ACL injuries in handball: prevention and injury prevention training

The cruciate ligament prevents the lower leg bone from sliding forward relative to the thigh bone, and it limits inward rotation of the lower leg. More than 90 percent of cruciate ligament injuries involve the anterior ligament [1]. The injury is most common in sports where the shoe grips the floor well and the knee rotates with the foot fixed, such as handball, football, basketball and alpine skiing [1][5].

NHI states that more than 4,000 new cases occur in Norway each year, and that about 70 percent of the injuries happen during sport. The age group 15 to 45 has the highest risk, and girls and young women are affected slightly more often than boys and men [1].

The incidence is clearly higher in women than in men in contact sports [5]. It is discussed whether anatomical and hormonal differences explain this, but there is no conclusion. Women more often have increased inward rotation of the hip, knees collapsing inward and greater torque in the knee on landing [5].

With an acute injury it is usually noticed immediately, often with a pop and instant pain. The knee often swells within a few hours, and the pain is often so severe that the knee is difficult to move or put weight on [1].

The injury is often evident on a simple clinical examination. In the acute phase, pain and swelling can make the examination difficult, and it may then be repeated after a few days or weeks. MRI confirms the diagnosis and shows the extent of the injury, and X-ray is used to rule out a fracture [1]. The injury often occurs together with damage to the meniscus, the collateral ligament or the joint capsule [1].

NHI describes that warm-ups with balance, coordination and strength exercises can reduce knee injuries, and that in some studies anterior cruciate ligament injuries were halved [1].

A systematic review with meta-analysis included 18 studies and 27,231 female participants, of whom 347 sustained an ACL injury. Neuromuscular training was associated with lower risk: from about 1 in 54 to 1 in 111 (OR 0.51). The effect was larger in programmes for middle and high school students than for college students and professional athletes [2].

The Norwegian study of female handball players in divisions I to III followed the teams over three seasons and compared with a control season. The reduction in the number of ACL injuries was not statistically significant for all divisions combined. The study was not randomised, and only 26 and 29 percent of the teams followed the programme as the criteria required in the two seasons. The authors consider that ACL injuries can be prevented with specific neuromuscular training, but that the effect depends on good adherence [3].

The programme in the Norwegian handball study consisted of three exercise sets with floor exercises, balance mats and balance boards, with five progression levels over five weeks. The exercises emphasised balance, knee control, landing and take-off, with the knee kept above the toes. A session took about 15 minutes. The programme was done three times a week for five to seven weeks in the start-up period, and then once a week during the season [3].

In the meta-analysis the programmes varied. The average session lasted about 24 minutes, and there were on average 2.5 sessions a week. Programmes with exercises for landing stability and lower body strength in every session had a better preventive effect, and all programmes included some form of instructor training. The authors mention Nordic hamstrings, lunges and calf raises as examples of strength exercises [2].

A Norwegian randomised study of 1,837 players aged 15 to 17 used a warm-up programme of 15 to 20 minutes at the start of every training session, the first 15 sessions in a row and then once a week. Fewer players in the intervention group had acute knee or ankle injuries (4.6 percent versus 8.6 percent), and adherence was 87 percent [4].

Not everyone needs surgery. After the acute phase, gradual rehabilitation is used to maintain mobility and strength. Surgery is the only way to repair a torn cruciate ligament, and the choice depends on the demands placed on the knee. Rehabilitation often takes about a year [1]. In children, surgery is usually postponed until they are fully grown [1].

If the knee swells quickly and is difficult to put weight on after a twist or a landing, it may be an ACL injury. The diagnosis is made by clinical examination and possibly MRI [1], and the injury should be assessed by a health professional. A knee that repeatedly gives way can be a sign of an injury that has not been clarified [1].

A physiotherapist can examine the function of the knee, go through previous injuries and loading, and together with you plan a training programme for balance, landing and strength. This can be relevant both before an injury and after an assessment or surgery. Read more about physiotherapy.

Can ACL injuries be prevented in handball?

Studies suggest fewer ACL injuries with neuromuscular training [2]. In the Norwegian handball study the reduction was not statistically significant overall, and the effect appeared to be linked to how well the teams carried out the programme [3].

Which exercises are part of an injury prevention programme?

The programmes described in the sources contain exercises for balance, knee control, landing and take-off, and strength exercises for the lower body [2][3].

How often should the team do the exercises?

It varies between programmes. The Norwegian handball study used three sessions a week for five to seven weeks, then one a week during the season [3]. The meta-analysis found an average of 2.5 sessions a week [2].

How do you notice an ACL injury?

The injury is often noticed immediately, with a pop and instant pain. The knee usually swells within a few hours and is difficult to put weight on [1].

Does an ACL injury need surgery?

Not everyone needs surgery. The choice depends on the demands placed on the knee, for example at work or in leisure time [1].

Knee pain without an acute injury can have other causes, for example jumper's knee or runner's knee. You can find more articles in the overview of articles.

This article was written by Dr.Dropin Fysikalske and is based on the sources listed below. It gives general information and does not replace an examination by a healthcare professional.

The websites were accessed and read on 22 October 2026.

1. Fremre korsbåndskade (Anterior cruciate ligament injury). NHI.no. Last updated 6 December 2024. Link

2. Petushek EJ, Sugimoto D, Stoolmiller M, Smith G, Myer GD. Evidence-based best-practice guidelines for preventing anterior cruciate ligament injuries in young female athletes: a systematic review and meta-analysis. Am J Sports Med. 2019;47(7):1744-1753. Link

3. Myklebust G, Engebretsen L, Brækken IH, Skjølberg A, Olsen OE, Bahr R. Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med. 2003;13(2):71-78. Link

4. Oppvarming forebygger idrettsskader blant unge (Warm-up prevents sports injuries among young people). Tidsskrift for Den norske legeforening. February 2005. Link

5. Johannessen T. Fremre korsbåndskader hos kvinnelige idrettsutøvere (Anterior cruciate ligament injuries in female athletes). NHI.no, Fra vitenskapen. 5 August 2024. Link