Wednesday, December 26, 2012

When To Begin Neuromuscular Training to Prevent ACL Injuries?

Here at the Science of Soccer Online, we have discussed the success of neuromuscular training as a way to lower the risk of anterior cruciate ligament (ACL) injuries. The research evidence is fairly conclusive that training programs focusing on balance, strength, technique, and flexibility can reduce the risk of injury, especially in female athletes. Based on this research, groups such as FIFA have developed warm-up programs that incorporate these exercises. Researchers at the Cincinnati Children’s Medical Center took a more detailed look at the research on the effectiveness of these programs. In particular, they were interested in the ages of the subjects used in the studies. They asked, are the programs more or less effective in younger players than in older athletes? As it turns out, initiating a neuromuscular training with pre- or early adolescents is highly effective and results in a substantial reduction in ACL injury risk.
The investigators analyzed the results from 14 studies that used neuromuscular training in an effort to reduce ACL injuries in female athletes. They included studies performed using both young and adult female athletes. Multiple sports were represented including soccer, volleyball, basketball, and team handball. Also, the age of the subjects ranged from 14 to 20 years.

When all 14 studies were analyzed as a group, the researchers found that neuromuscular training reduced the risk of ACL injury by nearly one-half (46%). When the studies were classified by the age of the subjects, they found that the greatest risk reduction occurred in mid-teens (14-18y). In this group, training reduced ACL injury risk by 72%! In late-teens (18-20y) risk was reduced by 52%. In early adults (+20y)

Based on their results, the researchers conclude that beginning a neuromuscular training program in the mid teenage years is very successful in lowering the risk of ACL injury. In fact, they suggest that beginning a program in the early or even pre-teen years may be even more effective. Developing strength, balance and technique early on may be a key to markedly reducing ACL injuries. Improving these characteristics may also enhance performance on the field or court.

Given this, the researchers make a strong argument for introducing neuromuscular training to young players. They also recommend it as a part of school-based physical education programs as well as sports team practices. Neuromuscular training is a very cost-effective way to enhance motor skills, promote physical activity and reduce the risk of future injury. For an investment of 15-20 minutes per day, the payoff in reduced injuries can be quite large. The goal is to promote health- and skill-related fitness with an eye towards injury prevention.

What are the keys to implementing a neuromuscular training program with young athletes? The authors point out several keys. First, balance training seems to be a very important component. The next most important is strength training. Second, proper supervision and feedback on performing exercises correctly is essential. That is, age appropriate instruction should be provided and athletes should be mature enough to follow instructions. Third, early emphasis is on technique. As the players are learning the exercises, volume and intensity should be minimized and the focus should be on performing them correctly. Finally, progression should be slow and individualized. Only after mastering the techniques of each exercise, should volume and intensity be increased.

This study shows that ACL injury risk can be reduced by 72% in players who begin an injury prevention program during their early and mid-teenage years. Other performance variables may be improved as well. This should be a clarion call for coaches as well as physical education teachers to include these exercises as part of their regular warm-up, training or class sessions. Programs such as the FIFA 11+ are simple to implement, can be easily modified for young athletes, and are proven to be very effective at reducing injury risk. Given that 15-20 minutes of practice is spent on a warm-up, why not include one that offers the added benefit of injury reduction?


Myer GD, Sugimoto D, Thomas S, Hewett TE (2012) The influence of age on the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes. American Journal of Sports Medicine, doi: 10.1177/0363546512460637