Triple play in ACL injury prevention: beyond the usual suspects.

By Drs Anne Benjaminse @AnneBenjaminse and Alli Gokeler @AlliGokeler

Owoeye and colleagues correctly addressed the concern of adherence to injury prevention programmes as key to achieve a societal health impact: ‘it takes more than just a prescription and education to get patients to take their drugs’.In order to be effective in the real world, uptake of the programme must be guaranteed.1-4 Currently, coaches and athletes use injury prevention programmes designed by researchers, however, uptake has been low to date seen by the continuous rise of ACL injuries per 1000 athlete-exposures.But, why is uptake low? Often times, we see that trainers and coaches hesitate to implement prevention exercises or even stop the proposed program,6-10due to a lack of 1) facilities/resources, 2) leadership/knowledge, 3) player enjoyment/engagement, or 4) training time/link to training goals.10 Some athletes find that prevention exercises ‘take too long’, are ‘boring’, ‘have no performance benefits’ or ‘are too difficult’. As a follow up on previous work by Owoeye et al., we would like to contribute innovative ideas on how to optimize adherence to injury prevention programmes.

Advancing adherence by co-creation 

First, we propose that when designing injury prevention programs, the end-users (trainers, coaches, athletes, club board, parents) are involved from the beginning.3, 11By recognizing the end-users and their beneficiary needs through co-creation, the intervention can be tailor-made to suit their needs. For long-term implementation, co-creation and a ‘train-the-trainer’ approach should be used to have the end-users consider the program as their own,12 which is also supported by the culture of the club.

One solution is to develop an athletic skill program that entails elements to improve athlete’s performance (eg, shot accuracy or changing direction as quickly as possible) as well as reduce some intrinsic risk factors for injury (eg, how athlete lands after shot or how athlete conducts the cutting movement). In other words, enhancing athletic skills of athletes in a challenging, fun, interactive, motivational and sport specific context.

Optimal motor learning – triple play

Second, an athlete’s ability to create stable motor output in a complex athletic environment and avoid an injurious situation during sport specific activities is key in injury prevention. To optimise the potential of motor learning, Wulf et al. propose the following model (Figure 1),13where (1) applying an external focus of attention and promoting intrinsic motivation by (2) autonomy and by (3) creating enhanced expectancies, will increase goal action coupling.

Advancing adherence by increasing retention

External focus of attention

With even relatively short training sessions, applying an external focus of attention (bottom part of the model, Figure 1) enhances learning movement patterns efficiently with high retention (ie, sustained effects over time).13-15 These findings show that a barrier such as ‘it takes too long’ could be countered when implementing a visual or verbal external focus of attention. The high retention means that the athletes may only need periodic maintenance (ie, is less time consuming) on a certain skill as a result of effective stimulation used to learn skills.

Figure 1: Optimal motor learning through external focus of attention and intrinsic motivation, adapted from Wulf et al.13


Advancing adherence by paying attention to basic psychological needs

Third, to increase adherence, we propose that attention is given to basic psychological needs of the athletes. This includes: 1) autonomy and 2) creating enhanced expectancies (ie, increasing feeling of competence) when implementing the injury prevention programme enhances intrinsic motivation (top part of the model, Figure 1).

Allowing athletes a certain extent of self-control over a practice condition can facilitate feelings of autonomy and competence, thereby fulfilling some fundamental psychological needs.16This in turn will enhance intrinsic motivation and internalisation,16 which is crucial for advancing adherence in injury prevention. When exercising, autonomy should be supported by providing the athletes with simple, but crucial, choices.13,17,18For example, this can be 1) task difficulty, 2) the practice material to exercise with, 3) when to receive feedback and 4) what type of feedback to receive (eg, verbal or visual or a combination, self-model or expert-model). At all times, the expert’s view and expertise is necessary. As an expert, always pay attention to safety and difficulty. That is, take care of the fact that an athlete picks an exercise that is challenging (learning effect), but not too difficult (safety). In addition, consider how many choices you will provide during a practice session.

For each aspect of choice, an example is given below:
Ad. 1:To improve the capacity of an athlete to change direction quickly, an athlete can choose from three practice conditions:

  • In a square with a buddy, touching one of the four cones, where the athletes has to follow the buddy (social interaction and decision making included, but relatively small movements).
  • Sidestep cutting situation can be practiced with a 5m sprint, changing direction, followed by 5m sprint (more pressure on performance, greater on-field movement, but anticipated).
  • The same a sidestep cutting situation can be practiced with a 5m sprint, catching a ball which is thrown by a buddy at the turning point, changing direction, followed by 5m sprint (pressure on performance, greater on-field movement, unanticipated and attention has to be payed to the environment).

Ad. 2: When an athlete has chosen the third option of Ad 1. The choice can be given on what type of ball to practice with (ie, tennis ball, handball, basketball).

Ad. 3: Let the athlete choose when to receive feedback from the expert (trainer, coach, sport physical therapist) and/or what type of feedback to receive. This helps the athlete to stay in the flow of practicing and not being potentially interrupted.

Ad. 4:When the athlete indicates he/she wants to receive feedback, it is good to have several options available the athlete can choose from, picking an option that the athlete thinks is most valuable for the learning process at that time. For example, verbal external focus feedback or watching a self- or expert video of a given task.15, 19

Enhanced expectancies

Circumstances that enhance learners’ expectations and increase confidence, increase movement automaticity. The athlete will no longer have to worry about task execution, but can focus on the goal of the task. Providing positive feedback or reducing experienced task difficulty can alleviate learners’ concerns and increase perceptions of competence and self-efficacy.13,20,21In this context, it is of importance to note that athletes tend to request feedback after good trials. Coaches are encouraged to provide positive feedback to confirm competence, self-efficacy and enhancing intrinsic motivation.22


Competing interests

AB and AG report no conflicts of interest.

Anne Benjaminse is a post doctoral researcher at the Center for Human Movement Sciences, University Medical Center Groningen, University of Groningenand School of Sport Studies, Hanze University Groningen, Groningen, The Netherlands. Email:

Alli Gokeler is an ESSKA and GOTS board member. He is currently postdoctoral researcher at the Department of Neuroscience in Sports and Exercise, Institute of Sports Medicine, University of Paderborn, Germany. In addition, he is head clinical knowledge transfer at the Luxembourg Institute of Research in Orthopeadics, Sports Medicine and Science, Luxembourg, Luxembourg


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