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RESEARCH

Introduction

As young athletes become more and more competitive,

the risk for lower extremity injuries increases as well.

Injuries may be noted to the bony architecture, as seen in

fractures and Osgood–Schlatter’s disease, or may affect

the ligaments and muscles. One of these ligaments, the

anterior cruciate ligament (ACL), is a signiﬁ cant stabi-

lizer in the knee, and an injury to this can be a devastat-

ing event for a young athlete. It has been noted that fe-

male athletes, particularly those in the postpubescent

age, are at a three times greater risk for injury to the ACL

than same-age male counterparts ( Dharamsi & LaBella,

2013 ; Sutton & Bullock, 2013 ; Zazulak, Hewett, Reeves,

Goldberg, & Cholewicki, 2007 ). The injury initially

causes pain, followed by disability during the treatment

and recovery phase (often lasting 9–12 months), may in-

volve signiﬁ cant expense ($17,000–$88,000 per injury),

and cause long-term consequences to the athlete

( Dharamsi & LaBella, 2013 ; Mather et al., 2013 ). Risk

factors erroneously thought to be the reasons these post-

pubescent female athletes were at risk included anatom-

ical differences (narrow quadriceps [Q] angle, narrow

intracondylar notch), hormonal changes ( Grifﬁ n et al.,

2000 ; Postma & West, 2013 ; Sutton & Bullock, 2013 ),

lack of experience ( Sutton & Bullock, 2013 ), and even

poor coaching. Recently, studies have suggested the

greatest risk for ACL injury is weak core strength and

decreased proprioception, which are modiﬁ able risk fac-

tors ( Dharamsi & LaBella, 2013 ; Grifﬁ n et al., 2000 ;

Postma & West, 2013 ; Sadoghi, vonKeudell, & Vavken,

2012 ; Sutton & Bullock, 2013 ; Walden, Atroshi,

Magnusson, Wagner, & Hagglund, 2012 ; Zazulak,

Cholewicki, & Reeves, 2008 ; Zazulak et al., 2007 ). If an

injury prevention program (IPP) was designed to ad-

dress core strength and proprioception, would the post-

pubescent female athlete have a decreased risk of an ACL

injury?

Purpose

The purpose of this study was to evaluate an ACL IPP

that was created on the basis of evidence of the best

means of reducing these modiﬁ able risk factors, that is,

increasing core strength and proprioception. Exercises

from functional and applied kinesthetic science were

used as the basis for creating this program, as well as

principles for creating success in a sports season with

young female athletes, coaches, and athletic trainers.

The problem statement for this study was as follows: “In

female athletes participating in soccer (a noncontact

sport), will participation in an ACL IPP increase core

strength and proprioception over the course of a sports

season?” The hypothesis was that participation in the

IPP would increase core strength and proprioception at

the end of the sports season. Independent variables

were the measures of core strength and proprioception,

determined by six tests. Dependent variables were pre-

and postseason testing results.

BACKGROUND: In female high school athletes, soccer

continues to be a high-risk sport for sustaining an anterior

cruciate ligament injury

. Literature reviews indicate the best

injury prevention programs (IPPs) focus on increasing core

strength and proprioception in this age group.

PURPOSE: An IPP was created for a small Midwestern high

school girls’ soccer team. The goal of the study was to

evaluate the ef

fectiveness of the IPP on core strength and

proprioception.

METHODS: The IPP incorporated functional movement ap-

plied science and exer

cises. Students were tested pre- and

postseason. Results were analyzed using paired-samples t

tests.

RESULTS: Statistically signiﬁ cant r

esults in improved core

measures were noted.

CONCLUSION: This IPP, which utilized functional movement

and training, could be utilized by other teams for incr

easing

core strength and proprioception of players, as well as add-

ing to the body of literature utilizing functional movement.

Establishment and Evaluation of an

Anterior Cruciate Ligament Injury

Prevention Program

Rebecca Liebert

Rebecca Liebert, DNP, MSN, NP-C, ONP-C, Orthopaedic Nurse

Practitioner, Tomah Memorial Hospital, Tomah, WI; and Assistant

Professor, Family Nurse Practitioner Program, Viterbo University,

LaCrosse, WI.

The author has disclosed no conﬂ icts of interest.

DOI: 10.1097/NOR.0000000000000245

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Literature Review

A literature search was conducted on CINAHL,

MEDLINE, PubMed, and EBSCO utilizing delimiters of

“peer reviewed,” “anterior cruciate ligament,” “female

athlete,” and “injury prevention.” The focus of the

search included evaluation of existing IPPs and studies

predicting risk for ACL injury. In addition, searches

from

The Journal of the American Academy of

Orthopaedic Surgeons

and well as

The Journal of Bone

and Joint Surgery

were conducted. The number of arti-

cles from all sources was narrowed to 149. Numerous

articles were utilized from collaborating disciplines,

such as physical therapy, strength and conditioning, re-

search journals, and theory articles. Studies and articles

were included if they were less than 6 years old, al-

though some studies were reviewed for historical sig-

niﬁ cance, because frequency of injury of the ACL in the

female athlete has been documented in literature since

the 1990s. Multiple Level 1 (strong evidence in rand-

omized controlled trials, cohort studies) and Level 2

(prospective cohorts) studies were used, as well as sev-

eral meta-analyses and systematic reviews.

ANATOMICAL DIFFERENCES

Compared with males, females have a narrower intra-

condylar notch, more narrow Q angle, hormonal ﬂ uc-

tuations, and decreased quadriceps strength ( Boden,

Sheehan, Torg, & Hewett, 2010 ; Dharamsi & LaBella,

2013 ; Postma & West, 2013 ; Sutton & Bullock, 2013 ). In

addition, female athletes were noted to have decreased

core strength and proprioception ( Zazulak et al., 2007 ).

These areas of weakness cause the female athlete to land

with an increased valgus stance, have poorer neuromus-

cular and quadriceps control in maneuvers, increased

dependence on bones for landing technique versus mus-

cle strength, and have weaker cores causing trunk insta-

bility with poor balance techniques ( Boden et al., 2010 ;

Dharamsi & LaBella, 2013 ; Grifﬁ n et al., 2000 ).

INCREASED RISK OF INJURY

The greatest increase of ACL injuries has been noted in

the female soccer athlete, particularly between the ages

of 16–18 years (some studies noted the ages of

15–19 years), and these females were at 3:1 increased risk

of injury to the ACL compared with the same-age male

athlete ( Bien, 2011 ; Dharamsi & LaBella, 2013 ; Noyes,

Barber-Westin, Tutalo-Smith, & Campbell, 2013 ; Sutton

& Bullock, 2013 ). Ford, Shapiro, Myer, Van Den Bogert,

and Hewett (2010) noted a signiﬁ cant increase in injuries

in female athletes who have commenced puberty.

INJURY PREVENTION PROGRAM

In order for an IPP to be successful, several components

must be present. First, the program must contain meas-

ures to strengthen the core and involve neuromuscular

control ( Bien, 2011 ; LaBella et al., 2011 ; Postma & West,

2013 ; Walden et al., 2012 ; Zazulak et al., 2007 ). Neither

the meta-analyses nor the Level 1 studies were able to

determine what the best speciﬁ c exercises were. Second,

the IPP needs to be between 15 and 20 minutes, which

makes it easier to learn, and is more replicable in the

off-season ( Gilchrist et al., 2008 ; LaBella et al., 2011 ;

Pﬁ le et al., 2013 ). Third, a program should be low cost,

with little equipment necessary, and easy to implement

( Swart et al., 2014 ). For this IPP, functional science lit-

erature was examined for exercises to incorporate those

exercises that would include functional movement, as

sports occur in motion, versus static strengthening

( Bien, 2011 ; Myer, Ford, Palumbo, & Hewett, 2005 ;

Noyes et al., 2013 ; Reid, Birmingham, Stratford, Alcock,

& Gifﬁ n, 2007 ; Zazulak et al., 2008 ).

Components of the IPP

On the basis of the aforementioned literature review, a

15-minute program was developed that involved no ad-

ditional costs or equipment other than utilized by the

soccer team already. The exercises chosen in this pro-

gram were based on functional movement and consisted

of ﬁ ve exercises: the common lunge matrix (see Figure 1 ),

single leg hop, single leg deadlift, soccer ball toss, and

shuttle run. Most of the exercises were simple to begin

with and then progressed to an advanced level for the

athlete ready to safely advance. The common lunge ma-

trix, developed by Gary Gray of the Gray Institute ( www.

grayinstitute.com ), has been rigorously tested for

strength training. YouTube videos are available to learn

how to perform these exercises (https:// www.youtube.

com/watch?v = hNdfemgY9KI ). In addition, the re-

searcher produced videos of these exercises for demon-

stration purposes for the participants. The common

lunge matrix uses functional movement of lunges in the

frontal, sagittal, and transverse planes (see Figure 1).

These exercises were performed in a rotation, alternating

right and left legs ( Myer et al., 2005 ). With increasing

strength, athletes could progress to a lunge hop. This ro-

tation lasted about 5 minutes. The single leg hop ( Myer

et al., 2005 ) had athletes alternating hopping on each leg

for 15-second intervals for 2 minutes. As athletes pro-

gressed, they could advance to hopping forward and

backward, as well as lateral and rotational hops. A single

leg deadlift ( Bien, 2011 ) was performed for 3 minutes.

Again, this exercise could be progressed to hopping, as

well as using a water or sports bottle to lift as an added

weight to increase core strengthening and stability. The

soccer ball toss ( Bien, 2011 ; Cowley & Swensen, 2008 )

was performed standing on one leg, which increased

core stability while throwing. This exercise was done

with a partner and lasted about 2 minutes. Finally, the

team was divided into partners for a shuttle run incorpo-

rating forward/reverse/lateral and karaoke (also known

as grapevine) running styles (https:// www.youtube.com/

watch?v = maI6ZXtoYsA ). This lasted approximately 3

minutes. These exercises involved only the student and

inexpensive accessories—water bottles and soccer balls,

both of which were an integral part of practice.

Theory

The Promoting Action on Research Implementation in

Health Services (PARIHS) framework was utilized as

the basis of this project. PARIHS puts evidence-based

practice into action ( Ciliska et al., 2011 ). Stetler,

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Damschroder, Helfrich, and Hagedorn (2011) developed

a guide for use of this model. Their guide is task based,

which was appropriate for this project. Evidence-based

characteristics for this framework includes evaluating

research and guidelines (literature reviews), evaluating

the local environment for change (school and coaches

were supportive), consideration of costs (none to mini-

mal), and compatibility of the practice change.

Contextual readiness for implementation included the

culture, targeted group, and leadership support, which

were sought by the athletic director, coaches, students,

and school board. The researcher needed both expecta-

tions and activities to be discussed with the participants

(which included parents as well), availability on-site for

interaction with others (both at practice and at games to

answer questions of parents), and able to identify the

purpose of this change. Finally, successful implementa-

tion of this model included development of the plan, in-

cluding clinical interventions (development of the IPP),

matching patient (increased core strength and proprio-

ception), and organizational (decreased injuries) out-

comes, with evaluation of their success (postseason test-

ing) and remaining focused on interventions that will be

evaluated prospectively, while examining strengths and

weaknesses of the study during implementation as well

as retrospectively.

FIGURE 1. Soccer exercises.

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Methods

SAMPLE

A total of 49 subjects participating in soccer at a small

Midwestern high school were asked to participate in the

study. The sample was a convenience sample, including

all students participating in soccer, as the IPP was going

to become part of the practice warm-up. Educational

information was given at team meetings for students

and parents, allowing for question and answers. E-mail

addresses and phone numbers of researchers were pro-

vided for students. Students were assured that failure to

complete postseason testing would not affect their play-

ing time in games. Students younger than 18 years had

parental assent; those 18 years and older completed con-

sents. The investigational review board of Graceland

University of Independence, Independence, MO, ap-

proved the study. School board, athletic director, ath-

letic trainer, and coach approval was sought before con-

ducting the program. Conﬁ dentiality of participants was

ensured, as each student was assigned a random num-

ber for testing. Demographic sheets with identifying in-

formation were only available to the primary researcher

and kept off-site. Two students were injured preseason

and unable to test. Sixteen more students were unable to

complete postseason testing (two quit, two were not al-

lowed because of academic performance, four had other

injuries [head, arm, hip], and eight students were una-

ble to attend the postseason testing sessions). Thirty-one

students completed the program.

EDUCATION OF ATHLETES

The athletes were given educational material in multi-

ple ways to ensure proper form of doing the exercises.

The team captain was videotaped performing all the

exercises, and these tapes were provided on the team

social media page for review before and during the sea-

son. The athletic trainer was photographed doing the

exercises, and a training sheet was given to the students

as well as the coaches for referral. The primary and sec-

ondary investigators attended practice three times

weekly the ﬁ rst 4 weeks and then once weekly to moni-

tor the students’ form during practice. The investigators

made themselves available for questions of the students

to ensure safety and competency during the exercises at

practice, as well as at home games to meet with parents

and answer questions if needed.

DATA COLLECTION

Data were collected pre- and postseason by the investi-

gators of the study. The testing stations included

validated exercises determined from the literature

review as measures of core strength and neuromuscular

control.

INSTRUMENTS

General Demographics

Each participant completed a demographic sheet (see

Figure 2 ). Figure 2 noted name, assigned identiﬁ cation

number for conﬁ dentiality, birth date, parental assent or

student consent, onset of menarche, and assessment of

access to social media and educational materials. Figure 3

noted ID number, height, weight, body mass index, as

well as testing measures described in the following text.

Functional Pre- and Postseason Testing

The Star Excursion “Y balance” test is considered a gold

standard for neuromuscular control, as there is little

room for testing error, it has proven reliability and va-

lidity, and it tests movement in multiple directions in a

short amount of time ( Bien, 2011 ; Plisky, Rauh,

Kaminski, & Underwood, 2006 ). To increase reliability

of these results, two individuals trained in proper test-

ing, conducted both pre- and postseason testing.

Additional tests included the single leg hop and hold

( Reid et al., 2007 ), triple crossover hop ( Lim et al., 2009 ;

Mandelbaum et al., 2005 ; Reid et al., 2007 ), superman

( Bien, 2011 ), and the shuttle run (“T” test) for speed and

agility ( Lim et al., 2009 ; Mandelbaum et al., 2005 ; Noyes

et al., 2013 ; Semenick, 1990 ). The measurement of hip

internal and external range of motion was completed by

the same investigator pre- and postseason to reduce risk

of interrater reliability error (see Figure 3 ).

Likert Scale for Subjective Evaluation of

Program

As this program was new to the school soccer program,

student athletes were asked to evaluate the program

using a Likert scale (see Table 1 ). The Likert scale ranged

from 1 to 5, with 1 being “strongly disagree” and 5

“strongly agree.” Components of this evaluation in-

cluded ascertaining if the program was easy to learn, if

the educational materials were helpful, and if this pro-

gram would be replicable in the off-season.

DATA ANALYSIS

All data were analyzed using SPSS software (SPSS,

Chicago, IL). Statistical methods included paired-

samples

tests, evaluating pre- and postseason core

measures.

Results

For all paired-samples

tests, the α level was .05. The

total degree of freedom (

) was 30 (31 − 1 = 30). The

critical value for the

-test statistic, two-tailed test equal

= α /

= .05/30 = 2.042. Each measure of pre- and

postseason testing was compared. A total of 25 pairs of

data sets were evaluated. Samples from each test are in-

cluded in Table 2 .

Findings noted overall improvement of the athletes’

core strength and proprioception. Abdominal strength

improved as evidenced by the simple superman test

(

= .01, mean improved 9 seconds; see Figure 4).

Speed and agility improved as noted in the shuttle run

test (

= .02), although the difference in time improve-

ment for the test was less than 1 second. The single leg

hop and hold had varied ﬁ ndings, with no signiﬁ cant

improvement noted on the right (

= .29) or left

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(

= .23) single leg hop, or the right triple crossover

and hold (

= .88). However, the left triple crossover

and hold improved signiﬁ cantly (

= .01). Hip external

and internal rotation improved in both hips signiﬁ -

cantly (all with

= .001, except right hip internal rota-

tion

= .002; see Table 2 ). The Y balance test evaluates

each leg in six directions each, for a total of 12 differ-

ent ﬁ ndings (see Figure 5 ). Seven of 12 measures noted

statistically signiﬁ cant improvement (

< .05). Of the

ﬁ ve measures that did not show statistically signiﬁ cant

changes, four of ﬁ ve applied to the right lower extrem-

ity (see Figure 6 ).

The students were asked to evaluate the program.

Thirty-one students responded. As some students did

not watch the social media videos, the number of re-

spondents to those questions was less than 31 (see

Table 1 ). Results from the student evaluation were posi-

tive, with scores ranging from 3.03 to 4.54 on the Likert

scale. Evaluation of two main goals of this IPP, (1) that

exercises were easy to learn and (2) the exercises would

be replicable in the off-season, scored between “agree”

and “strongly agree” (scores > 4.16). This indicated that

these goals were achieved.

Discussion

The pre- and postseason scores noted improvement in

many tests. Signiﬁ cance was noted in seven of 12 meas-

ures of the Y balance test. Hip internal and external ro-

tation improved (

< .002), although the exercises fo-

cused on core strength and proprioception, not

increased ﬂ exibility. This improvement may be attrib-

uted to the stretching exercises or overall improvement

in ﬁ tness throughout the season. Times for the shuttle

run improved (

< .028). The superman test was signiﬁ -

cant for change (

< .010), with time increasing from 80

to 89 seconds. The single leg hold and triple crossover

improved for the left leg (

< .049 and

< .022) but not

for the right leg (

< .189 and

< .073). The reason for

this is not determined, but possibly as all exercises were

performed bilaterally, more improvement was noted on

the weaker leg.

FIGURE 2. Participant demographic sheet.

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As noted, components of an IPP, to be successful,

must be replicable in the off-season, easy to learn, and

inexpensive. This IPP required no tools or costs except a

soccer ball (part of the team sport) and water bottles.

The Likert scale evaluating the ability to perform in the

off-season with coaching has a means of 4.35/5. Students

felt the warm-up and practice time was appropriate

(4.06/5) and the exercises were easy to learn (4.16/5).

Interestingly, the perception of challenge of these exer-

cises was only 3.03/5, which may indicate more students

could have advanced to more difﬁ cult levels of exercises

as the season went on. Multiple methods of learning

were provided for students. Social media was used for

videos, but these had a poor response rate; the paper

handouts were perceived better for learning. The IPP

improved core strength and proprioception as evidenced

FIGURE 3. Pre- and postseason exercise testing. BMI = body mass index.

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TABLE 1. LIKERT SCORES OF ATHLETIC EVALUATION OF

ROGRAM

Item

Sample

Size

Mean

( SD )

The exercises were easy to learn 31 4.16

The exercises were challenging 31 3.03

I understood why we were doing this IPP 31 3.87

If I had questions, they were answered

clearly

31 4.54

The paper handouts helped me learn the

exercises

28 4.00

The videos on Facebook helped me learn

the exercises

20 3.30

I feel like I could do this program in the

off-season without someone coaching

31 4.35

The time it took to do the warm-up/IPP

seemed appropriate

31 4.06

Note . IPP = injury prevention program.

TABLE 2. PAIRED-SAMPLES T TEST OF SELECT PRE- AND POSTSEASON TESTS

Test Name Mean SD N t df p

Pair 1 P R HIR 38.74 6.57 31

− 3.442

30 .002

PO R HIR 42.16 5.21 31

Pair 2 P L HIR 40.51 7.25 31

− 4.652

30 .001

PO L HIR 44.41 6.41 31

Pair 3 P R HER 31.06 6.59 31

− 5.294

30 .001

PO R HER 36.54 5.40 31

Pair 4 P L HER 31.51 4.50 31

− 4.78925

30 .001

PO L HER 38.09 3.627 31

Pair 5 P R SLH 59.55 7.24 31

− 1.078

30 .290

PO R SLH 61.09 7.65 31

Pair 6 P R TCH 163.89 27.65 31

− 0.153

30 .880

PO R TCH 164.81 35.27 31

Pair 7 P L TCH 162.93 27.92 31

− 2.575

30 .015

PO L TCH 170.30 24.08 31

Pair 8 P L SLH 59.61 7.96 31

− 1.211

30 .235

PO L SLH 61.27 7.86 31

Note . HER = hip external rotation; HIR = hip internal rotation; L = left; P = preseason; PO = postseason; R = right; SLH = single leg hop

and hold; TCH = triple crossover hop and hold.

by nearly all measurements of pre- and postseason test-

ing. Students found the program easy to learn and rep-

licable in the off-season, but it could have been more

challenging.

These results indicate that this program design is a

means of increasing core strength and proprioception.

During this sports season, one student was not able to

participate in this program due to a hip injury. She ex-

perienced an ACL tear late season, but there is no direct

correlation that this injury would have been prevented

if she had been able to participate. Another student had

a knee strain. Several others had arm and head injuries

mid-season. Coaches indicated there were more inju-

ries this season than most but perceived there to be

fewer injuries to the knee and lower extremities.

Historically, this school and its female soccer athletes

are perceived to have had a low incidence of ACL injury

but actual statistics of injuries have not been tabulated

in past seasons.

Implications for future research for this school

would be evaluating the incidence of ACL injury over

time to determine if the number of injuries was reduced.

Future doctorate of nursing practice students could cor-

relate these ﬁ ndings over time to determine if this evi-

dence-based practice has long-term success.

Orthopaedic nurses could be involved with education of

student athletes, coaches, and athletic trainers.

Orthopaedic nurse practitioners may be able to evaluate

core strength of patients with other lower extremity in-

juries to determine if core strength assists with other

lower extremity injury prevention. As soccer is a sport

that often begins at the age of 4 or 5 years, incorporating

simple age-appropriate core strength and propriocep-

tive exercises at young ages may be beneﬁ cial as well.

This program could be replicated and tested in larger

studies, or as part of a randomized study, comparing

with other IPP, preexisting warm-up programs, or no

IPP. Weakness of this study included participants lim-

ited to primarily White or northern European descent,

middle class females in a rural town. The sample size

was small, at 31 athletes. Studies evaluating functional

movement as part of IPPs in soccer are limited. This will

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add to the body of knowledge of functional movement,

but more studies involving these types of movements

are needed.

Future Implications

The framework for this project, PARIHS, may be used in

the future, with similar programs with students partici-

pating in other sports such as volleyball or basketball. In

addition, examining the students over time or multiple

soccer seasons may provide additional data to deter-

mine if an overall decreased number of ACL injuries

would be noted because of establishment or participa-

tion in a program similar to this.

Both the problem statement and hypothesis were an-

swered, in that core strength and proprioception in-

creased by participation in this particular IPP. Future

studies may examine similar areas but may modify the

IPP or the length/duration of a program. This will add to

the body of knowledge for orthopaedic nurses, as well

as physical therapists, athletic trainers, and functional

sports science.

FIGURE 4. Paired-samples t -test statistics Black bars = preseason; gray bars = postseason. (A) Superman. (B) Shuttle and agility

run. PO SH = preseason shuttle and agility run; POSUP = postseason Superman; P SH = preseason shuttle and agility run;

PSUP = preseason Superman.

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FIGURE 5. Paired-samples means for Y balance. black = preseason; L = left; LA = left anterior; LAL = left anterolateral; LP = left

posterior; LPL = left posterior lateral; P = preseason; gray = postseason; PO = postseason; R = right; RA = right anterior;

RAL = right anterolateral; RP = right posterior; RPL = right posterior lateral; Y = Y balance.

FIGURE 6. Paired-samples t -test signiﬁ cance for Y balance test. L = left; LA = left anterior; LAL = left anterolateral; LP = left

posterior; LPL = left posterior lateral; P = preseason; PO = postseason; R = right; RA = right anterior; RAL = right anterolateral;

RP = right posterior; RPL = right posterior lateral; Y = Y balance.

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Conclusion

Injury prevention programs are necessary for athletes

of all ages. Because of increasing numbers of ACL in-

juries in female high school athletes, in particular soc-

cer players, it is important to prevent this costly injury

with potential long-term complications. Incorporating

exercises in motion, not just in static planes, has been

shown to increase core strength and proprioception,

which are known measures to decrease risk of ACL

injuries.

ACKNOWLEDGMENTS

The author thanks Mathew Herbst, MSPT, MS3, for in-

troducing knowledge of functional applied science and

past experience to help create this injury prevention

program, as well as assisting with all pre- and postsea-

son testing.

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ries: Mechanisms and risk factors . The Journal of the

American Academy of Orthopaedic Surgeons, 18 ( 9 ),

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