Skip to main content
SpringerLink
Log in

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

  • Systematic Review
  • Published:
Sports Medicine Aims and scope Submit manuscript

Abstract

Background

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.

Objective

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

Design

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

Setting

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.

Participants

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).

Results

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.

Conclusions

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. National Federation of State High School Associations. 2010 High School Participation Survey. Indianapolis, Ind: National Federation of State High School Associations; 2002.

  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.

    PubMed  CAS  Google Scholar 

  3. Gomez E, DeLee JC, Farney WC. Incidence of injury in Texas girls’ high school basketball. Am J Sports Med. 1996;24:684–7.

    Article  PubMed  CAS  Google Scholar 

  4. Toth AP, Cordasco FA. Anterior cruciate ligament injuries in the female athlete. J Gend Specif Med. 2001;4:25–34.

    PubMed  CAS  Google Scholar 

  5. Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train. 1999;34:86–92.

    PubMed Central  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

  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.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed Central  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed Central  PubMed  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    PubMed Central  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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. 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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  40. Boden BP, Dean GS, Feagin JA Jr, et al. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000;23:573–8.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

The authors have no potential conflicts of interest that are directly relevant to the content of this study. The authors would like to acknowledge funding support from the National Institutes of Health/NIAMS Grants R01-AR049735, R01-AR055563, and R01-AR056259. We would also like to thank the Sports Medicine Biodynamics teams at Cincinnati Children’s, the University of Kentucky, and The Ohio State University for all their helpful input and support.

Author information

Authors and Affiliations

  1. The Micheli Center for Sports Injury Prevention, Waltham, MA, USA

    Dai Sugimoto & Gregory D. Myer

  2. Division of Sports Medicine, Department of Orthopedics, Boston Children’s Hospital, Boston, MA, USA

    Dai Sugimoto

  3. Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 10001, Cincinnati, OH, 45229, USA

    Dai Sugimoto, Gregory D. Myer, Kim D. Barber Foss & Timothy E. Hewett

  4. Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati, OH, USA

    Dai Sugimoto, Gregory D. Myer, Kim D. Barber Foss & Timothy E. Hewett

  5. College of Health Science, University of Kentucky, Lexington, KY, USA

    Dai Sugimoto & Timothy E. Hewett

  6. Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA

    Gregory D. Myer & Timothy E. Hewett

  7. Athletic Training Division, School of Allied Medical Professions, The Ohio State University, Columbus, OH, USA

    Gregory D. Myer & Timothy E. Hewett

  8. Departments of Orthopaedic Surgery, Biomedical Engineering and Rehabilitation Sciences, University of Cincinnati, Cincinnati, OH, USA

    Timothy E. Hewett

  9. Sports Health & Performance Institute, The Ohio State University, Columbus, OH, USA

    Timothy E. Hewett

Authors
  1. Dai Sugimoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gregory D. Myer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kim D. Barber Foss
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Timothy E. Hewett
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Timothy E. Hewett.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sugimoto, D., Myer, G.D., Barber Foss, K.D. et al. Dosage Effects of Neuromuscular Training Intervention to Reduce Anterior Cruciate Ligament Injuries in Female Athletes: Meta- and Sub-Group Analyses. Sports Med 44, 551–562 (2014). https://doi.org/10.1007/s40279-013-0135-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40279-013-0135-9

Keywords

Search

Navigation