Anterior Cruciate Ligament (ACL) Tears and Pelvic Floor Coordination in Female Athletes: The Importance of Neuromuscular Control and Stability 

Athletes are no strangers to injuries, but one of the most significant and challenging injuries for many is an anterior cruciate ligament (ACL) tear. This injury, often resulting from sudden changes in direction, deceleration, or improper landing mechanics, has profound implications for both physical health and sports performance. For female athletes, however, the risk of ACL injury and reinjury is notably higher than their male counterparts, with research showing that women are five times more likely to reinjure the ACL after surgery. While much attention has been placed on factors like knee valgus and landing techniques, recent studies have also shed light on the importance of pelvic floor coordination and neuromuscular control in preventing these injuries. 

One of the most compelling reasons why female athletes are more susceptible to ACL injuries and subsequent reinjuries lies in poor neuromuscular control. Neuromuscular control refers to the brain’s ability to recruit muscles effectively, resulting in proper joint function and stability. When neuromuscular control is compromised, it can lead to misalignment and improper movement patterns, increasing the likelihood of injury. 

In the case of an ACL tear, poor neuromuscular control in the pelvic floor and hip muscles can manifest as improper knee mechanics during high-impact activities, such as jumping or landing. These poor mechanics allow for dynamic knee valgus which places excessive strain on the ACL. The lack of adequate hip and pelvic floor stability is a critical factor in ACL injury mechanics. 

Pelvic floor stability plays a more significant role in ACL injury prevention than most people realize. The pelvic floor, a group of muscles that form the base of the pelvis, serves not only to support internal organs but also to contribute to core stability. Proper coordination of the pelvic floor with the deep abdominal and back muscles is essential for maintaining optimal posture and preventing undue stress on the knees, especially during dynamic movements such as landing from a jump or changing directions. 

Research has shown that during landing, female athletes are more likely to exhibit an increased trunk lean away from the stance or pivot leg. This is often a result of poor postural control of the pelvic girdle, which may be weakened by insufficient pelvic floor and core strength. When the trunk leans away from the stance or pivot leg, the body’s center of gravity shifts, creating more stress on the knee joint. This increases the likelihood of knee valgus (inward collapse of the knee), a key risk factor for ACL tears. The pelvis and trunk should work in tandem to maintain an upright posture, allowing the body to absorb forces more evenly, especially during high-impact activities. 

Landing mechanics are crucial for reducing ACL injury risk, and hip strength plays a central role. The ability to control the pelvis and trunk during landing directly impacts knee mechanics. A common observation in ACL injuries is that athletes land with increased hip flexion and hip abduction. Increased hip flexion can also result from decreased posterior hip strength, often seen in athletes with poor gluteal (hip extensor) and pelvic floor strength. A lack of hip extension strength means the pelvis has less control during deceleration, resulting in inefficient movement patterns that may predispose the ACL to more shear forces. Additionally, weakened hip abductors contribute to dynamic knee valgus, which further elevates the risk of ACL tears due to the increased forces placed on the ligament. 

One of the most effective tests to assess an athlete’s readiness to return to sport after an ACL injury is the single-leg squat test. This test evaluates several key components of movement: hip stability, pelvic floor control, trunk posture, and knee mechanics. The single-leg squat test is a valuable tool for identifying deficits in neuromuscular control, such as insufficient hip stability or poor trunk control, which can increase the risk of reinjury. 

When performing the single-leg squat, athletes are required to balance on one leg while lowering their body into a squat position. The test places significant demands on hip and pelvic stability, including the pelvic floor muscles, which must coordinate with the core to maintain postural alignment. If an athlete demonstrates excessive trunk lean, loss of control in the pelvis, or poor knee alignment (such as excessive knee valgus), it may indicate a need for further rehabilitation to address these deficits before returning to sport. 

The correlation between postural control, core stability, and ACL injuries cannot be overstated. As mentioned earlier, an increased trunk lean and posterior center of gravity shift can place undue stress on the knee joint, increasing the likelihood of injury. In fact, a significant correlation has been found between the time it takes for athletes to stabilize their core during a single-legged jump and the occurrence of an ACL tear. Athletes with delayed core stabilization are at greater risk of ACL injury, as the delayed stabilization allows for more movement variability, increasing the chances of improper knee mechanics. 

Core stability, which includes the muscles of the trunk, pelvis, and hip, is critical for controlling the movement of the lower extremities. Proper core control allows the body to maintain a neutral posture and distribute forces more effectively during landing and cutting activities. When the core is weak or slow to stabilize, the body compensates by relying more on the knees and hips, creating an imbalance that increases the risk of ACL injury. 

The good news is that neuromuscular and proprioceptive training can significantly reduce the risk of ACL injuries. Training programs designed to improve stability, agility, and strength at the hip, pelvic floor, and core levels have been shown to lower ACL injury rates, particularly in female athletes. These programs focus on developing the muscles responsible for controlling the pelvis, trunk, and knees, ensuring that the body can handle high-impact movements efficiently and safely. 

For female athletes, injury prevention training should focus on improving hip strength, pelvic floor coordination, and postural control. Specific exercises targeting the gluteus muscles, hip abductors, and core muscles can help build the necessary strength for proper landing mechanics. Additionally, proprioceptive exercises—those that enhance awareness of body position in space—can help improve neuromuscular control and prevent compensatory movement patterns that increase injury risk. 

The relationship between ACL tears, pelvic floor coordination, and neuromuscular control highlights the importance of a comprehensive approach to injury prevention, especially for female athletes. With proper training and a focus on stability, agility, and strength, athletes can significantly reduce their risk of ACL injuries and reinjuries. The single-leg squat test provides valuable insights into an athlete’s readiness to return to sport, highlighting areas of weakness in pelvic and hip stability that could predispose them to further injury. By tailoring biomechanics training programs to address these factors, we can empower female athletes to perform at their best while minimizing the risk of ACL tears. 

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• Jennifer Cumming, PT, MSPT, CLT, WCS

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Disclaimer: This blog is here for your help. It is the opinion of a Licensed Physical Therapist. If you experience the symptoms addressed you should seek the help of a medical professional who can diagnose and develop a treatment plan that is individualized for you.