Training for Landing and

Cutting Stability in Young

Female Basketball and
Soccer Players
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Karina C. Howell, MS, CSCS

KCH Training, Columbia, South Carolina

ABSTRACT
ANTERIOR CRUCIATE LIGAMENT
(ACL) INJURIES IN FEMALE ATHLETES
OFTEN ARE NOT A RESULT OF
PHYSICAL CONTACT, RATHER INJU-
RIES TEND TO OCCUR DURING
LANDING, CUTTING, OR PIVOTING
TO CHANGE DIRECTION OR SPEED.
FEMALE BASKETBALL AND SOCCER
ATHLETES TEND TO EXHIBIT
BIOMECHANICAL AND NEUROMUS-
CULAR PATTERNS DURING THESE
MANEUVERS, WHICH CONTRIBUTE
TO THEIR HIGHER INCIDENCE OF
ACL INJURIES AMONG FEMALE AND
MALE ATHLETES PARTICIPATING IN
THE SAME SPORT. HOWEVER,
INJURY PREVENTION PROGRAMS
THAT INCORPORATE NEUROMUS-
CULAR, PLYOMETRIC, STRENGTH,
AND BALANCE TRAINING HAVE
BEEN BENEFICIAL IN REDUCING
INJURY RISK FACTORS AND
PROMOTING PROPER BIOMECHAN-
ICS TO PROMOTE KNEE STABILITY
BY DECREASING STRESS ON THE
ACL DURING THESE MANEUVERS.
INTRODUCTION
he bulk of anterior cruciate lig-
maneuvers are common occurrences
(32,22). Among these injuries, the
majority result from no forceful contact
by another individual, but rather the
ACL was damaged during deceleration,
acceleration, plant-and-cut movements,
sudden change of direction, landing
from a jump, or other movements that
can excessively load the knee. Such
loading combined with high injury risk
motions, such as knee valgus motion,
where the knee moves medially similar
to a “knock-knee” stance (Figures 1–4)
can potentially strain the ACL, making
it susceptible to possible damage
(3,20,46).
Commonly, female athletes tend to
exhibit knee valgus and decreased
knee flexion during landing, resulting
in anterior shear forces and stress on
the ACL. Moreover, they tend to per-
form cutting maneuvers with their
knees more extended (46). Conse-
quently, these events contribute to
the tendency of female athletes having
higher ACL injury rates than male
athletes in the same sport, and among
female athletes, basketball and soccer
players tend to have a higher inci-
dence of injury (3). Anatomical fac-
tors, such as intercondylar notch
width and knee joint laxity, along with
Unfortunately, these are factors that
are difficult to modify (unlike move-
ment patterns, muscle strength imbal-
ances, and muscle activation patterns)
all of which may be altered with
proper training. Therefore, current
ACL injury prevention interventions
have primarily focused on modifiable
biomechanical and neuromuscular
control factors, such as, knee abduc-
tion, hamstring recruitment, excessive
leg rotation, and decreased knee flex-
ion (2,19).
INJURY RATES OF HIGH SCHOOL
FEMALE BASKETBALL AND
SOCCER ATHLETES
When considering the overall injury
patterns of high school athletes in the
United States, boys may have a higher
injury rate particularly when sports not
commonly played by both genders, like
football and volleyball were included.
For instance, in a study that compared
severe injury rates in football, soccer,
basketball, volleyball, wrestling, base-
ball, and softball, severe injury rates
were higher in all the sports played
by boys (r 5 0.45) than those played
by girls (r 5 0.26). However, in the
same study, when severe injury rates

T ament (ACL) tears occur during

sports participation, particularly
sports such as soccer, basketball, and
football where pivoting and cutting
developmental and hormonal factors
(such as gender) ACL tensile strength,
and menstrual status have been pro-
KEY WORDS:
basketball; soccer; youth; female; off-
season; knee; injury; ACL; landing;
cutting; jumping; change of direction
posed as ACL injury risk factors.

66 VOLUME 35 | NUMBER 2 | APRIL 2013 Copyright Ó National Strength and Conditioning Association

Figure 1. Landing errors: Knee valgus
“knock-knee” motion, land-
ing on toes rather than on
the ball of foot, and feet are
not shoulder width apart.
Figure 2. Landing errors: Knee valgus
“knock-knee” motion, land-
ing on toes rather than on
the ball of foot, feet are not
shoulder width apart, and
feet are not symmetrical.
Figure 3. Landing errors: Knee valgus
“knock-knee” motion and feet
are not shoulder width apart.
were compared among common
sports, girls had significantly higher
severe injury rates than boys when
participating in the same sport such
as basketball or in a similar sport such
as softball (15). Female athletes tend
Figure 4. Landing errors: Knee valgus
“knock-knee” motion and feet
are not shoulder width apart.
Strength and Conditioning Journal | www.nsca-scj.com
to have higher injury rates than male
athletes particularly in comparable
sports such as basketball, soccer, base-
ball, and softball, where the rules of
play and equipment are similar. Spe-
cifically, it has been shown that girls’
basketball and soccer teams have
higher injury patterns than boys’ bas-
ketball and soccer teams (15,55). Fur-
thermore, in a surveillance of North
Carolina schools, girls’ soccer had the
second highest injury incidence when
comparing basketball, soccer, track,
baseball, softball, wrestling, cheerlead-
ing, volleyball, and football (36).
The difference in injury rates between
males and females are also present
when comparing knee injuries. The
knee is a commonly injured site among
high school athletes, and knee injuries
have been shown to make up the
majority of injuries requiring surgery
(15,35). Female basketball and soccer
players have been inclined to have
more knee injuries, knee surgery, and
ACL surgery than male basketball and
soccer players (55). The higher rates of
knee injury in female basketball and
soccer players compared with male
basketball and soccer players are con-
firmed by Darrow et al. (15) who
reported that girls had a higher amount
of severe injuries to their knees than
boys, and a large proportion of these
knee injuries were caused by complete
ligament tears. Although higher knee
injury rates in boys than in girls have
been observed (35) while examining
high school athletes in the sports of foot-
ball, soccer, basketball, baseball, wres-
tling, volleyball, and softball, these rates
may have differed if the knee injury rates
were examined among comparable
sports only.
Despite the lack of a comparison of
injury rates between males and females
in similar sports, Ingram et al. (35) con-
cluded that girls’ soccer and basketball
still ranked among the sports with the
highest knee injury rates, accompanied
only by football and wrestling, which
are primarily contact sports. Major
knee injuries caused by noncontact
mechanisms were twice as likely to
occur in females as males, and they
67
Training for Landing and Cutting Stability in Young Female
were the primary mechanism of injury
in girls’ basketball and soccer, which
were the top 2 high school girls’ sports
with the most frequent knee injuries
(35). Complete ligament tears in the
knee were most common among female
basketball and soccer players, with bas-
ketball players having a higher fraction
of reinjures to the knee (56), and female
athletes overall being more likely to
have higher rate of reinjures than their
male counterparts in comparable sports
(55). Such disparities among female bas-
ketball and soccer players compared
with other athletes are also evident
among collegiate athletes. Collegiate
women’s basketball and soccer players
have been shown to have statistically
higher rates of ACL injury than wom-
en’s lacrosse players (1) and men’s bas-
ketball and soccer players (23).
The higher prevalence of knee injury,
particularly ACL injury, in female ath-
letes compared with male athletes and
female basketball and soccer players
compared with other female athletes
provides strong evidence for injury pre-
vention training specifically within this
population to minimize the occurrence
of injury during activities involving little
or no player contact. Thus, this article
focuses on young female basketball and
soccer players in an effort to increase
the players’ strength and stability during
common and frequent sport-related
activities to reduce their risk of injury,
particularly knee injuries.
LANDING AND CUTTING PATTERNS
NEUROMUSCULAR AND
BIOMECHANICAL
CONSIDERATIONS
Biomechanical and neuromuscular fac-
tors have been related to ACL injury,
especially injuries occurring while piv-
oting, decelerating, cutting, and landing
from a jump (10). It has been suggested
that lower extremity alignment during
movement influences the amount of
stress on supporting structures of the
knee, such as the ACL. Lower extrem-
ity misalignment exacerbates the stress
on the ACL, leading to structural dam-
age over time or if combined with an
excessive load and force, it may result in
68 VOLUME 35 | NUMBER 2 | APRIL 2013
complete structure failure at that time.
High-risk lower extremity misalign-
ment, which occurs when the tibia
externally rotates and valgus motion oc-
curs at the knee, has been noted in soc-
cer players during cutting maneuvers.
Misalignments in basketball players
during landing occur when the players
hyperextend the knee with simulta-
neous internal rotation of the tibia
(9). Overall, female athletes tend to
cut and land with the knee more
extended, thereby placing more stress
on the knee. Neuromuscular factors
such as muscle activation and resultant
muscle strength and force are also sug-
gested to contribute to ACL injury.
Musculature around the knee provides
stability for the knee, yet gender differ-
ences have been found in muscular
strength, muscle recruitment, and mus-
cle coactivation patterns, which all
influence knee stability (46).
BIOMECHANICAL
CONSIDERATIONS
Knee flexion. Female athletes tend to
land and cut with less knee flexion
than male athletes, which may contrib-
ute to their higher incidence of ACL
injury (54). The ACL is the principal
restraint to anterior tibial displacement,
the forward sliding motion of the tibia
relative to the femur occurring when
the knee extends. Assuming 75% of
the force exerted by a fully extended
knee, the ACL endures more strain
with less knee flexion (50). Ligament
strain is referred to the deformation of
the ligament as a result of continued
loading. As ligaments are loaded ini-
tially, fibers in the ligaments elongate,
and as loading continues, the tissue stif-
fens and more force is required for con-
tinued elongation. This further
elongation is conveyed as strain and
refers to the deformation of the tissue
in reference to its original length. As
strain increases, the ligament is subject
to failure and potential subsequent rup-
ture and tearing (51).
The injury risk associated with decreased
knee flexion has been seen among female
adolescent basketball, soccer, and volley-
ball athletes who participated in
preseason biomechanical screenings and
regular season observational follow-up
for ACL injury incidence. Female ath-
letes who had an ACL injury in the reg-
ular season had a maximum knee flexion
during landing that was 10.58 less than
those who did not experience an ACL
injury, yet no difference in knee flexion
were found at initial contact (30). Initial
contact is the moment of first contact of
the feet with the ground and does not
constitute complete landing, which is
when the player is fully pushing against
the ground, resulting in a ground reaction
force. Ground reaction force is the force
the ground exerts on the body and is
equal in magnitude to body weight.
When landing from a jump, a player
dispels his or her momentum by push-
ing against the floor, resulting in
a ground reaction force that is equal
and opposite to the force exerted by
his or her body. However, during
deceleration, the ground reaction force
exceeds the force exerted by body
weight. The magnitude of the resultant
ground reaction force is influenced by
body posture during landing. Landing
with a stiff upright posture causes
a player to decelerate quickly, resulting
in large mean and peak ground reac-
tion forces, which may increase the
risk of injury. Landing with knees,
hip, and ankles flexed increases decel-
eration time, resulting in a smaller
ground reaction force (60) (Figure 5).
Adolescent athletes participating in
jumping sports, such as basketball,
tend to have an average peak vertical
ground reaction force that is 4.5 times
their body weight (45), and those par-
ticipating in gymnastics tend to land on
heels, toes, or without flexing knees
have been shown to have peak vertical
ground reaction forces that are 3 to 8
times their body weight. Coordinated
activity by skeletal muscles help con-
trol the motions of joints, and this
coordinated action helps to absorb
the compressing actions of the oppos-
ing forces of body weight and ground
reaction forces (60). Skeletal muscle
creates moments of force, the effect
of force that causes twisting, rotational,
or bending actions. These moments of

Figure 5. Proper landing technique:
Hips flexed, knee over mid-
foot, feet are shoulder width
apart, feet are symmetrical,
and landing on ball of foot.
force, also referred to as torque, control
joint motions (61). In the previously
mentioned study of female adolescent
basketball, soccer, and volleyball ath-
letes participating in preseason biome-
chanical screenings and regular season
observational follow-ups for ACL
injury incidence, the knee flexion
moment did result in knee flexion for
all athletes, but the athletes who even-
tually experienced an ACL injury
flexed the knee less during the presea-
son screenings and regular season
follow-ups compared with those who
remained uninjured (30).
The tendency of athletes to flex the
knee less during landing may be dem-
onstrated even more in practice and
games, where unlike a controlled lab-
oratory environment, maneuvers are
faster, immediate, and multidirectional,
causing knee flexion to decline further.
For instance, male and female high
school basketball players have been
shown to display significantly less knee
flexion when performing jumps that
were reactive rather than planned,
and they tended to have less maximum
knee flexion when jumping to the left
compared with jumping vertically or
to the right. Moreover, the effect of
jump anticipation and jump direction
on the degree of knee flexion was
larger in females, who had less knee
flexion during reactive jumps and
when jumping to the left compared
with males (57).
Cutting maneuvers can create large
knee flexion moments on the knee espe-
cially at the point when the player
pushes off the most, and these moments
are possibly the result of an increase in
flexion load (6). Knee flexion moments
can also vary depending on the angle of
the cut and whether the cut is abrupt or
planned, resulting in varying degrees of
knee flexion. Male soccer players have
been shown to experience a 19%
decrease in knee flexion when perform-
ing an unanticipated side-step cut at 608
(6). The degree of knee flexion can also
be influenced by the presence of a defen-
sive opponent. Increases in knee flexion
have been observed while performing
a cutting maneuver when a defensive
opponent was present; however, despite
this increase in knee flexion, female ath-
letes were more liable to have less knee
flexion during side-step cutting whether
a simulated defensive opponent was
present or not (44). Additionally, in
a study of male and female collegiate
recreational basketball, soccer, and vol-
leyball players, knee flexion angle
displayed by the females during cross-
cutting was 88 smaller than that dis-
played by males (42). Female basketball
and soccer players who land and cut
with little knee flexion may have an
increased risk of ACL injury considering
that most stress on the ACL occurs
when the knee is near full extension (50).
Knee valgus and varus alignments. In
addition to resisting anterior displace-
ment of the tibia relative to the femur,
the ACL also functions as a resistor to
valgus, varus, and tibia rotation. Valgus
loading of the knee causes the leg to
curve inward or adduct at the knee,
and varus loading causes the leg to
curve outward or abduct at the knee
(62). It is suggested that valgus and
varus knee alignments during landing
Strength and Conditioning Journal | www.nsca-scj.com
and cutting increase the risk of ACL
injury (25,54). The movements neces-
sary to land from a jump or perform
a cut may be responsible for the valgus
and varus occurrences at the knee
because these alignments are exhibited
more during landing and cutting than
during running (21). For instance, varus
and valgus motions were significantly
different during cutting maneuvers as
opposed to a straight run in male soc-
cer players (6).
Valgus or varus motions are also more
pronounced when the task is abrupt
and may occur more when players
perform maneuvers unexpectedly
(57). A particular side may also be
more susceptible to valgus motions
during landing and cutting, with female
high school basketball and soccer
players experiencing greater valgus
moments on their dominant side (the
leg the athlete would preferably use to
kick a ball) during landing and cutting
(14,17,29). Female athletes tend to
experience more valgus and varus knee
motions than male athletes during cut-
ting and landing. At initial contact,
female basketball and soccer players
have been shown to have greater knee
valgus when landing (18) and greater
knee abduction angles when cutting (5)
compared with their male counter-
parts. This tendency for valgus motion
in female athletes is not limited to the
point of initial foot contact or to land-
ing and cutting tasks only.
Malinzak et al. (42) observed that
female athletes consistently displayed
valgus motion throughout each cutting
task as well as during running. The
tendency for female athletes to have
more valgus motion than male athletes
was consistent despite gender differen-
ces such as height. For instance, female
basketball players tended to have sig-
nificantly more valgus motion during
landing compared with male players
even when the values were normalized
for height (17). These gender differen-
ces between males and females may
develop during adolescence, with girls
displaying more valgus motion as they
age, considering Hewett et al. (29)
found no difference in medial motion
69
Training for Landing and Cutting Stability in Young Female
between prepubertal boys and girls.
Medial motion refers to the movement
of the knee toward the midline of the
body; in other words, it indicates val-
gus motion, and in this study, prepu-
bertal girls tended to demonstrate
medial motion as much as prepubertal
boys. However, postpubertal girls dem-
onstrated more medial motion and
larger valgus angles during landing
compared with postpubertal boys and
prepubertal girls.
Notwithstanding this differentiation,
differences in valgus motion are not
apparent between sports, and high
school female basketball and soccer
players may have similar risks of injury
particularly when performing cuts
(14). Valgus and varus alignments are
a potential risk of ACL injury. Specifi-
cally, knee valgus moments and angles
are significant predictors of ACL injury
in adolescent female basketball and
soccer players (30). Players who had
an ACL injury during the regular sea-
son demonstrated greater knee abduc-
tion angles at initial contact and
maximum displacement during landing
in preseason screenings (30). Video
analysis measuring foot position and
lower extremity angles preceding
ACL injury revealed that knee abduc-
tion moments increased progressively
following initial foot contact with the
ground, and females had more knee
abduction than males (8).
Chaudhari and Andriachi (12), using
a lower extremity model, evaluated
knee alignments and resultant ACL
thresholds, which they defined as the
maximal amount of force the ACL can
endure before the joint opens medially
or laterally more than 88. According to
their model, the ACL injury threshold
was the highest, 5.1 times body weight,
during a neutral alignment. However,
when alignments changed to either
valgus or varus angles, the threshold
decreased to 2.2 and 2.1 times body
weight, respectively. In other words,
with valgus or varus motions in the
knee, the amount of force it takes to
injure the ACL would be less, and with
excessive valgus motion, the injury to
the ACL may be preceded by a medial
70 VOLUME 35 | NUMBER 2 | APRIL 2013
collapsing of the knee (39). Valgus
motions of the knee have been shown
to predict and precede ACL injury, and
female basketball and soccer players
tend to display these motions more
than male players, particularly during
landing and cutting; consequently,
these players may have an increased
risk of resultant ACL injury.
Hip motion. Increased hip adduction,
decreased hip flexion, and internal
rotation are also motions that may
subject athletes to an increased risk of
ACL injury (54). The degree of hip
adduction has been shown to predict
the degree of knee abduction or varus
motion during cutting in high school
female soccer players (34). Female bas-
ketball and soccer players also may
have an increased hip adduction during
landing causing knee valgus motion;
however, isolated hip adduction
moments may not be a risk factor for
ACL injury itself (2). Female athletes
tend to flex their hips less compared
with male athletes when cutting, and
this decrease in flexion is also seen
when facing a defensive opponent
(44). The degree of hip flexion during
landing helps determine the magnitude
of force at the knee because hip flexion
combined with knee and ankle flexion
help to decrease ground reaction forces
(2,60).
NEUROMUSCULAR
CONSIDERATIONS
Quadriceps and hamstrings strength.
Knee stability occurs passively and
dynamically. Bones, menisci, liga-
ments, and the joint capsule compose
the passive system of knee joint stabil-
ity (25). For example, the ACL primar-
ily stabilizes the knee by regulating
anterior and posterior translation,
varus and valgus motions, and internal
and external rotations (50). The
dynamic system of stability consists
of muscle contraction, occurring pri-
marily by volitional muscle activation.
Knee joint stability relies on a balance
between both systems, but variations in
strength between the quadriceps and
hamstrings in female athletes place
them at the risk of stressing their
ACL. As the knee extends, an anterior
force occurs at the knee, and the ACL
is responsible for regulating this force
by restraining the knee and resisting
anterior displacement.
In addition to this passive system of
knee stability, the hamstring functions
as an antagonist to this anterior
motion and contracts to help restrain
the knee joint by pulling it in the pos-
terior direction. If the quadriceps con-
tracts strongly when the knee is
between 08 of flexion (fully extended)
and 458 of flexion and the hamstring
contraction does not match the strong
quadriceps contraction, the anterior
force that is produced can considerably
stress the ACL possibly resulting in an
injury (25). Female basketball and soc-
cer players, who subsequently experi-
enced an ACL injury, when assessed
during preseason for dynamic strength,
had decreased hamstrings strength but
no decreased quadriceps strength com-
pared with male players (47). Quadri-
ceps strength in these female athletes
did not differ from that in male athletes,
but the decrease in hamstrings strength
resulted in the quadriceps being stron-
ger than the hamstrings. This imbal-
ance could have resulted in the
quadriceps overpowering the ham-
string and stressing the ACL, thereby
contributing to the conditions that
caused their injuries because female
athletes who did not experience an
ACL injury had decreased quadriceps
strength but no decreased hamstrings
strength compared with male athletes.
Therefore, it is important to use train-
ing programs that will challenge and
develop both the quadriceps and the
hamstrings.
Muscle co-contraction: quadriceps and
hamstrings balance in force. Balanced
co-contraction of the quadriceps and
hamstrings influences the degree of
anterior tibia translation and decreases
the anterior force stress on the knee. Li
et al. (41) demonstrated the effects of
isolated quadriceps loading and com-
bined quadriceps and hamstring loading
at angles of 08, 158, 308, 608, 908, and
1208 of knee flexion in cadaver knees.
During isolated quadriceps loading,
anterior tibial translation increased from
full extension (08) to 308 of knee flexion;
however, as knee flexion increased, ante-
rior tibial translation decreased. Forces
on the ACL, during isolated quadriceps
loading, increased from 08 to 158 of knee
flexion and then decreased as the knee
flexion angles increased. On the other
hand, when quadriceps loading was
accompanied with hamstring loading,
anterior tibial translation was signifi-
cantly reduced at all angles except at
08 and 158 knee flexion. Forces on the
ACL were significantly reduced with
quadriceps and hamstrings loading at
158, 308, and 608 of knee flexion. Forces
at 158 of knee flexion, which were high-
est with isolated quadriceps loading,
were reduced by 23%. Moreover, inves-
tigators found no significant difference
between isolated quadriceps loading
and combined quadriceps and ham-
string loading when the knee was fully
extended, suggesting that athletes
should avoid this knee position as much
as possible. Nevertheless, concurrent
hamstring contraction during move-
ments involving forceful quadriceps con-
traction is beneficial to reduce strain in
the ACL.
Timing of muscle recruitment and
muscle activation. Female athletes
tend to activate their quadriceps more
than their hamstrings, and their quad-
riceps tend to reach peak torque before
their hamstrings. When muscle activa-
tion patterns were measured in colle-
giate recreational basketball, soccer,
and volleyball athletes, via electromy-
ography (EMG), quadricep’s EMG
activity in females was consistently
greater than that in males especially
during running and side-cutting. Con-
versely, hamstring’s EMG activity in
females was less than that in males
particularly during running and
cross-cutting (42). Huston and Wojtys
(33) detected that female collegiate
athletes reach peak torque in knee flex-
ion slower than male collegiate ath-
letes, but their time to peak torque in
knee extension was similar. At higher
speeds, female athletes still reached
peak torque in hamstrings significantly
slower than male athletes; however,
their time to peak torque nearly
equated the peak torque time seen in
female nonathletes. Overall, investiga-
tors concluded that female athletes
generated peak torque in the hamstring
an average of 11 milliseconds after
reaching peak torque in the quadriceps,
whereas the other groups reached peak
torque in the hamstring an average of
3–6 milliseconds before reaching peak
torque in the quadriceps.
Activation of the hamstrings prevents
knee hyperextension, but the ability of
the hamstrings to prevent this motion
relies on the amount of force it is capa-
ble of producing, which indicates the
degree of muscle strength. It has been
suggested that hamstring antagonist
coactivation patterns are very low in
athletes who do not routinely engage
in training programs consisting of ham-
string strengthening exercises, but
significant changes in antagonist coac-
tivation patterns in the hamstrings
occur after a strength training program
(4). Such evidence supports the need for
female athletes to participate in training
programs that are designed to equally
train and strengthen the hamstrings and
quadriceps to minimize imbalances
between these muscles.
INJURY PREVENTION TRAINING
PROGRAMS
A REVIEW OF ACL INJURY
PREVENTION PROGRAMS
Neuromuscular training interventions
with emphasis on core strengthening,
joint stability, balance training, and
jump training have been shown to
modify and improve landing errors
such as knee valgus and varus motions,
and knee hyperextension (11,16,20). In
addition, plyometric training, which in-
cludes jumping drills such as wall
jumps and tuck jumps, has been imple-
mented in ACL injury intervention
programs in an attempt to modify inad-
equate muscle activation, decrease
landing forces, decrease valgus mo-
ments and knee rotations, and to
increase hamstring strength. Increases
in preparatory muscle coactivation, de-
creases in landing forces, and increases
Strength and Conditioning Journal | www.nsca-scj.com
in hamstring torque have been
observed after plyometric training
(13,31,48,52,58,63). Strength training
has been implemented as a component
of neuromuscular training programs
(49), as well as an isolated program,
and it has been shown to decrease knee
valgus and hip adduction, increase
muscle strength, and increase knee
flexion angle (26,27).
PLYOMETRIC TRAINING
Plyometric training involves multidi-
rectional consecutive jumping, where
the athlete jumps, lands, and immedi-
ately jumps again. Correct posture and
body alignment are emphasized as
well as jumping straight up rather than
leaning to the side or to the front or
back. Athletes are instructed to land
softly with knees and hips flexed while
immediately preparing to jump again
(31,58). Programs tend to progress in
the level of difficulty by requiring ath-
letes to transition from jumping and
landing with both feet to jumping
and landing with one foot (53) and
focus on building strength, power,
and agility (31). Plyometric training
has been shown to decrease landing
forces and knee abduction and adduc-
tion moments (31) and increase ham-
string strength (64).
Decreases in landing forces after plyo-
metric training have been observed in
college women involved in recrea-
tional sports (58) and in female high
school volleyball players who, for
example, decreased their peak landing
force by 22% (31). Increases in perfor-
mance have also resulted from plyo-
metric training. Improvements in
sprint speed and vertical jump height
in NCAA female soccer players (13),
increases in vertical height in high
school volleyball players (31), and in-
creases in average power and improved
body position in female collegiate bas-
ketball players (63) have been noted.
However, plyometric training alone
may not reduce the risk of ACL injury,
but it may be more effective when
combined with other types of training.
Female high school basketball, soccer,
and volleyball athletes were assessed
71
Training for Landing and Cutting Stability in Young Female
for ACL injury after a plyometric
program, where athletes trained for
20 minutes before or after practice.
Those who participated in the plyo-
metric program incurred the same
amount of ACL injuries as those ath-
letes who did not participate in the
program. Furthermore, all ACL inju-
ries were incurred by basketball and
soccer players, with basketball players
experiencing more injuries than soccer
players (53).
On the other hand, plyometric training
combined with other types of training
may decrease the risk of injury. For
instance, female high school soccer play-
ers who participated in plyometric
training, sports-specific cardiovascular
conditioning, sport cord drills, strength
training, flexibility training, and accelera-
tion drills with emphasis on body
position awareness and avoidance of
high-risk movements had less ACL inju-
ries than those who did not train in these
components. Specifically, trained athletes
had 1 ACL injury as opposed to 8 ACL
injuries in untrained athletes (24).
RESISTANCE/STRENGTH
TRAINING
Movement is a result of muscle force
acting on the skeletal system, specifi-
cally joints, causing torque or mo-
ments, expressed as rotating, twisting,
or bending actions. These actions
depend on how strongly the muscle
is stimulated and the degree of force
production in the muscle (37). The
maximal amount of force that a muscle
generates is referred to as the muscle’s
strength, and this strength is altered
with training (37). The concept of
strength training involves placing
a demand on muscles to perform
beyond their current levels, referred
to as overloading. When muscles are
consistently overloaded, the neuro-
muscular system adapts, resulting in
an increase in muscle size, increased
motor unit recruitment, and improved
coordination of the agonists, all of
which influence muscle strength.
Strength training exploits this principle
of adaptation and progressively over-
loads the body to elicit further
72 VOLUME 35 | NUMBER 2 | APRIL 2013
adaptations resultant in an increased
strength and an improved athletic per-
formance (37). Training increases
strength in the muscles specifically
trained, resulting in an increase in max-
imum voluntary contraction (27) dem-
onstrated through increases in
1-repetition maximum tests (7,38)
and improved athletic performance.
Recreational female athletes, following
a strength training program emphasiz-
ing quadriceps, hamstrings, gluteus
maximus, and gluteus medius develop-
ment, demonstrated an average
increase in strength in these muscles
ranging from 35% to 48% (27). A
strength gain in the hamstrings is
important when considering the role
of hamstring co-contraction in reduc-
ing ACL strain (64). Reductions in
ground reaction forces have also been
noted after strength training. In the
assessment of landing mechanics of
female recreational athletes who par-
ticipated in strength training and those
who did not, athletes performed initial
jumps and then were given immediate
feedback on their jumping and landing
biomechanics. Athletes were allowed
to view their jumps along with demon-
strations of proper jumping and land-
ing technique before performing
subsequent jumps. Those who partici-
pated in the strength training program
experienced a greater decrease in peak
vertical ground reaction force. Peak
knee anterior shear force also
decreased in this group, but increased
in the group with no strength train-
ing. Although both groups experi-
enced a decrease in knee valgus
moment and an increase in knee flex-
ion during landing, the magnitude of
both was greater in athletes who did
not participate in a strength training
program (26). Others have indicated
no changes in lower extremity
motion patterns such as peak ante-
rior tibial shear force and vertical
ground reaction force with only
strength training (27), suggesting that
although strength training is benefi-
cial for strength gains, it may not
be very effective in translating the
increases in strength to modifying
some of the biomechanical injury risk
factors such as decreased knee flex-
ion and knee valgus that are associ-
ated with ACL injury. Such factors
may be modified more effectively
with more dynamic training that is
more representative of common athletic
maneuvers; however, resistance training
is an essential component of overall
training because it provides a solid foun-
dation for athletic performance.
NEUROMUSCULAR TRAINING
In an 8-week training program imple-
mented with female basketball and soc-
cer players, players were categorized
into 2 groups consisting of either plyo-
metric training or basic resistance train-
ing. Players trained in their respective
programs 3 days a week for 30 minutes
each day. Both groups significantly
improved in quadriceps strength, but
there was no significant difference in
hamstring and hip abduction strength
between baseline and postintervention.
Kinematic data revealed that both pro-
grams promoted increases in knee flex-
ion at initial contact, peak knee flexion,
and time to peak knee flexion during
landing. Both groups also demonstrated
a decrease in knee flexion moment and
hip flexion moment; however, there
was no difference in vertical ground
reaction force between the groups
(40). Thus, this study further indicates
the need for a more comprehensive
training program.
Individually, each training program
may be effective in altering some mod-
ifiable factors associated with an
increased risk of ACL injury such as
the degree of knee flexion, quadriceps
and hamstring muscle strength and
force imbalances, landing forces, and
knee valgus motions. However, a train-
ing program that incorporates all or
most of these individual programs, such
as neuromuscular training programs,
may prove more effective. Neuromus-
cular training tends to incorporate
strength training, balance training, plyo-
metric training, and proprioceptive
training, in addition to core strengthen-
ing and dynamic joint stability training.
Such training has been shown to
increase knee flexion, decrease knee
 Table 1
A sample 8-week program designed for increased landing and cutting stability

Routine 1 Sets Repetitions/Time Routine 2 Sets Repetitions/Time

Weeks 1 and 2
Single-leg balance circuit—each 2 12 Body weight squats (on whistle, 2 20
exercise: 908 leg lift and single-leg 5-second hold on each squat
figure 8 before blowing whistle)
Body weight squats 3 20 Body weight split squat (on 2 10
whistle, 5-second hold on each
split squat before blowing
whistle)—each leg
Overhead squat with dowel 2 12 Wall sits 2 30 sec
Stationary lunges 3 8 Jump rope 2 1 min
Lying hamstring curls (with resistance 3 8 Line jumps (front/back and 2 30 sec
band) side/side)
Straight-leg hip abduction 2 10 Low-intensity depth jumps (from 2 10
first step of bleachers working
on proper knee alignment and
hip flexion)
Bent-leg hip abduction 2 10 Up/back 2 30 sec
Hip bridge 2 10 Agility ladder drills: 1-foot run, 3 rotations
2-foot run, lateral run
Weeks 3 and 4
Single Leg Balance Circuit—each exercise: 2 12 Body weight squats (on whistle, 2 20
908 leg lift, single-leg figure 8, and 5-second hold on each squat
hopping to balance before blowing whistle)
Body weight squats 3 20 Body weight split squat (on 2 10
whistle, 5-second hold on each
split squat before blowing
whistle)—each leg
Overhead squat with dowel 2 12 Wall sits 2 45 sec
Forward lunge 3 8 Jump rope (double and single leg) 2 2 min
Hamstring curls (with stability ball) 3 8 Line jumps (front/back and side/ 2 30 sec
side)
Straight-leg hip abduction 2 10 Low-intensity depth jumps (from 1 10
first step of bleachers working
on proper knee alignment and
hip flexion)
Hurdle run/sprint through 3 rotations
Bent-leg hip abduction 2 10 Hurdle hops (jump and stick) 3 rotations
Cook hip lift 2 12 Hurdle hops (continuous) 3 rotations
Weeks 5 and 6
Single-leg balance circuit—each 2 15 Body weight squats (on whistle, 2 15
exercise: 908 leg lift, single-leg figure 10-second hold on each squat
8, hopping to balance before blowing whistle)

(continued)

Strength and Conditioning Journal | www.nsca-scj.com 73

Training for Landing and Cutting Stability in Young Female

Table 1
(continued )
Body weight squats 3 20 Body weight split squat [on 2 8
whistle, 10-second hold on
each split squat before
blowing whistle)—each leg
Sandbag squats (squats with contoured 3 8 Lateral hurdle hops with sprint 4 rotations
sandbags on shoulders) (2 each side)
Backward lunge 3 8 Figure 8 3 rotations
Up/downs (eccentric exercise for 3 8 Box drill 3 rotations
hamstrings)
Wall jumps 2 30 sec Zig-zag/change of direction drill 3 rotations
Jump and reach 2 30 sec Agility Ladder Drills: hop scotch 3 rotations
and straddle hops
Squat jumps 2 30 sec Free-style Jumping:
Heiden and Stick/Skaters 2 5 jumps each side
Power Skips 2 10 yards
Monster walks (with resistance bands) 2 10 yds (down Hurdle hops (jump and stick) 2 rotations
and back)
Ball squeezes (with soft elastic ball) 3 20s Hurdle hops—single leg 2 rotations
(continuous)
Side-to-side (with rope): (a) position 2 15
rope at hip height; (b) move side to side
under rope in an athletic stance, with
hips and knees flexed, head up, feet at
least shoulder width apart—without
rounding back—clearing
both shoulders on each side; (c)
under and back is one repetition
Weeks 7 and 8
Single-Leg Balance Circuit—each 3 30 s Lateral hurdle hops with sprint 4 rotations
exercise: single leg ball tosses (each (2 each side)
leg) and mirror drill
Body weight squats (on whistle) 3 20 Figure 8 3 rotations
Sandbag squats (squats with 3 12 Box drill 3 rotations
contoured sandbags on shoulders)
Walking lunge 3 10 yd Zig-zag/change of direction drill 3 rotations
One-leg bench squat 2 10 Lateral shuffle 3 30 s
Up/downs (eccentric exercise for 3 12 Lateral quickness 3 30 s
hamstrings)
Leg abduction (with tubing) 2 10 Lateral quickness with drop step 3 30 s
Leg adduction (with tubing) 2 10 Star Drill 3 rotations

74 VOLUME 35 | NUMBER 2 | APRIL 2013

 Table 1
(continued )
Side to side (with rope): (a) position 2 15
rope at hip height; (b) move side to side
under rope in an athletic stance, with
hips and knees flexed, head up, feet at
least shoulder width apart—without
rounding back—clearing
both shoulders on each side; (c)
under and back is one repetition

flexion moment and knee valgus
moment, and decrease maximum
knee valgus in female collegiate bas-
ketball and soccer players during
landing (11). Promising results have
also been observed in female high
school basketball, soccer, and volley-
ball athletes who participated in
a 6-week program with similar com-
ponents and sessions occurring 3 days
a week for 60–90 minutes per session
(28). Athletes who trained in the pro-
gram had significantly less ACL inju-
ries than those who did not train in
the program. Moreover, this reduction
in ACL injury may persist over
seasons.
Female soccer players aged 14–
18 years were observed for 2 consec-
utive seasons while participating in
a 20-minute prepractice program.
Investigators found that those who
trained had significantly lower occur-
rences of ACL injury than those who
did not train. In the first season, the
trained group experienced 2 ACL
tears and the untrained group
experienced 32 ACL tears, and in
the second season, the trained group
experienced 4 ACL tears compared
with 35 ACL tears in the untrained
group (43).
Neuromuscular training has also been
shown to increase performance in
female high school athletes. Basket-
ball, soccer, and volleyball players
have increased strength, improved
jump distance and height, and
decreased sprint times after a training
program incorporating plyometric
training, core strengthening and bal-
ance, resistance training, and speed
training consisting of interval sprint-
ing with nonresisted and partner-
resisted sprinting (49). Additionally,
female soccer players aged 13–18
years who trained 3 times a week
before practice had faster sprint times
(50). Considering the evidence, it
would be beneficial to use a multicom-
ponent program when attempting to
increase knee stability when landing
and cutting because such a program
may prove more effective.
OFF-SEASON TRAINING
PROGRAM
The following landing and cutting
stability training program (Table 1)
is intended to train athletes in such
a way that they have sufficient neu-
romuscular activation, muscular
strength, and technique to success-
fully land and cut with less stress on
their knee joint, which may translate
to reduction in injury risk. The train-
ing program incorporates strength,
plyometric, lateral, agility, balance,
and coordination as well as flexibility
training, all of which are incorporated
with emphasis on being aware of
body position and moving with bal-
ance and stability (Table 2). Overall,
the training program is aimed to
teach athletes how to move properly,
and the strength gained provides
them with the capacity to do so. All
training days should be preceded by
a proper dynamic warm-up, which
should include linear and lateral
movement to prepare the athletes
for subsequent activities, and training

Table 2
Training program components for increased landing and cutting stability

Training Purpose
Strength/resistance Counter muscle imbalances in the hamstring and quadriceps and strengthen the hip and thigh, and
reinforce proper knee alignment. Includes body weight training where incorporate exercises (i.e.,
body weight squats) that use the athlete’s body weight as resistance with emphasis on strength,
coordination and control, proper knee alignment, and hip flexion
Balance and coordination Encourage body control and stability during movements. Includes single leg balance training
Plyometric Strength, power, proper landing mechanics
Lateral and agility Lateral movement, changing directions, cutting
Flexibility training Improve range of motion especially in hip, hamstrings, and quadriceps

Strength and Conditioning Journal | www.nsca-scj.com 75

Training for Landing and Cutting Stability in Young Female
should conclude with proper stretch-
ing and flexibility exercises. This off--
season training program may
coincide with other team training
and serve as an additional component
to routine strength and conditioning
and sports skills training.
Conflicts of Interest and Source of Funding:
The author reports no conflicts of interest
and no source of funding.
Karina C.
Howell is the
strength and
conditioning
coach and owner
of KCH
Training.
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