Knee Surg Sports Traumatol Arthrosc (2010) 18:824–830

DOI 10.1007/s00167-009-0901-2

KNEE

A meta-analysis of the effect of neuromuscular training

on the prevention of the anterior cruciate ligament injury
in female athletes
Jae Ho Yoo Æ Bee Oh Lim Æ Mina Ha Æ Soo Won Lee Æ
Soo Jin Oh Æ Yong Seuk Lee Æ Jin Goo Kim

Received: 19 March 2009 / Accepted: 6 August 2009 / Published online: 4 September 2009
Ó Springer-Verlag 2009

Abstract Female athletes are more prone to anterior
cruciate ligament (ACL) injury than their male counter-
parts, presumably because of anatomical, hormonal, and
neuromuscular differences. Of these three, only the neuro-
muscular component can be modified by preventive exer-
cise. 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 ran-
domized controlled trials or prospective cohort studies were
J. H. Yoo
Department of Orthopaedic Surgery,
Soonchunhyang University Hospital,
Bucheon, South Korea
B. O. Lim
Sports Science Institute, Seoul National University,
Seoul, South Korea
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

M. Ha
Department of Preventive Medicine,
Dankook University College of Medicine, Introduction
Cheonan, South Korea
Anterior cruciate ligament (ACL) injuries in athletes are
S. W. Lee
common [1], and female athletes are 4–6 times more prone
Department of Orthopaedic Surgery, Sunlin Hospital,
Pohang, South Korea to these injuries than their male counterparts at similar
levels of exertion, despite the fact that the majority of ACL
S. J. Oh
J. G. Kim (&) injuries occur in males [1–3]. The reported incidence of
Orthopedic Department, Sports Medical Center,
ACL injury is as high as 1.6 per 1,000 player-hours for elite
Seoul Paik Hospital, Inje University,
2 Ka Jur Dong, Chung Gu, Seoul 100-032, Korea female players in team handball during matches [4], and
e-mail: boram107@hanmail.net the overall annual incidence of ACL injury in women is
about 38,000 cases in the United States [5]. Regardless of
Y. S. Lee
recent advances in the treatment of ACL, osteoarthritis of
Department of Orthopedic Surgery,
Korea University Ansan Hospital, the knee occurs ten times more in ACL-injured knees [6].
Seoul, South Korea Therefore, prevention is a key component in reducing the

123
Knee Surg Sports Traumatol Arthrosc (2010) 18:824–830
impact of ACL injury. Furthermore, the cost of treatment,
loss of participation in a sports during in-season, the long-
term rehabilitation required, and residual disability under-
score the importance of prevention of ACL injuries [2, 7,
8], and this is particularly true for female athletes.
Many theories have been proposed explain the female
susceptibility to ACL injury, which include anatomical,
hormonal, and neuromuscular hypothesis [2]. However, the
anatomical and hormonal components are useful in terms
of understanding the phenomenon, they cannot be modu-
lated. The neuromuscular background that renders the
female athletes more susceptible to ACL injuries is a more
attractive topic for research, because it can be improved by
preventive training. The majority of ACL injuries in ath-
letes are non-contact injuries that occur during sudden
deceleration, changes in direction such as cutting or side-
kicking, or landing after a jump [9, 10]. Furthermore,
biomechanical studies have shown that females land from a
jump and change direction in a more erect posture than
males with knees and hips close to full extension [9, 11–
14], which jeopardizes the balance of quadriceps and
hamstrings [9, 12, 15]. In addition, women tend to land
after a jump or side-kick with greater knee valgus and
reduced internal knee varus moment [16–20], which alto-
gether place the ACL at an increased risk of injury.
Several different preventive programs have been attemp-
ted [3, 8, 21–25], and each of these is based on different
design concepts and emphasizes different components of
preventive exercise including plyometrics, strengthening,
balancing, endurance, and stability. However, the overall
effectiveness of preventive exercise with respect to enhanc-
ing neuromuscular control and preventing ACL injuries in
female athletes remains to be verified [26]. Furthermore, it
has not been determined which program is most effective, and
how a program should be scheduled, and it is not known
which biomechanical component of protocol plays a conse-
quential role. They also encompass different level of com-
mitment, which should be taken into due consideration for the
professional athletes lie in a unique situation [26].
The purpose of this study was to evaluate the effective-
ness of ACL injury prevention programs for female athletes
using meta-analysis approach, and to identify the essential
components of the prevention programs. We hypothesized
that neuromuscular training program is effective at pre-
venting ACL injury, and that more effective training
protocols could be devised by identifying contributory
components by analyzing previously proposed protocols.
Materials and methods
An evaluation committee consisting of three orthopedic
surgeons and one biomechanical investigator, all of whom
825
had considerable experience in the care of the ACL injury
participated in the study. An extensive search of the liter-
ature was performed. As of June 2007, a computerized
Medline search was conducted using multiple Boolean
operators and combinations of the following eight key-
words: knee injury, ACL injury, gender difference, injury
prevention, neuromuscular training, plyometrics, strength-
ening training, and balance training (Table 1). The Coch-
rane Database for Systemic Reviews was also searched to
identify any studies that may have been published in the
orthopedic, rehabilitation, or biomechanical literature. In
addition to the web-based search, three investigators per-
formed a manual search of Journals published in English or
Korean. The proceedings of the American Academy of
Orthopaedic Surgeons and textbooks also were scrutinized
manually. Finally, contents experts interested in ACL
injury preventive neuromuscular training programs were
contacted for additional studies that may have been missed.
Identified articles were evaluated by grading level of
evidence, as follows: (1) randomized controlled trial, (2)
prospective cohort study, (3) retrospective case control
study, (4) case series, (5) case report or expert opinion.
Only randomized controlled trials and prospective cohort
studies were included. Each member of the evaluation
committee scrutinized the identified articles and catego-
rized each one by marking A: included in the current study,
B: considered including after committee discussion;
favorable, C: decided after committee discussion; unfa-
vorable, D: excluded from the study, according to the
relevance of the study.
A total of 2,215 articles were identified form the key-
word search and 2,184 studies were excluded after
reviewing abstracts. A review of the remaining 31 inves-
tigations by evaluation committee ruled out 24 studies, and
left 7 eligible studies by Hewett et al. [26], Heidt et al. [21],
Soderman et al. [8], Myklebust et al. [3], Mandelbaum
Table 1 Search terms used in the systemic review
Subject Search terms
Knee injury Knee injury, knee trauma
ACL injury ACL tear, ACL rupture,
cruciate ligament injury
Gender difference Sex difference, between male
and female
Injury prevention Injury avoidance
Neuromuscular training Neuromuscular coordination,
neuromuscular exercise
Plyometrics Plyometric exercise,
plyometric training
Strengthening training Strengthening exercise
Balance training Balance exercise,
equilibrium training
123
826 Knee Surg Sports Traumatol Arthrosc (2010) 18:824–830

et al. [23], Peterson et al. [24], and Pfeiffer et al. [25]
(Fig. 1).
To assess the overall effects of preventive programs by
pooling the data, we documented numbers in the trained
and untrained groups and the incidences of ACL injury in
each group. To identify the significant components of the
preventive programs, the subgroup analyses were con-
ducted on parameters included in more than one study.
Ages was divided by 18 years for devoted college athletic
competition was implemented from that age. The types of
sports included were soccer and handball. The training
times were classified as pre-season, in-season, and both the
pre- and in-seasons. The biomechanical components of the
preventive programs were plyometrics, strengthening, and
balancing exercises (Table 2).
A meta-analysis was performed on an intention-to-treat
basis. For each study, odds ratios (OR) and 95% confidence
intervals (CI) were calculated from the frequency tables of
Fig. 1 Schematic of the literature search procedure
individual studies analyzed by Mantel–Haenszel common
OR estimate. The DerSimonian and Laird’s methods were
used as random-effects model to obtain summary ORs and
95% CIs. Heterogeneity between studies was tested using
the chi-square test. Publication bias was assessed using the
Egger regression asymmetry test and the Begg and
Mazumdar adjusted rank correlation test [27, 28]. The
Egger test makes more assumptions and is more sensitive
to many types of bias than the Begg and Mazumdar test
[29]. Subgroup analyses were performed in the same
manner using ORs and 95% CIs. All statistical analyses
were performed using STATA (version 9.2 [Special Edi-
tion]; Stata Corp., College Station, TX, USA).
Results
Five of the seven studies supported the efficacy of the
preventive programs, while the other two studies did not.
The meta-analysis conducted by pooling the seven eligible
studies showed that the incidence of ACL injury was 34 of
3,999 in trained group, and 123 of 6,462 in untrained group
with an OR of 0.40 and a 95% CI of [0.27, 0.60] in the
fixed model, which demonstrated the effectiveness of the
preventive training (Table 3; Fig. 2). No significant heter-
ogeneity was found among studies (Table 3), and no sig-
nificant publication bias was evident (Fig. 3).
The results of the subgroup analysis are outlined in
Table 4. The OR [95% CI] of subjects under the age of 18
was 0.27 [0.14, 0.49] and training among these subjects
proved to have a more favorable effect than on adults with
0.78 [0.230, 2.64]. Training had more effect on soccer, 0.32
[0.19, 0.56] than on handball, 0.54 [0.30, 0.97]. Pre- and in-
season training 0.54 [0.30, 0.97] was effective, while pre-
season training, 0.35 [0.10, 1.21], or in-season 0.32 [0.17,

Table 2 Type of sports, subject age, and the number of ACL injuries in trained and untrained groups
Study Year of Age (years) Type of sport Training time Biomechanical component
publication

Hewett et al. [22] 1999 14–18 Soccer, volleyball, Pre-season Plyometric strengthening
basketball
Heidt et al. [21] 2000 14–18 Soccer Pre-season Plyometric strengthening
Soderman et al. [8] 2000 20.4 ± 4.6 Soccer In-season Balancing
20.5 ± 5.4
Myklebust et al. [3] 2003 16–35 Handball Pre-season Plyometric balancing
In-season
Mandelbaum et al. [23] 2005 14–18 Soccer In-season Plyometric strengthening agility
Peterson et al. [24] 2005 Adult Handball Pre-season Plyometric balancing
In-season
Pfeiffer et al. [25] 2006 14–18(?) Soccer, volleyball, In-season Plyometric agility
basketball

123
Knee Surg Sports Traumatol Arthrosc (2010) 18:824–830 827

Table 3 The odds ratios and confidence intervals of the seven respective studies
Study Untrained Trained OR [95% CI]a
Uninjured Injured Uninjured Injured

Hewett et al. [22] 453 10 364 2 0.25 [0.05, 1.14]

Heidt et al. [21] 250 8 41 1 0.76 [0.09, 6.25]
Soderman et al. [8] 99 1 117 4 3.38 [0.37, 30.78]
Myklebust et al. [3] 913 29 891 17 0.60 [0.33, 1.10]
Mandelbaum et al. [23] 3,751 67 1,879 6 0.18 [0.08, 0.41]
Peterson et al. [24] 137 5 133 1 0.21 [0.02, 1.79]
Pfeiffer et al. [25] 859 3 574 3 1.50 [0.30, 7.44]
Total 6,462 123 3,999 34
M–H pooled OR (fixed) 0.40 [0.27, 0.60]
D?L pooled OR (random) 0.49 [0.24, 1.02]
Fixed model: heterogeneity v2 = 12.55 (df = 6) P = 0.051, test of OR = 1: z = 4.52 P = 0.000
Random model: heterogeneity v2 = 12.55 (df = 6) P = 0.051, estimate of between-study variance Tau-squared = 0.4435, test of OR = 1:
z = 1.90 P = 0.057
M–H Mantel–Haenszel, D?L DerSimonian & Laird’s methods, OR odds ratio, CI confidence intervals
a
ORs and 95% CIs estimated by the Mantel–Haenszel pooled OR estimate

Fig. 2 Meta-analysis of the effect of neuromuscular training on the
prevention of the anterior cruciate ligament injury in female athletes.
The contribution of each study to the meta-analysis (it weight) is
represented by the area of a box whose center represents the size of
the effect estimated in that study. The incidence of ACL injury was 34
among 3,999 in the trained group, and 123 among 6,462 in the
untrained group with the ORs and 95% confidence intervals of 0.40
and 0.27 to 0.60 in the Mantel–Haenszel’s fixed model and 0.49 and
0.27 to 1.02 in the DerSimonian and Laird’s random model, which
manifested the effectiveness of the preventive training by this meta-
analysis

0.59] was not. The plyometric 0.37 [0.24, 0.55] and
strengthening components of training protocol [0.21 [0.11,
0.43] vs. 0.69 [0.41, 1.15]] were effective whereas bal-
ancing [0.63 [0.37, 1.09] vs. 0.27 [0.14, 0.49]] was not.
Discussion
The most important finding of the present study was that
neuromuscular preventive programs were found to be
effective at preventing ACL injuries in female athletes. The
favorable effect of training was more pronounced in
subjects under 18 years of age, and for soccer rather than
handball. The pre- and in-season training was found to be
more effective than either pre-season or in-season training
alone. Plyometric and strengthening components of exer-
cise protocols were found to be more essential than bal-
ancing. All of the above findings could be incorporated into
the neuromuscular training protocols designed to prevent
ACL injuries of female athletes.
The mechanism of ACL injury can be divided into
contact and non-contact. The non-contact mechanism
constitutes to 70% of overall incidence [10, 30–32]. The
contact type of ACL injury is determined by the disposition

123
828 Knee Surg Sports Traumatol Arthrosc (2010) 18:824–830

non-contact ACL injury were 0.36 and [0.23, 0.54], which

Fig. 3 Begg’s funnel plot for publication bias in meta-analysis of the
effect of neuromuscular training on the prevention of the anterior
cruciate ligament injury in female athletes. Egger test, P = 0.64;
Begg’s test, P = 0.37 or odds ratio; SE standard error
of the knee and the nature of the external force at the time
of injury, which cannot be prevented by preventive exer-
cise [31]. Neuromuscular preventive programs target non-
contact ACL injuries [2, 31]. Five of the seven identified
studies in the current study compared non-contact ACL
injury [2, 3, 23–25], while the other two [8, 21] studies
provided no information on non-contact or contact type of
injury. Moreover, the number of injured ACLs after a
second intervention season was not documented in
Myklebust’s study [3]. The OR and 95% CI of the
remaining four studies [2, 23–25] which focused only on
is even more affirmative for preventive training.
Intention to treat (ITT) and the per-protocol (PP) based
analyses should be differentiated. ITT is based on the ini-
tial treatment intent, not on the treatment eventually
administered, and is founded on the assumption that
sometimes patients do not all receive optimal treatment.
Thus, ITT more appropriately represents the real-life situ-
ation. It provides information about the potential effects of
a treatment policy rather than on the potential effects of a
specific treatment [33]. PP, unlike ITT, concerns only
patients who completed the entire treatment protocol and is
useful when the object of interest is the actual efficacy of
treatment [34]. In the Hewett et al.’s meta-analysis [2], the
data were not analyzed by consistent manner in that the
Hewett’s et al.’s [22] and the Soderman et al.’s [8] study
were analyzed by PP basis, while the others by ITT basis.
In the present study, we applied the ITT method to every
study included except the Hewett’s et al. [22] study, which
could not be interpreted by ITT basis. Therefore, we con-
ducted the current study by more decent analysis with
consistent principle.
The intensity of each study protocol deserves attention
for it must be at a certain level to have a positive effect [2].
Program intensities were very different for the Soderman’s
[8] and the Hewett’s [22] protocols. The balance board
training used for female soccer players in Soderman’s
prospective randomized study [8] was a home-based pro-
gram followed by and additional 10–15 min of standard
physical training, initially conducted daily for 30 days and

Table 4 Subgroup analyses of age, type of sports, training time, and biomechanical component
Factors Subgroups Studies Untrained Trained OR Test for Publication bias
[ref no.] [95% CI]a heterogeneity
Uninjured Injured Uninjured Injured P value (df) Begg’s Egger’s
P value P value

Age B18 [21–23, 25] 5,313 88 2,858 12 0.27 [0.14, 0.49] 0.10 (3) 0.31 0.22
Adult [24, 25] 236 6 250 5 0.78 [0.23, 2.64] 0.08 (1) – –
Type of sports Soccer [8, 21–23, 25] 5,412 89 2,975 16 0.32 [0.19, 0.56] 0.03 (4) 0.09 0.07
Handball [3, 24] 1,050 34 1,024 18 0.54 [0.30, 0.97] 0.35 (1) – –
Training time Pre-season [21, 22] 703 18 405 3 0.35 [0.10, 1.21] 0.40 (1) – –
In-season [8, 23, 25] 4,709 71 2,570 13 0.32 [0.17, 0.59] 0.01 (2) 0.30 0.09
Pre- and in-season [3, 24] 1,050 34 1,024 18 0.54 [0.30, 0.97] 0.35 (1) – –
Biomechanical Plyometric (?) [3, 21–25] 6,363 122 3,882 30 0.37 [0.24, 0.55] 0.10 (5) 1.00 0.97
component Plyometric (-) [8] 99 1 117 4 – – – –
Strengthening (?) [21–23] 4,454 85 2,284 9 0.21 [0.11, 0.43] 0.45 (2) 0.30 0.24
Strengthening (-) [3, 8, 24, 25] 2,008 38 1,715 25 0.69 [0.41, 1.15] 0.23 (3) 0.73 0.62
Balancing (?) [3, 8, 24] 1,149 35 1,141 22 0.63 [0.37, 1.09] 0.19 (2) 1.00 0.87
Balancing (-) [21–23, 25] 5,313 88 2,858 12 0.27 [0.14, 0.49] 0.10 (3) 0.31 0.22
OR odds ratio, CI confidence intervals, df degree of freedom, – not applicable
a
ORs and 95% CIs estimated by the Mantel–Haenszel pooled OR estimate

123
Knee Surg Sports Traumatol Arthrosc (2010) 18:824–830
then at 3 times per week for the remainder of the season.
The results showed no significant differences between
training and control groups [8]. The other protocols
required more concentrated participation and higher
degrees of exercise intensity. Hewett et al. [22] incorpo-
rated a comprehensive exercise of high intensity program.
Training session times in the reviewed studies varied from
10 to 75 min. Hewett et al. (75 min) [22] and Heidt et al.
(60 min) [21] implemented comprehensive protocols,
which are probably too difficult to execute in-season per-
iod, whereas Pfeiffer et al. (20 min) [25], Peterson et al.
(10 min) [24], Mandelbaum et al. (20 min) [23], Mykle-
bust et al. (15 min) [3], Soderman et al. (10–15 min) [8]
proposed a relatively short programs, which might be
integrated into a regular exercises in-season, causing less
burden for the athletes. Great care should be taken when
pooling the data during meta-analysis due to the different
intensities of intervention. The odds ratio and the 95% CI
from the six studies excluding Soderman’s study were 0.37
and [0.24, 0.55], respectively, indicating that training
programs of high intensity had a more favorable effect on
ACL injury prevention.
The prevention of non-contact ACL injury should focus
on neuromuscular–biomechanical factors for they are the
only components modifiable by training [35]. Exercise
protocols should include warming-up, plyometrics,
strengthening, balancing, agility, flexibility, postural
adaptation, and an athletic performance enhancement pro-
gram [36]. In our subgroup analysis, the plyometric,
strengthening, and balancing components were found to be
the major three components of interest. Plyometric exer-
cises increase power, muscle strength, and speed [23, 36],
whereas strengthening exercises including walking lunge,
Russian hamstrings, single toe raise increase the muscle
power to stabilize the knee joint. The effect of the bal-
ancing exercises could be enhanced by proprioceptive
exercises [3, 37]. Neuromuscular exercise programs that
combine plyometric, strengthening, and balancing have
been shown to decrease the ACL injury risk and to enhance
the athletic performance [3, 22, 37]. Hewett et al. [22]
reported that the plyometric exercises have a positive effect
on the prevention of ACL injury and that the balancing
exercises alone without other biomechanical components
do not. On the other hand, Pfeiffer et al. [25] concluded
that plyometric training does not have a favorable effect on
the preventions of ACL injury. It has also been reported
that a combination of strengthening and balancing exer-
cises has synergistic benefit by enhancing the dynamic
stability and decreasing injury risk [38–40]. Although the
optimal combination of neuromuscular—biomechanical
components remains to be verified, our study shows that
plyometric and strengthening components are probably
necessary factors of any training program.
829
The unique environment female athletes are placed in
should be taken into consideration, as should the cost-
effectiveness and the effect of a training program on
performance and compliance [2, 3, 23, 36]. Impractical
protocols that are time-consuming and expensive cannot
be realistically implemented. As a matter of fact, athletes
are not normally well motivated to participate in pre-
ventive programs unless they enhance athletic perfor-
mance [36]. Therefore, the addition of exercise to
improve the overall athletic performance effect of a pre-
ventive training should have a positive effect on com-
pliance [36].
Meta-analysis study has intrinsic limitations. The pool-
ing the mixed design studies can make interpretations
difficult and sometimes leads to false results. Furthermore,
the heterogeneous nature of treatment protocols is another
concern [2], such as the aforementioned various intensities
of the exercise programs. Nevertheless, in the present
study, the positive effect of preventive exercise was always
evident. The rarity of the ACL injury incidence poses
another problem in study design in terms of the statistical
power of conclusion drawn from the findings of individual
preventive training programs.
Conclusion
This meta-analysis shows that ACL injury preventive
exercise programs are effective in female athletes, espe-
cially in those under 18 years of age, and for soccer players
rather than handball players. Plyometric and strengthening
exercises were found to be essential components of such
training protocols, whereas balancing exercises were not.
References
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 23:694–701
2. Hewett TE, Ford KR, Myer GD (2006) Anterior cruciate ligament
injuries in female athletes: part 2, a meta-analysis of neuromus-
cular interventions aimed at injury prevention. Am J Sports Med
34:490–498
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 inter-
vention study over three seasons. Clin J Sport Med 13:71–78
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 sea-
sons. Scand J Med Sci Sports 7:289–292
5. Toth AP, Cordasco FA (2001) Anterior cruciate ligament injuries
in the female athlete. J Gend Specif Med 4:25–34
6. Fleming BC (2003) Biomechanics of the anterior cruciate liga-
ment. J Orthop Sports Phys Ther 33:A13–A15
123
830
7. Grindstaff TL, Hammill RR, Tuzson AE, Hertel J (2006) Neu-
romuscular control training programs and noncontact anterior
cruciate ligament injury rates in female athletes: a numbers-
needed-to-treat analysis. J Athl Train 41:450–456
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 8:356–363
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 16:113–122
10. McNair PJ, Marshall RN, Matheson JA (1990) Important features
associated with acute anterior cruciate ligament injury. N Z Med
J 103:537–539
11. Draganich LF, Jaeger RJ, Kralj AR (1989) Coactivation of the
hamstrings and quadriceps during extension of the knee. J Bone
Joint Surg Am 71:1075–1081
12. Draganich LF, Vahey JW (1990) An in vitro study of anterior
cruciate ligament strain induced by quadriceps and hamstrings
forces. J Orthop Res 8:57–63
13. Kirkendall DT, Garrett WE Jr (2000) The anterior cruciate liga-
ment enigma. Injury mechanisms and prevention. Clin Orthop
Relat Res 372:64–68
14. Renstrom P, Arms SW, Stanwyck TS, Johnson RJ, Pope MH
(1986) Strain within the anterior cruciate ligament during ham-
string and quadriceps activity. Am J Sports Med 14:83–87
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 10:78–84
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 35:1745–1750
17. Ford P, Hodges NJ, Huys R, Williams AM (2006) The role of
external action-effects in the execution of a soccer kick: a com-
parison across skill level. Motor Control 10:386–404
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 37:1003–1012
19. McLean SG, Huang X, Su A, Van Den Bogert AJ (2004) Sagittal
plane biomechanics cannot injure the ACL during sidestep cut-
ting. Clin Biomech (Bristol, Avon) 19:828–838
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 36:1008–1016
21. Heidt RS Jr, Sweeterman LM, Carlonas RL, Traub JA, Tekulve
FX (2000) Avoidance of soccer injuries with preseason condi-
tioning. Am J Sports Med 28:659–662
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–
706
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 pre-
venting anterior cruciate ligament injuries in female athletes:
2-year follow-up. Am J Sports Med 33:1003–1010
123
Knee Surg Sports Traumatol Arthrosc (2010) 18:824–830
24. Petersen W, Braun C, Bock W, Schmidt K, Weimann A, Dre-
scher W, Eiling E, Stange R, Fuchs T, Hedderich J, Zantop T
(2005) A controlled prospective case control study of a preven-
tion training program in female team handball players: the Ger-
man experience. Arch Orthop Trauma Surg 125:614–621
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 88:1769–1774
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 34:299–311
27. Begg CB, Mazumdar M (1994) Operating characteristics of a rank
correlation test for publication bias. Biometrics 50:1088–1101
28. Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in
meta-analysis detected by a simple, graphical test. BMJ 315:629–
634
29. Macaskill P, Walter SD, Irwig L (2001) A comparison of meth-
ods to detect publication bias in meta-analysis. Stat Med 20:641–
654
30. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ,
Kaufman KR (1994) Fate of the ACL-injured patient. A pro-
spective outcome study. Am J Sports Med 22:632–644
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 ante-
rior cruciate ligament injuries: risk factors and prevention strat-
egies. J Am Acad Orthop Surg 8:141–150
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 65:154–162
33. Lachin JM (2000) Statistical considerations in the intent-to-treat
principle. Control Clin Trials 21:167–189
34. Leandro G (2004) Meta-analysis in medical research. In: The
handbook for the understanding and practice of meta-analysis.
Blackwell, Oxford, pp 98
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 56:397–406
36. Myer GD, Ford KR, Hewett TE (2004) Methodological approa-
ches and rationale for training to prevent anterior cruciate liga-
ment injuries in female athletes. Scand J Med Sci Sports 14:275–
285
37. Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A (1996) Pre-
vention of anterior cruciate ligament injuries in soccer. A pro-
spective controlled study of proprioceptive training. Knee Surg
Sports Traumatol Arthrosc 4:19–21
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 22:285–290
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 14:88–94
40. Paterno MV, Myer GD, Ford KR, Hewett TE (2004) Neuro-
muscular training improves single-limb stability in young female
athletes. J Orthop Sports Phys Ther 34:305–316
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.