Neuromuscular Training Programs
Moderate strength evidence from pooled analyses with a small effect size (Number Needed to Treat=109) supports that neuromuscular training programs could reduce ACL injuries.

Rationale
One moderate strength study of female adolescent handball players and two low strength studies of adult male and adolescent female soccer players demonstrated significant reduction in ACL injuries after neuromuscular training.80, 19, 66  Five moderate strength studies showed a non-significant reduction and one moderate strength study showed a non-significant increase in ACL injuries (note: we were unable to confirm statistically significant reductions in injury reported by some of the aforementioned studies when reanalyzing the raw data).36, 46, 48, 61, 85, 109  No high strength double-blind randomized control trials implementing neuromuscular training interventions were identified, likely due to the difficulty in blinding of athletes and the need to cluster randomize athletes by team.  A two-step process of pooled analyses was employed. The initial pooled analysis contained all best available quality studies meeting the a priori inclusion criteria for this recommendation (Figure 11. Meta-Analysis of All Investigations Meeting Inclusion Criteria for ), showed no quantitative heterogeneity (0%), and indicated a relative risk reduction of 53 (20 to 72%). However, content and delivery methods among programs in these studies demonstrated qualitative heterogeneity; therefore a subset of the most homogeneous programs was identified. Programs were considered homogeneous if they contained similar exercise modalities and training implementation strategies (e.g., plyometrics, strengthening, instructor feedback to athletes).  The second pooled analysis of the homogeneous programs (Figure 12. Meta-Analysis of Investigations that Employed the Most Homogeneous Intervention) confirmed significant relative risk reduction of 62 (41 to 79%) favoring neuromuscular training programs for prevention of non-contact ACL injuries. The majority of the reported programs were coach-led and compliance was fair to poor, when reported. The current analyses indicate that the number needed to treat to prevent one ACL injury is approximately109 athletes (Figure 13. Number Needed to Treat (NNT) Analysis for Most Homogeneous Investigations (NNT =108.75)). An assessment of the studies included in this analysis demonstrated no publication bias (Figure 1D)
 
Potential Benefits of Implementation
The benefits of a neuromuscular training program implementation as part of a sports competition regime include a reduced risk of sustaining a sports related ACL injury.
 
Potential Harms of Implementation
No studies reported a significant increase in injury in those who participate in a neuromuscular training program for ACL injury prevention. 
 
Future Research
Future research from multi-site studies utilizing a standardized neuromuscular training program with large populations of high-risk athletes is recommended to further establish efficacy.  In addition, there is a need to investigate methods to optimize protocols (i.e., exercise modality), improve delivery and instruction (i.e., training feedback) and improve coach and athlete compliance. Lastly, a majority of the studies included adolescent and adult female soccer, basketball, volleyball and handball players. Future research that includes other high risk sports as well as male athletes is warranted to expand the generalizability of these results.

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