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ACL Injury: The Importance of Proprioceptive Training

Abstract: A recent meta-analysis finds that anterior cruciate ligament (ACL) injuries are associated with measured proprioceptive deficits. This adds to the evidence of older demonstrations showing how proprioceptive training can decrease the incidence of ACL injuries by 85% to 88%. For lower extremity joint injuries, the ideal rehabilitation program will include specific proprioception assessment and training.

ACL Injury PhysioProprioception refers to the body’s internal sensory system that informs the nervous system regarding joint movement and position. Inasmuch as appropriate muscle force, timing of muscular contraction, and coordination of muscular contractions all play a role in joint protection, proprioception plays an important role in preventing joint injury. Inadequate information from the proprioceptive system compromises a person’s ability to adapt to external destabilizing forces (e.g. unexpected uneven terrain), and it compromises a person’s ability to apply muscular force in a measured fashion (e.g. failing to use the hamstrings in a timely fashion to decelerate a kicking motion).

It has long been hypothesised that proprioceptive deficits contribute to the likelihood of ACL injuries. The consensus view also holds that lower extremity joint injuries create proprioceptive deficits.1,2 A recent meta-analysis supports the connection between ACL injuries and proprioceptive deficits.3 Nicola Relph and colleagues combined the results of six investigations covering 191 injured ACLs. These investigations quantified proprioceptive acuity either in terms of the threshold to detect passive motion or joint position sense. By both measures, knees with injured ACLs demonstrated significantly poorer proprioception compared to contralateral knees and compared to healthy controls. Their study was not structured to differentiate whether the proprioceptive deficit was the cause or the result of the injury, but their meta-analysis definitely demonstrates that ACL injuries are associated with proprioceptive deficits.

Add to this two sports training studies from Italy and the United States.4,5 Combined, these investigations followed more than 1,600 amateur and semi-professional football players. Half the athletes received a supervised proprioceptive training program as part of their normal warm-up routine, and half of the players trained as normal. The groups that received the proprioceptive training experienced 85% to 88% fewer ACL injuries.

This data demonstrates that proprioceptive training can prevent initial ACL injury and re-injury. Both patients who present with ACL pain and patients who present with ACL injury should be considered for proprioceptive testing as part of a biomechanical assessment. Clearly, patients who have had an ACL repair should have rehabilitation that includes proprioceptive assessment and training. Similarly, other lower-extremity joint and muscle injuries, especially ankle sprains, are likely to cause or signal a proprioceptive deficit that should be addressed. At Advanced Physiotherapy and Injury Prevention, our physiotherapists are well-versed in the role of proprioception in joint stability. We have provided free training to more than a hundred area coaches on the subject. Practitioners can refer with confidence that Advanced Physiotherapy will thoroughly rehabilitate joint injuries.


1.Marks P, Droll K, Cameron-Donaldson M. Does ACL reconstruction prevent articular degeneration? In: Hewett T, Shultz S, Griffin L, editors. Understanding and preventing noncontact ACL injuries. Champaign: Human Kinetics; 2007. p. 31-46.

2.Reimann B, Lephart S. The sensorimotor system, part II: The role of proprioception in motor control and functional joint stability. J Athl Train. 2002 Jan-Mar; 37 (1): 80-84.

3. Relph N, Herrington L, Tyson S. The effects of ACL injury on knee proprioception: a meta-analysis. Physiotherapy. 2014 Sep 30; 100 (3): 187-95.

4. Mandelbaum B, Silvers H, Wantanabe D, et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes. The American Journal of Sports Medicine. 2005; 33 (7): 1003-1010.

5. Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior curciate ligament injuries in soccer – a prospective controlled study of proprioceptive training. Knee Surg, Sports Traumatol, Arthroscopy. 1996; 4: 19-21.

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