It's a Balancing Act.
How Balance Training Can Save 60% of ACLs
Let's be honest, hearing the words "ACL injury" can send a shiver down the spine of any athlete, coach, or physio.
It’s that all-too-common injury that can halt a promising season, demand gruelling rehab, and cast a long shadow over an athlete's career.
For years, we've been searching for the most effective ways to combat this, and I'm thrilled to share that some fresh, compelling research is shining a powerful spotlight on a key weapon in our arsenal.
Just imagine being able to tell your athletes or yourself that there’s a proven approach to significantly cut down the risk of this dreaded injury.
Well, a brand new, comprehensive systematic review and meta-analysis (Su et al., 2025) has just dropped, and its findings are too important not to shout about.
It zeroes in on the power of something fundamental: balance training.
The Lowdown on the Latest Evidence
This isn't just another small RCT or cohort study.
Su and colleagues (2025) went big, conducting a meta-analysis that sifted through data from eight different studies.
We're talking a massive cohort of 20,336 soccer players and over 1.5 million hours of on-field exposure.
This kind of large-scale analysis gives us real confidence in the conclusions drawn.
They set out to answer a crucial question…
“How much impact do injury risk reduction programs, specifically those armed with balance training exercises, actually have on reducing ACL injuries among soccer players?”
What Did They Find?
The headline news from this powerhouse study is nothing short of spectacular.
The analysis revealed that soccer players who participated in injury risk reduction programs incorporating balance training exercises saw their incidence of ACL injuries plummet by a staggering 58% per 1,000 exposure hours, compared to players who weren't involved in such programs (Injury Risk Ratio [IRR] 0.42).
Yes, you read that right – a potential 58% drop!
This isn't just a marginal gain; it's a massive leap forward in our ability to protect players and keep them performing at their best.
But wait. There’s more…
Beyond that jaw-dropping overall reduction, the study by Su et al. (2025) unearthed some other vital nuggets of information:
Greater Protection for Female Athletes: The research indicates that these programs might be even more beneficial for female soccer players. They experienced a phenomenal 61% reduction in ACL injury rates (IRR 0.39), while male participants still saw an excellent 50% reduction (IRR 0.50). The authors point towards differences in baseline neuromuscular mechanics and strength profiles as potential reasons (Su et al., 2025). This is a critical insight, especially given the higher ACL injury rates typically seen in female athletes.
The "Dose" is Crucial: Frequency and Duration Really Matter:
Frequency: Stepping up the commitment pays off. Programs with three or more training sessions per week achieved a 57% reduction in ACL injury rates (IRR 0.43). While less frequent programs (fewer than three sessions) still provided a solid 43% reduction (IRR 0.57), more is clearly better here.
Duration: Time invested per week also counts. Interventions lasting 20 minutes or more weekly resulted in a 50% decrease in ACL injury rates (IRR 0.50). This edged out the 46% reduction (IRR 0.54) seen with shorter weekly durations (less than 20 minutes).
This clearly points to a dose-response relationship. Consistent, dedicated engagement with these exercises amplifies their protective power.
But 20mins Warm-Up Each Session? I’ve Only Got 1hr…
Now, we all know that one of the biggest hurdles with any prevention program, including comprehensive ones like the FIFA 11+ (which is rich in the balance exercises Su et al. (2025) highlighted), is often the time commitment and ensuring consistent compliance.
Finding that dedicated 20+ minutes for the full program before every training session can be a real challenge for busy teams and athletes.
This is where some other fantastic research offers practical, evidence-based solutions.
A study by Whalan and colleagues (2019) looked at semi-professional soccer players. They investigated what happened if Part 2 of the 11+ program (the strength-focused exercises like plyometrics, and core work) was rescheduled to after the main training session, instead of before.
The results were compelling: not only did this switch maintain the program's effectiveness in reducing overall injury incidence, but it actually improved player compliance and led to a significant reduction in severe time-loss injuries (those over 28 days) and the total number of days lost to injury!
Building on this, Veith and colleagues (2021) explored whether performing Part 2 of the 11+ at home three times a week would be a viable option for elite male academy players.
The great news?
It was!
They found similar improvements in performance measures like eccentric hamstring strength and jump height when compared to doing those exercises at training. Critically, there was no increase in injury risk.
What these valuable studies tell us is that while the components of well-structured injury prevention programs are vital, we have some evidence-backed flexibility in how and when we schedule certain parts, particularly the strength elements. This is a potential game-changer for adherence, helping ensure athletes get the necessary dose of these protective exercises even if the full program can't always be slotted into one pre-training block.
Actionable Tips from The ACL Hub
So, how do we translate this exciting research into real-world wins?
For Health Professionals (Physiotherapists, Coaches, S&C Staff):
If balance training isn't already a cornerstone of your ACL injury risk reduction programs, this research screams that it needs to be.
Acknowledge the increased vulnerability and the enhanced protective effect for female athletes. Your programs should be finely tuned to their specific needs.
The evidence supports aiming for at least three sessions a week, with a warm-up that includes balance work for a cumulative 20 minutes per session, to get the biggest bang for your buck.
Struggling to find 20 minutes? You know that slow, steady jog around the oval that you’re currently doing, followed by sitting on the ground doing some half-assed static stretches? Yeah. We need to replace that with this kind of stuff.
Arm your athletes, fellow coaches, and support staff with this knowledge. Understanding the 'why' dramatically improves adherence and effort.
Remember, balance training often shines brightest as part of a well-rounded neuromuscular training program (think FIFA 11+ which includes strength, plyometrics, agility). This study reinforces just how vital that balance piece is.
For Patients and Athletes:
These aren't just tick-box exercises. Truly engage with tasks that challenge your balance, proprioception (your body's GPS), and control. They are your knee's best friends.
Sporadic efforts won't cut it. The research underscores that regular, consistent training makes the real difference. Stick to the plan your physio or coach sets out.
Effective balance training needs to be progressively challenging. If it feels like a walk in the park, it's probably time to level up – discuss this with your health professional.
Don't wait for an injury to take this seriously. These exercises are your proactive shield.
If you're on a team, ask about the injury prevention strategies in place. Your long-term health is worth the conversation.
If you’re a bit lost and still don’t know what exercises to do, how to do them effectively and how best incorporate them into your warm-ups before training and games (hello 3x per week!), here is a direct link to the FIFA 11+ program to give you evidence-backed options for balance exercises to incorporate with your athletes.
Also here is another Football specific injury prevention resource put together by the medical Staff at Football Australia called the Perform +
Final Thoughts
The findings from Su et al. (2025) are a powerful reminder that we're continuously improving our understanding and our ability to protect athletes.
This meta-analysis delivers a clear, evidence-backed message: focused injury risk reduction programs, with a strong emphasis on balance training, can dramatically reduce the scourge of ACL injuries in soccer.
Let's champion these strategies, implement them diligently, and work together to ensure more players enjoy long, healthy, and successful careers on the pitch.
Train smart, stay strong!
Mick Hughes (Sports & Exercise Physiotherapist)
Founder, The ACL Hub
References:
Su, W., Wang, J., Ying, Y., Lu, B., Liu, H., Zhou, Z., Liu, C., & Yun, H. (2025). Injury risk reduction programs including balance training reduce the incidence of anterior cruciate ligament injuries in soccer players: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research, 20(1), 248. https://doi.org/10.1186/s13018-025-05639-w
Veith S, Whalan M, Williams S, Colyer S, Sampson JA. Part 2 of the 11+ as an effective home-based exercise programme in elite academy football (soccer) players: a one-club matched-paired randomised controlled trial. Sci Med Footb. 2021 Nov;5(4):339-346. doi: 10.1080/24733938.2021.1874616. Epub 2021 Jan 25. PMID: 35077306.
Whalan M, Lovell R, Steele JR, Sampson JA. Rescheduling Part 2 of the 11+ reduces injury burden and increases compliance in semi-professional football. Scand J Med Sci Sports. 2019 Dec;29(12):1941-1951. doi: 10.1111/sms.13532. Epub 2019 Aug 22. PMID: 31376194.
I'll put my hand up: Over the years I started to just incorporate it into SL hinge and squat tasks rather than focus on it as an isolated task.
I'm bringing it back, Baby! 👍🫡