Therapeutic Exercise Protocol for the Prevention of Anterior Cruciate Ligament Injuries in Female Football Players With Dynamic Knee Valgus
Phase: NA
Conditions: Anterior Cruciate Ligament Injuries
Sponsor: Amanda Coves García

STUDY PROTOCOL WITH SAP  
 
TITLE 
Therapeutic exercise protocol for the prevention of anterior cruciate ligament injuries in female football 
players with dynamic knee valgus. 
 
 
DOCUMENT DATE: 30/07/2023 
 
 
 
 
 
 
 
 
 
 
 

INTRODUCTION 
In recent years there has been an exponential growth of women participating in team sports such as 
football. Around 29 million footballers worldwide are women. In addition, the numbers are constantly 
growing with an estimated 51% increase in the number of registered players, as is the interest of the 
female society in this sport1. The popularity and visibility of women's football is associated with an 
increase in the number of lower extremity injuries, especially with a high risk of knee injuries. Of all 
the knee injuries that can occur, women are particularly susceptible to anterior cruciate ligament (ACL) 
injuries. The ACL plays an important role in knee kinematics2. It stabilizes the joint in full extension, 
prevents rotational loads and anterior displacement of the tibia3. These injuries are a major current 
problem4,5 accounting for 16% to 32% of all injuries and 43% of the injury burden during the sports 
season6. Regardless of their level of participation, female footballers have between 2 and 8 times7 times 
the risk of suffering ACL injuries compared to their male counterparts5 performing similar training8,9,10. 
Injury incidence rates among female soccer players range from 1.1 to 3.1 injuries per 1000 hours of 
training and from 12.6 to 23.6 injuries per 1000 hours of play over the past decade1. 
Most ACL injuries among female players occur without contact from another player5. Current 
evidence suggests that the etiology of these lesions is multifactorial and results from the interaction of 
modifiable and non-modifiable risk factors5,11-14. They can be caused by poor biomechanics on the field 
during sport-specific movements that female footballers frequently execute; due to anatomical 
differences in the lower kinematic chain15 (ACL weakness, generalized tibiofemoral laxity, narrow 
intercondylar grimace, hormonal fluctuations, unfavorable alignment of the pelvis, hip, knee and foot 
or presence of valgus knees)11; and lack of neuromuscular control5,13,15. The two most common 
mechanisms that can produce these non-contact injuries during dynamic sports activities are plantar and 
cutting or a sudden slowdown5. Neuromuscular control is a modifiable risk factor, therefore non-contact 
ACL injuries could be prevented if proper prevention protocols are established. In addition, Coves 
García et al.16 suggests that the recovery of neuromuscular control is fundamental and essential to reduce 
the incidence of these injuries2,17,18 and to maintain correct joint biomechanics in female athletes. Shams 
et al.19 and Sasaki et al.20 support its importance and define it as proper muscle timing and proper force 

generation. In addition, Arundale et al.7 and  others point out that the most common neuromuscular 
disorders in women, which can contribute to ACL injuries, are the high landing forces and knee 
movements that occur in the frontal plane in addition to lower hip and knee flexion angles due to muscle 
weakness during landing, using the quadriceps to stabilize the knee joint. It can lead to compensatory 
patterns21 in muscle co-contraction actions22, greater degrees of ankle eversion, asymmetric landings 
and poor ability to control the trunk7 associated with a high moment of abduction and valgus collapse 
during jump-landing tasks or posterior displacement of the center of gravity compared to men2,14,17. 
According to Cannon et al.23 Inadequate neuromuscular control of proximal motor components (trunk 
and hip) also negatively influences the control of knee biomechanics during dynamic sports tasks. Zago 
et al.11 note that the joint biomechanics of ACL injuries during football matches is the same between 
male and female footballers. In addition, they confirm that 80% of injuries occur among female 
footballers because the load on valgus, internal rotation and hip abduction is significantly higher than in 
footballers during sports tasks.  
Among all the most commonly cited biomechanical risk factors for this injury, dynamic valgus knee 
(DKV) has been documented as the highest risk factor24 for non-contact ACL injury17,23,25 in female 
soccer players. This movement pattern is the result of combining three main components: internal 
rotation and hip adduction and knee abduction, in addition to distal joint modifications such as anterior 
translation and tibial external rotation and ankle eversion. It can also transmit harmful loads to the 
internal collateral ligament, internal meniscus and ACL.14,24,26-29 
The rehabilitation period after suffering an ACL injury is long and demanding. In addition, it is 
estimated that the average time to return to play in women's football is about 8.5 months or more6, which 
can mean the premature end of the player due to a decrease in her sports performance2. These injuries 
can cause significant morbidities in the short and long term, highlighting chronic knee instability, 
persistent knee pain30, meniscal and cartilaginous lesions or premature osteoarthritis of the knee6,11. 
 

Justification for the study 
Current training methods include preventive strategies focused on modifying neuromuscular and 
biomechanical risk factors31,32 using non-football-specific tasks such as eccentric exercises  or verbal or 
visual feedback combined with plyometric, core, balance, resistance or trunk strengthening exercises. 
These could be the most effective to positively modify the screening, identification and correction of 
dangerous movement patterns1,26 such as DKV during jump-landing tasks14,21,31,33,34. However, no 
uniform criteria have been established to design a precise intervention protocol, with specific tasks 
linked to women's football, nor has it been proposed to optimize current programs despite having a high 
number of injuries associated with DKV33,34. On the other hand, there is no consensus or unification on 
the establishment of defined parameters regarding the effective dosage of a specific training program, 
since there is great heterogeneity in terms of the doses and times of the scheduled exercises. These 
preventive programs are effective in the short term, but it is not equally confirmed whether they produce 
positive effects in the long term31. Current evidence reports that the implementation of specific 
preventive programs according to the sport practiced is imperative to reduce the incidence of ACL 
injuries. In addition, in terms of exercise effectiveness, it suggests a 51% reduction in these 
injuries2,20,35,36. 
Based on the review recently published in the journal Fisioterapia16, we proceed to propose, as a 
continuation of the current research process, an exercise protocol, as well as its dosage in female 
footballers with DKV, in order to reduce the risk of ACL injuries. 
 
 
 

OBJECTIVES AND HYPOTHESES 
Main objective 
To assess the efficacy of a comprehensive and specific training protocol focused on female players 
with DKV in preventing ACL injuries. 
Specific objectives 
1. To investigate the effects of a specific protocol as a preventive method of ACL injuries on the 
physical performance of female football players. 
2. To analyze the injury incidence of ACL among players with DKV in both groups. 
3. Check the changes in the neuromuscular control of the knee measured with the "drop vertical 
jump test" (DVJ) in both groups after the corresponding training proposal. 
4. To evaluate the biomechanics of landing with jump landing measured with the landing error 
scoring system (LESS) in participants in both groups. 
5. To analyze the perceived satisfaction rates of the athletes, using the SF-12 questionnaire after 
the intervention. 
6. Know the effective dosage of a specific protocol for the prevention of ACL injuries. 
PICO Question 
In soccer players with DKV... Does a specific training protocol reduce the risk of ACL injuries compared 
to the conventional program? 
Study hypothesis 
A comprehensive and specific 12-week training protocol for the 2023-2024 season will significantly 
reduce the risk of ACL injuries compared to conventional training for female soccer players with DKV. 

METHODOLOGY 
Ethical documents and prior registration 
This study has the Authorization of the Ethics Committee of the Responsible Research Office of the 
Miguel Hernández University of Elche for the 2022/2023 academic year and will be registered as a 
clinical trial in the clinicalTrial platform. 
 
Studio Design 
The study is designed as a randomized and controlled, double-blind, unicentric and parallel group 
clinical trial protocol that will be carried out with the female players of Elche CF and Intercity CF in the 
province of Alicante. The recommendations of the SPIRIT guide36 have been followed for the realization 
of this study. Annex I. 
Before starting the study, they will be provided with a written informed consent that they must sign 
to record their intention to participate in it, being able to revoke it at any time and accepting the 
conditions that will appear in the document (Annex II). They will be randomly assigned to a 
conventional fitness training program or a specific training protocol for 12 weeks. This study will consist 
of 3 time measurement points, the first prior to the intervention, the second at the end of the 6-week 
period of intervention and the last at 4 weeks after its completion. The study schedule and flowchart are 
in Annex III and IV, respectively.  
 
Participants 
The recruited population will be formed by the 44 elite players (22 per team) with a federative record 
belonging to the first senior team of Elche CF and Intercity CF of the province of Alicante of the national 
women's football league during the 2023-2024 season, where three weekly training sessions of one hour 
each are carried out. Prior to the collection of data, permission will be requested from the Club and the 
coach of both teams to carry out the study at the Martínez Valero Stadium in Elche. In the same way, 

the recruitment will be carried out through a direct contact, as an interview, with the coach, the 
physiotherapist and the physical trainer of the participating teams.  
Inclusion and exclusion criteria 
The inclusion criteria will be: 
• 
Football players registered and federated in the corresponding team. 
• 
With an age range between 18 and 35 years. 
• 
Minimum experience of one year playing football. 
• 
With the presence of DKV. 
The exclusion criteria will be: 
• 
Previously injured subjects of ACL or other knee ligament injury. 
• 
Subjects with a history of lower extremity injuries that have resulted in surgery during the six 
months prior to the study. 
• 
Players with chronic illnesses that may affect test results. 
• 
Subjects who practice other sports in the professional field. 
 
Study variables and measurements 
To record the number of injuries produced among the players of both groups at the end of the study 
and the frequency of weekly training, an Excel table will be used. The kinetics and kinematics of the 
lower extremities will also be analyzed with a motion capture system, surface EMG markers and a force 
platform. The LESS scoring system (Annex V)  and the DVJ task will be used to identify the risk of 
injury during the jump-landing task and the presence of DKV among the players, respectively. In 
addition, we will measure their pre- and post-intervention satisfaction rates using the SF-12 
questionnaire38. Annex VI. 

Sample size 
An analysis was performed with Epidat 4.2 software to calculate the sample size required in the 
present study. A comparison of independent means will be performed and a standardized mean 
difference of 1, a significance level of 0.05, a 95% CI and a power of 90% will be considered, which 
determines a total sample size of 44 subjects, 22 in each group. It is necessary to consider an 
abandonment rate, so we will increase the sample by 10%. Therefore, the total sample size will be 48 
women, 24 in each study group. Annex VII. 
 
Randomization and blinding 
Teams will be randomly assigned to one of the two groups  in a simple manner and will be performed 
once  subject selection  has been completed. This assignment will be hidden and will be carried out by 
a person independent of the study. The randomization method will consist of the toss of a coin assigning 
"heads" to the intervention group and "tails" to the control group. 
The study will have two physiotherapist evaluators, with at least five years of clinical experience. 
They will be responsible for the collection and analysis of data, assessments and evaluation of the final 
results. There will also be two sports physiotherapists, with at least five years of experience in the sports 
field, who will be responsible for the explanation and supervision of the exercises, in addition to being 
knowledgeable about the execution of specific training protocols. 
A double-blind masking will be carried out, in which the evaluating physiotherapists and the players 
themselves will be blinded. Sports physiotherapists will be the only professionals who will not be. In 
addition, interventions and measurements will be performed in separate rooms, which will facilitate the 
blinding of subjects and evaluators. 
 

Intervention 
First, an invitation will be made to all the players who are part of the teams mentioned above during 
the 2023-2024 preseason with the aim of starting the intervention during that same season. All 
respondents will receive a Google survey via WhatsApp. This questionnaire will include questions about 
the inclusion and exclusion criteria to select the study sample of interest as well as questions about their 
sports background (position, dominant limb and sports experience); anthropometric measurements (age, 
height, BMI and weight), which will be provided by the coaches of the selected teams; and aspects 
related to training (frequency of weekly training and rest period). After completing the survey, three 
weeks prior to the start of the clinical trial, all players who agree to participate must undergo a final 
screening to be included in the study.  This screening will consist of undergoing a qualitative analysis 
of the DVJ (Annex VIII), so that, through a simple visual examination, the inclusion of those players 
who do not present DKV can be ruled out and only those who test positive for DKV can be registered. 
After selecting the final number of players, a joint talk will be given to both teams to expose the 
dynamics of the study and the confidentiality of the data. Subsequently, pre-intervention measurements 
will be carried out by the evaluating physiotherapists to record the initial state of the players. These 
measures will be: the quantitative analysis of the DVJ, the LESS score, the initial score in the SF-12 
scale, the biomechanics of the lower extremities, the muscular activation of the lumbo-pelvic complex 
and the lower extremity. 
During the 12 weeks that the intervention will last, periodic measurements will be made. The last 
one will take place one month after the end of it. In addition, the players will be asked to refrain from 
consuming performance stimulants, tobacco or alcohol, non-steroidal anti-inflammatory drugs 
(NSAIDs) or analgesics 24 hours before each session, as well as strenuous exercise. As a reminder, a 
WhatsApp will be sent to each athlete the day before each session, indicating the time at which they will 
be scheduled for training the next day. The appearance of pain during the sessions will not be allowed 
and, if at any time it appears, the training of the player in question will be stopped immediately and 
recorded for further analysis. 

The intervention will consist of performing 3 weekly training sessions for 12 weeks to reach a total 
of 36 sessions of 30-60 minutes each. The days that will be set for training will be Mondays, Wednesdays 
and Fridays, leaving a rest day between sessions to ensure adequate recovery and quality training. The 
physical trainers will have to agree so that the training load in both groups is very similar.  
Next, we will proceed to detail the intervention that will be carried out in each of the two groups of 
this clinical trial: 
 
Conventional fitness training group 
The players who belong to this group will maintain the usual practice of football training, so no new 
intervention will be applied. 
 
Training group with a specific ACL injury prevention protocol 
This protocol is based on prevention programs that use a multifaceted approach, effective in 
reducing the risk of ACL injuries compared to those who used only one type of exercise14,21,34. A wide 
variety of studies defend the importance of working the muscles of the trunk, hip and knee to prevent 
DKV23,28,30. Therefore, lumbo-pelvic stabilization training (core stability) that includes motor stability 
and strengthening of the gluteal muscles, in addition to strengthening the lower limb itself, will lead to 
a significant improvement in neuromuscular control of the lower extremities and trunk in addition to 
producing a significant decrease in DKV and valgus moments10,18,20,24,29,30,32.  
The proposed exercise protocol will be designed taking into account the inclusion of three main 
components. Annex IX: 
• 
Lumbo-pelvic stabilization exercises. 
• 
Lower limb strengthening exercises. 
• 
Integration exercises (plyometrics and balance). 
The exercises integrated into the programme will be organised into three phases of implementation: 

- 
Phase 1 (adaptation - 1st month): Its objective is that the players learn and integrate new patterns 
while they train.  
 
- 
Phase 2 (Proficiency - 2nd month): Aims for players to master new patterns in a controlled 
environment. 
 
- 
Phase 3 (performance - 3rd month): Its objective is to perform exercises in situations as specific 
as possible and close to the demand and explosiveness of movements typical of the pitch.  
During the execution of all the exercises, verbal and visual imputs will be received, such as the 
presence of a full-body mirror so that they can correct positions and verbal indications focused on 
lumbo-pelvic stability and the biomechanics of the lower limb to improve the concentration and 
motivation of the players during the execution of the scheduled exercises9, 12,17,21,33.  
The progression of the exercises will be established by increasing the speed of execution of the 
same, increasing the complexity of the task to be performed and by promoting neurocognitive 
implications (for example, counting backwards from 10 to 0 during the execution of the exercises). In 
addition, compliance with the proposed protocol will be verified through weekly self-reported 
questionnaires that will be sent via WhatsApp and will be part of the records to be analyzed later by the 
evaluators. 
 
Expected results 
The results we expect to obtain from the intervention group are directly related to the modification 
of risk factors such as DKV and the decrease in the injury incidence of ACL. It is expected to improve 
proprioception, body balance and motor control, not only of the lower extremities, but of the entire 
lumbo-pelvic complex. In addition, it is expected to improve sports performance and ball control on the 
pitch. 
All changes that occur between the players in the intervention group will be measured and recorded. 
Changes in the neuromuscular control of the knee and the mechanical behavior of the joints proximal 
and distal to it23,28 will be analyzed with a jump-landing test (DVJ)19,27,28,32. Taking advantage of the 

previous test, the biomechanics of the jump landing will be evaluated and the risk of non-contact injuries 
will be identified using the LESS scoring system. In addition, during the execution of the DVJ, the data 
obtained from the activation of the different pre- and post-intervention muscle groups will be collected 
and processed with an EMG system19,27,29,30. All these positive changes would imply a lower incidence 
of injury for the players in the intervention group, as well as higher levels of satisfaction compared to 
the control group. 
 
Statistical analysis 
First, qualitative variables will be described with frequencies and percentages. For these variables, 
hypothesis tests will be performed using the Chi-squared test. On the other hand, quantitative variables 
will be expressed with median and interquartile range (IQR) or with mean, standard deviation and 
confidence interval (95% CI). It should be verified that the data follow a normal distribution with the 
Shapiro Wilk test to test this hypothesis. If it were not met, a nonparametric test such as the Mann-
Whitney test would be performed. If, on the other hand, it follows a normal distribution, an ANOVA 
test will be carried out to contrast the mean difference and assess whether or not the results of the clinical 
trial have been significant. A level of bilateral statistical significance (limit for judging a result as 
statistically significant) of α = 0.05 shall be established for all hypothesis contrasts. The data will be 
analyzed with the statistical program SPSS. 
Budget estimate 
The budget available for this study is limited to material costs, since we have the collaboration of 
the team of physiotherapists from several clinics in the province of Alicante. Therefore, we will select, 
from among those who are willing to collaborate, both the evaluating and sports physiotherapists for the 
study. In addition, they will provide much of the materials needed to conduct the study. If, on the other 
hand, the collaborating clinics did not have all the necessary material, the cost of more specific devices 

such as the mDurance surface EMG (€ 5,500 approx.) and the BMS force platform (€ 3,000 approx.) 
should be included in the budget.  
 
 
 
 
FUTURE EXPECTATIONS OF THE STUDY 
 
This clinical trial protocol seeks to encourage coaches of women's soccer teams to follow this type 
of program because of its potential benefits in preventing ACL injuries. Annex X. Almost all the studies 
reviewed confirm that there are varied prevention programs (plyometrics, balance, strength, among 
others) that provide a significant improvement in DKV and, therefore, in the prevention of ACL injuries, 
but none of them has been based on a standard dosage or applied specifically to female footballers in 
this age range who have the highest injury rate5,14,19,21,34. On the other hand, studies such as Willadsen 
et al.31 report short-term benefits and intervention programs that do not exceed 6-8 weeks of training14. 
The purpose of this study is to implement a standardized protocol for a period of 12 weeks (longer 
intervention time) in players of senior women's teams with the aim of achieving long-term benefits. 
 
Limitations 
 
• The study will be carried out only with female footballers of a specific age range, so that, when 
extrapolating the results, data such as the prevalence of ACL injuries could not be generalized to the 
entire population, so it would reduce external validity. 
 
• We would not have all the control over the execution of the exercises described in the protocol, since 
the physiotherapists in charge of giving instructions would not be constantly controlling how each 
player performs the exercises, only at the beginning of the program or when introducing new 
exercises. 

 
• To properly quantify the load, it might be more appropriate to do so with an accelerometer. It would 
serve to better control the exercise since, when the speed decreased, it would be indicative of stopping 
the exercise. 
• As in almost any study, there is a risk of abandonment of the subjects, which increases with the 
duration of the study. Being a 12-week intervention, dropout rates could be higher. 
• The relationship of the menstrual cycle in female footballers could be considered throughout the 
protocol, since there could be alterations in the performance and execution of the exercises11. 
 
Strengths 
 
• Observer bias will be mitigated because measurements will be performed by two different 
physiotherapists. Both will not know the results of the other measurements made to prevent their 
expectations from influencing the result. 
 
• This type of protocol is focused on the specific needs of players with DKV, which should be 
promoted among women's football coaches because it helps reduce the incidence of ACL injuries. 
• Few published studies have developed multifaceted and specific intervention protocols for this group 
like the present one, despite the benefits that scientific evidence suggests for this type of 
program14,21,34. 
• Nowadays, women's football is becoming increasingly important, a fact that leads to an increase in 
the incidence of ACL injuries and, therefore, increases economic and research investment.  
  
 
 
 
 
 

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