The Knee Injury That Ends a Season – Why Female Netballers Face Higher Risk

A sudden pop, a buckling knee and a season changed in half a second. Anterior cruciate ligament injuries are among the most serious injuries encountered in field and court sports.

For netballers, the combination of repeated acceleration, braking, pivoting and single-leg landing creates substantial demands on the knee. Injury research consistently identifies the ankle and knee as the two major injury sites in netball. ACL injuries occur less frequently than ankle sprains, but their long rehabilitation time and potential long-term consequences make them particularly significant.

Netball requires athletes to accelerate, receive the ball, stop rapidly and establish a grounded landing foot—often while reacting to an opponent or preparing for the next pass.

Video analyses of ACL injuries in elite netball have commonly identified landing and rapid deceleration situations. Injuries have frequently occurred when the athlete lands with limited knee flexion, has most of their weight over one leg or attempts to change direction immediately after receiving the ball.

This does not mean that one particular landing position always causes an ACL injury. An ACL rupture usually results from a combination of movement demands, external forces and the athlete’s current physical capacity.

In comparable sports involving cutting, pivoting and landing, female athletes have been reported to experience ACL injuries at rates approximately two to eight times higher than male athletes. The precise difference varies according to the sport, age group, competition level and how exposure is measured.

The reasons are multifactorial and include both nonmodifiable and modifiable influences.

Nonmodifiable factors may include:

• ACL and knee-joint anatomy
• joint morphology
• ligament laxity
• age and biological maturation
• hormonal influences

Modifiable factors may include:

• lower-limb strength and power
• trunk and hip control
• landing and deceleration strategies
• exposure to cutting and pivoting tasks
• fatigue resistance
• overall training preparation

Anatomical factors cannot be altered through exercise. Strength, neuromuscular control and movement capacity, however, can be trained.

ACL injuries cannot all be prevented, but the risk can be substantially reduced.

Neuromuscular injury-prevention programs combine several elements, including:

• lower-limb strengthening
• plyometric training
• balance and coordination
• landing and deceleration technique
• cutting and change-of-direction drills
• trunk and hip control

A major meta-analysis found that neuromuscular and proprioceptive programs reduced ACL injury rates by approximately 51%. More recent clinical guidelines have reported reductions approaching two-thirds across the included studies.

These programs are not a one-off screening session or a short preseason intervention. They are most useful when introduced before the season and performed consistently as part of regular training throughout the year.

Adherence matters. A well-designed program cannot reduce injury rates when players perform it infrequently or abandon it once competition begins.

Dynamic knee valgus describes an inward movement of the knee during tasks such as landing, squatting or changing direction. It may reflect a combination of trunk position, hip control, knee loading and foot placement.

Excessive or poorly controlled movement can be addressed through appropriate strength and movement training. However, one landing test—or the appearance of knee valgus alone—cannot reliably predict which athlete will sustain an ACL injury.

Movement assessment is therefore better used to identify trainable qualities than to label an athlete as either “high risk” or “safe.”

ACL reconstruction and rehabilitation can restore a high level of function, but surgery does not guarantee a return to the athlete’s previous sport.

A systematic review involving more than 7,500 participants found that after ACL reconstruction:

• 81% returned to some form of sport
• 65% returned to their preinjury level
• 55% returned to competitive sport

Younger athletes who resume sport face a particularly substantial reinjury risk. Athletes younger than 25 who return to sport have been reported to experience a second ACL injury rate of approximately 23%, involving either the reconstructed knee or the opposite knee. Risk is especially elevated during the first two years after returning.

ACL injury also increases the likelihood of longer-term structural changes within the knee. One meta-analysis with a minimum mean follow-up of ten years found moderate-to-severe radiographic osteoarthritis in 20.3% of ACL-injured knees, compared with 4.9% of uninjured contralateral knees.

Associated meniscal and cartilage injury may further increase the long-term joint burden.

Every netball team should include a structured injury-prevention warm-up incorporating strength, landing, balance and change-of-direction exercises.

Individual assessment may also be valuable for athletes who:

• have previously injured an ACL
• are returning after another significant knee injury
• lack confidence when landing or changing direction
• demonstrate substantial strength deficits
• have had limited preparation before returning to competition
• experience recurrent knee pain, instability or swelling.

PEP program: key ACL-prevention components

A PEP program—Prevent injury and Enhance Performance—is a structured neuromuscular warm-up designed to improve the strength, balance and movement control needed for landing, stopping and changing direction.

For netballers, it should include:

• Dynamic warm-up: jogging, lateral movement and progressive court-based drills to prepare the athlete for higher-speed activity.
• Lower-limb strength: exercises targeting the hamstrings, quadriceps, calves, gluteals and trunk.
• Balance and single-leg control: progressing from stable single-leg tasks to catching, reaching and landing challenges.
• Jumping and landing technique: land softly with hip and knee flexion, maintain knee control and avoid a stiff, upright landing.
• Deceleration: practise lowering the centre of mass and controlling the final steps before stopping.
• Change of direction: use planned and reactive cutting drills while maintaining trunk and lower-limb control.
• Progressive difficulty: increase speed, unpredictability, single-leg loading and netball-specific ball skills as technique improves.
• Consistent use: perform the program regularly as part of training and match warm-ups, rather than as a short preseason block.

Netball Australia’s KNEE Program is an on-court injury-prevention warm-up for junior, recreational and elite players. It focuses specifically on take-off and landing, deceleration and change-of-direction technique, with four main program components and exercises scaled to the player’s level.

Netball Australia reports that its program is designed to improve movement efficiency and reduce knee and ankle injuries associated with landing. Its coach manual states that injury-prevention programs may reduce ACL injury risk by approximately 30–70%, although no program can eliminate all ACL injuries.