Anterior Cruciate Ligament Injuries in Female Athletes: Part 2, A Metaanalysis of Neuromuscular Interventions Aimed at Injury Prevention. Am J Sports Med

Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 10001, Cincinnati, OH 45229, USA.
The American Journal of Sports Medicine (Impact Factor: 4.36). 03/2006; 34(3):490-8. DOI: 10.1177/0363546505282619
Source: PubMed


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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Available from: Timothy E Hewett, Jan 25, 2016
    • "Neuromuscular reeducation techniques have been successfully used in rehabilitation for other chronic injury populations—specifically, after anterior cruciate ligament (ACL) reconstruction and in rehabilitation for patients following ankle sprain (Hewett et al., 2006;Myer et al., 2008;O&apos;Driscoll and Delahunt, 2011;Williams et al., 2001). Emphasizing pelvic stability during functional tasks (e.g., single limb standing, walking, running, and hopping) effectively improves gait mechanics (O'Driscoll and Delahunt, 2011), increases hip abductor strength (Myer et al., 2008), increases joint stability (Williams et al., 2001), and prevents further injury (Hewett et al., 2006). The findings of this case series support that these techniques may also be successful in a post-THA population, expanding the utility of these training techniques and improving movement quality for these patients. "
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    ABSTRACT: Background: Following total hip arthroplasty, patients demonstrate compensatory movement strategies during activities of daily living such as walking and stair climbing. Movement compensations are important markers of functional decline in older adults and are related to poor functional capacity. Despite increased utilization of hip arthroplasty, persistent movement compensation, and functional performance deficits, no consensus on postoperative rehabilitation exists. Neuromuscular reeducation techniques offer a strategy to improve movement quality by emphasizing hip abductor performance and pelvic stability. This case series illustrates changes in movement strategy around the hip in response to targeted neuromuscular reeducation techniques after hip arthroplasty. Methods: Five participants received an 8-week exercise program following total hip arthroplasty, emphasizing targeted neuromuscular reeducation techniques hallmarked by specific, weight-bearing exercise to improve hip abductor performance and pelvic stability. Five additional participants were supervised and followed for comparison. Findings: Participants in the neuromuscular reeducation program improved their internal hip abductor moments and vertical ground reaction forces during walking and stair climbing. They also improved their functional performance and hip abductor strength outcomes. Interpretation: Targeted neuromuscular reeducation techniques after total hip arthroplasty provided a positive effect on biomechanical outcomes, functional performance, and muscle strength. Through focused use of the hip abductor muscles, increased internal hip abductor moments were observed. This intervention potentially promotes pelvic stability, and may contribute to improved performance on tasks such as stair climbing, fast walking, and balance. The results suggest that neuromuscular reeducation offers a unique effect on movement strategy and function for patients following total hip arthroplasty.
    No preview · Article · Dec 2015 · Clinical biomechanics (Bristol, Avon)
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    • "Despite the modest success of anterior cruciate ligament(ACL) injury prevention efforts (Hewett et al., 2006; Yoo et al., 2010), the precise injury mechanism(s) and most appropriate factors to be targeted via these efforts remain unclear (Griffin et al., 2006), and injury surveillance over nearly two decades indicates that ACL injury rates have not changed (Agel et al., 2005; Arendt and Dick, 1995; Hootman et al., 2007). However, numerous investigations have established that anterior tibial translation and shear force, and knee valgus motion and moment result in ACL loading (DeMorat et al., 2004; Li et al., 1999; Markolf et al., 1995; Withrow et al., 2006), thus minimizing these ACL loading mechanisms would seemingly limit ACL injury risk. "
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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.
    Full-text · Article · Oct 2013 · Clinical biomechanics (Bristol, Avon)
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    • "season . It would be interesting to assess the effects of plyometrics in a longer duration training program . Similarly the study of Hewett et al . ( 1999 ) was also performed for only 6 weeks . It is interesting that for the volleyball players , no ACL injuries were noted either in the control or the intervention groups in both relevant studies ( Hewett et al . , 1999 ; Pfeiffer et al . , 2006 ) . This finding may be attributed to the biomechanics of volleyball not exposing athletes to injury , as there is a low incidence rate of ACL injury in volleyball from epidemiologic studies ( Hootman et al . , 2007 ) ."
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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.
    Full-text · Article · Jan 2013 · Physical Therapy in Sport
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