A Systematic Review and Meta-analysis of Anterior Cruciate Ligament Injury Prevention Programs: Training to Stay in the Game

BACKGROUND: Approximately 400,000 anterior cruciate ligament (ACL) reconstructions are performed each year in the United States. Effective ACL injury prevention programs may be paramount in reducing this significant injury burden. PURPOSE: To determine the effectiveness of ACL injury prevention programs and generate updated guidelines to protect athletes from these injuries. STUDY DESIGN: Meta-analysis, Level of evidence, 2. METHODS: The Embase, PubMed, and Ovid (MEDLINE) databases were searched in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies focused on ACL injury prevention as opposed to treatment and provided data on ACL injury rates after intervention implementation. Using random-effects models, the authors generated the pooled risk ratio (RR) for all data and female-only data, <18 years versus ≥18 years of age data, handball data, soccer data, and balance board data. RESULTS: Eighteen articles were identified (9 randomized controlled trials, 9 prospective cohort studies). The 25,166 studied athletes (mean age, 19.3 ± 3.6 years; >85% female) played handball, soccer, basketball, or volleyball. All interventions were studied for a minimum of 1 season (mean, 1.3 ± 0.59). Athletes who participated in an ACL injury prevention program were significantly less likely to sustain an ACL rupture with a pooled RR of 0.46 (95% CI, 0.36-0.57). When analyzed by age, there was a significant risk reduction in ACL rupture for both athletes <18 years and ≥18 years (RR, 0.35 [95% CI, 0.22-0.55] and RR, 0.50 [95% CI, 0.38-0.64], respectively). The pooled RR was also statistically significant for female players (RR, 0.57 [95% CI, 0.43-0.74]), soccer and handball athletes (RR, 0.30 [95% CI, 0.19-0.46] and RR, 0.66 [95% CI, 0.46-0.96], respectively), and players participating in programs including balance boards (RR, 0.49 [95% CI, 0.35-0.67]). CONCLUSION: Athletes who did not partake in an ACL injury prevention program were nearly twice as likely to sustain an ACL rupture compared with those who did. This study provides strong support for using neuromuscular training programs to significantly reduce the risk of ACL rupture among athletes.