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Specific exercise effects of preventive neuromuscular training intervention on anterior cruciate ligament injury risk reduction in young females: meta-analysis and subgroup analysis
  1. Dai Sugimoto1,2,3,4,5,
  2. Gregory D Myer1,3,4,6,7,
  3. Kim D Barber Foss3,4,
  4. Timothy E Hewett3,4,5,6,7,8
  1. 1The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
  2. 2Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA
  3. 3Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  4. 4Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati, Ohio, USA
  5. 5College of Health Science, University of Kentucky, Lexington, Kentucky, USA
  6. 6Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
  7. 7Departments of Orthopaedic Surgery, Biomedical Engineering and Rehabilitation Sciences, University of Cincinnati, Cincinnati, Ohio, USA
  8. 8Department of Physiology and Cell Biology, Orthopaedic Surgery, Family Medicine, Anatomy and Biomedical Engineering, OSU Sports Medicine Sports Health & Performance Institute, The Ohio State University, Columbus, Ohio, USA
  1. Correspondence to Dr Dai Sugimoto, The Micheli Center for Sports Injury Prevention and Boston Children's Hospital, 9 Hope Ave, Suite 100, Waltham, MA 02453, USA; dai.sugimoto{at}


Context Clinical trials have demonstrated that preventive neuromuscular training (PNMT) can be effective to reduce ACL injuries in young females. However, the magnitude of the overall effect of PNMT for ACL injury reduction has not reached consensus. In addition, the effects of individual exercises in PNMT that optimise ACL injury reduction are unknown.

Objective The purpose of this project was to systematically review previously published clinical trials and evaluate types of exercises that best support ACL injury reduction in young females.

Data sources The key words ‘knee’, ‘anterior cruciate ligament’, ‘ACL’, ‘prospective’, ‘neuromuscular’, ‘training’, ‘female’, and ‘prevention’ were used for studies published from 1995 to May 2012 in PubMed and EBSCO host.

Study selection Inclusion criteria for the current analysis were: (1) documented number of ACL injuries, (2) employed a PNMT intervention that aimed to reduce ACL injuries, (3) had a comparison group, (4) used a prospective controlled study design, (5) recruited female athletes and (6) recorded exercises implemented in the PNMT.

Data extraction The number of ACL injuries and female athletes in each group (control and intervention) were extracted. In addition, exercises were categorised into four types and analysed for each investigation.

Data synthesis A total of 14 clinical trials met the inclusion criteria. The subgroup analyses identified fewer ACL injuries in PNMT that focused on strengthening (OR 0.32, 95% CI 0.23 to 0.46, p=0.001), proximal control exercises (OR 0.33, 95% CI 0.23 to 0.47, p=0.001) and multiple exercise interventions (OR 0.32, CI 0.22 to 0.46, p=0.001).

Conclusions The current subgroup analyses indicate strengthening, proximal control exercises and multi exercise genres increased efficacy in PNMT intervention designed to reduce ACL injury in young female athletes.

  • Knee ACL
  • Evidence based review
  • Exercise
  • Intervention effectiveness

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