This article was downloaded by: [University North Carolina - Chapel Hill]

On: 09 August 2012, At: 11:12

Publisher: Taylor & Francis
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Research in Sports Medicine: An

International Journal
Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/gspm20

Prevention of ACL Injury, Part II: Effects

of ACL Injury Prevention Programs on
Neuromuscular Risk Factors and Injury
Rate
a b c d
Boyi Dai , Daniel Herman , Hui Liu , William E. Garrett & Bing
a
Yu
a
Center for Human Movement Science, Division of Physical Therapy,
University of North Carolina, Chapel Hill, North Carolina, USA
b
Department of Physical Medicine & Rehabilitation, School of
Medicine, University of Virginia, Charlottesville, Virginia, USA
c
Sports Biomechanics Laboratory, School of Human Movement
Science, Beijing Sports University, Beijing, China
d
Sports Medicine Center, Duke University Medical Center, Durham,
North Carolina, USA

Version of record first published: 28 Jun 2012

To cite this article: Boyi Dai, Daniel Herman, Hui Liu, William E. Garrett & Bing Yu (2012): Prevention
of ACL Injury, Part II: Effects of ACL Injury Prevention Programs on Neuromuscular Risk Factors and
Injury Rate, Research in Sports Medicine: An International Journal, 20:3-4, 198-222

To link to this article: http://dx.doi.org/10.1080/15438627.2012.680987

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions

This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representation
that the contents will be complete or accurate or up to date. The accuracy of any
instructions, formulae, and drug doses should be independently verified with primary
sources. The publisher shall not be liable for any loss, actions, claims, proceedings,
 demand, or costs or damages whatsoever or howsoever caused arising directly or
indirectly in connection with or arising out of the use of this material.
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012
 Research in Sports Medicine, 20:198–222, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1543-8627 print/1543-8635 online
DOI: 10.1080/15438627.2012.680987

Prevention of ACL Injury, Part II: Effects of ACL

Injury Prevention Programs on Neuromuscular
Risk Factors and Injury Rate

BOYI DAI
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

Center for Human Movement Science, Division of Physical Therapy, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

DANIEL HERMAN
Department of Physical Medicine & Rehabilitation, School of Medicine,
University of Virginia, Charlottesville, Virginia, USA

HUI LIU
Sports Biomechanics Laboratory, School of Human Movement Science,
Beijing Sports University, Beijing, China

WILLIAM E. GARRETT
Sports Medicine Center, Duke University Medical Center, Durham, North Carolina, USA

BING YU
Center for Human Movement Science, Division of Physical Therapy, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

Prevention strategies have been developed based on existing

knowledge in an attempt to alter neuromuscular control and
lower extremity biomechanics in order to reduce anterior cruci-
ate ligament (ACL) injury rates. These strategies have included
different training programs ranging from injury education to
multicomponent training. Many training programs have been
demonstrated as resulting in altered lower extremity movement
patterns. The effects of current training programs on ACL injury
rate, however, are inconsistent. This review was focused on the
effects of current ACL injury training programs on neuromuscular
risk factors and ACL injury rate. Recommendations were made

Received 16 August 2011; accepted 26 December 2011.

Address correspondence to Bing Yu, Division of Physical Therapy, CB# 7135 Bondurant
Hall, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599. E-mail: byu@med.
unc.edu

198
 Prevention of ACL Injury, Part II 199

based on the available evidence for clinicians and coaches to

implement ACL injury prevention programs.

KEYWORDS anterior cruciate injury, injury mechanisms, risk

factors, biomechanics, prevention

Although anterior cruciate ligament (ACL) injury risk factors are still not
entirely clear, prevention strategies and training programs have been devel-
oped based on existing knowledge in an attempt to alter neuromuscular
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

control and lower extremity biomechanics in order to reduce ACL injury

rates. This review was focused on the effects of current ACL injury training
programs on neuromuscular risk factors and ACL injury rates.

EFFECTS OF ACL INJURY PREVENTION PROGRAMS ON

NEUROMUSCULAR RISK FACTORS

Most of the strategies and training programs for ACL injury prevention in cur-
rent literature have been demonstrated as resulting in altered lower extremity
movement patterns (Table 1). Application of these positive results, how-
ever, has been limited by the comprehensive nature of the programs. Most
of these programs employ several different training components ranging
from plyometrics to balance training to strength training; as such, we have a
limited appreciation for how these components act individually and in con-
cert, which may limit both the efficiency and efficacy of these interventions.
Furthermore, these programs may have different effects in different ages,
sports, levels of play, and risk factor groups. Understanding the mechanism
of action of these injury prevention strategies and their effects in different
populations will help scientists and clinicians improve existing programs and
develop new strategies in future research and clinical practice.

INJURY EDUCATION

Technical and physical training strategies may not be the only meth-
ods of improving landing techniques. A recent study demonstrated that
increasing knowledge of ACL injury could also improve landing tech-
niques for the purpose of preventing ACL injury (Iversen & Friden, 2009).
A total of 133 female high school basketball players and 12 coaches
participated in this study. The anatomy and function of the knee and
ACL, possible risk factors for ACL injury, ACL injury prevention strate-
gies, and appropriate landing techniques were presented to the players
and coaches during the season. Players’ and coaches’ knowledge of ACL
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

TABLE 1 Effects of Injury Prevention Programs on Neuromuscular Risk Factors

General training Specific training Training frequency

modality References modality and duration Training effects Limitations

Injury education Iversen and Friden, Education regarding One 45-minute Increased percentage of No control group;
2009 ACL injury didactic and good landings during Only one study
knowledge, skill-based games with basketball
prevention strategies, presentation players
and landing
techniques
Feedback training Prapavessis and Augmented or sensory Immediate feedback Augmented feedback Only immediate
McNair, 1999 feedback decreased peak effects in
ground reaction force laboratory settings
during landing
Onate et al., 2005 Video based expert The self feedback and
feedback, combined feedback
self-feedback or increased knee flexion

200
combined feedback and decreased peak
ground reaction force
during landing
Dempsey et al., Verbal instruction Keeping the foot to the
2007 midline and the torso
upright reduced peak
knee valgus and
internal rotation
moments during
cutting
Dempsey et al., Verbal and visual 15 minutes / session, Training decreased peak No control group
2009 feedback 2 sessions / week, knee valgus moment
6 weeks during cutting
Strength training Herman et al., 2008 Progressive resistance 3 sessions / week, No differences in knee Strength training
training for lower 9 weeks and hip kinematics and was conducted
extremity muscles kinetics during a during less
stop-jump functional tasks
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

Herman et al., 2009 Feedback with or Immediate feedback Feedback decreased Only immediate
without strength peak vertical ground feedback effects
training reaction force and in laboratory
increased knee flexion, settings
hip flexion, and hip
abduction during a
stop-jump. Increased
hip abduction angle
and decreased peak
knee anterior shear
force were only
observed in the
strength trained group.
Cochrane et al., Machine-based leg curl 30 minutes / session, Machine-based training Limited exercise for
2010 and leg pressing; 3 sessions/ week, increased the knee the strength
free-weights leg curl 12 weeks external flexion training; gain in
and squat; balance moment and decreased individual muscle
training; combined peak valgus moment strength was

201
machine-based during the landing of unknown.
strength and balance cutting; free-weights
training training increased the
internal rotation
moment, and
decreased knee flexion
during the take-off of
cutting; balance
training group reduced
peak valgus and
internal rotation
moments during the
landing of cutting; the
combined group
showed no change.
(Continued)
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

TABLE 1 (Continued)

General training Specific training Training frequency

modality References modality and duration Training effects Limitations

Plyometric Hewett et al., 1996 Progressive training 2 hours / session, Training decreased peak Small sample size;
training including technique, 3 sessions / week, landing force, knee time and
fundamental, and 6 weeks adduction angle, and resources
performance phases abduction moments consuming
during a volleyball
block jump
Vescovi, Canavan, Progressive training 40–60 minutes / Training decreased peak
and Hasson, 2008 including technique, session, 3 sessions / ground reaction force
fundamental, and week, 6 weeks by 7.4% during landing
performance phases
Myer et al., 2006 Maximum effort 90 minutes / session, Both training reduced hip

202
plyometric training 3 sessions / week, adduction, knee
with feedback; 6 weeks abduction, maximum
balance and ankle eversion, and
stabilization training increased knee flexion
with feedback during drop vertical
jump or medial drop
jump
Irmischer et al., Progressive jump 20 minutes / session, Training decreased peak Small sample size
2004 landing training 2 sessions / week, vertical forces and rate
9 weeks of force development
during landing
Zebis et al., 2008 Progressive plyometric 20 minutes / session, Training increased Small sample size
and balance training 2 sessions / week, semitendinosus EMG
18 weeks before landing; no
changes in kinematics
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

Multi-component Myer et al., 2005 Plyometric and 90 minutes / session, Training increased range Time and resources
training movement, core 3 sessions / week, of knee flexion motion consuming
strengthening and 6 weeks and decreased
balance, resistance maximum knee
training, and speed valgus/varus torques
training during landing.
Lephart et al., 2005 Flexibility, resistance, 30 minutes / session, Training increased knee Small sample size
balance, and 3 sessions / week, and hip flexion angles,
plyometric exercises 8 weeks decreased knee and
hip external flexion
moments, and gluteus
medius EMG during
prelanding
Pollard et al., 2006 PEP: warm-up, 15–20 minutes / Training decreased hip No control group
stretching, session, 2–3 sessions internal rotation and

203
strengthening, / week, one soccer increased hip
plyometrics, and season abduction during a
agility exercises landing
Lim et al., 2009 PEP 20 minutes / session, Training increased knee Small sample size
all training sessions, flexion angle, inter
one basketball knee distance, and
season decreased hamstring-
to-quadriceps EMG
ratio and maximum
knee extension
moments during a
landing
(Continued)
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

TABLE 1 (Continued)

General training Specific training Training frequency

modality References modality and duration Training effects Limitations

Chappell and Core strengthening, 10–15 minutes / Training decreased knee No control group
Limpisvasti, 2008 dynamic stability, session, 6 sessions / valgus moment during
balance, jump, and week, 6 weeks a stop jump and

204
plyometric exercises increased knee flexion
during a drop jump
task
Grandstrand et al., Plyometrics, strength, 20 minutes / session, No significant changes in Small sample size;
2006 and flexibility 2 sessions / week, knee separation knee separation
exercises 8 weeks was the only
kinematic variable
 Prevention of ACL Injury, Part II 205

injury, attitude toward ACL injury prevention, as well as players’ landing

techniques were evaluated at the beginning and end of the season. After the
intervention, players and coaches significantly increased their knowledge of
ACL injury, but they did not change their attitude toward ACL injury preven-
tion. In addition, the percentage of good landings significantly increased.
Although this study has demonstrated the potential role of education in ACL
injury prevention programs, well designed clinical trials with control group
and quantitative evaluation of landing techniques are needed to confirm the
effects of injury education.
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

FEEDBACK TRAINING

Feedback training is a commonly used method to teach and learn physi-

cal techniques. Feedback training can be used as an intervention to change
motor control strategies such as movement biomechanics to perform those
athletic tasks in which ACL injury frequently occurs. Prapavessis and McNair
(1999) studied the effects of augmented and sensory feedback on the lower
extremity kinematics and kinetics in drop landing tasks. Subjects in the
augmented feedback group received instructions regarding their landing
techniques. Subjects in the sensory group relied on their own feeling to land
softly. The augmented feedback group significantly decreased their verti-
cal ground reaction force after training, while the sensory feedback group
showed no change. Onate et al. (2005) investigated different video feedback
on jump landing techniques. The expert feedback group viewed a trained
expert conducting jump landing tasks. The self-feedback group viewed their
own jump landing tasks. The combined feedback group viewed both the
expert’s and their own jump landing tasks. A nonfeedback group served
as the control group. The self-feedback and combined feedback groups had
more knee flexion and less peak ground reaction force than the expert feed-
back and control groups. Dempsey et al. (2007) studied the effects of trunk
lean angle and frontal and transverse plane foot placement on knee flex-
ion angle and knee moment in a side cutting task, and they later reported
that training subjects to appropriately position the support foot and torso
in cutting tasks significantly reduced peak valgus moment during the land-
ing phase of cutting tasks (Dempsey, Lloyd, Elliott, Steele, & Munro, 2009).
These studies have demonstrated that feedback training could be very effec-
tive at providing immediate alterations to lower extremity motion patterns.
It should be noticed, however, that these studies only showed the immedi-
ate or short term effects of feedback training in laboratory settings. The long
term retention of the training effects is still not clear. Considering most of
the athletic tasks and sports techniques are complicated movements, studies
are needed to determine retention of the effects of feedback training and
 206 B. Dai et al.

the time and intensity of feedback required to integrate the changes into
competitive athletic practice.

STRENGTH TRAINING

Strength training is a common component in regular training programs.

Previous studies suggest that strength training alone might not be suffi-
cient to positively alter biomechanical risk factors associated with ACL injury
(Cochrane et al., 2010; Herman et al., 2008). When combined with feedback
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

training, however, strength training could increase the capacity of athletes

to improve their movement patterns. Herman et al. (2009) investigated the
effects of feedback training with or without strength training on lower
extremity biomechanics. The subjects in the strength training group com-
pleted a 9-week program targeting the thigh and hip muscles of recreational
female athletes. After completing technical training using the “combined”
augmented feedback technique as described by Onate et al. (2005), the
peak vertical ground reaction force decreased and knee flexion, hip flexion,
and hip abduction increased in both the strength trained and non-strength
trained groups; however, increased hip abduction angle and decreased peak
knee anterior shear force were only observed in the strength trained group
after the technical training. These studies suggest that although strength
training alone does not alter lower extremity kinematics and kinetics in
athletic tasks, it may improve the magnitude of effect achieved by feed-
back training. In contrast, Cochrane et al. (2010) studied the effects of
12-week balance and weight training on knee angles and moments during
running, sidestepping, and cross stepping tasks in male rugby athletes. The
balance training group decreased peak valgus and peak internal moments,
but weight training tended to increase the applied knee load. The lack of an
additive effect from strength training in the study by Cochrane et al. (2010)
compared with the findings by Herman et al. (2009) is noteworthy due to
the differences in the subject populations in terms of gender (male versus
female) and activity level (competitive versus recreational). It is possible
that the lack of an additive effect in the study by Cochrane et al. (2010) is
that their subjects already possessed sufficient strength for the study task,
which was much more unlikely in the study by Herman et al. (2009), par-
ticularly given the level of strength gains (as high as 50%). Differences also
existed in terms of the intervention strategy to which strength training was
an addition (balance versus feedback training). Strength training may be a
more effective and efficient investment as an injury prevention strategy in
populations in which strength deficits are more likely and/or are in con-
junction with a limited set of other strategies. The contrasts between these
two studies underscore the importance of having a better understanding
 Prevention of ACL Injury, Part II 207

as to how different strategies interact with one another and affect different
populations.

PLYOMETRIC TRAINING

Plyometric training is a physical training method to improve power and

speed, and it is also commonly included in ACL injury prevention programs.
Several studies investigated the effects of high density plyometric training on
lower extremity motion patterns. Hewett, Stroupe, Nance, and Noyes (1996)
studied the effects of a 6-week plyometric training program on lower extrem-
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

ity biomechanics during landing in female high school volleyball players.

Peak landing force, knee adduction angle, and abduction moment decreased
after the training. By using similar interventions as Hewett et al. (1996),
Vescovi, Canavan, and Hasson (2008) reported a reduction in vertical ground
reaction force after the training in college females. Myer, Ford, Brent, and
Hewett (2006) investigated the effects of a similar plyometric training proto-
col on lower extremity biomechanics of high school female athletes during
two landing tasks. After the training, the subjects had decreased maximum
ankle eversion, knee abduction, and hip adduction angles. The training also
increased initial knee flexion angle. These studies demonstrate the ability
of high intensity plyometric training to produce robust positive alterations
in neuromuscular characteristics associated with ACL injury, and should be
considered as a core component for ACL injury prevention programs.
The effects of low intensity plyometric training on lower extremity
motion patterns were also investigated. Irmischer et al. (2004) studied the
effects of a knee ligament injury prevention program on impact force in
active women. The subjects in the intervention group received a 9-week
training with a focus on power and technique training for lower extrem-
ity alignment during jumping and landing tasks. Significant reductions were
observed in peak vertical impact force during landing. Zebis et al. (2008)
studied the effects of an 18-week plyometric and balance training pro-
gram on knee and hip angles and muscle activities during side-cutting.
They reported significantly increased semitendinosus EMG before and dur-
ing landing, but no changes were observed in quadriceps and gastrocnemius
EMG, and knee and hip angles. These studies suggest that low intensity
plyometric trainings have small effects on lower extremity biomechanics
that affect ACL loading. The lack of robust significant findings in these stud-
ies underscores the importance of gaining better insight into appropriate
training intensity and volume.

MULTICOMPONENT TRAINING

Attempting to maximize training effects, many neuromuscular training pro-

grams have included different combinations of strength training, plyometric
 208 B. Dai et al.

training, balance training, and feedback training in an attempt to maximize

training effects on lower extremity motion patterns and the risk for ACL
injury. Myer, Ford, Palumbo, and Hewett (2005) studied a comprehensive
6-week neuromuscular training program on performance and lower extrem-
ity biomechanics for female athletes. In addition to performance gains,
subjects in the intervention group had increased range of knee flexion
motion and decreased maximum knee valgus/varus moment. This study
suggests that high intensity and long duration comprehensive neuromuscular
training with high clinician to subject ratios can significantly decrease biome-
chanical risk factors and increase performance. This type comprehensive
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

training program is clinician intensive and requires a lot of time and

resources, however, which may limit their applications in clinical practice
and to large recreational athletes who do not have access to the required
clinical personnel and training facilities.
Lephart et al. (2005) compared the effects of an 8-week combined
plyometric and basic resistance training program on neuromuscular and
biomechanical characteristics in high school female athletes. Subjects in
the group with the plyometric training component demonstrated increased
knee and hip flexion angles, decreased knee and hip flexion moments, and
increased prelanding EMG of gluteus medius. This study seems to suggest
that the plyometric training is an important component in multiple com-
ponent training programs. It is not quite clear, however, if the changes in
movements in this study were due to plyometric training or the combination
of plyometric training with other training components.
To improve the efficiency of the training programs and compliance, sev-
eral studies replaced traditional warm-up protocols with comprehensive ACL
prevention training. The most-studied warm-up program for ACL injury pre-
vention is the Santa Monica Prevent Injury Enhance Performance Program
(PEP; Mandelbaum et al., 2005). The PEP is a 15–20 minute warm-up rou-
tine including a warm-up, stretching, strengthening, plyometrics, and agility
exercises. Pollard, Sigward, Ota, Langford, and Powers (2006) reported
significantly less hip internal rotation and greater hip abduction after the
PEP training in female soccer players. Lim et al. (2009) reported increased
knee flexion angle, increased interknee distance, decreased hamstring-to-
quadriceps EMG ratio, and decreased maximum knee extension moment
during a landing task after PEP training in female basketball players.
Chappell and Limpisvasti (2008) found that knee valgus moment during
a stop jump task decreased, and that initial knee flexion and maximum
knee flexion angles increase during a drop jump task after a low intensity
neuromuscular training in female soccer and basketball players. Conversely,
Grandstrand, Pfeiffer, Sabick, DeBeliso, and Shea (2006) did not observe
significant differences in knee separation values during a landing task in
soccer players after implementing a modified warm-up program. It should
be noted, however, that the program in Grandstrand et al. (2006) was only
 Prevention of ACL Injury, Part II 209

conducted twice a week, and knee separation was the only biomechani-
cal variable. Although the specific results vary across these studies, they do
indicate that low intensity neuromuscular training programs such as PEP can
have a positive effect on lower extremity biomechanics in athletic tasks and
thus lower the risk for ACL injury.

RESPONSE OF HIGH- AND LOW-RISK GROUPS

Besides reducing the training time needed for ACL prevention programs,
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

another way to improve efficiency is to apply training programs specifically

to those athletes who are in sports with high ACL injury rates and possess
at-risk lower extremity movement patterns for ACL injury. Myer, Ford,
Brent, and Hewett (2007) compared the effects of a 7-week neuromuscular
training on peak knee abduction moment in a drop landing and vertical
jump task between subjects with high and low baseline peak abduction
moments. Subjects were categorized as at high risk for ACL injury if the
baseline knee abduction moment was greater than 25.25 Nm. The results
of this study demonstrated that only subjects in the high-risk group signifi-
cantly decreased their knee abduction moment after the training. DiStefano,
Paudua, DiStefano, and Marshall (2009) studied the effects of a general-
ized and stratified training program on movement patterns during landing
in youth soccer players. Both training sessions lasted 10–15 minutes and
were conducted three to four times per week over a season. The results
demonstrated that subjects with poor landing techniques before training
improved significantly more after training than those with good landing tech-
niques before training. These studies demonstrated that training programs
for improving lower extremity neuromuscular characteristics are most effec-
tive only when they are specifically applied to those athletes whose landing
techniques need to be improved. Considering that the risk of noncontact ACL
injury is a function of age, these studies indicate a need to assess the effects
of these programs on different age groups. Also, it has been noticed that
these interventions were applied to the postpuberty populations. Applying
these interventions to prepuberty populations may result in greater response
to the intervention.

EFFECTS OF INJURY PREVENTION PROGRAMS

ON ACL INJURY RATE

Although studies have shown significant effects of a variety of training

programs on movement patterns as previously discussed, these training pro-
grams cannot be called effective unless they are effective in reducing the
actual noncontact ACL injury rate. Unfortunately, assessing the outcome of
 210 B. Dai et al.

training programs in terms of noncontact ACL injury rate is a difficult task.

Only a small number of studies attempted to evaluate training programs with
an ACL injury rate as an outcome measure (Table 2).

INJURY EDUCATION

Ettlinger, Johnson, and Shealy (1995) studied the effects of an education pro-
gram armed to increase awareness of ACL injuries and dangerous situations
on ACL incidence rate in alpine skiing in one season. Compared with two
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

previous seasons and expected ACL injuries number, ACL injuries decreased
by 62% in the intervention group, but no decrease was observed in the
control group. Although this study has demonstrated a significant effect of
ACL injury prevention education on ACL injury rate, it should be noted that
alpine skiing is an individual sport in which the mechanism of ACL injury is
quite different from those in team sports such as soccer, basketball, and team
handball. How education programs affect ACL injury rate in team sports is
still unknown and needs to be investigated in future studies.

BALANCE/PROPRIOCEPTION TRAINING

Caraffa, Cerulli, Projetti, Aisa, and Rizzo (1996) studied the effects of a propri-
oceptive training on ACL injury rate in soccer players during three seasons.
After 3 years, the incidence of ACL injuries per team per season in the inter-
vention group was 0.15 versus 1.15 in the control group. Söderman, Werner,
Pietilä, Engström, and Alfredson (2000) studied the effects of balance board
training on the lower extremity traumatic injuries in female soccer players.
After the season, four ACL injuries occurred in the intervention group and
one in the control group. Compared with the study of Caraffa et al. (1996),
the lack of preventive effects in the Söderman et al. (2000) study could be
due to the differences in training modalities (supervised training vs. home
training) and a high dropout rate. More important is that the statistical power
of the study by Söderman et al. (2000) was limited by the small number of
participants.

STRENGTH TRAINING

Cahill and Griffith (1978) compared the incidence of knee injuries in high
school football players between 4 years without preseason conditioning and
4 years with preseason conditioning. They noted a 41% reduction in all
knee injuries and a 63% reduction of severe knee injuries that need surgi-
cal repairs in the years with preseason conditioning. The ACL injury rate,
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

TABLE 2 Effects of Injury Prevention Programs on Injury Rate

General training Specific training Training frequency and

modality References modality duration Training effects Limitations

Injury Education Ettlinger, Johnson, and Knowledge regarding Phase I training was ACL injuries Only one study in
Shealy, 1995 risky behavior, risky conducted at the decreased by 62% alpine skiing
situation, and beginning of the in the
effective responses season with 1 hour intervention
during alpine skiing presentation; Phase II group
training was conducted
at the middle of the
season
Balance training Caraffa et al., 1996 Progressive balance 20 minutes / session, all The incidence of
board training practice sessions ACL injuries per
during the preseason team per season
and three sessions / in the
week during the intervention

211
competitive season group was
0.15 versus
1.15 in the control
group
Söderman et al., 2000 Home based balance 10–15 minutes / session, Four ACL injuries A high dropout rate
board training each day for first occurred in the and low statistical
30 days and then three intervention power were
sessions / week during group and one in observed
the season the control group
Strength training Cahill and Griffith, Preseason conditioning 90 minutes / session, A 41% reduction in Injuries during
1978 including 3 sessions / week, all knee injuries previous years
cardiovascular, weight 6 weeks and a 63% were used as a
training, flexibility, reduction of control
and agility exercises severe knee
injuries
(Continued)
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

TABLE 2 (Continued)

General training Specific training Training frequency and

modality References modality duration Training effects Limitations

Wedderkopp et al., Ankle disk training and 15 minutes, all practice 1 knee sprain in the Small number of
1999 functional strength sessions, 1 team intervention injury cases
training handball season group and 5 in
the control group
Wedderkopp et al., Functional strength 15 minutes, all practice The addition of Small number of
2003 training with or sessions, 1 team ankle disk injury cases
without ankle disk handball season training decreased
training the number of
traumatic injuries,
but not knee

212
injuries
Plyometric Pfeiffer et al., 2006 Progressive jump 20 minutes / session, two Three ACL injuries Nonrandomized
training landing training sessions / week, in the design; small
1 sports season intervention number of injury
group and 3 in cases
the control group
Multi-component Hewett et al., 1999 Progressive training 60–90 minutes / session, The knee injury Nonrandomized
training including technique, 3 sessions / week, rates were 0.43 design;
fundamental, and 6 weeks (incidence / inappropriate
performance phases 1000 exposures) statistical analysis;
in untrained small number of
female athletes injury cases
and0.12 in trained
female athletes
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

Myklebust et al., 2003 Floor, balance mat, and 15 minutes/ session, Twenty-nine ACL Nonrandomized
wobble board 3 sessions / week for injuries during the design; injuries
exercises first 5–7 weeks, control season, during previous
1 session / week for 23 injuries during years were used
the rest of the season the first as a control; a
intervention high dropout rate
season, and
17 injuries during
the second
intervention
season
Petersen et al., 2005 Balance, jump landing, 10 minutes/ session, One ACL injury in Nonrandomized
and technique 3 sessions / week for the intervention design; small
training first 8 weeks, 1 session group and 5 in number of injury
/ week for competition the control group cases

213
period
Heidt et al., 2000 Cardiovascular, 3 sessions/ week, No significant Small number of
plyometric, strength, 7 weeks during difference in ACL injury cases
and flexibility training preseason injury rate
between training
and control
groups
Mandelbaum et al., PEP 20 minutes / session, all Training decrease Nonrandomized
2005 training, 2 years ACL injury rate by design
88% for the first
season and 74%
for the second
season
(Continued)
 Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

TABLE 2 (Continued)

General training Specific training Training frequency and

modality References modality duration Training effects Limitations

Gilchrist et al., 2008 PEP 20 minutes / session, all ACL injury rate in Small number of
training, 1 regular the intervention injury cases
season group was
0.20 versus
0.34 per
1000 exposures in

214
the control group
without statistical
significance
Olsen et al., 2005 Warm up, technique, 15–20 minutes / session, Three ACL injuries Small number of
balance, and strength first 15 sessions in the injury cases
exercises training and then once intervention
a week during the group and 10 ACL
season injuries in the
control group
 Prevention of ACL Injury, Part II 215

however, was not reported. More recently, Wedderkopp, Kaltoft, Lundgaard,

Rosendahl, and Froberg (1999) studied the effects of functional strength
and ankle disc training on traumatic and overuse injuries in young team
handball players for a 10-month season. The functional strength training
includes activities for all major muscle groups to achieve an appropriate
warm-up. One knee sprain was found in the intervention group and five in
the control group. After this study, Wedderkopp, Kaltoft, Holm, and Froberg
(2003) compared functional strength training alone with functional strength
training and training with ankle disc in young female handball players. After
a season, the group using the ankle disc had a significantly lower number
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

of traumatic injuries; however, knee injuries alone were not significantly

different between the two groups. These results support the findings by
Herman et al. (2009) that strength training alone is insufficient to produce
desired changes in neuromuscular characteristics of interest. Although there
was a lack of an effect on knee injuries in the combined group, it was likely
reasonable to include strength training as a component of the intervention
given the age and skills levels of the athletes. Furthermore, the lack of an
effect on knee injuries may have been due to relatively low strength training
intensity and volume, as well as a relatively small study sample size.

PLYOMETRIC TRAINING

Pfeiffer, Shea, Roberts, Grandstrand, and Bond (2006) studied the effects of
a plyometric-based exercise program on ACL injuries in high school female
soccer, basketball, and volleyball players. The training program focused on
power and technique training of lower extremity alignment during jumping
and landing tasks with progressive phases. Three noncontact ACL injuries
occurred in the intervention group and three in the control group. These
results indicate that single component plyometric training did not reduce
ACL injury rate, which are contradictory to the results of those studies
that demonstrated high volume plyometric training alters lower extremity
biomechanics in a manner that would likely reduce the risk for noncontact
ACL injury. The volume of plyometric training in this study was not par-
ticularly high, however, and it is more analogous to that used in studies
conducted by researchers such as Irmischer et al. (2004), as noted previ-
ously. Other possible explanations for this lack of a positive finding include
that the movement patterns this plyometric training program altered are not
relevant to the mechanism of ACL injury.

MULTICOMPONENT TRAINING

A greater number of investigations have been performed using

multicomponent training strategies, and there are indications that a
 216 B. Dai et al.

comprehensive approach may positively impact injury rates under the rel-
atively controlled conditions of a study. Issues regarding study size and
design, however, restrict being able to draw broad conclusions.
Hewett, Lindenfeld, Riccobene, and Noyes (1999) studied the effect of
a 6-week preseason neuromuscular training program as mentioned before
(Hewett et al., 1996) on incidence of knee injuries among high school female
volleyball, basketball, and soccer players. The knee injury rate of the control
group was 3.6 times higher than that of the training group and 4.8 times
higher than that of untrained male counterparts. The validity of the statistical
analysis of this study has been questioned, however, and alternative statis-
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

tical analyses for such a study with small sample size would demonstrate
no statistical difference between training and control groups (Clancy, 2000;
Lyman, 2000).
Myklebust et al. (2003) studied the effects of a neuromuscular training
program on competitive female handball players over three seasons. The
intervention included three components which were floor, balance mat, and
balance board exercises. There were 29 ACL injuries during the control sea-
son, 23 injuries during the first intervention season, and 17 injuries during the
second intervention season. A significant reduction in noncontact ACL injury
in the second season was reported in comparison with the control season.
Smaller-sized investigations help support the findings by Myklebust
et al. (2003) to some degree. Petersen et al. (2005) studied an injury pre-
vention program on ACL injuries in female handball players. The prevention
program included awareness and knowledge of ACL injuries, balance board
exercises, and jump training. After one season, the control group had five
ACL ruptures (0.21 injuries/1,000 hours) compared with one in the interven-
tion group (0.04 injuries/1,000 hours). Heidt, Sweeterman, Carlonas, Traub,
and Tekulve (2000) investigated the effects of the preseason conditioning
program on the occurrence and severity of soccer injuries in high school
female players. A significantly lower general injury rate was found in the
training group compared with the control group; however, no significant
difference was found in ACL injury rate between training and control groups
(2.4% and 3.1%).
As previously noted, warm-up protocols have been designed based on
comprehensive ACL prevention training to improve efficiency and compli-
ance. Although these protocols have had more consistent positive results
concerning more general categories of injury, the effects specifically on ACL
injury rates have been mixed. Mandelbaum et al. (2005) studied the effects
of a PEP program on prevention of ACL injury for female soccer players in
two seasons. An incidence rate of 0.05 (injuries/1,000 exposures) was found
in the intervention group compared with 0.47 in the control group in the
first year in which the PEP program was implemented. An incidence rate
of 0.13 exposures was found in the intervention group, which was signifi-
cantly different compared with 0.51 in the control group in the second year.
 Prevention of ACL Injury, Part II 217

Gilchrist et al. (2008) studies the effects of a PEP program on ACL incidence
rate in NCAA soccer players. After a season, the total ACL injury rate in the
intervention group was 0.20 (injuries/1,000 exposures) versus 0.34 in the
control group without statistical significance. Noncontact ACL injury in the
intervention athletes was 0.06 versus 0.19 per 1,000 exposures without sta-
tistical significance either. Olsen, Myklebust, Engebretsen, Holme, and Bahr
(2005) studied the effect of a warm-up program on knee and ankle injuries
for young handball players. The training consisted of warm-up, technique,
balance, and strength exercises with the aim to improve the awareness and
control of knees and ankles. A total of 1,837 players participated in the
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

study, with 958 in intervention group and 879 in control groups. Three ACL
injuries were found in the intervention group while 10 in the control group
during the season in which the study was conducted, which was not noted
to be statistically significantly different apart from a more general category
of knee ligament injuries.

INJURY PREVENTION SUMMARY

The above reviewed studies combined together indicate that research results
of the effects of current training programs on ACL injury rate are inconsistent.
As previously mentioned, evaluating the outcome of training programs in
terms of ACL injury rate is a difficult task. Current literature contains only
a small number of studies on this topic. Even with this small number of
studies, few can be categorized as a randomized clinical trial that is the gold
standard for studying the effects of intervention. These studies had least
one of the following critical limitations: small sample size, lack of random
assignment of subjects to groups, lack of blinding, short follow-up, lack
of control of historical events, and inappropriate statistical analysis. These
limitations have to be seriously considered when interpreting the results of
current literature and designing future studies on this topic.
If the above reviewed studies only showed that the effects of train-
ing programs on ACL injury rate are uncertain, recent epidemiological
data appeared to indicate that the ACL injury rate remains at a high
level. An examination of the NCAA injury surveillance system database
showed that the ACL injury rate for women’s soccer, men’s basketball, and
women’s basketball remains unchanged from 1990 to 2002 (Agel, Arendt,
& Bershadsky, 2005). Further examination of the same database found that
the ACL injury rate for 15 sports significantly was increasing by an aver-
age of 1.3% each year from 1988 to 2004 (Hootman, Dick, & Agel, 2007).
These findings suggest that either the current prevention programs for ACL
injury are ineffective or the implementation of these programs is ineffective
or lacking. Low compliance may be a likely explanation of the ineffective-
ness of the current ACL injury prevention programs. Söderman et al. (2000)
 218 B. Dai et al.

showed a drop-out rate as high as 49% in the intervention group, and actual
training time was as low as 50% of required training time. Myklebust et al.
(2003) reported a compliance with ACL injury prevention programs as low
as 29%. The low compliance with ACL injury prevention programs is not
surprising. Many training programs require a substantial amount of time—
from 15 to 90 minutes per session (Irmischer et al., 2004; Mandelbaum et al.,
2005; Myer et al., 2006). Besides a substantial amount of time, many train-
ing programs also require expensive training equipment to implement the
programs and experienced clinicians to monitoring the quality of training.
These requirements may be serious barriers to compliance with ACL injury
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

prevention programs.

SUMMARY

Many training programs have been developed for ACL injury prevention.
Although studies demonstrated the effects of these programs on at-risk
movement patterns in research environments, the effects of these training
programs on the actual ACL injury rates are still not clear, and the ACL injury
rate over time has not decreased as might be expected with the development
and implementation of effective and efficient injury prevention programs.
Additional research is needed to make significant strides in reducing the
ACL injury rate.
The effects of neuromuscular training on lower extremity movement
patterns need to be further studied not only in an experimental environment
but also in an actual practice and competition environment. Differences of
the effects of the training programs for different sports, skill level, age, and
levels of risk need to be understood. Research efforts are particularly needed
to develop those training programs with low or no demands of additional
time and clinical or material resources. Finally, well-designed randomized
clinical trials are needed to determine the effects of those training programs
on ACL injury rate.

RECOMMENDATIONS

Despite limitations in current literature on prevention of ACL injury, it is

advisable for clinicians and coaches to implement ACL injury prevention
programs, particularly in high risk sports and populations. Although signifi-
cant questions remain, some recommendations may be made based on the
available evidence. It should be noted that no study on ACL injury pre-
vention has demonstrated any significant detrimental effects. Due to the
limitations at this time and the ongoing research, these recommendations
are likely to continually change, and periodic reassessment of the literature
is encouraged.
 Prevention of ACL Injury, Part II 219

Injury prevention programs at most levels of competition should be

quick and compact, with few to no additional required equipment or
resources in order to attain high rates of implementation. The warm-up
model is one method that may be used to fulfill these requirements. As indi-
cated previously, however, training volume appears to be a key element to
injury prevention programs; as such, a warm-up model injury prevention
program should be rigorously implemented as a part of every conditioning
session, practice, and competition in an effort to ensure appropriate train-
ing volume. Higher levels of competition with more elite athletes may have
access to additional time, material, and personnel resources, allowing the
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

introduction of other components and more complex exercises.

In order to help streamline these prevention programs to improve effi-
ciency and implementation, there must be consideration of the components
contained therein. Strengthening exercises should be considered at lower
levels of competition and with younger athletes, but they may not be
as important with higher level and more mature athletes. Given sufficient
training volume, plyometrics has been a core element of the majority of
studies demonstrating positive results and should receive strong consider-
ation. Balance training has also shown some positive results, but it may
require additional equipment such as wobble boards. Although sufficient
time and training is rarely available to implement a feedback component as
rigorous as seen in the literature, elements such as verbal feedback should
always be included during the performance of other base components of
the program. Additional focus may be achieved by obtaining a preseason
risk assessment by a qualified healthcare provider in order to focus time and
resources on those deemed at relatively greater risk. Finally, early-season
education of administrators, coaches, parents, and athletes regarding ACL
injuries and the importance of injury prevention in order to promote stake-
holder buy-in may be more important to the success of the program as any
possible direct protective effects of this component.

REFERENCES

Agel, J., Arendt, E. A., & Bershadsky, B. (2005). Anterior cruciate ligament injury in
national collegiate athletic association basketball and soccer: A 13-year review.
The American Journal of Sports Medicine, 33(4), 524–530.
Cahill, B. R., & Griffith, E. H. (1978). Effect of preseason conditioning on the inci-
dence and severity of high school football knee injuries. The American Journal
of Sports Medicine, 6(4), 180–184.
Caraffa, A., Cerulli, G., Projetti, M., Aisa, G., & Rizzo, A. (1996). Prevention of
anterior cruciate ligament injuries in soccer. A prospective controlled study of
proprioceptive training. Knee Surgery, Sports Traumatology, Arthroscopy, 4(1),
19–21.
 220 B. Dai et al.

Chappell, J. D., & Limpisvasti, O. (2008). Effect of a neuromuscular training program

on the kinetics and kinematics of jumping tasks. The American Journal of Sports
Medicine, 36(6), 1081–1086.
Clancy, W. G. (2000). Letters to the editor. The American Journal of Sports Medicine,
28(4), 615.
Cochrane, J. L., Lloyd, D. G., Besier, T. F., Elliott, B. C., Doyle, T. L., & Ackland, T. R.
(2010). Training affects knee kinematics and kinetics in cutting maneuvers in
sport. Medicine and Science in Sports and Exercise, 42(8), 1535–1544.
Dempsey, A. R., Lloyd, D. G., Elliott, B. C., Steele, J. R., & Munro, B. J.
(2009). Changing sidestep cutting technique reduces knee valgus loading. The
American Journal of Sports Medicine, 37(11), 2194–2200.
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

Dempsey, A. R., Lloyd, D. G., Elliott, B. C., Steele, J. R., Munro, B. J., & Russo, K. A.
(2007). The effect of technique change on knee loads during sidestep cutting.
Medicine and Science in Sports and Exercise, 39(10), 1765–1773.
DiStefano, L. J., Padua, D. A., DiStefano, M. J., & Marshall, S. W. (2009). Influence
of age, sex, technique, and exercise program on movement patterns after an
anterior cruciate ligament injury prevention program in youth soccer players.
The American Journal of Sports Medicine, 37(3), 495–505.
Ettlinger, C. F., Johnson, R. J., & Shealy, J. E. (1995). A method to help reduce the
risk of serious knee sprains incurred in alpine skiing. The American Journal of
Sports Medicine, 23(5), 531–537.
Gilchrist, J., Mandelbaum, B. R., Melancon, H., Ryan, G. W., Silvers, H. J., Griffin,
L. Y., . . . Dvorak, J. (2008). A randomized controlled trial to prevent noncontact
anterior cruciate ligament injury in female collegiate soccer players. The
American Journal of Sports Medicine, 36(8), 1476–1483.
Grandstrand, S. L., Pfeiffer, R. P., Sabick, M. B., DeBeliso, M., & Shea, K. G. (2006).
The effects of a commercially available warm-up program on landing mechan-
ics in female youth soccer players. Journal of Strength and Conditioning
Research, 20(2), 331–335.
Heidt, R. S., Jr., Sweeterman, L. M., Carlonas, R. L., Traub, J. A., & Tekulve, F. X.
(2000). Avoidance of soccer injuries with preseason conditioning. The American
Journal of Sports Medicine, 28(5), 659–662.
Herman, D. C., Onate, J. A., Weinhold, P. S., Guskiewicz, K. M., Garrett, W. E., Yu, B.,
& Padua, D. A. (2009). The effects of feedback with and without strength train-
ing on lower extremity biomechanics. The American Journal of Sports Medicine,
37(7), 1301–1308.
Herman, D. C., Weinhold, P. S., Guskiewicz, K. M., Garrett, W. E., Yu, B., &
Padua, D. A. (2008). The effects of strength training on the lower extrem-
ity biomechanics of female recreational athletes during a stop-jump task. The
American Journal of Sports Medicine, 36(4), 733–740.
Hewett, T. E., Lindenfeld, T. N., Riccobene, J. V., & Noyes, F. R. (1999). The
effect of neuromuscular training on the incidence of knee injury in female
athletes. A prospective study. The American Journal of Sports Medicine, 27(6),
699–706.
Hewett, T. E., Stroupe, A. L., Nance, T. A., & Noyes, F. R. (1996). Plyometric training
in female athletes: Decreased impact forces and increased hamstring torques.
The American Journal of Sports Medicine, 24(6), 765–773.
 Prevention of ACL Injury, Part II 221

Hootman, J. M., Dick, R., & Agel, J. (2007). Epidemiology of collegiate injuries
for 15 sports: Summary and recommendations for injury prevention initiatives.
Journal of Athletic Training, 42(2), 311–319.
Irmischer, B. S., Harris, C., Pfeiffer, R. P., DeBeliso, M. A., Adams, K. J., & Shea,
K. G. (2004). Effects of a knee ligament injury prevention exercise program on
impact forces in women. Journal of Strength and Conditioning Research, 18(4),
703–707.
Iversen, M. D., & Friden, C. (2009). Pilot study of female high school basketball
players’ anterior cruciate ligament injury knowledge, attitudes, and practices.
Scandinavian Journal of Medicine & Science in Sports, 19(4), 595–602.
Lephart, S. M., Abt, J. P., Ferris, C. M., Sell, T. C., Nagai, T., Myers, J. B., & Irrgang,
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

J. J. (2005). Neuromuscular and biomechanical characteristic changes in high

school athletes: A plyometric versus basic resistance program. British Journal
of Sports Medicine, 39(12), 932–938.
Lim, B. O., Lee, Y. S., Kim, J. G., An, K. O., Yoo, J., & Kwon, Y. H. (2009). Effects of
sports injury prevention training on the biomechanical risk factors of anterior
cruciate ligament injury in high school female basketball players. The American
Journal of Sports Medicine, 37(9), 1728–1734.
Lyman, S. (2000). Letters to the editor. The American Journal of Sports Medicine,
28(6), 918.
Mandelbaum, B. R., Silvers, H. J., Watanabe, D. S., Knarr, J. F., Thomas, S. D., Griffin,
L. Y., . . . Garrett, W., Jr. (2005). Effectiveness of a neuromuscular and propri-
oceptive training program in preventing anterior cruciate ligament injuries in
female athletes: 2-year follow-up. The American Journal of Sports Medicine,
33(7), 1003–1010.
Myer, G. D., Ford, K. R., Brent, J. L., & Hewett, T. E. (2006). The effects of plyometric
vs. dynamic stabilization and balance training on power, balance, and landing
force in female athletes. Journal of Strength and Conditioning Research, 20(2),
345–353.
Myer, G. D., Ford, K. R., Brent, J. L., & Hewett, T. E. (2007). Differential
neuromuscular training effects on ACL injury risk factors in “high-risk” versus
“low-risk” athletes. BMC Musculoskeletal Disorders, 8, 39.
Myer, G. D., Ford, K. R., Palumbo, J. P., & Hewett, T. E. (2005). Neuromuscular
training improves performance and lower-extremity biomechanics in female
athletes. Journal of Strength and Conditioning Research, 19(1), 51–60.
Myklebust, G., Engebretsen, L., Braekken, I. H., Skjolberg, A., Olsen, O. E., &
Bahr, R. (2003). Prevention of anterior cruciate ligament injuries in female team
handball players: A prospective intervention study over three seasons. Clinical
Journal of Sport Medicine, 13(2), 71–78.
Olsen, O. E., Myklebust, G., Engebretsen, L., Holme, I., & Bahr, R. (2005). Exercises
to prevent lower limb injuries in youth sports: Cluster randomised controlled
trial. BMJ , 330(7489), 449.
Onate, J. A., Guskiewicz, K. M., Marshall, S. W., Giuliani, C., Yu, B., & Garrett,
W. E. (2005). Instruction of jump-landing technique using videotape feed-
back: Altering lower extremity motion patterns. The American Journal of Sports
Medicine, 33(6), 831–842.
Petersen, W., Braun, C., Bock, W., Schmidt, K., Weimann, A., Drescher, W., . . .
Zantop, T. (2005). A controlled prospective case control study of a prevention
 222 B. Dai et al.

training program in female team handball players: The German experience.

Archives of Orthopaedic and Trauma Surgery, 125(9), 614–621.
Pfeiffer, R. P., Shea, K. G., Roberts, D., Grandstrand, S., & Bond, L. (2006). Lack
of effect of a knee ligament injury prevention program on the incidence of
noncontact anterior cruciate ligament injury. The Journal of Bone and Joint
Surgery. American Volume, 88(8), 1769–1774.
Pollard, C. D., Sigward, S. M., Ota, S., Langford, K., & Powers, C. M. (2006). The
influence of in-season injury prevention training on lower-extremity kinematics
during landing in female soccer players. Clinical Journal of Sport Medicine,
16(3), 223–227.
Prapavessis, H., & McNair, P. J. (1999). Effects of instruction in jumping technique
Downloaded by [University North Carolina - Chapel Hill] at 11:12 09 August 2012

and experience jumping on ground reaction forces. The Journal of Orthopaedic

and Sports Physical Therapy, 29(6), 352–356.
Söderman, K., Werner, S., Pietilä, T., Engström, B., & Alfredson, H. (2000). Balance
board training: Prevention of traumatic injuries of the lower extremities in
female soccer players? A prospective randomized intervention study. Knee
Surgery, Sports Traumatology, Arthroscopy, 8(6), 356–363.
Vescovi, J. D., Canavan, P. K., & Hasson, S. (2008). Effects of a plyometric program
on vertical landing force and jumping performance in college women. Physical
Therapy in Sport, 9(4), 185–192.
Wedderkopp, N., Kaltoft, M., Holm, R., & Froberg, K. (2003). Comparison of two
intervention programmes in young female players in European handball—with
and without ankle disc. Scandinavian Journal of Medicine & Science in Sports,
13(6), 371–375.
Wedderkopp, N., Kaltoft, M., Lundgaard, B., Rosendahl, M., & Froberg, K. (1999).
Prevention of injuries in young female players in European team handball.
A prospective intervention study. Scandinavian Journal of Medicine & Science
in Sports, 9(1), 41–47.
Zebis, M. K., Bencke, J., Andersen, L. L., Dossing, S., Alkjaer, T., Magnusson, S. P.,
. . . Aagaard, P. (2008). The effects of neuromuscular training on knee joint
motor control during sidecutting in female elite soccer and handball players.
Clinical Journal of Sport Medicine, 18(4), 329–337.