Gokeler et al.

Journal of Experimental Orthopaedics (2018) 5:22

https://doi.org/10.1186/s40634-018-0137-5
Journal of
Experimental Orthopaedics

COMMENTARY Open Access

A novel approach to enhance ACL injury

prevention programs
Alli Gokeler1,2,3* , Romain Seil1, Gino Kerkhoffs4,5,6 and Evert Verhagen6,7,8

Abstract
Efficacy studies have demonstrated decreased anterior cruciate ligament (ACL) injury rates for athletes participating
in injury prevention programs. Typically, ACL injury prevention programs entail a combination of plyometrics,
strength training, agility and balance exercises. Unfortunately, improvements of movement patterns are not
sustained over time. The reason may be related to the type of instructions given during training. Encouraging
athletes to consciously control knee movements during exercises may not be optimal for the acquisition of
complex motor skills as needed in complex sports environments. In the motor learning domain, these types of
instructions are defined as an internal attentional focus. An internal focus, on one’s own movements results in a more
conscious type of control that may hamper motor learning. It has been established in numerous studies that
an external focus of attention facilitates motor learning more effectively due to the utilization of automatic
motor control. Subsequently, the athlete has more recourses available to anticipate on situations on the field
and take appropriate feed forward directed actions. The purpose of this manuscript was to present methods
to optimize motor skill acquisition of athletes and elaborate on athletes’ behavior.
Keywords: Injury prevention, ACL, Motor learning, Sports specific, Athletic level

Background group had a lower incidence of ACL injuries compared to

Despite the preventive efforts introduced over the those who followed their routine warm-up (Silvers-Granelli
past decades, anterior cruciate ligament (ACL) injury et al., 2017). It should be noted however, that reduction of
rates in sports have unfortunately not decreased (Agel ACL injuries was only achieved in players in the lower
et al., 2016). From 2004 through 2013, statistically divisions but not those who played in the higher divisions
significant increases in the average annual number of (Silvers-Granelli et al., 2017). In other words, efficacy of
injuries (controlled for athletic exposures) have been current ACL injury prevention programs has not been
reported for men’s and women’s college basketball, ice demonstrated for all age groups of different sex, level of
hockey, field hockey, football, and volleyball (Agel et al., play and type of sports.
2016). The efficacy of ACL injury prevention programs Based on the aforementioned, there is room and need
appears to primarily affect young female athletes who can for optimization of current ACL injury prevention pro-
expect about a 52% reduction of ACL injury risk when grams. To present an overview, this commentary has
commencing an ACL injury prevention program (Sadoghi been outlined in four sections. First, it analyzes the
et al., 2012). The literature is scarce regarding the efficacy current knowledge of ACL injury mechanisms. In the
of prevention programs to reduce ACL injuries in male second section we will review risk factors for ACL injur-
athletes (Alentorn-Geli et al., 2014). A cluster randomized ies. Thirdly, the content of existing ACL injury preven-
study revealed that male football players who were allo- tion programs will be discussed. Finally, we will present
cated to a FIFA11+ intervention (Soligard et al., 2008) ACL injury prevention interventions based on principles
of motor learning that aim to improve motor skills of
* Correspondence: [email protected] the athlete in a context of an actual game.
1
Luxembourg Institute of Research for Orthopedics, Medicine and Science in
Sports, 76 rue d’Eich, L-1460 Luxembourg, Luxembourg
2
Department of Applied Neuroscience in Sports and Exercise, Institute of
Sports Medicine, University of Paderborn, Paderborn, Germany
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Gokeler et al. Journal of Experimental Orthopaedics (2018) 5:22 Page 2 of 6

What is known about the non-contact ACL injury handball, some form of perturbation occurred, leading up
mechanism? to an ACL injury in 12 out of 20 cases (Olsen et al., 2004).
A non-contact ACL injury mechanism usually involves These collective findings highlight differences in playing
single-legged landing or sidestep cutting (Krosshaug et situations in various sports preceding an ACL injury.
al., 2007). Slight player-to-player contact may also con- Unfortunately, reflex mechanisms fail to protect the
tribute to the onset of injury (Koga et al., 2010). Even if knee joint from injury, as an ACL injury occurs within
there is no direct contact to the knee, slight physical 50 ms after ground contact (Koga et al., 2010), which is
contact results in a sudden change of planned move- faster than the time needed by the central nervous sys-
ments of the athlete. This puts the athlete at risk for an tem of about 120–140 ms to generate an appropriate re-
ACL injury as there is only a very limited time frame for sponse (Hopkins et al., 2009).
corrective action.
Differences in non-contact ACL injuries sustained dur- Individual risk factors for non-contact ACL injuries
ing ball handling and defensive action in high school ACL injury prevention programs are based on linear re-
sports have been studied (Monfort et al., 2015). In lationships between presence of risk factors and the ac-
high-school basketball, increased lower extremity injury tual occurrence of the ACL injury (Bahr, 2016). Recently,
risk was observed for those players involved in defensive Bittencourt et al. (Bittencourt et al., 2016) proposed a
actions (Monfort et al., 2015). In football, no differences complex system approach (Fig. 1) to enhance the under-
in injury rates were found between ball handling or de- standing of injury etiology. Briefly, this approach high-
fensive actions (Monfort et al., 2015). In a study that lights a non-linear interaction between risk factors from
used video analysis of actual ACL injuries in high school, different dimensions (biomechanical, psychological,
college and at the professional level, found that the physiological and training characteristics) as a web of
majority of injuries occurred during offensive actions determinants, and how these may result in injuries
(Krosshaug et al., 2007). The attention of the injured (Bittencourt et al., 2016). One can appreciate the com-
player was most commonly focused at the basket rim, plexity of the interaction of various factors which may
followed by an opponent or a focus on the ball (Krosshaug lead to an injury after an inciting event. Some of them
et al., 2007). Walden et al. identified a top three of are modifiable and are key components of current ACL
non-contact ACL injury mechanisms in professional foot- injury prevention programs.
ball which were 1) pressing with a defensive action to-
wards opponent, 2) re-gaining balance after kicking and 3) Content ACL injury prevention programs: Structure and
landing after heading (Walden et al., 2015). Similar for weaknesses
youth female and male and elite female handball, the ma- ACL injury prevention programs entail a combination of
jority of ACL and other lower extremity injuries occurred plyometrics, strength training, agility and balance exer-
in the attacking phase by back or wing players doing a cises (Sadoghi et al., 2012, Gagnier et al., 2013). They are
plant-and-cut maneuver or a single-leg landing movement generally applied to entire teams without individualization
(Olsen et al., 2004, Olsen et al., 2006). In elite female to correct players’ specific deficiencies. The premise is that

Fig. 1 Complex model for sports injury (example 15 year old female football player). The interaction between the various risk factors are
presented. The variables that represent risk factors circled by darker lines have more interactions than variables circled by lighter lines
(adapted from Bittencourt et al. (Bittencourt et al., 2016)
Gokeler et al. Journal of Experimental Orthopaedics (2018) 5:22 Page 3 of 6

through such universal exercises, the athlete acquires suf- ability to sustain optimal motor control while engaging
ficient neuromuscular control and strength to handle un- in complex athletic environments, whilst minimizing
expected situations such as a sudden change of planned their risk to sustain an ACL injury. We acknowledge
movements, that may result in high joint loads. Hence, that this is only one piece of the puzzle amongst many
the preventive effectiveness largely depends on neuromus- other potential prevention strategies recently identified
cular feedback mechanisms which will be activated once (Vriend et al., 2017).
the athlete encounters a potential injury mechanism.
ACL injury prevention programs typically include Principles of motor learning
practicing pre-planned motor skills in a predictable Attentional focus
environment with a focus on lower extremity align- It is generally assumed that athletes benefit from informa-
ment (Hewett et al., 2005). In the motor learning do- tion in the process of acquiring motor skills by directing
main this is defined as practicing closed motor skills the attention to movements (Beilock et al., 2002). Simi-
(Schmidt, 2005). One could argue that this approach larly, in ACL injury prevention, instructions direct the ath-
lacks a transfer towards the unpredictable and com- lete’s attention to various aspects of movements. In the
plex demands placed on the athlete while on the field motor learning domain, this type of attentional focus is
(Monfort et al., 2015). For example, in any injury termed “internal focus” (Wulf et al., 1998). Instructions
mechanism, an athlete is embedded in a playing situ- are directed towards the execution of the movements itself
ation where external factors such as possession of a such as “keep the knee over the toe”; “land with a flexed
ball and position of team mates and opponents are in- knee”; “raise the knee to the level of the hip” or “land with
volved (Olsen et al., 2004, Boden et al., 2009). These your feet shoulder-width apart” (Risberg and Holm 2009,
attentional and environmental interactions effects on Wilk et al., 2012). Unfortunately, encouraging athletes to
neuromuscular function are largely not addressed in improve awareness and knee control during balance, cut-
current ACL injury prevention programs (Grooms and ting, jumping, and landing (Holm et al., 2004) requires at-
Onate 2016). Ideally, athletes should acquire the ability to tentional capacity. In turn, this limits the available
sustain optimal motor control while engaging in complex capacity for fast and complex motor skills that are needed
athletic environments, whilst minimizing their risk to sus- for quick responses to an opponent’s action.
tain an injury. Conversely, an external focus of attention is induced
when an athletes’ attention is directed towards the out-
Potential ways of improvement come or effects of the movement (e.g. landing from a
In ACL injury prevention programs, athletes learn jump: “try to land on the makers on the floor”). It has
motor skills in rather controlled conditions which rely been established in numerous studies that an external
on neuromuscular feedback mechanisms (Myklebust focus of attention facilitates motor learning more effect-
et al., 2003). Given the demands on the field, pre- ively by utilization of unconscious or automatic processes
ventative training should focus on interventions that (Wulf et al., 2001, Lohse et al., 2012, Lohse and Sherwood
incorporate elements of anticipation, perturbations, 2012, Wulf, 2012). Finding from a systematic review,
focus of attention and visual-motor control within clearly established that using instructions with an external
complex task environmental interaction (Grooms and focus result in better motor performance and movement
Onate 2016). Adequate anticipation of a potential technique (increased retention) compared to an internal
high-risk injury situation may give the athlete suffi- focus of attention (Benjaminse et al., 2015a, b, c). This is
cient time to avoid the situation. In case the time illustrated by greater knee flexion angles, more center of
frame is too short to avoid the situation, the athlete mass displacement, lower peak vertical ground reaction
may have an opportunity to prepare for the change in force and improved neuromuscular coordination, while
direction and/or an upcoming perturbation. Such maintaining or improving performance (e.g. jump height,
feed-forward mechanisms are important as it allows jump distance) (Benjaminse et al., 2015a, b, c). These find-
the muscles time to generate force and control cor- ings are promising, as this yields an optimum between
rect lower extremity alignment during landing. diminishing ACL injury risk (improved movement tech-
A potential limitation of current ACL injury preven- nique) without a reduction in performance. By using an
tion training is the lack of transfer from practiced exer- external focus instruction, motor skills require less atten-
cises with high conscious control, to the automatic tional demands as these are executed in a more automated
movements required for complex unanticipated events fashion. Hence, more recourses are available to anticipate
on the field (Benjaminse et al., 2015a, b, c). In the next on situations on the field and take appropriate feed for-
section of this manuscript we will discuss various princi- ward directed actions. An example is presented illustrating
ples of motor learning that targets attentional and envir- the use of an external focus of attention to improve pos-
onmental factors. The goal is that athletes acquire the tural stability (Fig. 2).
Gokeler et al. Journal of Experimental Orthopaedics (2018) 5:22 Page 4 of 6

of their reactions, which is based on the ability to detect

visual cues earlier and more precisely in the game’s pat-
terns recognition and make better predictions of the op-
ponent’s actions, even before some significant preparatory
movements occur (Bishop et al., 2013).
A critical question is whether an athlete needs to be
told what specific visual cues to look for, or can be
learned without explicit verbal information (Farrow and
Abernethy 2002). Implicit training using limited visual
information about the direction of the ball in tennis, im-
proved athletes’ prediction accuracy after the interven-
tion. An explicit learning group, who received specific
kinematic information about the tennis serve of the op-
ponent, didn’t demonstrate any improvement in antici-
patory skills (Farrow and Abernethy 2002).
A recent technological innovation has made it possible
to modify visual input. These stroboscopic glasses (e.g.
Senaptec Strobe, Senaptec, Beaverton, USA; Nike
SPARQ Vapor Strobes, Nike Inc., Beaverton, USA) have
the ability to partially obstruct vision by intermittently
switching from clear to opaque, allowing highly com-
plex, dynamic athletic maneuvers to be performed under
degraded visual input (Grooms and Onate, 2016,
Grooms et al., 2017). Interestingly, training with strobo-
scopic glasses has been shown to improve anticipatory
skills (Smith and Mitroff 2012). Those athletes who
trained with stroboscopic glasses achieved earlier and
more accurate responses to visual cues compared to a
Fig. 2 Postural stability. An athlete is practicing to improve postural control group (Smith and Mitroff 2012). Applied to ACL
stability. To promote an external focus of attention the athlete
should be instructed to “focus on keeping the bar horizontal”.
injury prevention, training athletes to improve their an-
Instruction such as “stabilize your knee” are less effective because ticipatory skills may give them the much-needed window
this induces an internal focus of attention of opportunity to avoid high risk situations.

Video-feedback
Implicit learning
Observational learning, as with video feedback is an effect-
The aim of implicit learning methods is to minimize the
ive way to enhance motor skill learning (Onate et al.,
amount of explicit knowledge about movement execu-
2005). In two randomized controlled trials (Benjaminse et
tion that is accumulated during learning. One method is
al., 2015a, b, c, Welling et al., 2016), subjects received feed-
including “analogy” instructions during the acquisition
back during the two maneuvers in which ACL injuries
of new skills. Analogy, or metaphoric description of the
most often occur: sidestep cutting and landing from a
action, connects with a visual image, to help the athlete
jump (Olsen et al., 2004). Recreational male basketball ath-
learn a movement skill (Liao and Masters 2001). For ex-
letes who received visual feedback, were able to improve
ample, for an athlete to learn a softer landing strategy
their sidestep cutting technique, whilst performance (run-
(more knee flexion) the instruction could be “when you
ning speed) was maintained compared over a group who
land from a jump, try to image you’re landing on raw
received internal focus instructions (Benjaminse et al.,
eggs and you don’t want to crack them”. The use of ana-
2015a, b, c). Similarly, in a double legged jumping task,
logies may serve the same purpose by inducing an exter-
video instruction had beneficial effects on landing tech-
nal focus of attention (Wulf and Lewthwaite 2016).
nique in female and male athletes whilst performance
Moreover, one of the most interesting and widely unex-
(jump height) was maintained (Welling et al., 2016).
plored aspects of implicit learning is its connection with
factors of anticipation and decision making in relation to
performance. It has been shown that expert athletes are Differential learning
better in these areas compared to less experienced ath- When using differential learning practicing movement
letes. They have an advantage in the speed and accuracy skills, the movement patterns themselves are intentionally
Gokeler et al. Journal of Experimental Orthopaedics (2018) 5:22 Page 5 of 6

varied during practice. This principle suggests that by

having athletes perform a variety of movement patterns, a
self-organized process of learning is initiated (Schöllhorn
et al., 2006). Through the process of experimentation with
different movement patterns, target goals, and by learning
alternative means of performing a task (rather than only
practicing the supposedly correct movement form), ath-
letes learn an individualized motor solution that works
best for themselves given the environmental context and
constraints of their own bodies (Magill and Hall 1990).

Contextual interference
The contextual interference in motor learning is defined Fig. 3 A badminton player practicing reaction task using the
as the interference in performance and learning that Microgate Witty SEM system (Microgate, Bolzano, Italy). The
arises from practicing one task in the context of other Microgate Witty SEM shown here consist of a framework
holding three LED lights that illuminate green in a random
tasks (Magill and Hall 1990). The amount of contextual order. In this set-up, the player has to respond quickly and
interference may vary, between low contextual interfer- move the racquet in front of the LED that turns green
ence in blocked practice and random practice at the high
end of contextual interference. Variability of practice (or
varied practice) is an important component to context- interaction that should match the context of the specifics
ual interference, as it places task variations within learn- and level of sports.
ing (Magill and Hall 1990). The variation as discussed Based on the optimal challenge point framework, com-
here in context of contextual interference refers to the plexity and the related chance of achievement of the
variation in planning of practice and is different than various skills should be adopted to the skill level of the
what Schmidt (Schmidt, 2005) proposed to practice with athlete (Guadagnoli and Lee 2004). That means that elite
a lot of variation. Clinicians must decide how to best athletes should have different levels of challenge com-
schedule practice to facilitate learning. Although varied pared to recreational athletes. Using principles of motor
practice may lead to poor performance throughout the learning strategies in ACL injury prevention may en-
acquisition phase, the variety of practice organization re- hance skill acquisition more efficiently and increase the
sults in improved retention and transfer of motor learn- transfer of improved motor skills to sports activities.
ing (Porter and Magill 2010). Of note, skill level of an This has been clearly established in various controlled
athlete is a factor that may need to be considered in studies, but needs to be validated in a real-world sce-
terms of amount of contextual interference provided nario. To increase evidence, future research should focus
(Porter and Magill 2010). In general, lower level athletes on which, if any, combinations of the presented novel
benefit more from low contextual interference, whereas techniques work best. The approach presented may also
elite athletes do well with high levels of contextual enhance adoption by athletes as novel motor learning
interference. based programs entail more specific elements they
recognize from their sports.
Practical implications and future directions
Authors’ contributions
As outlined in the ACL injury mechanism section, the
AG, RS, GK and EV participated equally in drafting the manuscript. All of the
cascade of events taking place that led to the ACL injury authors read and approved the final manuscript.
are vastly different between sports and age groups. The
results support implementing sport-specific interven- Competing interests
The authors declare that they have no competing interest.
tions to account for the variation in playing situations.
Subsequently future ACL injury prevention interventions
should incorporate elements specific for type and level Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
of sports tailored to the individual athlete. An athlete published maps and institutional affiliations.
should be progressively exposed to comparable physical,
environmental, and psychological stressors which they Author details
1
Luxembourg Institute of Research for Orthopedics, Medicine and Science in
will face in the sport they participate in. Sports, 76 rue d’Eich, L-1460 Luxembourg, Luxembourg. 2Department of
An example is given how novel concepts may be incor- Applied Neuroscience in Sports and Exercise, Institute of Sports Medicine,
porated in future ACL injury prevention (Fig. 3) that uses University of Paderborn, Paderborn, Germany. 3University of Groningen,
University Medical Center Groningen, Center for Human Movement Sciences,
linking of attention, anticipation, decision making and re- Groningen, Netherlands. 4Academic Center for Evidence based Sports
action speed. Hence, reflecting a task-athlete-environment Medicine (ACES), Academic Medical Center, Amsterdam, Netherlands.
Gokeler et al. Journal of Experimental Orthopaedics (2018) 5:22 Page 6 of 6

5
Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Krosshaug T, Nakamae A, Boden BP, Engebretsen L, Smith G, Slauterbeck JR et al
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(ACHSS), IOC Research Center, Academic Medical Center/VU Medical Center, analysis of 39 cases. Am J Sports Med 35:359–367
Amsterdam, Netherlands. 7Department of Public and Occupational Health, Liao CM, Masters RS (2001) Analogy learning: a means to implicit motor learning.
Amsterdam Movement Sciences, VU University Medical Center, Amsterdam, J Sports Sci 19:307–319
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of Human Biology, University of Cape Town, Cape Town, South Africa. of attentional focus on accuracy and fatigue. Acta Psychol 140:236–245
Lohse KR, Wulf G, Lewthwaite R (2012) Attentional focus affects movement
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2nd edn. Routledge, London
Magill RA, Hall KG (1990) A review of the contextual interference effect in motor
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