This systematic review compared neuromuscular training to any other intervention for preventing anterior cruciate injury in female athletes. Women were the focus of this evaluation because they are about three times more likely than men to injure their anterior cruciate ligament. The primary outcome was the number of anterior cruciate ligament injuries, but a precise definition of what was considered an anterior cruciate ligament injury was not provided. Meta-analysis was used to compare neuromuscular training to control conditions. In addition to determining the effectiveness of neuromuscular training, this review aimed to identify the common and effective components of anterior cruciate ligament neuromuscular training programs using meta-regression.

Prospective controlled trials were identified using sensitive searches in two databases (PubMed/Medline and CINAHL Plus). The PEDro scale was used to evaluate the risk of bias of the included trials. The review included 18 articles reporting the results for 20 trials (26,925 participants), 11 randomised controlled trials and nine non-randomised controlled trials. The mean PEDro score was 5.5 out of 10 (standard deviation 2.3). The average training dose was 57 sessions over 18.2 hours (or 24 minutes/session for 2.5 sessions/week). All neuromuscular training programs included instruction on proper program implementation for those carrying out the training. The included trials were conducted in soccer (n=7), handball (n=5), basketball (n=3), floorball (n=1) and mixed (n=4) sports in school (n=10), professional (5 trials), university (3 trials) and mixed-level (2 trials) athletes.

Compared to control interventions, neuromuscular training reduced the risk of anterior cruciate ligament injury from 1 in 54 to 1 in 111 (odds ratio 0.51; 95% confidence interval (CI) 0.37 to 0.69). Unfortunately the outcomes were not reported relative to exposure. Meta-regression indicated that the dose of neuromuscular training did not impact on injury risk, but the timing of training may be important. Neuromuscular training conducted only in the pre-season did not reduce the risk of anterior cruciate ligament injury (OR 0.59, 95% CI 0.16 to 2.15), while in-season only or combined pre-season and in-season training did reduce the risk of injury (OR 0.50, 95% CI 0.36 to 0.70). Programs targeting school-aged athletes had a larger effect (OR 0.38, 95% CI 0.24 to 0.60) than in older athletes (OR 0.65, 95% CI 0.48 to 0.89). Programs that contained knee stabilisation during landing and lower limb strengthening exercises were more effective than programs that did not contain these exercises. Programs that included balance, core-strengthening, stretching, or agility exercises were no more effective than programs that did not incorporate these components.

The review concluded that neuromuscular training reduces anterior cruciate ligament injury in female athletes. Data from the meta-regression were used to produce a best-practice checklist that can be used to evaluate neuromuscular training programs.

Petushek EJ, et al. Evidence-based best-practice guidelines for preventing anterior cruciate ligament injuries in young female athletes: a systematic review and meta-analysis. Am J Sports Med 2019;47(7):1744-53

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