Let's Get Our Female Athletes Squatting Again: A Comprehensive Approach to ACL Injury Prevention

· 6 min read
Let's Get Our Female Athletes Squatting Again: A Comprehensive Approach to ACL Injury Prevention
Photo by Alora Griffiths / Unsplash


As strength coaches, our primary goal should be preventing injuries. No matter how strong or fast we can make our athletes, these improvements are rendered useless if they are sidelined by injuries. Although we cannot control every variable once the athlete is in the game, we can implement numerous strategies within our training environment to "better the chances" that our athletes remain injury-free during competition.

Each year, one out of every 100 high school female athletes and one out of every 10 college female athletes experiences an ACL injury. This statistic is alarming. At our training facility, where I predominantly work with female teams, it is concerning to consider that one out of every ten women who walk through our doors will sustain an ACL injury. This incidence is not just a number; it's a reflection of the severe impact these injuries have on the athlete's career and well-being.

The Scope of the Problem

According to the NCAA, approximately 2,000 female athletes are expected to tear their ACLs each year. This means that females have eight times the risk of ACL injuries compared to their male counterparts. The reasons behind this disparity are multifaceted. One significant factor is the lack of hamstring strength relative to quadriceps strength. The NCAA also reports that an ACL surgery costs the university approximately $25,000. Beyond the financial impact, the athlete loses their playing season and possibly a scholarship in an instant. The recovery process is lengthy and often grueling, involving months of rehabilitation and physical therapy.

Identifying the Causes

When a female athlete first steps through our doors, she is often extremely quad-dominant. This is not surprising given that much of their athletic careers involve running, jumping, kicking, and other knee-dominant movements. While strong quadriceps are beneficial, when we test their hamstring strength in relation to their quadriceps strength, we often find that their hamstrings are significantly weaker. This imbalance between the quadriceps and hamstrings is a critical factor in knee stability.

Research shows that the balance of power and recruitment between the quadriceps and hamstrings is crucial for knee stability in sports. The Q/H (Quad to Hamstring) ratio in female athletes tends to favor quadriceps strength over hamstrings. Women are more likely to be quad-dominant, meaning they engage their quadriceps first in knee-dominant exercises, which increases stress on the ACL. This imbalance not only predisposes them to ACL injuries but also affects their overall athletic performance.

Our Approach: Emphasizing the Posterior Chain

Our article is titled, "Let's Get Our Female Athletes Squatting Again," so let's discuss how we increase hamstring strength and improve the Q/H ratio. Ensuring optimal hamstring and glute activation is paramount. We incorporate exercises like glute/ham raises, bodyweight hamstring negatives, leg curls, Romanian deadlifts, glute bridges, Swiss ball hamstring curls, and mini-band adduction/abduction walks. These exercises target the posterior chain, which includes the hamstrings, glutes, and lower back muscles. Strengthening these muscles helps balance the strength between the front and back of the thigh, reducing the risk of ACL injuries.

However, persuading female athletes to embrace squats can be challenging. Common concerns include, "I don't want my legs to get bigger," "I don't want to look like those women bodybuilders," and "I only want to look toned." It is our job to sell the squat as a crucial tool for their athletic development and injury prevention. To overcome these objections, we need to educate our athletes on the benefits of squatting, not only for their performance but also for their long-term health.

woman lifting barbell
Photo by Danielle Cerullo / Unsplash

Why Squats?

You might wonder, "Why squats?" While there are numerous ways to train an athlete, squats provide significant muscle activation and work. Squats are a compound movement, meaning they engage multiple muscle groups simultaneously. This not only builds strength but also improves coordination and stability.

We instruct squats with a wide stance, as research shows this improves glute engagement. We emphasize verbal cues to "sit back, sit back, sit back" to engage the hamstrings more. For additional glute work, we may use a mini-band around the knees to employ Reactive Neuromuscular Training (RNT). This technique slightly adducts the knees into a valgus position, cueing the glute medius to activate and abduct the knees back into a neutral alignment, thus enhancing glute medius engagement.

Moreover, squats are versatile. They can be modified to suit different fitness levels and goals. Variations such as goblet squats, split squats, and single-leg squats allow us to tailor the exercise to the individual needs of each athlete. This adaptability makes squats a valuable tool in our training arsenal.

Addressing Common Misconceptions

When introducing squats to female athletes, it is essential to address and dispel common misconceptions. Many athletes are concerned about developing bulky muscles or looking too muscular. We emphasize that squatting will not make them look like bodybuilders but will instead enhance their strength, power, and athleticism. We also highlight the functional benefits of squatting, such as improved balance, agility, and overall performance on the field or court.

In addition, we educate our athletes about the importance of progressive overload. By gradually increasing the weight and intensity of their squats, they can continue to build strength without the risk of injury. Proper technique is also crucial. We provide detailed instruction on the correct form and offer constant feedback to ensure that our athletes are performing the exercise safely and effectively.

Implementing a Comprehensive Training Program

While squats are a key component of our training program, they are not the only exercise we use to prevent ACL injuries. Our approach is holistic and includes a variety of exercises designed to strengthen the entire body, improve flexibility, and enhance coordination. In addition to squats, we incorporate exercises such as lunges, deadlifts, and plyometrics to build strength and power. We also include stability and balance exercises, such as single-leg stands and bosu ball drills, to improve proprioception and reduce the risk of injury.

Flexibility and mobility exercises are also essential. Tight muscles can limit range of motion and increase the risk of injury. We include dynamic stretching and foam rolling in our warm-up routine to prepare the muscles for exercise and static stretching in our cool-down routine to improve flexibility.

woman lifting barbel
Photo by Sven Mieke / Unsplash

Monitoring and Assessing Progress

Monitoring and assessing progress is a crucial part of our training program. We regularly test our athletes' strength, flexibility, and balance to ensure that they are making progress and to identify any areas that need improvement. This allows us to adjust their training program as needed and to provide individualized feedback and support.

In addition to physical assessments, we also monitor our athletes' mental and emotional well-being. The psychological aspect of training is often overlooked, but it is just as important as the physical aspect. We provide a supportive and positive environment where our athletes feel motivated and confident in their abilities. We also encourage open communication and provide resources for mental health support when needed.


In conclusion, while I may not claim to be an expert, I have learned enough to make a difference. Since we began focusing on improving the posterior chain in our female athletes, our ACL injury rates have decreased dramatically. As strength coaches, it is our responsibility to do everything possible to prevent injuries. Whether you choose to incorporate squats into your program is up to you, but neglecting posterior chain exercises is not an option if you aim to prevent ACL injuries.

By addressing the specific needs of female athletes, educating them on the benefits of strength training, and implementing a comprehensive and individualized training program, we can significantly reduce the risk of ACL injuries. This not only helps our athletes stay on the field but also enhances their performance and overall well-being.


  1. Adams, Erik, M.D., Ph.D., An Increased Risk of ACL Rupture in Female Athletes. Midwest Institute of Sports Medicine, Epidemiology, 2002.
  2. Griffen, Letha Y., M.D., Better Understanding of ACL Injury Prevention. The NCAA News, October 2000.
  3. Boden, Barry, M.D., Letha Griffin, M.D., Ph.D., and William Garrett Jr., M.D., Ph.D., Etiology and Prevention of Non-contact ACL Injury. The Physician and Sportsmedicine, v28, 4, April 2000.
  4. Courdes, Laura, For Women, ACL Tears All Too Common. The DePauw.com, December 1999.
  5. Mannie, Ken and Tim Wakeham, Strength Training for Female Athletes. Coach and Athletic Director, v70, 5, December 2000.
  6. Arendt, E., & Dick, R. (1995). Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. The American Journal of Sports Medicine, 23(6), 694-701.
  7. Myer, G. D., Ford, K. R., Palumbo, J. P., & Hewett, T. E. (2005). Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. The Journal of Strength & Conditioning Research, 19(1), 51-60.