercise freely with no band.
This exercise can be progressed once again by performing a Resisted COD Skier Cut. This setup will resist the athlete out of the cut and force them to maintain a low center of mass so the band doesn’t pull them over.
Teaching an athlete to efficiently change directions in their sport is a great way to improve athletic performance as well as mitigate the risk of injury. In this article, we discussed how we can utilize a set of guiding principles to reintroduce the shuffle/cut and crossover run movement patterns back into our athletes’ training programs. We started by using wall drills and skier cuts to help our athletes to achieve desired postures as well as shin angles while changing directions. In our next blog, we will continue this discussion by covering the Pattern and Power tiers of the Performance Pyramid. These tiers will include the patterns of the shuffle/cut and crossover run as we progress to more complex and sports specific exercises.
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