Anterior cruciate ligament injuries in female athletes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention.

Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 10001, Cincinnati, OH 45229, USA.
The American Journal of Sports Medicine (Impact Factor: 4.7). 03/2006; 34(3):490-8. DOI: 10.1177/0363546505282619
Source: PubMed

ABSTRACT Female athletes have a 4 to 6 times higher incidence of anterior cruciate ligament injury than do male athletes participating in the same landing and pivoting sports. This greater risk of anterior cruciate ligament injury, coupled with a geometric increase in participation (doubling each decade), has led to a significant rise in anterior cruciate ligament injuries in female athletes. The gender gap in anterior cruciate ligament injury, combined with evidence that the underpinnings of this serious health problem are neuromuscular in nature, leads to the development of neuromuscular interventions designed to prevent injury. A systematic review of the published literature yielded 6 published interventions targeted toward anterior cruciate ligament injury prevention in female athletes. Four of 6 significantly reduced knee injury incidence, and 3 of 6 significantly reduced anterior cruciate ligament injury incidence in female athletes. A meta-analysis of these 6 studies demonstrates a significant effect of neuromuscular training programs on anterior cruciate ligament injury incidence in female athletes (test for overall effect, Z = 4.31, P < .0001). Examination of the similarities and differences between the training regimens gives insight into the development of more effective and efficient interventions. The purpose of this "Current Concepts" review is to highlight the relative effectiveness of these interventions in reducing anterior cruciate ligament injury rates and to evaluate the common training components between the training studies. In addition, the level of rigor of these interventions, the costs and the difficulty of implementation, the compliance with these interventions, and the performance benefits are discussed. This review summarizes conclusions based on evidence from the common components of the various interventions to discuss their potential to reduce anterior cruciate ligament injury risk and assess their potential for combined use in more effective and efficient intervention protocols.

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    ABSTRACT: Greater hamstring musculotendinous stiffness is associated with lesser anterior cruciate ligament loading mechanisms during both controlled joint perturbations and dynamic tasks, suggesting a potential protective mechanism. Additionally, lesser hamstring stiffness has been reported in females, potentially contributing to their greater risk of anterior cruciate ligament injury. However, the factors which contribute to high vs. low stiffness are unclear. Muscle geometry and architecture influence force production and may, therefore, influence stiffness. The purpose of this investigation was to evaluate the contributions of geometric and architectural muscle characteristics to hamstring stiffness. Thirty healthy individuals (15 males, 15 females) volunteered for participation. Biceps femoris long head cross-sectional area, pennation angle, fiber length, tendon stiffness, and posterior thigh fat thickness were assessed via ultrasound imaging, and strength was measured via isometric contraction. Stiffness was assessed via the damped oscillatory technique. Following normalization to anthropometric factors, only strength (r=0.535) and posterior thigh fat thickness (Spearman ρ=-0.305) were correlated with stiffness. Normalized tendon stiffness (0.06 vs. 0.10N/m·kg(-1)) and strength (7.1 vs. 10.0N·kg(-1)) were greater in males, while posterior thigh fat thickness (10.4 vs. 5.0mm) was greater in females. Greater posterior thigh fat thickness may influence stiffness by contributing to greater intramuscular fat and shank segment mass, and lesser muscle per unit mass in the thigh segment. These findings suggest that training designed to increase hamstring strength and decrease fat mass may be beneficial for anterior cruciate ligament injury prevention.
    Clinical biomechanics (Bristol, Avon) 10/2013; DOI:10.1016/j.clinbiomech.2013.10.011
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    ABSTRACT: Background Anterior Cruciate Ligament (ACL) injury is frequently encountered in sports. Purpose To analyze the effects of ACL injury prevention programs, on injury rates in female athletes between different sports. Methods A comprehensive literature search was performed in September 2012 using Pubmed Central, Science Direct, CINAHL, PEDro, Cochrane Library, SCOPUS, SPORTDiscus. The key words used were: ‘anterior cruciate ligament’, ‘ACL’, ‘knee joint’, ‘knee injuries’, ‘female’, ‘athletes’, ‘neuromuscular’, ‘training’, ‘prevention’. The inclusion criteria applied were: (1) ACL injury prevention training programs for female athletes; (2) Athlete–exposure data reporting; (3) Effect of training on ACL incidence rates for female athletes. Results 13 studies met the inclusion criteria. Three training programs in soccer and one in handball led to reduced ACL injury incidence. In basketball no effective training intervention was found. In season training was more effective than preseason in ACL injury prevention. A combination of strength training, plyometrics, balance training, technique monitoring with feedback, produced the most favorable results. Conclusion Comparing the main components of ACL injury prevention programs for female athletes, some sports-dependent training specificity issues may need addressing in future studies, related primarily to the individual biomechanics of each sport but also their most effective method of delivery.
    Physical Therapy in Sport 01/2013; DOI:10.1016/j.ptsp.2013.12.002
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    ABSTRACT: Knee injuries are highly prevalent in athletic populations, particularly among female athletes. Many of these injuries occur during landing from a jump. Various comprehensive knee injury prevention programs have been developed to date. However, there is a need to determine which components of these programs contribute directly to changes in knee biomechanics. Therefore, the purpose of this study was to investigate the immediate effect of three different simple verbal instructions on knee biomechanics during landing in adult female recreational athletes. Three-dimensional kinematic and kinetic analysis of landing from a countermovement jump was conducted in a counterbalanced cross-over repeated measures design. Results indicated that the instruction to land with equal weight distribution reduced the asymmetry of peak vertical ground reaction force compared to the control condition. The instruction to land softly reduced peak vertical ground reaction force and increased peak knee flexion compared to the control condition. The instruction to land with knees over toes increased peak knee flexion compared to the control condition. These findings indicate that verbal instruction may be a key component of the effects seen in previous research studies that have investigated the benefits of more complex training programs designed to reduce knee injury risk in female athletes.
    The Knee 06/2011; 19(4):399-403. DOI:10.1016/j.knee.2011.05.005


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