Sports Medicine

, Volume 44, Issue 4, pp 551–562 | Cite as

Dosage Effects of Neuromuscular Training Intervention to Reduce Anterior Cruciate Ligament Injuries in Female Athletes: Meta- and Sub-Group Analyses

  • Dai Sugimoto
  • Gregory D. Myer
  • Kim D. Barber Foss
  • Timothy E. Hewett
Systematic Review



Although a series of meta-analyses demonstrated neuromuscular training (NMT) is an effective intervention to reduce anterior cruciate ligament (ACL) injury in female athletes, the potential existence of a dosage effect remains unknown.


Our objective was to systematically review previously published clinical trials and evaluate potential dosage effects of NMT for ACL injury reduction in female athletes.


This study took the form of a meta- and sub-group analysis.


The keywords ‘knee’, ‘anterior cruciate ligament’, ‘ACL’, ‘prospective’, ‘neuromuscular’, ‘training’, ‘female’, and ‘prevention’ were utilized in PubMed and EBSCO host for studies published between 1995 and May 2012.


Inclusion criteria set for studies in the current analysis were (i) recruited female athletes as subjects, (ii) documented the number of ACL injuries, (iii) employed an NMT intervention aimed to reduce ACL injuries, (iv) had a control group, (v) used a prospective control trial design, and (vi) provided NMT session duration and frequency information.

Main outcome measures

The number of ACL injuries and female athletes in each group (control and intervention) were compared based on duration, frequency, and volume of NMT via odds ratios (ORs).


A total of 14 studies were reviewed. Analyses that compared the number of ACL injuries with short versus long NMT duration showed greater ACL injury reduction in female athletes who were in the long NMT duration group (OR 0.35, 95 % CI 0.23–0.53, p = 0.001) than in those in the short NMT duration group (OR 0.61, 95 % CI 0.41–0.90, p = 0.013). Analyses that compared single versus multi NMT frequency indicated greater ACL injury reduction in multi NMT frequency (OR 0.35, 95 % CI 0.23–0.53, p = 0.001) compared with single NMT frequency (OR 0.62, 95 % CI 0.41–0.94, p = 0.024). Combining the duration and frequency of NMT programs, an inverse dose-response association emerged among low (OR 0.66, 95 % CI 0.43–0.99, p = 0.045), moderate (OR 0.46, 95 % CI 0.21–1.03, p = 0.059), and high (OR 0.32, 95 % CI 0.19–0.52, p = 0.001) NMT volume categories.


The inverse dose-response association observed in the subgroup analysis suggests that the higher the NMT volume, the greater the prophylactic effectiveness of the NMT program and increased benefit in ACL injury reduction among female athletes.


  1. 1.
    National Federation of State High School Associations. 2010 High School Participation Survey. Indianapolis, Ind: National Federation of State High School Associations; 2002.Google Scholar
  2. 2.
    Messina DF, Farney WC, DeLee JC. The incidence of injury in Texas high school basketball. A prospective study among male and female athletes. Am J Sports Med. 1999;27:294–9.PubMedGoogle Scholar
  3. 3.
    Gomez E, DeLee JC, Farney WC. Incidence of injury in Texas girls’ high school basketball. Am J Sports Med. 1996;24:684–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Toth AP, Cordasco FA. Anterior cruciate ligament injuries in the female athlete. J Gend Specif Med. 2001;4:25–34.PubMedGoogle Scholar
  5. 5.
    Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train. 1999;34:86–92.PubMedCentralPubMedGoogle Scholar
  6. 6.
    Griffin LY, Albohm MJ, Arendt EA, et al. Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting, January 2005. Am J Sports Med. 2006;34:1512–32.PubMedCrossRefGoogle Scholar
  7. 7.
    Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female athletes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med. 2006;34:490–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33:492–501.PubMedCrossRefGoogle Scholar
  9. 9.
    Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism. Br J Sports Med. 2009;43:417–22.PubMedCrossRefGoogle Scholar
  10. 10.
    Zazulak BT, Hewett TE, Reeves NP, et al. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med. 2007;35:1123–30.PubMedCrossRefGoogle Scholar
  11. 11.
    de Marche Baldon R, Lobato DF, Carvalho LP, et al. Effect of functional stabilization training on lower limb biomechanics in women. Med Sci Sports Exerc. 2012;44:135–142.Google Scholar
  12. 12.
    Lephart SM, Abt JP, Ferris CM, et al. Neuromuscular and biomechanical characteristic changes in high school athletes: a plyometric versus basic resistance program. Br J Sports Med. 2005;39:932–8.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Myer GD, Ford KR, Brent JL, et al. Differential neuromuscular training effects on ACL injury risk factors in “high-risk” versus “low-risk” athletes. BMC Musculoskelet Disord. 2007;8:39.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Myer GD, Brent JL, Ford KR, et al. A pilot study to determine the effect of trunk and hip focused neuromuscular training on hip and knee isokinetic strength. Br J Sports Med. 2008;42:614–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42:311–9.PubMedCentralPubMedGoogle Scholar
  16. 16.
    Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27:699–706.PubMedGoogle Scholar
  17. 17.
    Kiani A, Hellquist E, Ahlqvist K, et al. Prevention of soccer-related knee injuries in teenaged girls. Arch Intern Med. 2010;170:43–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Mandelbaum BR, Silvers HJ, Watanabe DS, et al. 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. 2005;33:1003–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Soderman K, Werner S, Pietila T, et al. 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 off J ESSKA. 2000;8:356–63.CrossRefGoogle Scholar
  20. 20.
    Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. J Bone Joint Surg Am. 2006;88:1769–74.PubMedCrossRefGoogle Scholar
  21. 21.
    Myer GD, Sugimoto D, Thomas S, et al. The influence of age on the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a meta-analysis. Am J Sports Med. 2012;41:216–24.PubMedCentralPubMedGoogle Scholar
  22. 22.
    Gagnier JJ, Morgenstern H, Chess L. Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis. Am J Sports Med. 2013;41:1952–62.PubMedCrossRefGoogle Scholar
  23. 23.
    Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training programs. J Bone Joint Surg Am. 2012;94:769–76.PubMedCrossRefGoogle Scholar
  24. 24.
    Nikander R, Malkia E, Parkkari J, et al. Dose-response relationship of specific training to reduce chronic neck pain and disability. Med Sci Sports Exerc. 2006;38:2068–74.PubMedCrossRefGoogle Scholar
  25. 25.
    LaBella CR, Huxford MR, Grissom J, et al. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. Arch Pediatr Adolesc Med. 2011;165:1033–40.PubMedCrossRefGoogle Scholar
  26. 26.
    Myklebust G, Engebretsen L, Braekken IH, et al. Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med. 2003;13:71–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Steffen K, Myklebust G, Olsen OE, et al. Preventing injuries in female youth football—a cluster-randomized controlled trial. Scand J Med Sci Sports. 2008;18:605–14.PubMedCrossRefGoogle Scholar
  28. 28.
    Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004;17:59–67.PubMedCrossRefGoogle Scholar
  29. 29.
    Heidt RS Jr, Sweeterman LM, Carlonas RL, et al. Avoidance of soccer injuries with preseason conditioning. Am J Sports Med. 2000;28:659–62.PubMedGoogle Scholar
  30. 30.
    Olsen OE, Myklebust G, Engebretsen L, et al. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ (Clin Res Ed). 2005;330(7489):449.CrossRefGoogle Scholar
  31. 31.
    Petersen W, Braun C, Bock W, et al. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg. 2005;125:614–21.PubMedCrossRefGoogle Scholar
  32. 32.
    Gilchrist J, Mandelbaum BR, Melancon H, et al. A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med. 2008;36:1476–83.PubMedCrossRefGoogle Scholar
  33. 33.
    Pasanen K, Parkkari J, Pasanen M, et al. Effect of a neuromuscular warm-up programme on muscle power, balance, speed and agility: a randomised controlled study. Br J Sports Med. 2009;43:1073–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Walden M, Atroshi I, Magnusson H, et al. Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial. BMJ (Clin Res Ed). 2012;344:e3042.Google Scholar
  35. 35.
    Yoo JH, Lim BO, Ha M, et al. A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes. Knee Surg Sports Traumatol Arthr. 2010;18:824–30.CrossRefGoogle Scholar
  36. 36.
    Vila-Cha C, Falla D, Farina D. Motor unit behavior during submaximal contractions following six weeks of either endurance or strength training. J Appl Physiol. 2010;109:1455–66.PubMedCrossRefGoogle Scholar
  37. 37.
    Chilibeck PD, Calder AW, Sale DG, et al. A comparison of strength and muscle mass increases during resistance training in young women. Eur J Appl Physiol Occup Physiol. 1998;77:170–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. Am J Sports Med. 2005;33:524–30.PubMedCrossRefGoogle Scholar
  39. 39.
    Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med. 1995;23:694–701.PubMedCrossRefGoogle Scholar
  40. 40.
    Boden BP, Dean GS, Feagin JA Jr, et al. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000;23:573–8.PubMedGoogle Scholar
  41. 41.
    Myklebust G, Maehlum S, Engebretsen L, et al. Registration of cruciate ligament injuries in Norwegian top level team handball. A prospective study covering two seasons. Scand J Med Sci Sports. 1997;7:289–92.PubMedCrossRefGoogle Scholar
  42. 42.
    Walden M, Hagglund M, Werner J, et al. The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc. 2011;19:3–10.PubMedCrossRefGoogle Scholar
  43. 43.
    Li RT, Lorenz S, Xu Y, et al. Predictors of radiographic knee osteoarthritis after anterior cruciate ligament reconstruction. Am J Sports Med. 2011;39:2595–603.PubMedCrossRefGoogle Scholar
  44. 44.
    Lohmander LS, Ostenberg A, Englund M, et al. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthr Rheum. 2004;50:3145–52.CrossRefGoogle Scholar
  45. 45.
    Oiestad BE, Holm I, Aune AK, et al. Knee function and prevalence of knee osteoarthritis after anterior cruciate ligament reconstruction: a prospective study with 10 to 15 years of follow-up. Am J Sports Med. 2010;38:2201–10.PubMedCrossRefGoogle Scholar
  46. 46.
    Oiestad BE, Holm I, Engebretsen L, et al. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10–15 years after anterior cruciate ligament reconstruction. Br J Sports Med. 2011;45:583–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Soligard T, Nilstad A, Steffen K, et al. Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br J Sports Med. 2010;44:787–93.PubMedCrossRefGoogle Scholar
  48. 48.
    Sugimoto D, Myer GD, Bush HM, et al. Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. J Athl Train. 2012;47:714–23.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2013

Authors and Affiliations

  • Dai Sugimoto
    • 1
    • 2
    • 3
    • 4
    • 5
  • Gregory D. Myer
    • 1
    • 3
    • 4
    • 6
    • 7
  • Kim D. Barber Foss
    • 3
    • 4
  • Timothy E. Hewett
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
  1. 1.The Micheli Center for Sports Injury PreventionWalthamUSA
  2. 2.Division of Sports Medicine, Department of OrthopedicsBoston Children’s HospitalBostonUSA
  3. 3.Cincinnati Children’s Hospital Medical CenterCincinnatiUSA
  4. 4.Sports Medicine Biodynamics Center and Human Performance LaboratoryCincinnatiUSA
  5. 5.College of Health ScienceUniversity of KentuckyLexingtonUSA
  6. 6.Department of Pediatrics, College of MedicineUniversity of CincinnatiCincinnatiUSA
  7. 7.Athletic Training Division, School of Allied Medical ProfessionsThe Ohio State UniversityColumbusUSA
  8. 8.Departments of Orthopaedic Surgery, Biomedical Engineering and Rehabilitation SciencesUniversity of CincinnatiCincinnatiUSA
  9. 9.Sports Health & Performance InstituteThe Ohio State UniversityColumbusUSA

Personalised recommendations