Superior compliance with a
neuromuscular training programme is associated with fewer ACL injuries and
fewer acute knee injuries in female adolescent football players: secondary
analysis of an RCT

Hagglund, Isam Atroshi, Philippe Wagner, Markus Walden. Published Br J Sport Medicine: 2013 Oct; 47(15):974-9. doi:
10.1136/bjsports-2013-092644. Epub 2013 Aug 20

Take Home Message: Neuromuscular
training programs have shown to significantly reduce the number of ACL injuries.
Previous literature identified that a young starting age has the greatest protective
benefit for ACL injuries. This study added to the existing evidence that high
compliance with NMT programs is another key factor in reducing ACL injuries.

training (NMT) has established its role in injury prevention, especially at the
knee. It is known that the initiation of NMT at a young age leads to more
effective injury prevention; however other factors such as compliance have not
had such support in the literature. Therefore, Hagglund et al. investigated
compliance with NMT programs as another key element in successful knee injury
prevention. Hagglund performed a sub-study of a previously published randomized control trial,
which examined the use of NMT programs for the prevention of acute knee injuries
in adolescent female soccer players. The end points for Hagglund’s analysis
were anterior cruciate ligament (ACL) injury rate for the primary outcome, acute
knee injury, and severe knee injury (caused a greater then four week absence).
The study population consisted of 2471 athletes in the intervention group and
2085 athletes in the control group. The intervention group was further
subdivided into low, intermediate, and high compliance groups based on their
completion of NMT sessions per week. Decreasing compliance was observed for the
individual player (~ -5% per month) over the course of the season, as well as
attendance of practice sessions (~ -2% per month). The decrease in practice
attendance rates was most noticed in the intermediate compliance tertile
(decrease by 12%) and low compliance tertiles (decrease by 29%), while the high
compliance tertile only showed a decrease of 5%. Injury rates showed a
significant reduction (88%) in ACL injury between the high compliance and low
compliance tertiles of the individual athlete group. The rate reduction of
severe or acute knee injuries in the high and intermediate compliance tertiles
was between 72% and 90% when compared to the low compliance tertile.

of this study suggest that compliance is another key limiting factor of NMT
programs in the prevention of knee injuries. One advantage of such warm-up
programs is that it can be implemented and monitored by the coaching staff,
which in turn can also pose a problem. The coaching staff at times is only
interested in short term success and may place the potential of significant
knee injuries second. Adolescent athletes or ones that do not compete on the
highest level may not recognize the importance of warm-up programs, and as a
result, may not perform them correctly or at all. Hagglund provides a feasible
solution to maximizing the exposure to NMT programs, by implementing it for
every practice, which guarantees that each athlete is exposed to such warm-up
programs. A previous study by Myer concluded that
implementation of NMT programs for adolescent female athletes ages 14 to 18 years
shows the greatest benefit in ACL injury prevention. Judging by those two
studies, age and compliance are important factors for a successful NMT program,
however questions for the durability of NMT benefits remains.

Questions for Discussion: How can
compliance with NMT programs be increased and maintained over the course of a
season? How many NMT sessions per week are necessary to obtain the greatest
benefit? How can exposure to NMT programs be increased?

by: Stephen Thomas


Hägglund M, Atroshi I, Wagner P, & Waldén M (2013). Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT. British Journal of Sports Medicine, 47 (15), 974-9 PMID: 23962878