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While many anterior cruciate ligament (ACL) prevention programs have been published, few have achieved significant reductions in injury rates and improvements in athletic performance indices; both of which may increase compliance and motivation of athletes to participate.
Athlete exposures (AE) were documented for every practice and game the players (trained and control) participated in on a weekly basis. Before training, approximately 80% of the athletes had a distinctly abnormal lower limb valgus alignment position on landing (empirically designated as ? 60% normalized knee separation distance). A supervised neuromuscular retraining program (18 sessions) was developed, aimed at achieving both of these objectives. IntroductionIt is well known that adolescent female athletes have a 4- to 8-fold higher incidence of sustaining a complete noncontact anterior cruciate ligament (ACL) injury compared with male athletes participating in the same sport or activity [1,2,3]. Coaches, athletic trainers, and research assistants assisted with ensuring weekly AE logs were completed.
Do not allow the heel to touch the ground.Heel walkWalk on the heels and keep the legs straight. Single-Leg Hop TestsStatistically significant improvements were found in the mean distances hopped for both single-leg hop tests for the right and left legs (Table 5). Vertical Jump TestsStatistically significant improvements were noted for the two vertical jump tests; however, the ES were small. The changes in neuromuscular indices were measured after training in 1000 female athletes aged 13–18 years, and the noncontact ACL injury rate in 700 of these trained athletes was compared with that of 1120 control athletes. A complete ACL injury is indicated by 5 mm or more of increased anteroposterior tibial displacement on an instrumented or clinical Lachman test and a fully positive pivot shift test (grade 2 or 3 on a 0–3 point scale). One-tailed paired t tests were used to determine whether significant differences existed between pre-train and post-train test results. The distribution of the athletes before and after training according to four normalized knee separation distance categories is shown in Figure 1. At least two-thirds of ACL tears are noncontact in nature and occur when an athlete is cutting, pivoting, accelerating, decelerating, or landing from a jump [4,5,6]. Do not lock the knees, but keep them slightly flexed.Straight leg marchWalk with both legs straight, alternating lifting up each leg as high as possible without compromising form. There was no significant difference in the mean limb symmetry between pre-train and post-train values for both hop tests.
The short- and long-term consequences of ACL injuries in young athletes include high cost of medical treatment, a heightened risk of future reinjuries (to both knee joints), psychological morbidity, lost productivity in work or school, potential for lost scholarship funding, and premature osteoarthritis [7,8,9,10]. ACL ruptures were determined clinically according to grade 2–3 Lachman [31] and pivot shift [32] tests and magnetic resonance imaging. Before training, 13% had abnormal symmetry (<85%) in the triple crossover hop, whereas after training, only 2% continued to have abnormal values. The neuromuscular retraining program was effective in reducing noncontact ACL injury rate and improving athletic performance indicators.
Over the past 20 years, many ACL injury prevention programs have been developed in an effort to decrease the injury rate in female athletes [11,12]. Do not the lean backward.Leg cradleWalk forward and keep the entire body straight and neutrally aligned. The ACL crude incidence rate ratios were calculated for the trained and control groups per 1000 AE and tested for significance. In the triple hop test, 8% had abnormal values before training and 2% had these values after training.
There is tremendous variation among these programs in regard to the components that comprise the intervention, the duration and intensity of training, supervision and compliance tracking, and when training takes place (pre-season or within-season).

In addition, Fisher’s exact test was conducted to determine whether the proportion of injuries in the trained group was significantly difference from the proportion of injuries in the control group. Consensus statements from research retreats and committees agree that the ideal ACL-injury prevention program remains unclear in terms of exercise components, amount of supervision required, and timing due to the complex problem of the injury itself [13,14,15,16]. Reviews of published programs have suggested that plyometric and strengthening components are important components, and that the favorable effects of training are most pronounced in female soccer players under 18 years of age [17,18,19,20,21].Investigators from the sixth ACL Research Retreat recommended that ACL injury prevention programs should be evaluated to determine their effect on both noncontact ACL injuries and athletic performance indices [15]. Hold this position for 3 s, then place the foot back down and repeat with the opposite leg.Hip rotator walkPretend there is an obstacle directly in front of you.
It has been hypothesized that programs that have a positive influence on both injury rate reduction and performance enhancement will have better compliance with training [15]. This is due to the perception that convincing athletes, parents, coaches, and others of the necessity for injury prevention training may be more successful if evidence exists that athletic performance will also benefit. Although several programs have reported ACL injury incidence data, few have undergone a rigorous assessment of their ability to improve athletic performance indices.A 6-week, 18-session supervised ACL injury prevention program was developed and first described in 1996 [22]. Subsequently, this program was shown to significantly reduce the incidence of noncontact ACL injuries in young female athletes [23]. A group of 366 athletes that completed training had 17,222 athlete-exposures (AE) and 0 noncontact ACL injuries.
Repeat with the opposite leg.High knee skipThis exercise involves skipping in which one knee is driven up in the air as high as possible, while the other is used to land and hop off the ground.
Studies in relatively small numbers of athletes that completed this training program (34 volleyball players [24], 57 basketball players [25], 62 soccer players [26]), demonstrated significant improvements in athletic indices such as estimated VO2max [24,25,26], agility and sprint tests [26], a sit-up test [24], and vertical jump tests [24,26].
Swing the arm opposite of the high knee up in the air to help gain height.High kneesThis exercise involves jogging where, with each step, the knees are driven up as high as possible using short, choppy steps. Video Drop-JumpAfter training, statistically significant improvements and large ES were found in the absolute cm of knee separation distance and in the normalized knee separation distance values (Table 4).
There were also improvements in overall lower limb alignment on landing during a video drop-jump in these athletes [24,25,26].
The shoulders and hips are kept square throughout the exercise.Glut kicksThis exercise involves jogging where, with each step, the athlete kicks the feet back as if trying to reach the gluts with the heel, using short, choppy steps.
As our experience continued to grow with this training program, we wished to determine if these same goals (significant decrease in ACL injury rates and increase in athletic performance indices) would be met in a larger group of athletes.The goal of this investigation was to determine, in a group of 1000 female adolescent athletes, if significant improvements occurred after training in tests that measured neuromuscular and athletic indices such as lower limb alignment on a drop-jump, distance and limb symmetry on single-leg hop tests, agility, speed, lower limb muscle strength, and estimated VO2max. The shoulders and hips are kept square throughout the exercise.Stride outBegin jogging forward using an exaggerated running form.
The second goal was to determine noncontact ACL injury rates in a subset of 700 of the trained athletes compared with 1120 control athletes matched for age, sport, and body mass index.
Drive the knees as high as possible and kick the feet back, as if trying to make a large complete circle with the legs. We hypothesized that this program would significantly improve neuromuscular and athletic performance indicators and significantly decrease the risk of noncontact ACL injuries in female high school athletes. Stay up on the balls of the feet throughout the exercise.All-out sprintSprint forward as fast as possible, making sure to maintain proper technique and running form. Single-Leg Hop TestsThe first 57 athletes tested completed one single-leg hop test (triple) [34]. Then, because no limb symmetry problems were detected, we added a second hop (triple crossover [34]) in order to potentially detect limb asymmetry in more athletes. In the triple crossover hop test, three consecutive hops were done on one leg, crossing diagonally over the measuring tape on each hop. The athletes had to be in control and hold the landing of the third hop for 3 s for the test to be valid.

For athletes who completed both hops, the triple hop was done first on each leg, followed by the triple crossover hop. The right-left leg limb symmetry index was calculated by dividing the maximum distance hopped (best result) of the right leg by the maximum distance hopped (best result) of the left leg, and then multiplying the result by 100. Study DesignThe athletes underwent a series of tests no more than one week before the first training session (pre-test) and no more than one week after the last training session (post-test) in either the laboratory or at the training sites, which were usually indoor high school gymnasiums or soccer fields. Before testing and training, the athletes completed approximately 10 min of supervised dynamic warm-up exercises.
Training sessions lasted 1–1.5 h and were held three days a week (Monday, Wednesday, Friday) in the afternoons for six weeks. Because neuromuscular and athletic performance testing evolved over time, with the addition and deletion of certain tests, not all subjects underwent the same tests reported. In addition, certain agility and speed tests were designated for specific sports and, therefore, were not conducted in all athletes.
Then, the athletes side-shuffled to their left without crossing their feet to another cone placed 4.5-m away. After touching this cone, they side-shuffled to their right to a third cone placed 9-m away, side-shuffled back to the middle cone, and then ran backwards to the starting position. The time to complete this test was recorded with a digital stopwatch in one-hundredths of a second.
Multi-Stage Fitness TestA common field test used to estimate maximal oxygen uptake (VO2max) is the 20-meter multi-stage fitness test (MSFT).[47]. The equipment required are the MSFT commercially available audio compact disc (CD) and a CD player. On command, the athletes ran back and forth between the two cones in time to recorded beeps on the CD.
The athletes performed shuttle runs back and forth along the 20-m course, keeping in time with the series of signals (beeps) on the CD by touching the appropriate end cone in time with each audio signal. The frequency of the audible signals was progressively increased until the athletes reached volitional exhaustion and could no longer maintain pace with the audio signals, indicated when three beeps were missed in a row.
The level and number of shuttles reached before the athletes were unable to keep up with the audio recording were recorded. The athletes were positioned in the device with appropriate torso, pelvis and thigh straps placed according to the manufacturer’s protocol. The pivot point of the arm of the dynamometer was aligned with the lateral epicondyle of the knee, with the knee flexed to 90°. Gravitational factors were calculated by the dynamometer and automatically compensated for during the tests. The athletes were familiarized with the machine and the test velocity by performing three to four sub-maximal trials. Verbal encouragement was given throughout the tests, as the athletes were told to kick as hard and as fast as possible, but no visual feedback was available. A total of 10 repetitions were completed and the highest peak torque value used for analyses. Acceptable reliability of isokinetic measurements in children and adults have been reported by many investigators [52,53,54,55,56].

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