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Weak In The Knees

A Pittsburgh hospital developed a program to prevent ACL injury and promote overall health.

By Beth Puliti

Though basketball, soccer and football players are among the most common to injure their anterior cruciate ligaments (ACL), all athletes are at risk. Tears to the ACL can occur from contact or non-contact injuries. A strike to the side of the knee while making a football tackle can tear the ACL, as can sprinting, stopping, changing direction, pivoting, landing from a jump or overextending the knee.1

The ACL, which lies in the middle of the knee, prevents the tibia from sliding out in front of the femur. Once this ligament is torn, the athlete is advised to discontinue play until he is evaluated and treated. Before an evaluation of a serious knee injury takes place, the joint shouldn’t be moved and a splint should be positioned to straighten the knee, according to The National Institutes of Health.

Rehabilitation professionals at Allegheny General Hospital (AGH) in Pittsburgh recognized that Physical Therapy and muscle building exercises can help to prevent ACL injury and regain joint motion and leg strength. So they designed an ACL injury prevention program to help participants improve lower-body strength, core stability, reaction times and balance.

“We hope we can turn the corner on an epidemic that has a lot of unanswered questions,” says Craig Castor, ATC, supervisor of sports medicine in AGH’s human motion rehabilitation program.


The ACL injury prevention program at AGH consists of sports medicine physicians, Physical Therapists and athletic trainers. Originally, the purpose of the program was to prevent injury. But health care providers are finding that patients who complete the program after an ACL tear leave better suited to reclaim an active lifestyle.

“Patients are also more confident to get back to participating in activities. With PT visits cut by insurance restrictions, this has become a good program for return to sport,” says Castor.

Rachel Berg, PT, senior manager in AGH’s Human Motion Rehabilitation program, says the program can prevent injury and promote health.

The program now includes return to sport training and functional training for people who have had ACL injuries or surgeries, with the goal of returning athletes to their sports as quickly and safely as possible, says Berg.

She notes that Physical Therapy and muscle-building exercises help prevent ACL injuries. Health care providers in the human motion rehab program teach patients better jump mechanics and landing techniques, along with single-leg strengthening and balance/proprioception. They also work on core and lower-extremity strengthening, especially hamstrings.

“We instruct clients in appropriate active warm-ups and do a lot of single-leg strengthening activities,” she says.

Female athletes are reportedly 4 to 6 times more likely to sustain a sports-related non-contact ACL injury than male athletes.2 Berg notes several theories for this frequency.

  • When jumping, girls tend to land with straighter knees than boys.
  • Girls have a larger Q angle (the angle between the femur and the tibia). The average Q angle in women is 17 degrees, compared with 14 degrees in men.
  • Hormonal influences in women and girls may cause increased ligamentous laxity.


In this program, athletic trainers and Physical Therapists work together to treat patients.

“Our Physical Therapists do much more acute care after the surgeries. Our athletic trainers work directly with the athletes prior to surgery and they perform additional rehab at the schools during acute care and again for functional training when they are released from therapy,” he says.

The team approach has worked well for a long time, Castor says. By having multiple professional disciplines work with athletes, they can provide a better level of care to the athlete.

“In both the professional and college settings, these people would be rehabbing more than once a day. We can give that attention to our high school athletes as well. Our reward comes in the form of working with these athletes before and during injury, and then getting to see them back in competition,” Castor adds.

Berg agrees. “The biggest benefit of having athletic trainers and Physical Therapists working together is having a high level of competence/expertise across the continuum of the program-from acute post-surgical patients with the PTs to return to sport and functional training aspects with the ATCs,” she says.

The biggest obstacle the human motion rehab program encountered so far is having enough staff to meet the growing needs of the community, says Berg. Castor says it’s hard to devote time to the program as well.

“We have been at this for a year and word is spreading, so we are trying to accommodate the needs of our athletes the best we can,” he says. “It would be difficult to dedicate a person full-time to this, but we feel that it has become an important part of our sports medicine program.”


  1. Medline Plus. (2008). Anterior cruciate ligament (ACL) injury. Accessed at
  2. Myer, G., Ford, K. et al. (2007). Differential neuromuscular training effects on ACL injury risk factors in “high-risk” versus “low-risk” athletes. BMC Musculoskeletal Disorders.

Beth Puliti is senior associate editor and Web editor of ADVANCE and can be reached

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