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Neuromuscular Training Availability and Efficacy in Preventing Anterior Cruciate Ligament Injury in High School Sports: A Retrospective Cohort Study

Murray, Jared J. BA*; Renier, Colleen M. BS; Ahern, Jenny J. BA, BS; Elliott, Barbara A. PhD, MDiv, BCC§

Clinical Journal of Sport Medicine: November 2017 - Volume 27 - Issue 6 - p 524–529
doi: 10.1097/JSM.0000000000000398
Original Research

Objective: To document neuromuscular training (NMT) availability and its relationship to anterior cruciate ligament (ACL) injuries in 4 major high school sports by gender, sport, and rural/urban geography, with the hypothesis that increased exposure to NMT would be associated with fewer ACL injuries.

Design: A retrospective cohort study.

Setting: All Minnesota high schools identified in the Minnesota State High School League (MSHSL) database for fall 2014 boys' football and soccer, and girls' volleyball and soccer.

Participants: All high school athletic directors were surveyed to report their school's fall 2014 experience; 53.5% returned the survey reporting experience with one or more of the sports.

Intervention: Athletic directors documented each sport's preseason and in-season exposure to NMT (plyometric exercises, proximal/core muscle strengthening, education and feedback regarding proper body mechanics, and aerobics) and licensed athletic trainers.

Main Outcomes: Reported ACL injuries by sport, gender and rural/urban.

Results: More than two-thirds of teams incorporated facets of NMT into their sport. Among male athletes, soccer players exposed to licensed athletic trainers experienced significantly fewer ACL injuries (P < 0.005), and NMT was associated with significantly fewer ACL injuries in football (P < 0.05) and soccer (P < 0.05). Female athletes did not demonstrate similar associated improvements, with volleyball injuries associated with increased NMT (P < 0.001), and soccer injuries not associated with NMT. However, girl soccer players in rural settings reported fewer ACL injures compared with urban teams (P < 0.001).

Conclusions: Most fall high school sports teams were exposed to NMT, which was associated with fewer ACL injuries for male, but not for female athletes. Improved gender- and sport-specific preventive training programs are indicated.

Supplemental Digital Content is Available in the Text.

*MS 4, University of Minnesota Medical School of Medicine, Minneapolis, Minnesota;

Essentia Institute of Rural Health, Essentia Health, Duluth, Minnesota;

Independent School District 709, Duluth, Minnesota; and

§Department of Family Medicine and Community Health, University of Minnesota Medical School, Duluth, Minnesota.

Corresponding Author: Barbara A. Elliott, PhD, MDiv, BCC, Med 155, 1035 University Drive, Duluth, MN 55812 (

Supported by HRSA, Grant number D56HP20690, Predoctoral Training Grant in Primary Care, James G. Boulger (PI).

The authors report no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received April 30, 2016

Accepted August 08, 2016

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.