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PEP Warm-Up Exercises Reduce Female ACL Injury Risk

Following a specially-designed program of warm-up exercises (PEP program) significantly improves muscle strength and flexibility and biomechanical imbalances blamed for the epidemic of anterior cruciate injuries among female athletes, a 2009 study says. 

Researchers in South Korea found that female high school basketball players following a slightly modified version of the Prevent Injury and Enhance Performance program over an 8-week period had better strength, flexibility and biomechanics compared with a control group not following the program. The findings are reported in the September 2009 issue of the American Journal of Sports Medicine. 1

Increased compliance

The study noted that one of the advantages of the PEP program over other injury prevention programs developed in recent years to reduce the risk of ACL injuries in female athletes is that it takes only 15minutes during warm up and 5 minutes during warm/cool down to complete and can be integrated into a team's pre-practice or game routine. This makes implementation feasible and practical, even for younger populations, and increases compliance.

The study was "exactly what we wanted to see," said Holly Silvers, MTP, ACL Prevention Project Coordinator at the non-profit Santa Monica Orthopedic and Sports Medicine Research Foundation, which developed the popular PEP program a decade ago. It is"valuable because it shows that the PEP is not only practical, costeffective, and uses time efficiently - all factors that affect compliance -  but that it works." 

The advantage of PEP, Silvers noted, is that, because it is a warm-up program, it essentially "kill two birds with one stone: not only reducing the specific ACL injury risk to female athletes but the more general risk of injury resulting from inadequate warm-up before sports."  

Season-long program urged

The athletes involved in the Korean study followed the program for 8 weeks, and the authors speculated that a minimum of 4 to 6 weeks was needed to obtain measurable benefits in ACL injury reduction. Silvers,however, recommends that the PEP exercise regimen be started in the pre-season and continue over the course of the entire season.  "We are finding in our studies that the benefits of PEP, not just in reducing non-contact ACL injuries to which female athletes are particularly susceptible, but in those resulting from player-to-player contact, is particularly significant in the second half of a season."


           PEP (Prevent Injury and Enhance Performance) Training Program (Overview)2
 Exercise  Distance  Repetitions/Elapsed Time
1. Warm-Up     

Jog line to line (cone to cone)


Soccer: End line to midfield and back

Basketball: 100 yards

Elapsed time: 0 - .5 minute

Shuttle Run (side to side)


Soccer: End line to midfield and back

Basketball: 100 yards

Elapsed time: .5 to 1 minute

Backward Running

Soccer: sideline to sideline

Basketball: 100 yards

Elapsed Time: 1 - 1.5 minutes
2. Stretching
Calf stretch   30 seconds x 2 reps; Elapsed Time: 1.5 to 2.5 minutes
Quadriceps stretch   30 seconds x 2 reps; Elapsed Time: 2.5 to 3.5 minutes
Figure Four Hamstring stretch
  30 sec x 2 reps; Elapsed time: 3.5 to 4.5 minutes
Inner thigh stretch
  20 sec x 3 reps; Elapsed time: 4.5 to 5.5 minutes
Hip flexor stretch   30 sec x 2 reps; Elapsed time: 5.5 to 6.5 minutes
3. Strengthening
Walking Lunges
  3 sets x 10 reps; Elapsed time: 6.5 to 7.5 minutes
Russian Hamstring
  3 sets x 10 reps; Elapsed time: 7.5 to 8.5 minutes
Single Toe Raises
  2 sets x 30 reps; Elapsed time: 8.5 to 9.5 minutes
 4. Plyometrics
Lateral hops over cone
  20 reps; Elapsed time: 9.5 to 10 minutes
Forward/backward hops over cone   20 reps; Elapsed time: 10 to 10.5 minutes
Single-leg hops over cone
  20 reps; Elapsed time: 10.5 to 11 minutes
Vertical jumps with headers
  20 reps; Elapsed time: 11 to 11.5 minutes
Scissors jump
  20 reps; Elapsed time: 11.5 to 12 minutes
5. Agilities    
Shuttle run with forward/backward running
  Elapsed time: 12 to 13 minutes
Diagonal runs
  Elapsed time: 13 to 14 minutes

Bounding runs

44 yards Elapsed time: 14 to 15
 6. Alternative exercises - Warm down and Cool Down
Bridging with alternating hip flexion
  30 reps on each side
Abdominal crunches
  30 reps x 2 reps
Single and double knee to chest (supine)
  30 sec x 2 reps
Figure Four Piriformis stretch - supine   30 sec x 2 reps
Seated butterfly stretch-seated
  30 sec x 2 reps


1. Lim, Bee-Oh, et al. Effects of Sports Injury Prevention Training on the Biomechanical Risk Factors of Anterior Cruciate Ligament Injury in High School Female Basketball Players.  Am J Sports Med. 2009: 37(9):1728-1734.

2. To download a free copy of the full PEP program, click here.

Created September 22, 2009