How the Women’s World Cup Raised the ACL Discussion Again.

During the Women’s Soccer World Cup currently being held in Australia and New Zealand, the world’s media revisited a topic that many of us physical therapists specialized in this area have become exhausted with.  How to reduce ACL injuries with the female athlete. The reason why this topic has reached world media outlets is because the equivalent of an entire squad of players will missed this year’s tournament due to ACL injury. 

 This seems an unusually high number, but a high incidence of ACL injuries among female athletes can be found at all levels of the game.
Many female athletes have spoken out about the need for more funding into this area, and while this would help avoid the majority of studies being conducted on men and the results being incorporated into female sport. There is a great deal of information we know about preventing ACL injury that is currently being ignored. 
What We Already Know…………….

The reality is that females are as much as 3.5 times more likely to sustain an ACL injury than male athletes (Arden et al. 1999, Voskcanian et al. 2013). The reasons are many and both modifiable and non-modifiable.

The non-modifiable risk factors are factors such as the menstrual cycle and the effect of hormones on ligament stiffness, less muscle mass, anatomical factors such as the female Q-angle (The wider angle of the femur from pelvis to knee) and subtle differences in knee joint anatomy from interarticular notch width to tibia angle. 

Studies into the modifiable factors have considered many elements such as gender roles where females are less likely to be multi-sport athletes or engage in ‘athletic play’ as adolescents, therefore theorized to have less body awareness. The main thrust of research shows that we should be focusing on understanding and training the female athlete appropriately. We should be incorporating specific gym and field-based training strategies specific to the female athlete’s needs.  

What do we do About it?

My personal experience on this topic is that we have an audience that is willing to listen but not ready for change. 
 I see an ACL injury (particularly in adolescent sport) as a welfare issue. An ACL injury causes significant pain and disability with a return to sport taking 12 months in most cases. Not to mention the mental side of injury with removal of an individual from their hobby and social group. The long-term health of the knee after an ACL injury is also the topic of much research and discussion among experts.The extra bit of detail is that of the athletes who return to multi-directional sport, 20-28% will go on to sustain a second ACL injury (Bodkin et al. 2021.)In short…..the impact is significant and the relative attention to prevention is small.

There are a magnitude of protocols that can easily be incorporated into a team’s training that have been shown to significantly decrease the risk of an ACL injury. An accumulation of data across numerous studies shows a potential 70% reduction in risk. (Sugimoto D et al. 2012). The issue is that compliance with these protocols is very limited. I am sure coaches have numerous initiatives they would like to introduce themselves and feel limited by time. We must also accept that few athletes and parents are asking for prevention programs over quality coaching sessions and results on the field. Physical therapists are not innocent either, I have seen many instances where PTs dip their toe in the injury prevention world and prescribe sessions that are time consuming or inadequate to decrease risk of injury.

The Future is Bright.

We are better off than we were 10 years ago. The female athlete is being taken seriously with improved financial, research and team support. Injury prevention programs will eventually become the norm as it makes sense, as a good prevention program also has the same elements as a performance program.

 Athlete testing is currently seeing an evolution with high tech devices that were previously unattainable to any party except at elite sport, are now becoming more affordable and field assessable. There is no longer an excuse for professionals to claim to offer injury prevention or injury rehab and not have access to this level of detail with testing.

If you want to do your part, please feel free to forward this email to an athlete or coach, it may make a huge difference.If you know someone who has sustained an ACL injury please put them in touch, I am offering to test the first few athletes who contact me a free force plate testing session to highlight any vulnerabilities as unfortunately you never graduate from ACL rehabilitation, you manage the risk factors for life.

The Untapped Potential of Performance Monitoring. The Counter Movement Jump 

For many of us we spend hours in the gym or on the field each week in the hope that we are getting better at our chosen pursuit. However, we are not robots, and many internal and external factors can mean that a great training program is not always great for us. I have at least 3 personal stories I can share of times when I got heavily into a training program that actually decreased my performance on the Soccer field. 

So how do we know if our training program is helping or hurting?

I say on nearly a daily basis, ‘if we are not testing, we’re guessing’so it is beneficial to have a periodic measure to determine if we are still on the right path to meet our goal. This can be a multitude of simple tests relevant to your goal. Today I am going to talk about one of the more common ones used, the countermovement jump (CMJ).The CMJ is a simple test that requires no expensive and can give us a lot of valuable information from our readiness to train to the effectiveness of our program.

What is a CMJ?

The CMJ is a way of measuring lower body power. The movement consists of hands on hips in a position of rest, before dipping down and jumping as high as possible. Success is measured in jump height. There are many simple ways of measuring the CMJ from chalk on a wall to free apps on your phone.

If you want to get really into the detail as I do, the Forcedecks (as pictured) can give you very detailed information on asymmetries and performance throughout the eccentric and concentric phase which can highlight where the opportunities are when looking for significant detail in your programming. You can also complete some basic calculations yourself comparing CMJ and squat jump performance to determine if you could see better gains focusing on either strength or power-based exercises.
What is the CMJ’s link to performance? 

The CMJ has significant correlation with performance for lower limb power-based sports to include sprint performance (Hudgens et al. 2013) and Olympic lifting (Vizcaya et al. 2009). Your best jumpers will most likely be your best sprinters or lifters.

If we use Olympic lifting as an example, maximal lifts require power but also technique. A CMJ will be a useful measure to determine the success of a training period even if that period does not result in new personal best. In Olympic lifting a CMJ can be a useful measure of progress without the fatigue associated with maximal lifting. This is specifically relevant when peaking for competition. A CMJ has also been widely studied and a quick Google search will give you population data so you can compare yourself against your demographic.  
CMJ and fatigue monitoring.

A CMJ is a sensitive tool to monitor fatigue. A comparison to historical data can determine an individual’s level of recovery or if an individual is overtraining. Consider a soccer team who competed in a weekend tournament and Tuesday was their first session back. A CMJ could be used determine their readiness to train. If the CMJ has decreased >10%, it is likely that further recovery is needed. Adding a physically demanding session at this point will only further fatigue the athlete, potentially affecting next weekend’s performance or even leading to injury.
CMJ and returning from injury.

If you have been periodically incorporating CMJs into your training, you automatically have some great data to determine your readiness to return to the activity of your choice. Single leg jump data can also be very useful to determine asymmetries, as we can often disguise deficits with a superhuman effort from the uninjured side. 

Remember that if you are not testing you’re guessing, so consider an objective test that is suitable for your activity goal. Contact Kick Performance Therapy if you have any questions or unsure if a CMJ is appropriate for you.

Sports Physical Therapy Must Evolve!

If you are looking for physical therapy with the ultimate goal of returning to sport, you don’t have to look too far to find multiple clinics claiming to offer sports physical therapy services. But what does that mean? And is that individual or clinic adequately skilled to offer that service? I will let you make your own decisions after reading the next few paragraphs.

Firstly, lets define who can offer sports physical therapy services or call themselves a sports physical therapist? The answer is any physical therapist who wants too! And for a physical therapist why wouldn’t you make that claim to work with on average a younger demographic who is motivated to put the work in. The next question is…. have they had experience of working directly with sports teams or high-level individuals? And the answer again is probably the majority haven’t. So where does that leave us? To credit the physical therapy population, they are generally very studious and are keen to seek extra qualifications in their chosen field, so you may find a PT who has gone the extra yards and achieved some qualifications and does deserve respect. But that is certainly not all PTs. My major issue here is not the individual, but how the profession is structured and the speed of development of mainstream sports physical therapy over the last few decades.

In my lifetime and as a graduate of sports science, I can appreciate how far sports science has come over the last few decades, and how it continues to influence how we train and recover in relation to our sports. This has cascaded though the general population with the use of wearable technologies. And while I look to sports scientists among other professions to better myself, I often look back at my profession in amazement of how far behind we are in certain elements of our practice. As I said before, we have some incredibly skilled PTs who are pushing the boundaries in the niches of their various fields, and the top sports physical therapists are doing incredible work. But if we take the middle 80% of our profession which are the PTs you will most likely visiting, we are falling behind the minimum standards we should be delivering.

Allow me to present my case……..

If you are a multi-directional athlete, for example a soccer player, you are running 8-15k a game making multiple sprints, cuts, and putting forces through the body of anywhere from 2-6 times our body weight at 10/10 effort. If you were looking to return to soccer from injury, what might be the standard tests a PT may complete to determine your state of readiness to return? These would likely be a manual muscle tests where a PT pulls on a limb and asks you to resist and then decides if you are strong enough to return to sport. They would likely also conduct a few hop tests to determine your ability to act dynamically on the affected limb. But would you trust the same level of detail on any other element of your life that may cause you pain or injury? In sport, it is often milliseconds and inches that define success and failure, what we should be doing as PTs is working and testing athletes to the highest demands of their sports, as it is at those levels that success and failure will be determined. We should be incorporating technologies such as force plates, that not only accurately measure fractional differences in forces being produced at maximal effort, but also the timings of that force being produced. For example, you might be stronger for attending physical therapy, but have you completed the right exercises so you can produce that force and make adjustments within a few milliseconds to react to unexpected external loads on the field? Most sports physical therapy clinics won’t be able to answer that question comprehensively. Also where is the on-field fitness component to physical therapy? Getting the athlete up to match fitness should be an essential part of sports PT. Your tissue’s ability to demonstrate a ‘good’ hop test will look very different after 60 minutes of playing if you haven’t explored those intensities of play since your injury. These issues are just the tip of the iceberg when we look at managing the athlete back to sport. From my experiences working in sport, a significant portion of the rehab takes place on the field, allowing the athlete’s tissue to experience sport specific stresses which no level of gym lifting will match.

Probably my biggest compliant is that the majority of sports physical therapy operates as a business! High volume of patients and no time to get into the details before the next client arrives. And I sympathize with talented sports PTs who just do not have the facilities or the time to deliver quality content because they are stuck in 300 sq ft gym with just a few weights and a maximum of 20-30 minutes of quality time once all administrative responsibilities are completed. How can you possibly assess, test, interpretate finding and plan for that athlete’s progression at the highest level possible? Imagine your body is a high-performance car, would you trust a mechanic that pulls on a few parts, revs the engine a few times and then says you’re good to go? Or a mechanic that uses advanced technologies to explore all the nuances of the car’s technology, before taking it out on a track to determine performance during and after high-performance tasks?

As physical therapists the technology exists for us to better ourselves and give the athlete the service they deserve. As a client we need to ask questions about the service we are getting and find someone who is performing at the forefront of their profession.

Managing the Off-season

For many recreational leagues in Oregon the winter brings the off-season and with that comes many opportunities and threats for participating in sport in 2023. The opportunities are that with no weekend competitive sport and potentially mid-week training, you now have the time and physical capacity to put it the specialized work for next season. This may be rehabilitation themed if the 2022 season has been limited by injury, or this may be an opportunity to work on some acceleration, agility, strength, power among a myriad of other opportunities.

Here is the threat! The offseason for a lot of us despite our best intentions means a significant reduction in activity (or chronic load). The graph below from Tim Gabbett’s 2020 paper (Debunking the Myths About Training Load, Injury and Performance: Empirical Evidence, Hot Topics and Recommendations for Practitioners) illustrates the dangers of letting our chronic load drop in preparation for the next season.

This graph is a nice illustration to show that if your brief post season rest (which is well deserved and recommended) becomes multiple weeks or months, then we are significantly increasing our risk of injury next season. Craig Purdham 2015 paper for the Australian Instititue of Sport estimated that 4 weeks of little to no activity would take around 6 weeks of training to mitigate the increased risk of injury. Where continuing to train at 80% of previous workload for the same period would take around 1 week to mitigate the same risk.

Look at your offseason as an opportunity! Take care of your body, try new activities but have a plan so you do not roll into your next season underprepared

Nathan Evans MSPT, CSCS, XPS.

Why Developing the Squat is so Important

When working with athletes we should be looking to assess and develop the squat. This is even more important when working with younger athletes as periods of rapid growth will change their ability to adequately perform the squat and this does not always return.

So why does it matter? The squat is a fundamental movement that has an important role with both injury prevention and performance. The more effective you can squat the greater the potential you have to absorb or generate force, taking away excessive strain or generating that extra force that makes the difference in getting past that defender.

Currently there is noticeable segregation in how we consider and approach injury prevention and performance enhancing skills, however, the foundations of both elements are the same! You need to have the basic strength, range of movement, and the ability to perform basic movement patterns to achieve both successfully.

The next section will show how prevalent the squat position is within the game of soccer. Being a physical therapist first, I must talk injury prevention. The ACL injury gets a lot of press due to its prevalence within youth sport. One of the most important injury prevention interventions starts with the squat. An ACL injury is the result of the inability to absorb force while landing or changing direction. Most sporting programs devote more attention to generating force with sprinting and jumping drills, however, we decelerate 2-3 times more frequently than we accelerate. To absorb force or decelerate requires strength through coordinated flexion of the hip and knee, the squat! Failure to do so results in movement compensation and an increased risk of injury.

Why not test yourself or your team?

If your squat looks a little different than the first picture (Picture 1.1), then you have a great opportunity to improve. Record a squat on your phone and see if it resembles the first picture. People will vary slightly as we are all made different, but if your squat could use some work, it could be the best thing you do this year to improve your performance and decrease the likelihood of injury.

Feel free to send me your video so we can talk about your squat


Imagine the scenario, you are taking your defensive line up to the halfway line, the ball is lost and suddenly the ball is behind your defensive line. You need to rapidly decelerate faster than the attacker (note the effective squatted deceleration
position in picture 2.1) and recover to defend against the attack. The inability to achieve a squatted position will result in a slower compensated movement strategy and a slower recovery. Often compensation is seen using a straight leg deceleration position and an excessive heel plant which is the movement most associated with an ACL injury

The cut! Both 90 degree and 45 (2.2 & 2.3) are more frequently acknowledged to be a cause of injury. And although the classic squat position is not so obvious, this movement requires the absorption of force via ankle knee and hip while maintaining balance through the trunk (a squat!) before exploding out of that position in another direction at a greater rate than your opponent. Often it is milliseconds that defines getting past your opponent or losing possession. A more obvious example of the benefits of the squat position not pictured here is the vertical jump. Getting into that low squat position helps you to maximize ‘triple extension’ and jump height meaning being able to push from the ground and extend (straighten) hips
knees and ankles to maximize force generation and therefore jump height before absorbing force through a squatted position. Limited squat means a limited ability to generate force

Final example is shielding the ball (2.4). If you are protecting the ball from a bigger defender, you are going to have to get your center of mass low to the ground. Maintaining an upright position will mean you will get pushed off the ball. The bigger the defender and the more pressure you are under will mean the
lower to the ground you will have to go. If you do not have the ability to squat then you will be unsuccessful in this scenario.

1.1 A good demonstration of the squat with good knee and hip flexion with slight forward lean
1.2 Common compensatory pattern. Excessive trunk lean with the inability to get into a deep squat position.
1.3 Collapse of the knees towards each other, often a sign of weakness around the hip and ankles.
1.4 The inability to get low into the squat position, potentially avoiding weaker hip extensors.


2.1 Effective deceleration by absorbing force through a squatted position

2.2 Deep squatted position of right leg
2.3 Ability to utilize a slightly squatted position to explode left will make the difference in getting past a player
2.4 The greater the pressure the greater the need to squat low