Article Text

Knee injury and ACL tear prevention programmes (PEDro synthesis)
  1. S Eileen Meyer,
  2. Tiê P Yamato,
  3. Bruno T Saragiotto
  1. The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to S Eileen Meyer, The George Institute for Global Health, Level 3/50 Bridge Street, NSW 2000, Sydney, Australia; saraeile{at}

Statistics from

This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database ( PEDro is a free, web-based database of evidence relevant to physiotherapy.

▸ Donnell–Fink LA, Klara K, Collins JE, et al. Effectiveness of knee injury and anterior cruciate ligament tear prevention programs: a meta–analysis. PLoS ONE 2016;10:e0144063.


Knee injuries account for 10 to 25% of all sport-related injuries in young athletes.1 Athletes performing jumping, pivoting and cutting are at high risk to knee injury, including anterior cruciate ligament (ACL) tears. This can cause instability, damage to menisci or cartilage, and early osteoarthritis.2–4 The USA reports ∼250 000 ACL-related injuries yearly,5 of which 80 000–100 000 result in reconstructive surgeries.6 There has been a growing body of research investigating prevention programmes for knee and ACL injuries. These programmes usually focus on neuromuscular and proprioceptive training aiming to reduce landing forces and adduction and abduction moments.


The aim of this review was to investigate the effects of neuromuscular and proprioceptive training on knee and ACL injury prevention as well as to identify factors that increase the efficiency of such training.

Searches and inclusion criteria

Searches were conducted on PubMed, MEDLINE/EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science databases up to December 2014. Studies assessing the effectiveness of neuromuscular or proprioceptive intervention in humans for preventing knee and ACL injury were included. Risk of bias of the included studies was assessed using the Jadad scale.


Studies reporting any kind of neuromuscular or proprioceptive intervention in order to prevent knee or ACL injuries were considered eligible.

Main outcome

Knee or ACL injury incidence.

Statistical methods

Incidence rate ratio (IRR) and 95% CIs were used to estimate the effect of treatments. Meta-analyses were undertaken using random-effect models. Publication bias was assessed graphically using funnel plots, and statistical heterogeneity was tested using H, I2 and Q-term. Meta-regression was used to determine the effect of various training strategies and study characteristics on the IRRs. Additionally, a subgroup analysis restricted to studies that reported non-contact injuries was conducted.


Twenty-four studies were included in this review (n=26 225 participants). Fourteen of the interventions were carried out on soccer players, four on handball players, one on floorball players, one on basketball players, one on Australian Army recruits and three on multiple sports. Twenty studies reported data on knee injury, and 16 on ACL injury.

The meta-analysis for knee injury, including 19 trials, indicates that neuromuscular/proprioceptive interventions significantly reduced knee injury by 27% (IRR 0.731, 95% CI 0.61 to 0.87). Regarding ACL injury prevention, the 14 studies included in the meta-analysis showed that neuromuscular/proprioceptive interventions significantly reduced ACL injury by 51% (IRR 0.493, 95% CI 0.29 to 0.85).

In a meta-regression analysis, age (classified as high school aged or younger vs older than high school aged), was not significantly associated with outcome for both knee and ACL injuries. Preseason training was significantly associated with a lower risk of knee injury when compared to in-season only. More recently published studies and those with lower risk of bias were associated with more conservative estimates of intervention efficacy for both knee and ACL injury.

Further, the subgroup analysis investigating the effectiveness of prevention intervention on non-contact injuries showed similar results to the main analysis (IRR 0.513, 95% CI 0.30 to 0.88).

Limitations and strengths

As 63% of the included studies focused on women, the results should be interpreted with caution for male populations. The compared studies used different prevention programmes, so the ability to detect effective training components was limited. Also, 56% of the studies did not include data from ‘drop-outs’ in their analyses, which may lead to an underestimation of the prevention programmes' effects.

The strengths of this meta-analysis are the inclusion of 24 studies analysing knee and ACL injury incidence as well as the statistical methods used.

Clinical implications

The meta-analyses suggest protective effects of proprioceptive or neuromuscular training on knee and ACL injury. Health professionals and athletic departments should consider the implementation of neuromuscular and proprioceptive injury prevention programmes in order to reduce the incidence of knee and ACL injuries in athletes.

View Abstract


  • Contributors SEM, TPY, BTS selected the systematic review, interpreted the data and wrote the manuscript.

  • Funding Tiê Parma Yamato is supported by CAPES (Coordination for the Improvement of Higher Education Personnel), Brazil, and Bruno Tirotti Saragiotto is supported by CNPQ (National Council for Scientific and Technological Development), Brazil.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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