Journal of Orthopaedic & Sports Physical Therapy

2OOl;3l(ll):655-66O

n
F

Proprioceptive Training and Prevention of

Anterior Cruciate Ligament injuries
A

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G. Cerulli, MD l s 2
D. I . Benoit, MScl
A. Caraffa, MD1s2
E Ponteggia, MD3
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edly stops, causes a high level of

strain on the ACL, which initiates
at foot contact when the leg is
most e ~ t e n d e dAlthough
.~
this
study confirms that the ACL will
be in high stress situations during
Key Words: injury prevention, knee joint, proprioception
sports, the point at which injury
may occur is still unknown. The
injury mechanism is triggered
n our experience, the anterior cruciate ligament (ACL) injury
through an interaction of kinerate of soccer players not trained in injury prevention is 1.15 per matic and kinetic variables that, by
team per season compared to players trained with a propriocep
definition, can only be altered by
tive training program (0.15; P < 0.001) in groups matched for
changing either the external or
practice and game exposure over 3 years.' Not surprisingly, the
internal forces acting on the body.
ACL injury causes the greatest financial expense and highest number of
In a noncontact injury situation,
player days missed in the sport.'*JJ As in most sports, ACL injuries in
the external forces may be altered
soccer occur from both contact and noncontact situations. Most ACL
by shoe-playing surface interface,
injuries occur between 0" and 30" knee flexion,SzJ primarily in nonconas
this is the only point at which
tact situations during running and jumping. In running, the movean
external force may act on the
ments associated with the injury include change of direction, rapid debody. The internal forces are govceleration, spontaneous stopping, and torsional movements. In j u m p
erned
by bone on bone forces, liging, the movements include landing with varus and internal rotation
ament
and soft tissue, and musstress or valgus and external rotation stress.
cles.
Muscle
contractions generate
Currently there is little research that identifies the critical phases of
the forces acting on the bones,
these movements that cause injury. However, recent advances with in
vivo ACL strain measurement during rapid deceleration have confirmed which alters the position of body
that the rapid deceleration movement, such as when a player unexpect- segments and also greatly affects
joint stiffness. When referring to
Let People Move Biomechanics Laboratory, Perugia, Italy.
alterations of postural control or
Department of Orthopaedic Surgery, University Hospital of Perugia, Italy.
body position, it thus implies an
Lecturer, Physical Medicine and Rehabilitation, University of Florence, Italy.
Send correspondence to Daniel Benoit, Let People Move, Via G.B. Pontani 9, Perugia, Umbria, associated alteration in neuromus06 128, Italy. E-mail: dbenoit@magma.ca
cular control.
This commentary describes a program developed to help reduce the incidence of anterior
cruciate ligament injuries in soccer players. The basic principles underlying the injury
prevention protocol are described with respect to the proprioceptive control mechanisms at
the knee joint. This is followed by a detailed description of the program. 1 Orthop Sports
Phys Ther .?OOl;3l:655-660.

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PROPRIOCEPTION AND THE KNEE JOINT

In order to describe the proprioceptive system, we
must first discuss the issue of proprioception. A proprioceptor may be described as a sensory receptor
that can detect stimuli generated by the system itself." Many authors have demonstrated the existence
of mechanoreceptors and free nerve endings in several parts of the knee joint. These receptors provide
the basis for the proprioceptive feedback system that
would allow adaptive changes to occur during preventive training programs, thus helping in the prevention of knee injuries during sports. For a proprioceptive training program to function, the premise is
that adaptations will take place based on the stimuli
the proprioceptors receive during or prior to initiation of the deleterious movement. This information
will alter the possibly programmed response in a
manner that modifies the mechanical conditions acting on the ACL. For this to occur, the injury mechanism, or pattern of movement, must be recognized
by the sensory control system as deleterious. A corrective response must then be initiated to modify the
movement of the involved limbs in a way that reduces or alters the stresses applied to the ACL by applying a different movement strategy. This implies an altered neuromuscular response, as the only way to alter a movement pattern is to modify the internal
forces applied to the system, that is, by changing
muscle activation patterns.
Currently in the literature, the evidence supports 2
main views of where the corrective response may be
initiated: (1) via peripheral feedback from sensory
receptors or (2) based on preplanning through the
central nervous system.Vt is beyond the scope of
this commentary to discuss these views; however, a
theme common to both views is that training may alter the neuromuscular response to unexpected perturbations. This indicates that, in some way, the feedback derived from sensory input may be modified to
alter neuromuscular response. It is possible that the
structures within the ACL9.'R.242H.x'
and soft tissues
within and around the knee jointl.H.10.1W.".2(i.27.21) may
provide sensory information that could contribute to
the proprioceptive system.

PROPRIOCEPTION AND THE ANKLE JOINT

Along with the knee, the ankle is an important
joint to consider in the prevention of ACL injuries,
as it will have a direct influence on tibial orientation
and, thus, the position of the ACL. Freeman and
Wyke14 found type I, 11, and N receptors in ankle
joint capsules and type I, 111, and N receptors in ankle ligaments in cats. Lynch et al" tested 10 uninjured subjects with a tilt platform to reproduce quick
ankle inversion and plantar flexion by recording
muscle contraction latency with surface electromyog-

raphy. The results showed that increasing the range

of motion of plantar flexion-inversion augments the
latency response of the peroneus muscles, while increasing inversion velocity reduces the latency time
in these same muscles. Sheth et alJ1used surface
electromyography to investigate the effect of proprioceptive training on the activation pattern of ankle
muscles during simulated ankle sprains in nonimpaired subjects. They concluded that 8 weeks of exercises on an ankle disk (15 minutes per day) led to
selective modulations in the sequence of muscle contraction. The pretrained athletes showed simultaneous activation of anterior and posterior tibialis,
peroneus longus, and flexor digitorum longus muscles, whereas in posttraining there was delayed activation of the inversion muscles, thus allowing the peroneals to counteract the sprain.
These studies demonstrate the importance of using
ankle disk exercises in an injury prevention training
program. Exercises on a disk cause quick ankle
movements that may be similar to those occurring
prior to or at the time of injury. This sensory input
may lead to improved kinesthesia (sense of movement) and proprioception (sense of position), factors that may be important for injury prevention.
Based on the information described here, we define a preventive proprioceptive training program as
a series of exercises or situations that will elicit a response from the nervous system in order to counteract external stimuli. The program must be progressive and include both situations controlled by the
athlete and those that change based on extrinsic factors. For example, directional changes elicited by
coaching instructions or bases of support disturbed
at random intervals are both situations that necessitate a neuromuscular response to effectively counter
the stimuli.

TRAINING AND PREVENTION

Knee joint alignment is directly affected by the
kinematics of the hip and ankle joints. For example,
sensory feedback and motion control at the foot and
ankle will directly affect tibial loading and orientation, thereby predetermining the condition in which
the ACL will be loaded. It is, thus, possible for knee
injury prevention to be initiated not at the knee but
at the ankle. The same situation is present with respect to the hip and femoral loading and orientation. Postural control following a perturbation or in
preparation for movement of a nonrelated segment
is not limited to the lower limb; instead, it is controlled by a complex interaction of anticipatory and
preparatory contractions also seen in the arms and
trunk muscle^.^^^ Horak and Nashner17 have found
that altering the base of support from a normal surface to one that is short in relation to foot length
will cause the control strategy to shift from the ankle

TABLE. Proposed training program.

Training
level
Level 1
Level 2
Level 3
Level 4

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Level 5

lmtructiom

Frequency

Balance training without a

board (1-legged stance on the
ground)
Balance training on a rectangular balance board (each leg
alternately)
Training on a round board
Training on a combined round
and a rectangular board
Training on a multiplanar board

2.5 min * 41d * 3lwk

2.5 min * 41d * 3lwk
2.5 min * 4/d * 3lwk
2.5 min * 4ld * 3/wk
2.5 min * 4ld * 3lwk

to the hip, respectively, as well as the base of s u p

port. Therefore, any training for the prevention of
knee injuries must take into consideration these other links in the kinetic chain of the lower limb, as
well as upper body postural control mechanisms.
Muscle fatigue seems to induce proprioceptive deteriorati~n.~.'"~
Therefore, the training program
must also include enough exercise sequences to elicit
fatigue and train these responses. Hamstring activity
appears to help reduce anterior tibia1 displacement
at certain joint angles and should also be stressed
during the training program. Further evidence of the
important role of the hamstrings may be deduced
from the fact that there is a greater latency of muscle
contraction in ACMeficient knees compared not
only with control groups of nonimpaired subjects,
but also with the uninjured contralateral side in the
same patient. The correlation between latency and
functional instability (frequency of giving way) in patients with ACL deficiencyJ insinuates that this function could play a protective role. Evidence that the
reflex hamstring contraction latency time can be reduced by performing proprioceptive exercises with
the aim of improving speed and facility of hamstring
contractions further supports the principles of injury
prevention training. A training program including
weight-bearing exercises and a progressive reduction
in stability (wobble board, eyes open and then
closed) with increasing repetitions and rate of contractions appears better than a traditional program
of muscle strengthening (non-weight-bearing and
graduated weight-resisted exercises) in improving reflex hamstring contraction latency and dynamic joint
stability2 A functional exercise program (training of
leg muscles while bearing weight and of trunk muscles to improve coordination, postural reactions, and
endurance) also appears to improve standing balance
in patients with ACL deficiency.%
Proprioceptive training must be performed
throughout the range of joint motion; this is important because the mechanoreceptors seem to be activated selectively at specific angles.20Muscle receptors
play a primary role in the intermediate range of motion, while joint receptors and muscle receptors are
J Orthop Sports Phys Ther*Volume 31 .Number 1 l .November 2001

FIGURE 1. Step-downs off of the training board.

more important in the extreme ranges of motion.

Muscle training focused on building endurance,
strength, and power is important along with the proprioceptive programs. Hewett et all" demonstrated
the importance of plyometric training in preventing
knee injuries in female athletes, reducing the injury
rate from 0.43 per 1000 exposures to 0.12 (P =
0.05), following a &week jump training program. A
Swedish study by Tropp et al,3%owever, demonstrated that coordination training might help to prevent
functional instability, reducing the frequency of ankle
sprains in athletes with previous ankle injury. The
training program was composed of exercises performed on a disk with a spherical undersurface, with
one leg straight and the other raised and flexed at
the knee while the arms were placed over the chest.
The training time was 10 minutes 5 times weekly for
10 weeks, then 5 minutes 3 times weekly; the length
of the study was 6 months. Comparing propriocep
tively trained and control groups, both composed of
players with previous ankle problems, the difference
in reinjury was significantly lower in the trained
group (5% vs. 25%; P < 0.01).
Following these same principles, our group applied
similar methods to determine if it is possible to reduce the incidence of ACL lesions in soccer players
by adding proprioceptive exercises to traditional training programs. In a prospective controlled study by
Caraffa et a17 of 600 soccer players (semiprofessional
or amateur teams), we evaluated the possible preventive effect of gradually increased proprioceptive training during 3 soccer seasons. A control group of 300

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FIGURE 2. Example of the proprioceptive neuromuscular facilitation exercises.

players was trained traditionally, without specific balance exercises, while the experimental group of 300
players followed a proprioceptive training program.
During 3 soccer seasons, 10 arthroscopically verified
ACL lesions occurred in the proprioceptively trained
group, while 70 were recorded in the traditionally
trained group (P < 0.001). The training program
used in this study, and today, is described below.
The experimental group was instructed to train 20
minutes per day, with 5 levels of difficulty (Table).
Each phase of training was performed for 3 to 6
training days, depending on proficiency, and all
FIGURE 4. Use of multiplanar board along the oblique axis.

I
FIGURE 3. Multiplanar board configuration.

training sessions lasted for at least 30 days. The athletes had to demonstrate proficiency in each phase
before progressing to the next level. This was selfdetermined based on the instruction that they could
perform the exercises without the need for additional support (the other foot or hand) in a consistent
manner and without fear of falling.
In addition, the subjects were instructed to perform anterior and posterior upstep exercises while
standing on the training board. F& this exercise, the
subjects used the free leg to step off of the board,
barely touching the floor with the free foot, and
then returned to the standing position (Figure 1).
This was repeated in a controlled manner and forced
the subject to maintain balance over a wide range of
knee joint angles. All subjects also took part in p r e
prioceptive neuromuscular facilitation exercises for
the lower limb, assisted by a trained technician (Figure 2). These proprioceptive neuromuscular facilitation exercises were performed as part of the regular
stretching routine during practice sessions. The technician performed these knee and hip exercises on
J Orthop Sports Phys Ther-Volume 31 *Number 1 1 -November 2001

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FIGURE 5. Increased training difficulty with 2 boards.

the subjects with the subjects in a supine position,

and the exercises included passive movements of
flexionextension, internal-external rotation, abduction-adduction movements, and combinations thereof. The subjects were then asked to reproduce these
same movement patterns unassisted (active movements). These exercises were meant to increase subject awareness of limb position; however, this effect
was not measured or quantified.
The subjects were also instructed to follow a modified version of the neuromuscular facilitation program described by Hervkou and Mksskan.I5 This consisted of using both a circular and a rectangular
board. The rectangular board, with 2 spheres placed
obliquely or along its longitudinal axis, allowed for
movement along 3 axes (Figure 3), depending on
the patient starting position and sphere placement.
The subject was instructed to perform forward lunges with deep knee bends using the rectangular board
along all 3 axes. The subject had to maintain the positional alignment of the knee above the foot (no internal or external rotation of the hip and control of
foot pronation and supination) (Figure 4). The degree of difficulty was increased by stepping off of a
raised height (eg, a stair) onto the board and performing the lunge to maximal knee bend. The subject would then perform the exercise by stepping off
of the circular board, keeping the trailing leg on it,
onto the rectangular board, or vice-versa (Figure 5).
Although not part of the original prevention program, additional tests may be added to further increase the degree of difficulty. These movements
could place the athlete in safe but unstable situations
that mimic the movement patterns known to cause
injury, such as hopping onto the training board, thus
training the athlete to adapt to unexpected situations
(Figure 6).
J Orthop Sports Phys Ther*Volume 31 Number 1 1 November 2001

FIGURE 6. Increased difficulty by hopping onto the training board.

CONCLUSIONS
Our previous results have indicated the potential
to reduce the incidence of ACL injuries in soccer
players; however, more work is necessary to optimize
these prevention protocols. A multifaceted approach
should be applied and customized based on the
needs of the athlete. The goal is to provide an interesting and challenging routine that puts the athlete
in situations that force a reaction to expected and
unexpected changes in the environment. Using the
techniques described, along with other innovative a p
proaches, we believe that the incidence of ACL injuries in soccer players can be reduced.

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J Orthop Sports Phys Ther.Volume 31 .Number 11 .November 2001