Team Physician’s Corner

Assessing the Effectiveness of M

Neuromuscular Training Programs
in Reducing the Incidence of
Anterior Cruciate Ligament Injuries
in Female Athletes
A Systematic Review
J. Herbert Stevenson,*y MD, Chad S. Beattie,y MD, Jennifer B. Schwartz,y MD,
and Brian D. Busconi,y MD
Investigation performed at the University of Massachusetts Medical Center, Worcester,
Massachusetts, USA

Background: Anterior cruciate ligament (ACL) injuries are more common in female athletes because of anatomic and biomechan-
ical factors. These injuries can have detrimental ramifications for the athlete and the health care system. Neuromuscular training
programs have been designed to modify risk factors and prevent ACL injuries.
Purpose: This systematic review evaluates studies that assess the effectiveness of neuromuscular training programs in reducing
ACL injuries in female athletes and provides an update to 2 previously published reviews.
Study Design: Systematic review.
Methods: Medline, Cochrane, and CINAHL databases were searched for relevant journal articles published from 1995 to 2011.
We performed a manual review of relevant articles, authors, and journals, including bibliographies from identified articles. Ten
studies were included in this review.
Results: Only 2 studies demonstrated a statistically significant decrease in ACL injuries with neuromuscular training programs.
Two additional studies showed a statistically significant decrease in subgroup analyses only. Four studies did show a trend
toward reduced ACL injuries with neuromuscular training programs but were unable to achieve statistical significance. Neuromus-
cular training programs utilizing plyometric exercises and a preseason component were the most beneficial. Two studies actually
showed an increase in injuries with intervention programs.
Conclusion: Neuromuscular training programs may be a useful adjunct to training, but current literature precludes our universal
recommendation of them.
Keywords: neuromuscular training; ACL; female; athlete

Anterior cruciate ligament (ACL) injuries are a common
sports injury often resulting in significant short- and long-
*Address correspondence to J. Herbert Stevenson, MD, Division of
Sports Medicine, University of Massachusetts Medical School, 281 Lin-
coln Street, Worcester, MA 01605, USA (e-mail: john.stevenson
@umassmemorial.org).
y
Division of Sports Medicine, University of Massachusetts Medical
School, Worcester, Massachusetts, USA.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 43, No. 2
DOI: 10.1177/0363546514523388
Ó 2014 The Author(s)
term morbidity. The exposure risk has been found to be 1 in
25,782 hours of athletic exposure.32 The consequences for ath-
letes may be devastating in terms of lost game time, length of
rehabilitation, and lost scholarship funding. The psychological
effect of missed participation in sports may lead to lowered
self-esteem, feelings of social isolation, lowered academic per-
formance,13,29 and a delayed return to sports.12,17 In addition,
ACL injuries may result in long-term disability and a signifi-
cant risk of osteoarthritis as adults, particularly when there is
an associated meniscal injury.21
Also, ACL injuries can contribute a substantial burden
to the health care system. A recent study of ACL recon-
struction using a cost-utility analysis found the lifetime
cost to society of an ACL reconstruction to be US$38,121.15

482
Vol. 43, No. 2, 2015 Effectiveness of Neuromuscular Training Programs in Female Athletes
Women are 2 to 8 times more likely than men to sustain
an ACL injury, with the majority of these being noncontact.1
Most of the anatomic and biomechanical differences between
male and female athletes arise after puberty, which is the
same developmental period when sex differences in ACL
injury rates occur.7,9,10 Women have wider hips, smaller
joints, increased joint laxity, smaller ACLs, increased body
mass index, and different patterns of biomechanical move-
ments when pivoting, jumping, and landing.28 Deficits in neu-
romuscular coordination and strength of stabilizing muscles
around the knee have been shown to place an increased stress
on the ACL and potentially predispose female athletes to inju-
ries.6,7 The importance of understanding the risk and pre-
venting injuries is particularly urgent because of female
participation in sports being at a historical high.19,20
Neuromuscular training programs have been designed to
modify risk factors and lower the incidence of ACL injuries.3
Some programs show promise in reducing ACL injuries, but
they are not without a price, and the financial cost of admin-
istering these programs must be a consideration before
implementation. Moreover, the time burden of these pro-
grams to athletic trainers, trained coaches/staff, and athletes
can be considerable. Given these relative costs, it is impor-
tant to examine the effectiveness of potential interventions.
Numerous studies of neuromuscular training programs
have been conducted. Some support the hypothesis that
ACL prevention programs reduce the incidence of injuries
in female athletes, while others refute this claim. Hewett
et al10 conducted the first known systematic review of neu-
romuscular training programs in 2005. Since that time,
further studies on this topic have been added to the body
of literature, necessitating an updated systematic review.
A more recent review was performed by Noyes and
Barber-Westin22 in 2012, which looked at both injury
reduction and athletic performance as outcomes of neuro-
muscular training programs. However, some recent stud-
ies of neuromuscular training programs and injury
reduction were not included in this review. This current
systematic review, focusing on injury reduction alone,
has allowed us to include 4 additional studies since Hewett
et al’s10 review. Furthermore, our review has taken the
additional step of critically reviewing the literature and
rating the quality of the articles included. This is the first
known published review of neuromuscular training pro-
grams and ACL injuries to implement a standardized
approach to the literature utilizing a validated rating
scale. The goal of this study was to draw evidence-based
conclusions on the effectiveness of neuromuscular training
programs for ACL injury prevention in female athletes
that can guide future practice and recommendations.
MATERIALS AND METHODS
A systematic review of the literature was performed. Two
independent reviewers, both fellowship-trained primary
care sports medicine physicians at the University of Mas-
sachusetts, performed the literature search. To identify
relevant journal articles for this review, Medline, the
Cochrane Database, and CINAHL were searched for
483
1976
Removal of duplicates
(475)
1501
Articles eliminated by title
(1381)
120
Articles added from Articles eliminated by
reference review (7) abstract review (100)
27
Articles eliminated after
data abstraction (17)
10
Articles included in
systematic review
Figure 1. Flow diagram of included and excluded studies.
studies published between 1995 and 2011. Ettlinger
et al3 published the first known study on ACL injury pre-
vention programs in 1995, which was why this year was
chosen as our start date. The following keywords were
combined with ‘‘ACL’’ AND ‘‘anterior cruciate ligament
injury’’ in all searches: knee injury, female athletes, neuro-
muscular, injury prevention, balance training, plyomet-
rics, soccer, and exercise therapy. We performed
a manual review of relevant articles, authors, and journals,
including bibliographies from identified articles.
Inclusion/Exclusion Criteria
English-only language studies were included if they con-
tained human participants, female athletes aged 6 to 64
years, and ACL injury incidence data. In addition, we lim-
ited our search to prospective cohort studies and random-
ized controlled trials because of some of the inherent
limitations of cross-sectional and case-control study
designs. We excluded studies that did not look at the
ACL injury as an end point but instead focused on the
effects of neuromuscular training programs on athletic
performance or on modifiable risk factors for ACL injuries.
We also excluded studies that did not include a control
group of female athletes who had not undergone the spe-
cific neuromuscular training program designed to prevent
ACL injuries.
Study Selection
The literature search initially produced 1976 articles (Fig-
ure 1). After duplicates were removed, 1501 articles
remained. Two reviewers independently assessed these
titles, and 1381 articles were excluded largely because
they were surgical in nature. One hundred twenty
abstracts were then independently reviewed, along with
the addition of 7 articles added from bibliographies of pre-
viously reviewed studies. Ultimately, 27 articles under-
went the data abstraction process. All disagreements
were resolved by consensus between the reviewers.
484 Stevenson et al The American Journal of Sports Medicine

TABLE 1
General Study Characteristics

No. of Downs and

Author Year Study Type Randomized Sports Age, y Seasons Black Score

Hewett et al9 1999 Prospective cohort No Basketball, soccer, volleyball 14-18 1 15

Heidt et al8 2000 Randomized controlled trial Yes Soccer 14-18 1 15.5
Soderman et al30 2000 Prospective cohort Yes Soccer 20-26a 1 16
Myklebust et al18 2003 Prospective cohort No Norwegian handball Adulta 3 14.5
Mandelbaum et al14 2005 Prospective cohort No Soccer 14-18 2 16.5
Petersen et al23 2005 Prospective cohort No German handball Adulta 1 12.5
Pfeiffer et al24 2006 Prospective cohort No Basketball, soccer, volleyball 14-18 2 13
Gilchrist et al5 2008 Randomized controlled trial Yes Soccer 18-22 1 16.5
Steffen et al31 2008 Randomized controlled trial Yes Soccer 13-17 1 16.5
Kiani et al11 2010 Prospective cohort No Soccer 13-19 1 14.5

a
Study population included professional or elite players.

Data Abstraction and Evaluation
Each author independently reviewed the targeted 27
articles and abstracted data from both the text and tables.
The data were then organized into tables to easily display
the information of interest to our study questions. Seven-
teen articles were further excluded during this data
abstraction process, leaving a total of 10 studies that
were included in our systematic review.
Quality Review
The quality of the 10 studies selected for final inclusion
was assessed using the modified Downs and Black2 crite-
ria. The Downs and Black criteria are a quality assessment
tool used to evaluate a study’s methodological quality. A
higher score indicates higher methodological quality.
Scores in our review ranged from 14.5 to 16.5 out of a max-
imum possible score of 26. The quality scores for all
included studies can be found in Table 1.
Most studies compared a distinct control group with
a different treatment group (group undergoing a neuromus-
cular training program) over the study’s time frame.
Myklebust et al18 used a slightly different model; they fol-
lowed the same group over a control season and then 2
additional treatment seasons in which they participated
in neuromuscular training programs. Pfeiffer et al24 fol-
lowed the same control and intervention groups over a 2-
season period. Mandelbaum et al14 also collected data
over 2 seasons but looked at a different treatment and con-
trol group during each season.
The sample sizes of the published studies ranged
widely, from 140 to 2946 participant seasons. Nine of the
10 articles expressed incidence as the number of injuries
per 1000 hours of exposure, where exposure was defined
as a unit of athletic activity in which one could sustain
an injury (typically a game or practice). It should be noted
that most studies did not report participant characteristics
such as race and ethnicity or whether athletes participated
in other sports.

Neuromuscular Training Programs

RESULTS
Characteristics of Included Studies
Table 1 provides a number of select characteristics of the
10 included studies. The majority (70%) were prospective
cohort studies published after 1998. Soccer was the most
common sport evaluated (8/10 studies). Basketball and vol-
leyball, 2 sports known for a higher incidence of ACL inju-
ries in female athletes,27 were only studied in 2 of the
included articles. Handball, a sport not common in North
America, was the lone sport evaluated in 2 of the articles.
Three distinct age populations were examined: high school
(14-18 years), college (18-22 years), and professional (the
minimum age used to define ‘‘professional’’ was not
reported). While 1 study investigated the effect of neuro-
muscular training programs over a 3-year period,18 the
remaining studies used a 1- to 2-year window to implement
training and collect data.
A breakdown of the neuromuscular training programs for
all 10 included studies can be found in Table 2. While no
2 programs were identical, there were similarities across
studies. In particular, plyometrics was a component of
80% of the studies, strength training 60%, and flexibility
40%. Balance training was investigated as a major compo-
nent in 3 articles and was the only mode of training that
was investigated on its own.
For the 4 studies reporting statistically significant
decreases in ACL injuries,5,9,14,18 plyometrics, strength
training, and flexibility were included in 75% of their inter-
vention programs. Plyometrics was an intervention compo-
nent in all but 1 study, demonstrating a positive trend
toward reducing ACL injuries. In fact, only 1 study utiliz-
ing plyometrics failed to show a decrease in ACL injuries.
Pfeiffer et al,24 using plyometric and agility exercises, actu-
ally showed a trend toward increased ACL injuries in the
intervention group. Interestingly, Soderman et al,30 with
Vol. 43, No. 2, 2015 Effectiveness of Neuromuscular Training Programs in Female Athletes 485

TABLE 2
Characteristics of Neuromuscular Intervention Programs and Training Regimensa

Neuromuscular Duration per

Author Intervention Frequency Timing Session, min Supervision
9
Hewett et al P, S, F 3/wk Preseason (6 wk) 60-90 Coaches
Heidt et al8 P, S, F 3/wk Preseason (7 wk) Not reported None
Soderman et al30 B 7/wk for 4 wk and then 1/wk In season 10-15 None
Myklebust et al18 P, B 3/wk, 1/wk Preseason (5-7 wk), in season 15, 15 Physical therapists
Mandelbaum et al14 P, S, F, A Before each game or practice Preseason, in season 20, 20 Coaches
Petersen et al23 P, B 3/wk, 1/wk Preseason (8 wk), in season 10, 10 Coaches
Pfeiffer et al24 P, A 2/wk In season 20 Coaches
Gilchrist et al5 P, S, F A 3/wk In season (12 wk) \30 Physical therapists
Steffen et al31 P, S, B, C Before 15 consecutive Preseason, in season 20, 20 Coaches, physical
training sessions therapists,
and then 1/wk ‘‘instructors’’
Kiani et al11 S, C, B, muscle 2/wk, 1/wk Preseason, in 20, 20 Physical therapists
activation season (8 mo)

a
A, agility; B, balance; C, core; F, flexibility; P, plyometrics; S, strength.

an intervention composed only of balance exercises, also
showed a significant increase in major injuries (which
included ACL injuries) in the trained group.
Reports of each neuromuscular training program esti-
mated time commitments of about 15 to 20 minutes
(excluding the Sportsmetrics program used by Hewett
et al,9 which took 60-90 minutes). The frequency of the pro-
grams varied depending on whether the exercises were
performed in the preseason or during the athlete’s regular
season. Four of the 7 authors who used a preseason proto-
col required programs to be performed 3 times per week.
Steffen et al31 did not specifically report preseason fre-
quency; instead, it was noted that athletes completed 15
consecutive training sessions before moving on to a once-
weekly protocol. Program frequency during the regular
season was typically 1 to 2 times per week. Gilchrist
et al5 used a higher frequency of 3 times per week during
the soccer season, and Soderman et al30 used a daily regi-
men for the first month of the season and then switched to
a 3-times weekly protocol. Interestingly, 3 of the 4 studies
that showed statistically significant decreases in the inci-
dence of ACL injuries used preseason training as part of
their intervention.5,9,14,18 In addition, 4 of the 5 studies
showing a trend toward a lower incidence of ACL injuries
in the intervention group also implemented their training
program during the preseason.8,11,23,31 The 2 studies that
showed a trend toward increased ACL injuries in the
trained group (Soderman et al30 and Pfeiffer et al24) used
the neuromuscular training program during the regular
season only. Because of the drastic time difference between
Hewett et al’s9 training sessions (60-90 minutes) compared
with the other neuromuscular training programs, it is dif-
ficult to make conclusions as to whether shorter or longer
workouts make a difference.
Incidence of ACL Injuries
Table 3 reports the incidence of ACL injuries in female ath-
letes for all 10 of our included studies. Incidence is
reported as the number of injuries per 1000 hours of expo-
sure unless stated otherwise. While there is clearly a trend
toward a lower incidence of ACL injuries in the interven-
tion group, only 2 authors (Hewett et al9 and Mandelbaum
et al14) achieved a statistically significant decrease in inju-
ries with neuromuscular training programs.
When comparing ACL injuries overall, Gilchrist et al5
did not achieve statistical significance. However, a sub-
group analysis did show a significant benefit to the inter-
vention program in some groups. Specifically, Gilchrist
et al5 looked at ACL injuries in intervention and control
groups during practices versus games, early versus late
in the season, and athletes with or without a history of
ACL injuries. They concluded that neuromuscular training
programs did significantly lower the incidence of ACL inju-
ries sustained in practices and late in the season. This may
be caused by the cumulative effects of the training pro-
grams. Neuromuscular training programs also signifi-
cantly lowered the incidence of noncontact ACL injuries
in athletes with a history of ACL injuries.
Myklebust et al18 also showed a statistically significant
decrease in ACL injuries only in a subgroup analysis,
which included elite female handball players. They also
demonstrated an overall significant reduction in noncon-
tact ACL injuries from the control season (n = 18) to inter-
vention season 2 (n = 7).
Soderman et al30 actually showed a significant increase
in major knee injuries (P = .02) in the intervention group.
In fact, 80% of the total ACL injuries occurred in this
group. Nevertheless, this increase in ACL injuries did not
reach statistical significance. Pfeiffer et al24 also showed
an increase in ACL injuries in the trained group, but
again, this did not reach statistical significance. This was
especially true when controlled for sport. The overall
ACL injury incidence in this study was doubled in the
trained group versus the control group (0.167 vs 0.078,
respectively). The incidence of ACL injuries in basketball
players was actually 4 times greater in the trained group
(0.476 vs 0.111, respectively). See Figure 2 for a comparison
486 Stevenson et al The American Journal of Sports Medicine

TABLE 3
Comparison of Sample Size, Number of Injuries, and Incidence of ACL Injuries per 1000 Hours of Exposurea

No. of ACL Injuries

(No. of Noncontact
Was There a Trend Statistical
No. of Athletes Injuries) Incidence
Toward Reducing Significance
Author Control Trained Control Trained Control Trained ACL Injuries? Reached
9
Hewett et al 463 366 5 (5) 2 (0) 0.22 0.12 Yes Yes
Heidt et al8 258 42 8 (NR) 1 (NR) — — Yes No, trend only
Soderman et al30 78 62 1 (NR) 4 (NR) 0.12 0.68 No (increased) No, trend only
Myklebust et al18 (elite control, 13 6, 5 2.82 1.09, 1.31 Yes Yes, for elite
intervention season 1,
intervention season 2)
Myklebust et al18 (control, 942 855, 850 29 (18) 23 (NR), 0.14 0.13, 0.09 Yes Nob
intervention season 1, 17 (7)
intervention season 2)
Mandelbaum et al14 1905, 1041, 32 (NR), 2 (NR), 0.47, 0.05, Yes Yes
1913 844 35 (NR) 4 (NR) 0.51 0.13
Petersen et al23 142 134 5 (5) 1 (0) 0.21 0.04 Yes No, trend only
Pfeiffer et al24 862 577 3 (3) 3 (3) 0.078, 0.167, No (increased) No, trend only
0.111c 0.476c
Gilchrist et al5 852 583 18 (10) 7 (2) 0.34 0.199 Yes Nod
Steffen et al31 1001 1091 5 (NR) 4 (NR) 0.08 0.06 Yes No, trend only
Kiani et al11 729 777 5 (NR) 0 (NR) 0.08 0 Yes Noe

a
ACL, anterior cruciate ligament; NR, not reported in studies.
b
Myklebust et al18 showed a statistically significant decrease in noncontact ACL injuries from control to intervention season 2 elite divi-
sion athletes.
c
Incidence of ACL injuries when looking at basketball alone.
d
Gilchrist et al5 did show a statistically significant reduction in ACL injuries in practices, late in the season, and with a history of ACL
injuries.
e
Kiani et al11 showed a statistically significant decrease in total knee injuries (which include ACL) but did not specify a statistical signif-
icance in ACL injuries alone.

able to show a statistically significant lower incidence

Figure 2. Incidence of anterior cruciate ligament injuries in
control (first bar) versus intervention (second bar) groups.
Incidence expressed as the number of injuries per 1000
hours of exposure. Heidt et al8 are not included because inci-
dences were provided as percentages.
of the incidence of ACL injuries in female athletes among
studies.
Contact Versus Noncontact ACL Injuries
Five studies reported injuries as contact or noncontact
(Table 3). Hewett et al9 and Myklebust et al18 were both
of noncontact injuries in the trained group, although
Myklebust et al’s18 program took 2 seasons to achieve
this. Gilchrist et al5 reported a trend toward a decreased
incidence of noncontact ACL injuries in the trained group,
but the results were not statistically significant. Pfeiffer
et al24 showed a trend toward an increased incidence of
noncontact ACL injuries with neuromuscular training.
Petersen et al23 also differentiated between types of inju-
ries. All of the injuries in their control group were noncon-
tact, while athletes in the trained groups suffered zero
noncontact injuries.
Compliance With Neuromuscular Training Programs
We were not able to fully assess the supervision and com-
pliance of neuromuscular programs among studies. While
we hypothesized that supervised programs with high com-
pliance would be the most useful, the information could not
accurately be obtained from all studies. Nine of the studies
attempted to monitor compliance, but the mode of evaluat-
ing this and documenting supervision varied. Four studies
had coaches supervising training programs and ensuring
compliance. Three studies had athletic trainers or physical
therapists in this role,5,18,31 while 2 studies had players
complete exercises unsupervised at home.8,30
Vol. 43, No. 2, 2015 Effectiveness of Neuromuscular Training Programs in Female Athletes
The other limitation to assessing compliance was that def-
initions for ‘‘acceptable’’ compliance varied across studies.
Steffen et al31 defined ‘‘compliant’’ as completing more than
20 sessions, while Myklebust et al18 used 15 sessions as their
cutoff. Kiani et al11 had coaches report whether their teams
completed 50%, 75%, or 100% of the sessions and included
the teams with 100% compliance into their subgroup analysis.
Three authors, in particular, performed subgroup anal-
yses based on compliance. Steffen et al31 and Myklebust
et al18 both showed no difference in overall ACL injury
rates between those who complied with the prescribed pro-
gram and those who did not. However, both authors noted
an overall low compliance rate in their studies, which may
have contributed to the finding of no difference between
the groups. Myklebust et al18 showed that the risk of an
ACL injury was reduced only in the elite group among com-
pliant athletes. Kiani et al11 reported overall ‘‘good’’ com-
pliance in their study and noted a decrease in knee
injuries when controlling for this.
DISCUSSION
Overall, the studies reviewed provided positive, but not
overwhelming, evidence that neuromuscular training pro-
grams can reduce the incidence of ACL injuries in female
athletes. Despite this trend, however, only Hewett et al9
and Mandelbaum et al14 were able to achieve statistically
significant differences in overall ACL injuries between
intervention and control groups.
Myklebust et al18 and Gilchrist et al5 achieved statisti-
cal significance in subgroup analyses only as noted in
Table 3. Myklebust et al18 found a statistically significant
decrease in noncontact ACL injuries from control to inter-
vention season 2 only in elite division athletes. Gilchrist
et al5 found a statistically significant reduction only in
ACL injuries in practices, late in the season, and those
with a history of ACL injuries. These programs could be
a useful adjuvant to training regimens, but according to
the current literature, their benefits should be interpreted
with caution. Although the risks of these programs appear
to be low, Soderman et al30 and Pfeiffer et al24 showed an
increase in ACL injuries in intervention groups. Thus,
while the data look promising, we cannot say with cer-
tainty that these programs are worthwhile.
In the first published systematic review on this topic,
Hewett et al10 concluded that there was a relative effec-
tiveness of intervention programs in reducing ACL injuries
in female athletes. While the data appeared promising in
2005, no study since then has been able to achieve a statis-
tically significant decrease in overall ACL injuries. While
we believe that neuromuscular training programs have
merit, our view is now more guarded. Hewett et al10
included 6 articles in their review, including an article by
Wedderkopp et al.33 We excluded this article because it
did not report on the incidence of ACL injuries specifically.
Our review features 5 articles that have been published
since this 2005 review, none of which achieved statistical
significance in showing an overall decreased incidence of
ACL injuries.5,11,23,24,31
487
Our current findings are similar to those of the recent
systematic review published in 2012.22 However, because
our focus was solely on ACL injury reduction, and not ath-
letic performance, we were able to include 4 additional
studies that looked at the effects of neuromuscular train-
ing on ACL injury incidence in female athletes.8,11,23,30
Furthermore, we have taken the additional steps of criti-
cally assessing each article utilizing a modified Downs
and Black quality rating scale as well as including some
subgroup analyses.2
Types of Intervention Programs
Our results suggest that plyometrics is an important com-
ponent of neuromuscular training programs. This may be
because plyometric work integrates many aspects of train-
ing including strength, agility, and balance. All of the
articles demonstrating some statistically significant reduc-
tion in ACL injuries included plyometrics as a key compo-
nent. Conversely, Soderman et al30 did not include
plyometrics as part of their program and noted an increase
in ACL injuries, as well as a statistically significant
increase in other major knee injuries, among the interven-
tion group. In addition, it appears that multifaceted pro-
grams incorporating different skill sets are most
beneficial. This is noted in the studies by Mandelbaum
et al,14 Gilchrist et al,5 and Hewett et al,9 who utilized 3
to 4 different modalities of training in their programs.
These studies also showed the most favorable results in
terms of lowering the incidence of ACL injuries in female
athletes. Conversely, the 2 studies showing the least favor-
able results (Soderman et al30 and Pfeiffer et al24) utilized
only 1 to 2 different training strategies.
Duration/Frequency of Intervention
It is unclear whether longer and/or more frequent training
sessions would allow an athlete to reap the greatest bene-
fit. Hewett et al9 (60-90 minutes) and Mandelbaum et al14
(20 minutes) did show good results using lengthy and fre-
quent programs, respectively. Conversely, Myklebust
et al18 were able to show significantly lower rates of non-
contact ACL injuries with just 15 minutes of specific train-
ing per week during the season. Petersen et al23
(10 minutes per week), Kiani et al,11 and Steffen et al31
(20 minutes per week) also suggest that brief programs
during the season may be sufficient to show benefit.
Although Hewett et al9 and Mandelbaum et al14 demon-
strated statistically significant decreases in ACL injuries,
it stands to reason that programs with larger time commit-
ments could be difficult to sustain over a longer period of
time. Most program designs had fairly comparable dura-
tions of training sessions (10-20 minutes) and frequencies
(1-3 times per week), and results did vary considerably.
The actual number of completed training sessions, which
was not reported in most studies, is likely more valuable
information than the prescribed number of sessions when
drawing conclusions about the effectiveness of programs.
This is where an analysis on compliance would be useful.
488 Stevenson et al
Timing of Interventions
Participation in neuromuscular training programs during
the preseason appears to be important for reducing ACL
injuries. The studies with statistically significant reduc-
tions in ACL injury rates (Hewett et al,9 Myklebust
et al,18 and Mandelbaum et al14) had athletes performing
preseason neuromuscular training. Pfeiffer et al24 and
Soderman et al,30 both of whom reported a trend toward
increased ACL injuries in trained athletes, did not include
a preseason component. No authors used neuromuscular
training programs as part of an off-season workout regi-
men. Further research is needed to look at the utility of
performing such programs in this time period.
Level of Sport
Few conclusions can be drawn about neuromuscular train-
ing programs and the level of sport. Only 3 studies
included professional or elite players.18,23,30 Myklebust
et al18 were the only authors to make conclusions based
on levels of professional athletics (elite vs Division I, Divi-
sion II, etc). Their results showed a statistically significant
decrease in ACL injuries in elite players only. This may be
because of longer seasons and more total training sessions,
better supervision of training sessions, and/or accessibility
to physical therapists. Presumably, elite athletes have
a greater motivation to train because more is at stake
(eg, financial loss) if an injury is sustained.
Type of Sport
Eight of our studies looked at soccer players, while the
remaining 2 evaluated handball athletes. Only Hewett
et al9 and Pfeiffer et al24 looked at ACL injuries in multiple
sports. Hewett et al’s9 study, however, had an uneven dis-
tribution of participants in the different sports between the
intervention and control groups. In their study, there were
fewer basketball and soccer players in the intervention
group than the control group (23% vs 41% and 27% vs
42%, respectively). Volleyball players, in contrast, made
up much more of the intervention group (17% of the control
vs 51% of the intervention group). Basketball and soccer
have recently been documented to have the highest ACL
injury rates among high school female athletes.27 This
unequal distribution of athletes and failure to control for
the sport may have biased the intervention group toward
lower injury rates, potentially exaggerating the benefits
of the intervention. Pfeiffer et al,24 who examined injury
rates between sports, noted an increased risk of ACL inju-
ries in basketball players who participated in the neuro-
muscular training programs. This leads us to believe that
although the current data view neuromuscular training
programs optimistically, we need to further evaluate their
benefit in a wider range of sports.
Compliance
When analyzing the potential benefits of neuromuscular
training programs, compliance should be clearly reported.
The American Journal of Sports Medicine
Despite what a program’s defined protocol may be, know-
ing how closely an athlete adhered to the program is a vital
piece of information. Some included studies did not com-
ment on compliance, while others did attempt to define
minimum acceptable levels of participation. The issue in
systematically reviewing the 10 studies is that definitions
of ‘‘acceptable’’ varied widely by author, which makes
a comparison difficult. In addition, the compliance rates
were often collected by players and/or coaches and so
may involve reporting bias. It would be unfortunate, and
potentially harmful, to discredit a program when the par-
ticipants may not have achieved enough ACL injury pre-
vention training to have shown a protective effect. On
the other hand, athletes have been known to train exces-
sively and therefore may have undertaken the program
more frequently than prescribed. This may give the
appearance of a positive effect, when in reality the pre-
scribed program may not have been rigorous enough to
provide benefit as it was originally written. Not having
uniform and complete compliance data is a major limita-
tion in evaluating this information and makes it difficult
to conclude whether the training program protocols are
truly beneficial or harmful.
Quality Rating
The quality of all included studies was rated utilizing the
modified Downs and Black scoring system (see Appendix
1, available in the online version of this article at http://
ajsm.sagepub.com/supplemental).2 There does not appear
to be a relationship between the quality of the study and
the effectiveness of a particular neuromuscular training
program in reducing ACL injuries. Although the narrow
range of scores makes this interpretation difficult, we
hypothesized that higher quality studies should have
been able to show similar effects of these training pro-
grams, whether positive or negative. Our results do not
support this hypothesis.
Limitations
The studies included in this review had several limitations.
The number of participants in each study was fairly low
(\1000 in each group), with the exception of Mandelbaum
et al.14 In addition, the overall number of ACL injuries was
low. This makes it difficult to draw firm conclusions.
Only 3 of the included studies were randomized con-
trolled trials, while 6 of the studies were observational pro-
spective (nonrandomized) cohort studies. Pfeiffer et al,24
for instance, allowed participants to choose which group
they would be in. This nonrandomization creates potential
discordance among groups and introduces inherent selec-
tion bias that is difficult to overlook.
No study had data available on characteristics of the
participants, including exact age, race, weight, or height.
All of these variables may be important to consider when
analyzing ACL injuries.4,32 Many studies also focused on
very specific and potentially homogeneous populations
(ie, Norwegian handball players,18 German handball play-
ers,23 Swedish soccer players30). There may be subtle
Vol. 43, No. 2, 2015 Effectiveness of Neuromuscular Training Programs in Female Athletes
nuances in these populations in terms of style and inten-
sity of play, types of drills and conditioning at practice,
body type, genetic variability, and other confounders that
make it difficult to generalize results worldwide.
Five studies did not comment specifically on contact ver-
sus noncontact ACL injuries.8,11,14,30,31 Presumably, neu-
romuscular training programs are designed to prevent
noncontact ACL injuries and may not affect those caused
by trauma. Finally, most studies did not comment on rates
of reinjury. Pritchett25 found that a single knee ligament
injury increased the likelihood of a subsequent injury to
the same knee by a factor of 3. Furthermore, Moretz
et al16 showed that young athletes with ACL injuries are
at an increased risk for reinjury. 26 From these data, one
could assume that a previously injured knee (ACL or other
injury) may be more susceptible to further damage. Neuro-
muscular training programs may have a larger benefit in
this population, as suggested by the Gilchrist et al5 sub-
group analysis, which showed a significant decrease in
ACL injuries among athletes with a history of ACL tears.
On the other hand, these athletes may increase the inci-
dence of ACL injuries in studies that do not control for pre-
vious knee injuries and may hide the potential benefit that
a program might offer.
Future Research
While current studies do have important implications for
ACL injury prevention, they have limitations. Future
research should aim to control for potential confounders
including sport, reinjury rates, mechanism of ACL injury,
age, and body characteristics of participants. In addition,
compliance rates need to be better recorded, and attempts
at randomizing study participants should be undertaken to
eliminate potential bias.
Conclusions and Implications for Practice
While the majority of the studies in this systematic review
suggest a trend toward a reduction in ACL injuries in
female athletes using a neuromuscular training program,
we cannot yet fully support its use because of the overall
lack of statistically significant evidence. We do not believe
that the current data are substantial enough to advocate
its widespread use. However, the overall risk appears to
be quite low in terms of injury, cost, and so on. The time
commitment on behalf of physicians, athletic trainers,
coaches, and athletes to implement and track these pro-
grams, as well as their comfort levels, needs to be consid-
ered and weighed against potential benefits when
deciding to implement these programs.
CLINICAL PEARLS
 There is moderate evidence that multifaceted neuromus-
cular programs involving preseason conditioning,
including plyometrics, may reduce the risk of ACL inju-
ries in female athletes.
489
 There is moderate evidence that neuromuscular pro-
grams that only utilize in-season conditioning do not
reduce ACL injuries in female athletes.
 There is moderate evidence that neuromuscular pro-
grams that only utilize proprioception or plyometrics
do not reduce ACL injuries in female athletes.
 Confounding variables and study limitations preclude
a definitive conclusion on the effectiveness of neuromus-
cular programs in reducing ACL injuries in female
athletes.
ACKNOWLEDGMENT
The authors acknowledge Judith Savageau, MPH, Univer-
sity of Massachusetts Department of Family and Commu-
nity Medicine, for help in article review.
An online CME course associated with this article
is available for 1 AMA PRA Category 1 CreditTM at
http://ajsm-cme.sagepub.com. In accordance with the
standards of the Accreditation Council for Continuing
Medical Education (ACCME), it is the policy of The Amer-
ican Orthopaedic Society for Sports Medicine that
authors, editors, and planners disclose to the learners
all financial relationships during the past 12 months
with any commercial interest (A ‘commercial interest’ is
any entity producing, marketing, re-selling, or distribut-
ing health care goods or services consumed by, or used
on, patients). Any and all disclosures are provided in
the online journal CME area which is provided to all par-
ticipants before they actually take the CME activity. In
accordance with AOSSM policy, authors, editors, and
planners’ participation in this educational activity will
be predicated upon timely submission and review of
AOSSM disclosure. Noncompliance will result in an
author/editor or planner to be stricken from participating
in this CME activity.
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