ACL injuries in football

What is an anterior cruciate ligament and what does it do?

The ACL is a connective tissue band in your leg connecting your tibia (shin bone) to your femur (thigh bone).

It is a crucial ligament – physically stabilising your knee and acting as a data center in the leg with its rich and complex sensory nerve receptor supply. It acts as a beacon for your brain, sending signals about your knee’s position when you’re moving, twisting, running, or jumping. Thus, giving valuable information about the knee’s tension, stretch, and movement. Unfortunately, much of that vital information is lost when you damage the ACL, making your knee feel unsteady.

Causes of ACL tears in football

Direct (DC), Indirect (IC) and Non-Contact (NC) ACL injuries

According to a recent study published in 2020 where 134 ACL injuries in elite football were examined. They found:

  • 44% of ACL injuries were non-contact
  • 44% of ACL injuries were indirect
  • 12% of ACL injuries involved contact to the knee

88% of ACL injuries in these football players were NC and IC injuries. These were caused by:

  •  Pressing or tackling an opponent (47%)
  •  Being tackled by an opponent (20%)
  •  Maintaining balance from kicking (16%)
  •  Landing from a jump (7%)

What is ‘pressing’ and ‘tackling’ in football?

Pressing means putting pressure on the ball to win it from your opponent. In contrast, tackling is interfering with the player in possession of the ball while they advance. Mechanical perturbation was identified as a significant cause of injury. Aggressive movement interactions and body distortions while players are defending or attacking (like during pressing and tackling) can cause ACL injuries.

For example, if a player’s upper body is bumped, pushed, or pulled while their lower body is fixed on the ground or performs an action, it can increase their risk of ACL injury.

A dominant movement pattern in ACL injury

The most common position in which ACL’s become injured is in a dynamic knee valgus. This is when your knee is bent, and your hip is out to the side and rotated inwards. It is a high-risk position for your knee and ACL.


Example of dynamic valgus load on knee.


Treating and preventing ACL injuries in football

The 2020 study mentioned earlier found that 25% of all ACL injuries happened in the first 15 minutes of the match.

Another study published in 2021 found that your cognitive skills, reaction time, and processing speed are also significant factors in preventing re-injury.

Why is this good to know?

It matters because it helps us focus our treatment and prevention strategies on the right things.

In the case of ACL rehab, readiness to play, when your muscles and nervous system are in sync and alert, is more relevant than any accumulated match play fatigue.

This indicates that your ACL injury rehab should involve cognitive or brain training to achieve the best outcomes. Examples include reactive drills and small-sided football games such as gates games or possession vs. pressure games.

It’s not only about musculoskeletal and cardiovascular fitness.

Is an ACL tear, a career ending injury in Football?

Don’t despair. There’s hope.

A 2018 study reports that 83% of athletes return to professional sport following ACL reconstruction.

And there is a real-world example you may be familiar with.

Football pundit and Newcastle’s favourite son, Alan Shearer CBE, ruptured his ACL in a game against Leeds United on Boxing Day 1992 while playing for Blackburn Rovers. The injury occurred in the first half of the game, unbeknown to him. Nevertheless, he scored 2 goals, and his team won 3-1 in that game. After his injury, the most prolific scorer in the history of the Premier League returned in the 93-94 season to score 31 goals in 40 games. Shearer attributes his success to return to play to this “Be patient, don’t cut corners, and do everything the Physio tells you.”

How long do most players take to return to play after an ACL tear?

9 months is the usually prescribed timeframe for a return to play following an ACL tear. Virgil van Dijk, from Liverpool FC, made his return after 9 months. Still, some players take 12-18 months to get back to full play.

Return to sport should be considered carefully. The decision-making process is complex and involves multiple stakeholders, depending on your competition level.

Usually, it’s a team decision with the athlete (you) at the centre of any it all.

The “must haves” for returning to football play include:

  • Single Leg Vertical Hop
  • Single Leg Forward Hop
  • Timed 6-meter single Leg Hop
  • Single Leg Triple Hop
  • Single Leg Triple Crossover Hop
  • Single Leg Lateral Hop
  • Single Leg Medial Hop
  • Single Leg Lateral Rotating Hop
  • Single Leg Medial Rotating Hop

Oh yes, even more hops than the Rapper’s delight.. -a hip, hop, the hippie, the hippie o the hip hip hop-a you don’t stop the rock.

These are a few examples of questions that may be asked by your rehab team before you can get back on the field safely:

  • Are you, the athlete, confident about returning to play? Do you trust your knee?
  • A structurally strong ACL replacement with robust integrity would make a happy Surgeon. What does your surgeon think?
  • Is the Physio happy with your range of movement, strength, and power around your knee? Can you achieve 90% or higher in the battery of hop tests in the return to sport assessment? How are your reaction times and adaptability?
  • Has your Coach been satisfied with your performance on the pitch? For example, can you adapt, move forward and backward at speed, change direction, jump when needed, or stop from a pace safely?
  • Does your Sports Psychologist feel confident that you have an optimistic attitude and mindset to return to sport unruffled and with a sense of assertiveness? Have you trained your “inner voice” appropriately? Do you have any other personal concerns that may adversely affect your match fitness?

Football ACL injury infographic by Vitality Physiotherapy

Return to football infographic by Vitality Physiotherapy

The final whistle

An ACL tear does not mean relegation. Instead, a well-structured plan with clear goals and the right team behind you is a recipe for a triumphant return to the pitch.


At Vitality Physio, we have the experience, knowledge, and wisdom to take you from your ACL injury back to the game you love.

We’re here to help you get fit and strong, and prepared with renewed confidence.

Want to chat with us about your injury? Book a free 15 min chat with us from the convenience of home.

Call to speak to one of our ACL experts: 02071939928

ACL injuries


We've all come across a friend or famous athlete who has had their season cut short through an ill-timed knee twist and alongside the dreaded "popping" sound. When this happens, it can be daunting.  

Understanding ACL injury and knowing what steps to take to recover will help you get back to the sport you love sooner. As mentioned in our ACL tear article, the ACL is one of the main ligaments controlling the stability of your knee, and injuries to the ACL occur more frequently in sports involving landing and pivoting actions like football, netball, or skiing.   

Diagnosis of ACL Injuries 

 The Lachman Test 

John Lachman (1919-2007) was an orthopaedic surgeon at Temple University in Philadelphia who invented the technique. It's considered the most reliable way to diagnose an ACL injury. It is used by Physios and Surgeons the world over.  

How is the Lachman test performed? 

The Lachman test is performed like this: 

  1. Lie flat on your back. Relaxed, with legs straight. 
  2. Your Physio places your knee in a slightly bent (and sometimes rotated) position. 
  3. One hand is on the back of your lower leg (just under your knee joint), and the other is on the front of your thigh. 
  4. They then pull your shin forwards firmly while stabilising your thigh.

 Why do we do the Lachman test?  

 To measure the endpoint and joint laxity.  

The endpoint is where the end of the joint movement is felt as the shin is pulled forward. If this endpoint feels further away than what's expected, then this may indicate an injured ACL.  

 Joint laxity is the general feel of your joint movement and the sense of how lax (or loose) your ACL feels compared to your other knee.  


Grading ACL tears with the Lachman test: 

  • Normal. There's no difference in movement or laxity between your left and right knees. 
  • Mild (grade 1). There's slightly more (about 2-5mm) movement than in your other knee. 
  • Moderate (grade 2). There's moderately more (about 5 to 10 mm) movement than in your other knee. 
  • Severe (grade 3). There's much more (10 to 15 mm) movement than in your other knee. 


Because we're all different and have varying baselines of "stiffness", the test should be done on your other leg too. This will give the Physio an accurate idea of what's typical for your joint.  

Anatomy of the L knee showing a ruptured ACL

The Pivot Shift test 

How is the pivot shift test performed? 

 1. Lie flat on your back. Relaxed, with legs straight.  

2. The Physio places one hand on your heel and the other just below the outer side of your knee.  

3. They apply pressure to the outside of your knee while internally rotating your lower leg and bending and straightening your knee. 

 The test is positive if your lower leg sinks backward when the knee is bent at 30-40 degrees. Sometimes a 'clunk' can be heard when this happens. 


Treatment options for ACL tears 

 There are two treatment options for an ACL injury: Conservative or surgical management.  

 Your age, previous injury, and fitness and rehab goals should be considered when deciding the best route to follow.  


Conservative management 

Conservative or non-surgical management involves a period of Physiotherapy treatment to restore your knee function to pre-injury level.  

Surgical management 

Having ACL surgery usually requires a minimum of 9 months of rehab tailored towards getting you back into your sport.  This may sound like a long time, but returning to sport too early can have negative implications. Mainly increasing your risk of re-injury.  


ACL Surgery  

What surgery is there for ACL tears, and what you can expect? 

 The most common type of ACL surgery is a reconstruction of a new tendon called a graft.  This is typically a minimally invasive procedure done via keyhole surgery using an arthroscope (a small camera through which your surgeon passes tiny surgical instruments).  First, the damaged ACL is removed, and then the graft is attached in its place. There are different types of grafts. They include:   

  • Autografts - Formed from tissues taken from another part of your body (like tendon tissue strands from your hamstring or patella tendon)  
  • Allograft - Formed from tissues taken from another person's body 
  • Synthetic - Formed from an artificial source or donor. 

Rehab is paramount to your ACL recovery (with or without surgery) . Without rehab, ACL surgery is meaningless. All the top knee surgeons agree.  Your ACL rehab determines the success of your recovery. We recommend an evidence-based programme that's divided into four progressive phases. In our experience, this process takes 9 to 18 months to complete.  

Phase 1: Restore knee extension and reduce swelling  

Immediately after sustaining your injury or after your surgery, the muscles around your knee may feel weak, and your joint may be swollen and painful. In addition, you may not be able to completely straighten your knee.  During this stage of your recovery, the aim is to reduce swelling and pain and get your knee completely straight again. This phase typically takes 2-3 weeks.  


Phase 2: Strength & Neuromuscular control 

 After you've passed the criteria to move onto phase 2, the fun stuff begins!  You'll introduce a new set of exercises, including squats, lunges, leg presses, and more. These will continue throughout your rehab programme, becoming more complex as you advance through the various stages. 


Phase 3: Plyometrics 

After passing all the phase 2 criteria, you can ramp up the fun a little more and start introducing hopping, jumping, landing, and running movements.  These sport-specific functional activities need to be retrained for your to safely return to your sport.  


Phase 4: Return to Sport  

Until this moment you have been working towards Phase 1-3.  Before you get back to your sport, you and your Physiotherapist should discuss how and plan how you will do it.  


General guidelines for ACL rehab 

  • Follow each phase-specific exercise and test and only move on to the next phase once you have mastered the current one. 
  • You need to achieve your rehab goals in the correct order to ensure you fully recover. 
  • If you stop or skip steps in your rehab, you can worsen your current injury or increase your chances of re-injury when you eventually return to your sport.   



Now that you know how to get a diagnosis, choose the proper treatment, and understand the rehab process better, you can move on from your ACL injury in the right direction. Yes, the rehabilitation process is long and requires dedication and patience. But, with the right team supporting you, your progress can be smoother, and it can be a whole lot more fun! 


Our highly experienced and knowledgeable Physiotherapists can get you where you want to be. So, call us now and put your ACL recovery planning in our hands! 

Knee Pain


Knee pain is common. For some, the simple activities of daily living such as walking or climbing stairs can become cumbersome when your knee hurts. For others a niggle in the knee can deteriorate and adversely affect sporting performance. There are many causes of knee pain, so it is important for you to know what is causing the pain. There are however some common themes that occur with most types of knee pain.

Why does my knee hurt?

The knee is comprised of many structures including ligaments (connects bones together) tendons (attach muscles to bone) and cartilage (the connective tissue between bones). Most injuries in this area are caused by multiple problems over a long period of time- this could include muscular weakness, overuse, direct trauma or even lifestyle factors.  

Most patients say that when their knee hurts, they tend to want to do less activity as more activity requires bearing extra load through the knees.  Otherwise simple activities such as climbing the stairs or even going on a run can feel scary.  Often, it leads to us searching for answers by having x-rays or scans.  Sometimes a scan can look really scary, and sometimes we are told that we have “bone rubbing on bone” or our cartilage has “completely gone”. This can increase fear and further reduce activity and weight bearing through the knee. 

However, just like we all get wrinkles or grey hair, age related chages to our knees are inevitable. Researchers now believe that inactivity is a major contributor to age-related diseases and disabilities, and that regular exercise can reduce or reverse those risks.

What should I do if I have knee pain?  

Most knee pain can be treated through a graded rehab programme. Typically, this consists of a combination of strength training, education and a good understanding of how to implement your programme.  It is important to have a supervised programme so that you know exactly where to start and know exactly how you are going to progress over the course of the rehab programme.  

When we strengthen the muscle around our knees we increase our knee’s ability to withstand the load that we tend to put on them on a daily basis.

FUN FACT:  Forces transmitted across the knee joint during normal walking range between 2 and 3 times body weight!

This makes them much less likely to experience pain in the future. Over recent times we have seen a huge body of evidence to suggest that an 8-12 week exercise programme can significantly reduce knee pain and symptom progression.  

What Should I Do Now?  

  • Seek out advice from a healthcare professional who understands knee pain and is up to date with the current research.
  • As mentioned before, scans are not always needed, and scans often do not correlate with the pain you are experiencing. 
  • Begin strength training with the supervision of a healthcare professional.  
  • Other factors to consider are sleep, diet and body weight- all of which can contribute to pain and pain sensitivity.  

 Here are some great simple knee exercises to try at home:


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