Introduction
Anterior cruciate ligament injuries are common injuries that occur when a person is pivoting, descending, or landing aggressively – this is a common scenario in many sports. ACL injuries are debilitating – they lead to large amounts time off sport/work, significant expenses for surgery & treatment and pain and extensive rehabilitation before returning to sport or work for many people. The incidence of ACL injuries and people having ACL reconstruction surgery is rising in Australia – this number is rising very quickly in those who require revision surgery (e.g. for reinjuries)
Thus, the focus has shifted
away from the treatment of ACL injuries to the prevention of ACL injuries. The aim is to reduce the burden, pain and economic costs associated with these injuries.
One aspect of prevention that has been gaining traction recently are injury prevention programs. One such program is the Santa Monica PEP (Prevent Injury, Enhance Performance) Program. The PEP program was initially developed in 1972, with the aim of reducing the number of ACL injuries in female soccer players. It is now commonly used for ACL injury prevention in different sports, and even for rehabilitation following ACL reconstruction to prevent reinjuries.
PEP Program Outline
The PEP program has 5 main goals that aim to target risk factors/deficits contributing to injury in different populations:
- Avoid Vulnerable Positions
- Increase Flexibility
- Increase Strength
- Include plyometric exercises into the training program
- Increase proprioception through agility drills
A lot of exercises may already be used as part of regular training sessions already. However, there are subtle technique cues and technicalities that need to be strictly observed for the exercises, to ensure that these drills/exercises are being performed correctly. This requires diligence and attention to detail from coaches, trainers, and players themselves.
The instructions for the performance of each exercise is provided with the program. It will be linked in PDF form at the bottom of the article.
The program consists of 6 sections:
- Warm Up
- Stretching
- Strengthening
- Plyometrics
- Agility Drills
- Cool Down (after training session)
The program should take approximately 25 minutes total (including 10 minutes for the cool down following training)
Evidence
Rodriguez et al, 2018 analysed the PEP program extensively and measured its effects on not only the reduction of lower limb injuries, but also muscle strength and knee alignment during vertical jumping. This was performed on 20 players, and they were followed up for 24 weeks while continuing the PEP program.
The study found a 20% 
improvement in jump technique (proper knee alignment), and significant increases in knee muscle strength (of the quadriceps and hamstrings), compared with values prior to commencing the PEP program. The other important observation noted was that there was a significant decrease in the Quadriceps:Hamstrings Ratio of strength. This means that the muscles controlling the knee from the front and the back are a more balanced in strength.
Research and studies have shown that knee alignment during vertical jumping, and Quadriceps:Hamstrings ratio are significant modifiable risk factors that contribute to ACL injuries. Thus, the PEP program is very effective at addressing these risk factors, hopefully reducing ACL injuries overall.
The study found that although lower limb injuries did not reduce during training or matches, there were no reported ACL or other ligamentous injuries. .
References
PEP program Link: https://www.aclstudygroup.com/pdf/pep-program.pdf
Rodríguez, C., Echegoyen, S., & Aoyama, T. (2018). The effects of “Prevent Injury and Enhance Performance Program” in a female soccer team. The Journal of Sports Medicine and Physical Fitness, 58(5), 659–663. https://doi.org/10.23736/S0022-4707.17.07024-4
By Clinton Huynh