A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes

  • Jae Ho Yoo
  • Bee Oh Lim
  • Mina Ha
  • Soo Won Lee
  • Soo Jin Oh
  • Yong Seuk Lee
  • Jin Goo Kim
Knee

Abstract

Female athletes are more prone to anterior cruciate ligament (ACL) injury than their male counterparts, presumably because of anatomical, hormonal, and neuromuscular differences. Of these three, only the neuromuscular component can be modified by preventive exercise. We aimed to evaluate the effect of a neuromuscular protocol on the prevention of ACL injury by performing meta-analysis, and to identify essential factors by subgroup analysis. An extensive literature review was conducted to identify relevant studies, and eventually, only seven randomized controlled trials or prospective cohort studies were included in the analysis. The odds ratios (OR) and the confidence interval (CI) for the overall effects of training and of potentially contributory factors were estimated. The OR and the 95% CI for the overall effect of the preventive training were 0.40 and [0.27, 0.60], respectively. Subgroup analysis revealed that an age under 18, soccer rather than handball, pre- and in-season training rather than either pre- or in-season training, and the plyometrics and strengthening components rather than balancing were significant. Meta-analysis showed that pre- and in-season neuromuscular training with an emphasis on plyometrics and strengthening exercises was effective at preventing ACL injury in female athletes, especially in those under 18 years of age. Further study is required to develop a relevant training program protocol of appropriate intensity.

Keywords

Anterior cruciate ligament Female athlete Neuromuscular training Prevention program Meta-analysis 

References

  1. 1.
    Arendt E, Dick R (1995) Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med 23:694–701CrossRefPubMedGoogle Scholar
  2. 2.
    Hewett TE, Ford KR, Myer GD (2006) Anterior cruciate ligament injuries in female athletes: part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med 34:490–498CrossRefPubMedGoogle Scholar
  3. 3.
    Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, Olsen OE, Bahr R (2003) Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med 13:71–78CrossRefPubMedGoogle Scholar
  4. 4.
    Myklebust G, Maehlum S, Engebretsen L, Strand T, Solheim E (1997) Registration of cruciate ligament injuries in Norwegian top level team handball. A prospective study covering two seasons. Scand J Med Sci Sports 7:289–292CrossRefPubMedGoogle Scholar
  5. 5.
    Toth AP, Cordasco FA (2001) Anterior cruciate ligament injuries in the female athlete. J Gend Specif Med 4:25–34PubMedGoogle Scholar
  6. 6.
    Fleming BC (2003) Biomechanics of the anterior cruciate ligament. J Orthop Sports Phys Ther 33:A13–A15PubMedGoogle Scholar
  7. 7.
    Grindstaff TL, Hammill RR, Tuzson AE, Hertel J (2006) Neuromuscular control training programs and noncontact anterior cruciate ligament injury rates in female athletes: a numbers-needed-to-treat analysis. J Athl Train 41:450–456PubMedGoogle Scholar
  8. 8.
    Soderman K, Werner S, Pietila T, Engstrom B, Alfredson H (2000) Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg Sports Traumatol Arthrosc 8:356–363CrossRefPubMedGoogle Scholar
  9. 9.
    Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D’Ambrosia R (1988) Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med 16:113–122CrossRefPubMedGoogle Scholar
  10. 10.
    McNair PJ, Marshall RN, Matheson JA (1990) Important features associated with acute anterior cruciate ligament injury. N Z Med J 103:537–539PubMedGoogle Scholar
  11. 11.
    Draganich LF, Jaeger RJ, Kralj AR (1989) Coactivation of the hamstrings and quadriceps during extension of the knee. J Bone Joint Surg Am 71:1075–1081PubMedGoogle Scholar
  12. 12.
    Draganich LF, Vahey JW (1990) An in vitro study of anterior cruciate ligament strain induced by quadriceps and hamstrings forces. J Orthop Res 8:57–63CrossRefPubMedGoogle Scholar
  13. 13.
    Kirkendall DT, Garrett WE Jr (2000) The anterior cruciate ligament enigma. Injury mechanisms and prevention. Clin Orthop Relat Res 372:64–68CrossRefPubMedGoogle Scholar
  14. 14.
    Renstrom P, Arms SW, Stanwyck TS, Johnson RJ, Pope MH (1986) Strain within the anterior cruciate ligament during hamstring and quadriceps activity. Am J Sports Med 14:83–87CrossRefPubMedGoogle Scholar
  15. 15.
    Simonsen EB, Magnusson SP, Bencke J, Naesborg H, Havkrog M, Ebstrup JF, Sorensen H (2000) Can the hamstring muscles protect the anterior cruciate ligament during a side-cutting maneuver? Scand J Med Sci Sports 10:78–84CrossRefPubMedGoogle Scholar
  16. 16.
    Ford KR, Myer GD, Hewett TE (2003) Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exerc 35:1745–1750CrossRefPubMedGoogle Scholar
  17. 17.
    Ford P, Hodges NJ, Huys R, Williams AM (2006) The role of external action-effects in the execution of a soccer kick: a comparison across skill level. Motor Control 10:386–404PubMedGoogle Scholar
  18. 18.
    Kernozek TW, Torry MR, VANH H, Cowley H, Tanner S (2005) Gender differences in frontal and sagittal plane biomechanics during drop landings. Med Sci Sports Exerc 37:1003–1012PubMedGoogle Scholar
  19. 19.
    McLean SG, Huang X, Su A, Van Den Bogert AJ (2004) Sagittal plane biomechanics cannot injure the ACL during sidestep cutting. Clin Biomech (Bristol, Avon) 19:828–838CrossRefGoogle Scholar
  20. 20.
    McLean SG, Lipfert SW, van den Bogert AJ (2004) Effect of gender and defensive opponent on the biomechanics of sidestep cutting. Med Sci Sports Exerc 36:1008–1016CrossRefPubMedGoogle Scholar
  21. 21.
    Heidt RS Jr, Sweeterman LM, Carlonas RL, Traub JA, Tekulve FX (2000) Avoidance of soccer injuries with preseason conditioning. Am J Sports Med 28:659–662PubMedGoogle Scholar
  22. 22.
    Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR (1999) The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Am J Sports Med 27:699–706PubMedGoogle Scholar
  23. 23.
    Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, Kirkendall DT, Garrett W Jr (2005) Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 33:1003–1010CrossRefPubMedGoogle Scholar
  24. 24.
    Petersen W, Braun C, Bock W, Schmidt K, Weimann A, Drescher W, Eiling E, Stange R, Fuchs T, Hedderich J, Zantop T (2005) A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg 125:614–621CrossRefPubMedGoogle Scholar
  25. 25.
    Pfeiffer RP, Shea KG, Roberts D, Grandstrand S, Bond L (2006) Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. J Bone Joint Surg Am 88:1769–1774CrossRefPubMedGoogle Scholar
  26. 26.
    Hewett TE, Myer GD, Ford KR (2006) Anterior cruciate ligament injuries in female athletes: part 1, mechanisms and risk factors. Am J Sports Med 34:299–311CrossRefPubMedGoogle Scholar
  27. 27.
    Begg CB, Mazumdar M (1994) Operating characteristics of a rank correlation test for publication bias. Biometrics 50:1088–1101CrossRefPubMedGoogle Scholar
  28. 28.
    Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629–634PubMedGoogle Scholar
  29. 29.
    Macaskill P, Walter SD, Irwig L (2001) A comparison of methods to detect publication bias in meta-analysis. Stat Med 20:641–654CrossRefPubMedGoogle Scholar
  30. 30.
    Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR (1994) Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med 22:632–644CrossRefPubMedGoogle Scholar
  31. 31.
    Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, Garrick JG, Hewett TE, Huston L, Ireland ML, Johnson RJ, Kibler WB, Lephart S, Lewis JL, Lindenfeld TN, Mandelbaum BR, Marchak P, Teitz CC, Wojtys EM (2000) Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg 8:141–150PubMedGoogle Scholar
  32. 32.
    Noyes FR, Mooar PA, Matthews DS, Butler DL (1983) The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am 65:154–162PubMedGoogle Scholar
  33. 33.
    Lachin JM (2000) Statistical considerations in the intent-to-treat principle. Control Clin Trials 21:167–189CrossRefPubMedGoogle Scholar
  34. 34.
    Leandro G (2004) Meta-analysis in medical research. In: The handbook for the understanding and practice of meta-analysis. Blackwell, Oxford, pp 98Google Scholar
  35. 35.
    Hewett TE, Myer GD, Ford KR, Slauterbeck JR (2007) Dynamic neuromuscular analysis training for preventing anterior cruciate ligament injury in female athletes. Instr Course Lect 56:397–406PubMedGoogle Scholar
  36. 36.
    Myer GD, Ford KR, Hewett TE (2004) Methodological approaches and rationale for training to prevent anterior cruciate ligament injuries in female athletes. Scand J Med Sci Sports 14:275–285CrossRefPubMedGoogle Scholar
  37. 37.
    Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A (1996) Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 4:19–21CrossRefPubMedGoogle Scholar
  38. 38.
    Heitkamp HC, Horstmann T, Mayer F, Weller J, Dickhuth HH (2001) Gain in strength and muscular balance after balance training. Int J Sports Med 22:285–290CrossRefPubMedGoogle Scholar
  39. 39.
    Holm I, Fosdahl MA, Friis A, Risberg MA, Myklebust G, Steen H (2004) Effect of neuromuscular training on proprioception, balance, muscle strength, and lower limb function in female team handball players. Clin J Sport Med 14:88–94CrossRefPubMedGoogle Scholar
  40. 40.
    Paterno MV, Myer GD, Ford KR, Hewett TE (2004) Neuromuscular training improves single-limb stability in young female athletes. J Orthop Sports Phys Ther 34:305–316PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Jae Ho Yoo
    • 1
  • Bee Oh Lim
    • 2
  • Mina Ha
    • 3
  • Soo Won Lee
    • 4
  • Soo Jin Oh
    • 5
  • Yong Seuk Lee
    • 6
  • Jin Goo Kim
    • 5
  1. 1.Department of Orthopaedic SurgerySoonchunhyang University HospitalBucheonSouth Korea
  2. 2.Sports Science InstituteSeoul National UniversitySeoulSouth Korea
  3. 3.Department of Preventive MedicineDankook University College of MedicineCheonanSouth Korea
  4. 4.Department of Orthopaedic SurgerySunlin HospitalPohangSouth Korea
  5. 5.Orthopedic Department, Sports Medical Center, Seoul Paik HospitalInje UniversitySeoulKorea
  6. 6.Department of Orthopedic SurgeryKorea University Ansan HospitalSeoulSouth Korea

Personalised recommendations