Journal of Athletic Training 2018;53(1):20–28

doi: 10.4085/1062-6050-173-16
Ó by the National Athletic Trainers’ Association, Inc Injury Prevention and Risk Factor Screening
www.natajournals.org

A School-Based Neuromuscular Training Program and

Sport-Related Injury Incidence: A Prospective
Randomized Controlled Clinical Trial
Kim D. Barber Foss, MS, LAT, ATC, CCRP*†‡; Staci Thomas, MS*;
Jane C. Khoury, PhD§||; Gregory D. Myer, PhD*¶**††;
Timothy E. Hewett, PhD*‡‡
*The SPORT Center, Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, OH; †Rocky
Mountain University of Health Professions, Provo, UT; ‡Department of Allied Health, Northern Kentucky University,
Fort Wright; §Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital, OH; ||Division of
Endocrinology, Cincinnati Children’s Hospital Medical Center, OH; ¶Departments of Pediatrics and Orthopaedic
Surgery, College of Medicine, University of Cincinnati, OH; **The Micheli Center for Sports Injury Prevention, Waltham,
MA; ††Department of Orthopaedics, University of Pennsylvania, Philadelphia; ‡‡Mayo Clinic Biomechanics
Laboratories and Sports Medicine Research Center, Departments of Orthopedic Surgery, Physical Medicine and
Rehabilitation & Physiology and Biomedical Engineering, Rochester and Minneapolis, MN

Context: An estimated 40 million school-aged children (age Main Outcome Measure(s): Injury rates were calculated
range ¼ 518 years) participate annually in sports in the United overall, by sport, and by competition level. We also calculated
States, generating approximately 4 million sport-related injuries rates of specific knee and ankle injuries. A mixed-model
and requiring 2.6 million emergency department visits at a cost approach was used to account for multiple injuries per athlete.
of nearly $2 billion. Results: Overall, the CORE group reported 107 injuries
Objective: To determine the effects of a school-based (rate ¼ 5.34 injuries/1000 AEs), and the SHAM group reported
neuromuscular training (NMT) program on sport-related injury 134 injuries (rate ¼ 8.54 injuries/1000 AEs; F1,578 ¼ 18.65, P ,
incidence across 3 sports at the high school and middle school
.001). Basketball (rate ¼ 4.99 injuries/1000 AEs) and volleyball
levels, focusing particularly on knee and ankle injuries.
(rate ¼ 5.74 injuries/1000 AEs) athletes in the CORE group
Design: Randomized controlled clinical trial.
Setting: A total of 5 middle schools and 4 high schools in a demonstrated lower injury incidences than basketball (rate ¼
single-county public school district. 7.72 injuries/1000 AEs) and volleyball (rate ¼ 11.63 injuries/
Patients or Other Participants: A total of 474 girls (222 1000 AEs; F1,275 ¼ 9.46, P ¼ .002 and F1,149 ¼ 11.36, P ¼ .001,
middle school, 252 high school; age ¼ 14.0 6 1.7 years, height ¼ respectively) athletes in the SHAM group. The CORE interven-
161.0 6 8.1 cm, mass ¼ 55.4 6 12.2 kg) were cluster tion appeared to have a greater protective effect on knee injuries
randomized to an NMT (CORE; n ¼ 259 athletes) or sham at the middle school level (knee-injury incidence rate ¼ 4.16
(SHAM; n ¼ 215 athletes) intervention group by team within each injuries/1000 AEs) than the SHAM intervention (knee-injury
sport (basketball, soccer, and volleyball). incidence rate ¼ 7.04 injuries/1000 AEs; F1,261 ¼ 5.36, P ¼ .02).
Intervention(s): The CORE intervention consisted of exer- We did not observe differences between groups for ankle
cises focused on the trunk and lower extremity, whereas the injuries (F1,578 ¼ 1.02, P ¼ .31).
SHAM protocol consisted of resisted running using elastic Conclusions: Participation in an NMT intervention program
bands. Each intervention was implemented at the start of the resulted in a reduced injury incidence relative to participation in
season and continued until the last competition. An athletic a SHAM intervention. This protective benefit of NMT was
trainer evaluated athletes weekly for sport-related injuries. The demonstrated at both the high school and middle school levels.
coach recorded each athlete-exposure (AE), which was defined
as 1 athlete participating in 1 coach-directed session (game or Key Words: epidemiology, middle school athletes, high
practice). school athletes, sport injuries, injury rates

Key Points
 Young female athletes participating in a neuromuscular training (NMT) program had a reduced injury incidence
compared with athletes participating in a sham intervention.
 Implementing the NMT program for female middle and high school athletes prevented injuries in basketball and
volleyball players over an athletic season.
 The protective effect of the NMT program was most pronounced for knee injuries in middle school volleyball athletes.

20 Volume 53  Number 1  January 2018

A
n estimated 40 million school-aged children (age Table 1. Examples of Core Exercises Completed Preseason
range ¼ 518 years) participate annually in sports Session 1 Exercise Performance Illustration
in the United States, which is a 21% increase in the Lateral jump and hold 8 repetitions on each Figure 1A
past decade.13 Researchers1,36 have estimated that these lower limb
athletes will sustain approximately 4 million sport-related Step hold 8 repetitions on each Figure 1B
injuries annually, requiring 2.6 million emergency depart- lower limb
ment visits at a cost of nearly $2 billion. These data indicate BOSUa (round) swimmers 2 sets of 10 repetitions Figure 1C
that targeted injury-prevention interventions are needed to BOSUa (round) double-
reduce the physical and economic burden of sport-related knee hold Two 20-s repetitions Figure 1D
Single-legged lateral 4 repetitions on each Figure 1E
injuries in young populations. AIREXb hop-hold lower limb
Among the many benefits for both sexes of participating Single tuck jump with soft
in athletics are an improved sense of wellbeing, better landing 2 sets of 10 repetitions Figure 1F
cardiorespiratory function, enhanced physical fitness, and Front lunges 10 repetitions on each Figure 1G
a positive body image; however, an inherent risk of sport- lower limb
related injury exists.69 Up to a 10-fold increased risk of Lunge jumps 10-s repetition on each Figure 1H
injury has been shown in female athletes compared with lower limb
BOSUa (flat) double-
male athletes, particularly for anterior cruciate ligament
legged pelvic bridges 2 sets of 10 repetitions Figure 1I
(ACL) sprains and patellofemoral pain.1013 Ankle injuries Single-legged 908 hop 8 repetitions on each Figure 1J
account for approximately 40% of high school injuries in hold lower limb
female athletes.14,15 Given the high prevalence of injury to BOSUa (round) lateral 10 repetitions on each Figure 1K
these 2 body regions, interventions should focus on overall crunch lower limb
injury reduction, as well as lowering the specific risks of Box double crunch 2 sets of 15 repetitions Figure 1L
ankle and knee injuries. In injury-surveillance research, Swiss ball back
investigators16 have reported injury rates of 4.4, 5.3, and hyperextensions 2 sets of 15 repetitions Figure 1M
1.7 per 1000 athlete-exposures (AEs) in high school-aged a
BOSU, Ashland, OH.
b
female athletes for basketball, soccer, and volleyball, Airex AG, Sins, Switzerland.
respectively. In a youth soccer-specific epidemiologic
study, Schiff et al17 found that female athletes had an Procedures
acute injury rate of 4.7 per 1000 AEs. Barber Foss et al18
We cluster randomized 259 athletes (103 middle school,
observed that middle school female athletes had a 50%
156 high school) to an NMT (CORE) intervention and 215
risk of injury during athletic participation.
athletes (119 middle school, 96 high school) to a sham
Given these increased rates and risks of injury, injury-
(SHAM) intervention group by team within each sport. The
prevention interventions are needed to target high-risk CORE intervention consisted of exercises focused on the
female adolescent athletes. Therefore, the purpose of our trunk and lower extremity, and the SHAM protocol
study was to conduct a prospective randomized controlled consisted of resisted running using elastic bands.19,20 Figure
clinical trial to evaluate the effects of a school-based 1 and Table 1 depict examples of exercises completed in
neuromuscular training (NMT) program on sport-related the preseason; Figure 2 and Table 2, in-season. Detailed
injury incidence across 3 different sports at the high school descriptions of these interventions have been published.19,21
and middle school levels. Each intervention was implemented at the start of the
season and continued until the last competition. From the
METHODS first day of team practice until the first competition, teams
were instructed to perform the training for 20 to 25 minutes,
Participants 3 times per week. When competition started, teams were
Female basketball (n ¼ 247), soccer (n ¼ 142), and instructed to perform a reduced-volume training protocol
volleyball (n ¼ 137) players from a single-county public
Table 2. Examples of Core Exercises Completed In-Season
school district in Kentucky comprising 5 middle schools
and 4 high schools participated in this investigation. The Session 19 Exercise Performance Illustration
526 roster players consisted of 474 individual athletes (age Step hold 8 repetitions on each Figure 2A
¼ 14.0 6 1.7 years, height ¼ 161.0 6 8.1 cm, mass ¼ 55.4 lower limb
6 12.2 kg), some of whom played more than 1 sport. Of BOSUa (flat) double-
these 474 athletes, 222 athletes participated at the middle legged pelvic bridges 2 sets of 8 repetitions Figure 2B
school level, and 252 athletes participated at the high Single-legged 908 hop 10 repetitions on each Figure 2C
hold lower limb
school level, and they could participate in multiple sports.
Single-legged Romanian 1 set on each lower Figure 2D
A total of 177 athletes incurred 241 independent injuries. dead lift limb
In this district, soccer and volleyball were fall sports, and Unanticipated hop to Three 5-s repetitions Figure 2E
basketball was a winter sport. Injuries were recorded for stabilization (level 1) on each lower limb
the specific season in which they occurred. All partici- Hop to stabilization and 3 repetitions on each Figure 2F
pants and their parents or guardians provided written reach (level 1) lower limb
informed assent and consent, respectively, and the Single tuck jump with soft
Cincinnati Children’s Hospital Institutional Review Board landing Two 10-s repetitions Figure 2G
approved the study. a
BOSU, Ashland, OH.

Journal of Athletic Training 21

Figure 1. Examples of neuromuscular-training intervention exercises completed preseason. A, Lateral jump and hold; B, step hold; C,
BOSU (round; Ashland, OH) swimmers; D, BOSU (round) double-knee hold; E, single-legged lateral AIREX (Airex AG, Sins, Switzerland)
hop-hold; F, single tuck jump with soft landing; G, front lunges; H, lunge jumps; I, BOSU (flat) double-legged pelvic bridges; J, single-
legged 908 hop hold; K, BOSU (round) lateral crunch; L, box double crunch; M, Swiss ball back hyperextensions.

for 10 to 15 minutes, 2 times per week, until the end of the Knee and ankle injuries included both sprains and strains.
competitive season. Knee injuries also included plica, fat pad, bursa, and
Athletes were evaluated by an athletic trainer (AT) weekly patellofemoral pain conditions. Athlete-exposures were
during each sport season for sport-related injuries. Injury was recorded weekly by a coach and verified by the study
operationally defined as (1) any injury causing cessation of coordinator (K.B.F.). An AE (ie, opportunity for injury) was
participation in the current session, (2) any injury that caused defined as 1 athlete participating in 1 coach-directed session
cessation of participation on the day after the day of onset, (game or practice).16,22 Exposure data were submitted by the
(3) any fracture, (4) any dental injury, and (5) any mild brain coach via a custom-built Sports Injury Surveillance System
injury, regardless of time missed from participation.16,22 (Cincinnati Children’s Hospital Medical Center Division of

22 Volume 53  Number 1  January 2018

Figure 2. Examples of neuromuscular-training intervention exercises completed while teams were in-season. A, Step hold; B, BOSU (flat;
Ashland, OH) double-legged pelvic bridges; C, single-legged 908 hop hold; D, single-legged Romanian dead lift; E, unanticipated hop to
stabilization (level 1); F, hop to stabilization and reach (level 1); G, single tuck jump with soft landing.

Journal of Athletic Training 23

Table 3. Examination of All Injuries: Rates by Exposure
CORE Intervention SHAM Intervention
Absolute Risk
Rate per Rate per Reduction Rate
No. of No. of 1000 AEs No. of No. of 1000 AEs per 1000 AEs
Sport Injuries Exposures (Standard Error)a Injuries Exposures (Standard Error)a F Value P Value (95% CI)
Overall 107 22 906 5.34 (0.51) 134 19 875 8.54 (0.54) 18.65 ,.001b 3.20 (1.71, 4.69)
High school 65 15 389 4.81 (0.52) 66 11 998 6.65 (0.62) 5.26 .02b 1.84 (0.25, 3.43)
Middle school 42 7517 6.00 (0.97) 68 7877 10.66 (0.88) 12.72 ,.001b 4.66 (1.98, 7.34)
Basketball 51 11 106 4.99 (0.63) 73 10 769 7.72 (0.63) 9.46 .002b 2.73 (0.92, 4.54)
High school 17 4917 3.32 (0.72) 23 3864 7.21 (0.89) 11.51 .001b 3.89 (1.44, 6.34)
Middle school 34 6189 6.14 (0.90) 50 6905 7.90 (0.80) 2.15 .14 1.76 (0.67, 4.19)
Soccer 25 6060 5.47 (1.10) 31 5409 7.64 (1.12) 1.92 .17 2.17 (1.01, 5.35)
High school 22 5758 4.80 (0.85) 23 4813 5.68 (0.93) 0.48 .49 0.88 (1.67, 3.43)
Middle school 3 302 9.93 (5.10) 8 596 13.42 (3.70) 0.31 .58 3.49 (3.20, 10.18)
Volleyball 31 5740 5.74 (1.09) 30 3697 11.63 (1.36) 11.36 .001b 5.89 (2.41, 9.37)
High school 26 4714 5.94 (1.00) 20 3321 7.40 (1.26) 0.82 .37 1.46 (1.74, 4.66)
Middle school 5 1026 4.03 (2.29) 10 376 20.70 (2.43) 24.98 ,.001b 16.67 (8.40, 24.94)
Abbreviations: AEs, athlete-exposures; CI, confidence interval; CORE, exercises focused on the trunk and lower extremity; SHAM, resisted
running with elastic bands.
a
Athlete-exposures were calculated by multiplying the number of team exposures by the number of athletes on the team.
b
Indicates difference (P , .05).

Bioinformatics, Cincinnati, OH). Injuries were recorded by (rate ¼ 5.47 injuries/1000 AEs) or SHAM (rate ¼ 7.64
the AT in the Sports Injury Monitoring System (Flan Tech injuries/1000 AEs; F1,150 ¼ 1.92, P ¼ .17) group.
Computer Services, Iowa City, IA).
Effect on Level
Statistical Analyses At the high school level, 48 (31%) of 156 CORE group
Data were analyzed by intervention for each reported athletes and 44 (46%) of 96 SHAM group athletes sustained
injury. Injury rates were estimated overall, by sport, and by at least 1 injury (v21 ¼ 5.82, P ¼ .02). At the middle school
competition level. Specific analyses were conducted on level, 32 (31%) of the 103 CORE group athletes and 53
knee and ankle injuries. Statistical analyses were performed (45%) of the 119 SHAM group athletes had at least 1 injury
in SAS software (version 9.3; SAS Institute, Cary, NC). We (v21 ¼ 4.24, P ¼ .04).
used v2 or Fisher exact tests to examine differences in
athletes with 1 or more injuries and a mixed-model Effect on Basketball Injuries
approach to compare injury rates between groups to
account for multiple injuries per athlete. The a level was The CORE group had a reduction in injuries (v21 ¼ 5.51, P
¼ .02). A total of 39 of 126 (31%) CORE group athletes and
set at .05.
55 of 121 (45%) SHAM group athletes sustained at least 1
injury. This reduction in injury incidence was most
RESULTS pronounced at the high school level, with only 14 of 53
Training was implemented in team (basketball, soccer, (26%) CORE group athletes versus 17 of 30 (57%) SHAM
and volleyball) clusters, which resulted in greater than 95% group athletes incurring an injury (v21 ¼ 7.49, P ¼ .006). At
compliance with data monitoring. Total exposures collected the middle school level, the number of injured athletes in
for the teams are presented in Table 3. A total of 80 (31%) the CORE group (25 of 73 [34%] athletes) and the SHAM
2
of the 259 CORE group athletes and 97 (45%) of the 215 group (38 of 91 [42%] athletes) was not different (v1 ¼
SHAM group athletes had at least 1 injury (v1 ¼ 10.16, P ¼ 0.97, P ¼ .33).
2

.001). The CORE group sustained 107 injuries (rate ¼ 5.34

injuries/1000 AEs), and the SHAM group sustained 134 Effect on Soccer Injuries
injuries (rate ¼ 8.54 injuries/1000 AEs; F1,578 ¼ 18.65, P , Of the 142 soccer athletes in the study, 74 were in the
.001; Table 3). We observed a 1.6-times reduction in injury CORE group, and 68 were in the SHAM group. They
rate between the CORE and SHAM intervention groups for comprised 116 high school and 26 middle school students.
all injuries over the investigation period, with an absolute Soccer was not a school-sponsored sport in the middle
risk-reduction rate of 3.20 (95% confidence interval [CI] ¼ school setting, which accounted for the small sample size.
1.71, 4.69) per 1000 AEs. The latter translates into a In the high school setting, the CORE group had 22 injuries
reduction of 128 injuries in our population alone. The (30%), and the SHAM group had 23 injuries (34%; v2 ¼
basketball (rate ¼ 4.99 injuries/1000 AEs) and volleyball 0.50, P ¼ .49). We did not observe a difference between 1

(rate ¼ 5.74 injuries/1000 AEs) athletes in the CORE group groups in injury reduction for soccer (P ¼ .17).
had lower injury incidences than the basketball (rate ¼ 7.72
injuries/1000 AEs) and volleyball (rate ¼ 11.63 injuries/
1000 AEs) athletes in the SHAM group (F1,275 ¼ 9.46, P ¼ Effect on Volleyball Injuries
.002 and F1,149 ¼ 11.36, P ¼ .001, respectively). We did not Of the 137 volleyball athletes, 24 of 85 (28%) CORE
observe a reduction for the soccer athletes in the CORE group athletes and 23 of 52 (44%) SHAM group athletes

24 Volume 53  Number 1  January 2018

Table 4. Examination of Knee and Patellar Injuries Only: Rates by Exposure
CORE Intervention SHAM Intervention
Absolute Risk
Rate per Rate per Reduction Rate
No. of No. of 1000 AEs No. of No. of 1000 AEs per 1000 AEs
Sport Injuries Exposures (Standard Error)a Injuries Exposures (Standard Error)a F Value P Value (95% CI)
Overall 60 22 906 3.12 (0.46) 72 19 875 4.97 (0.49) 7.57 .006b 1.59 (1.14, 2.34)
High school 32 15 389 2.37 (0.43) 32 11 998 3.37 (0.51) 2.26 .13 1.42 (0.89, 2.38)
Middle school 28 7517 4.16 (0.92) 40 7877 7.04 (0.83) 5.36 .02b 1.92 (1.07, 3.14)
Basketball 35 11 106 3.55 (0.56) 36 10 769 3.80 (0.56) 0.10 .75 1.07 (0.72, 1.65)
High school 12 4917 2.36 (0.63) 10 3864 2.93 (0.79) 0.32 .57 1.24 (0.49, 3.14)
Middle school 23 6189 4.35 (0.81) 26 6905 4.10 (0.72) 0.05 .82 0.94 (0.55, 1.64)
Soccer 11 6060 2.74 (0.96) 15 5409 4.19 (1.00) 1.12 .29 1.53 (0.64, 5.84)
High school 8 5758 1.66 (0.59) 9 4813 2.20 (0.64) 0.37 .54 1.32 (0.44, 5.70)
Middle school 3 302 9.93 (4.90) 6 596 10.07 (3.55) 0.00 .98 1.01 (inestimable)
Volleyball 14 5740 2.80 (1.00) 21 3697 8.70 (1.25) 13.59 ,.001b 3.12 (1.62, 11.61)
High school 12 4714 3.01 (0.89) 13 3321 5.15 (1.12) 2.21 .14 1.71 (0.80, 4.64)
Middle school 2 1026 1.31 (2.17) 8 376 17.70 (2.31) 26.78 ,.001b 13.51 (inestimable)
Abbreviations: AEs, athlete-exposures; CI, confidence interval; CORE, exercises focused on the trunk and lower extremity; SHAM, resisted
running with elastic bands.
a
Athlete-exposures were calculated by multiplying the number of team exposures by the number of athletes on the team.
b
Indicates difference (P , .05).

sustained at least 1 injury (v21 ¼ 3.66, P ¼ .056). Whereas school level (rate ¼ 1.31 versus 17.70 injuries/1000 AEs;
the reduction in basketball injuries was more prominent at F1,47 ¼ 26.78, P , .001) for the CORE versus SHAM
the high school level, the opposite was true of volleyball; 5 group. Of the 3 ACL injuries reported, 2 affected girls were
of the 25 (20%) middle school volleyball players in the assigned to the SHAM group.
CORE group versus 13 of the 20 (65%) players in the
SHAM group were injured (v21 ¼ 9.38, P ¼ .002). Effect on Ankle Injuries Only
We did not observe differences for ankle injuries between
Effect on Knee Injuries Only the CORE and SHAM groups overall, by level, or by sport
The effect of the CORE intervention on knee injuries is (Table 5).
presented in Table 4. The CORE intervention appeared to
have the greatest protective effect on knee injuries at the DISCUSSION
middle school level, with a knee-injury incidence rate of The purpose of our study was to prospectively evaluate
4.16 per 1000 AEs compared with 7.04 per 1000 AEs in the injury incidence in middle and high school athletes
SHAM group (F1,261 ¼ 5.36, P ¼ .02). Volleyball was the randomly assigned to an NMT (CORE) intervention group
only individual sport with a reduction in overall injuries compared with that in a SHAM group across the sports of
(rate ¼ 2.80 versus 8.70 injuries/1000 AEs; F1,149 ¼ 13.59, basketball, soccer, and volleyball. We observed a differ-
P , .001) and an even greater reduction at the middle ence in injury rates between the 2 groups, indicating that

Table 5. Examination of Ankle Injuries Only: Rates by Exposure

CORE Intervention SHAM Intervention
Absolute Risk
Rate per Rate per Reduction Rate
No. of No. of 1000 AEs No. of No. of 1000 AEs per 1000 AEs
Sport Injuries Exposures (Standard Error)a Injuries Exposures (Standard Error)a F Value P Value (95% CI)
Overall 27 22 906 1.26 (0.26) 30 19 875 1.63 (0.27) 1.02 .31 1.29 (0.76, 2.34)
High school 17 15 389 1.20 (0.31) 18 11 998 1.75 (0.36) 1.34 .25 1.46 (0.74, 3.25)
Middle school 10 7517 1.26 (0.43) 12 7877 1.41 (0.38) 0.06 .80 1.12 (0.42, 3.99)
Basketball 12 11 106 1.07 (0.36) 17 10 769 1.77 (0.36) 1.87 .17 1.65 (0.78, 5.57)
High school 5 4917 0.96 (0.50) 6 3864 2.04 (0.63) 1.82 .18 2.12 (inestimable)
Middle school 7 6189 1.56 (0.49) 11 6905 1.67 (0.44) 0.62 .43 1.07 (0.41, 3.45)
Soccer 6 6060 1.18 (0.55) 9 5409 1.85 (0.56) 0.72 .40 1.57 (inestimable)
High school 6 5758 1.36 (0.56) 8 4813 1.91 (0.62) 0.44 .51 1.40 (0.36, 14.79)
Middle school 0 302 0.00 (1.89) 1 596 1.68 (1.37) 0.52 .48 Inestimable
Volleyball 9 5740 1.59 (0.48) 4 3697 1.03 (0.60) 0.53 .47 0.65 (0.19, 2.49)
High school 6 4714 1.24 (0.51) 4 3321 1.32 (0.64) 0.01 .92 1.06 (inestimable)
Middle school 3 1026 2.09 (0.86) 0 376 0.00 (0.91) 2.79 .10 Inestimable
Abbreviations: AEs, athlete-exposures; CI, confidence interval; CORE, exercises focused on the trunk and lower extremity; SHAM, resisted
running with elastic bands.
a
Athlete-exposures were calculated by multiplying the number of team exposures by the number of athletes on the team.

Journal of Athletic Training 25

the CORE intervention program offered protection against substantially higher risk of ACL injury than male athletes
injury in young female athletes over the athletic season. In when playing basketball. One in approximately 80
particular, the protective effect of the CORE intervention female high school basketball players will sustain an
was most evident for reducing knee injuries. ACL injury.23,39,40 For the safety and long-term well-
Authors2326 of several meta-analyses have shown that being of our female athletes, we should focus on
NMT has a positive effect in reducing the incidence of implementing injury-prevention interventions at a young
ACL injury in adolescent female athletes. Considerable age. Our data showed a difference in injury rates between
debate persists about the effect of an NMT intervention on the CORE and SHAM groups (4.99 and 7.72 injuries/
ACL injury reduction in terms of the specific exercises 1000 AEs, respectively; P ¼ .002). This difference was
included (eg, strength, balance, plyometrics) as well as also evident at the high school level (3.32 and 7.21
duration, frequency, and athlete compliance.24,27 The injuries/1000 AEs, respectively; P ¼ .001) but not at the
CORE intervention that we implemented in this study in middle school level (6.14 and 7.90 injuries/1000 AEs,
the preseason and continued throughout the competitive respectively; P ¼ .14).
season included exercises focused on the trunk and hip. The Similar to basketball, the volleyball data showed a
protocol for this randomized controlled trial was modified protective effect of the CORE intervention versus the
from a previously published injury-prevention training SHAM intervention and a statistically lower injury
program.19,20 We modified the exercises to allow ATs and incidence rate (5.74 and 11.63 injuries/1000 AEs, respec-
coaches to incorporate the program into team practice so tively; P ¼ .001). However, the effect of level for volleyball
that the exercises would be performed in a timely but was opposite that for basketball, with an overall greater
effective manner. Anterior hopping, lateral hopping, trunk preventive effect of the CORE intervention observed at the
flexion, trunk extension, trunk rotation, hip extension, middle school than at the high school level (4.03 and 5.94
lunges, and plyometrics were progressed throughout the injuries/1000 AEs, respectively).
protocol to become more advanced as the program We focused on the specific effects on knee and ankle
continued. Video analysis of ACL injuries suggested that injuries because researchers have shown that these joints
lateral trunk flexion and medial knee collapse were are the 2 most injured body parts in children aged 5 to 14
common positions during an ACL injury.28,29 Therefore, years presenting to emergency departments41 or due to
athletes with decreased control of the trunk may be at athletic participation.6,42 For knee injuries, the CORE
higher risk of sustaining an ACL injury, and subsequently, intervention demonstrated a lower incidence rate for overall
NMT aimed at improving trunk control may improve these injuries; however, a sport-specific difference between
mechanics.13,19,2931 As hypothesized, athletes targeted with
intervention groups was demonstrated only in volleyball.
exercises focused on the trunk and hip in the CORE
Of particular importance was the effect at the middle school
intervention group had a reduced incidence of all injuries
level. Based on our data, the greatest effect will likely result
across levels and sports.
from initiating preventive interventions in this younger age
An estimated 15.5 million people participate in soccer in
the United States. Youth soccer participation is growing at group, which is consistent with current evidence.35 Au-
a rate of 11% to 22% per year.32,33 Soccer is the leading thors36,4345 of longitudinal biomechanical investigations
source of reported sport-related injury in girls.15 Each have indicated that a potential window of opportunity may
year, athletes (mean age ¼ 13 years33) receive medical exist before the peak injury incidence, which would be
attention in US emergency departments for an estimated optimal timing for initiating integrative NMT in female
1.6 million soccer-related injuries. Powell and Barber- athletes. Similarly, young female athletes tend to be
Foss16 reported an incidence rate of 5.3 injuries per 1000 particularly sensitive to the effects of integrative NMT,
AEs in soccer. The injury rates of the CORE and SHAM suggesting a potential sex-specific opportunity for enhanc-
groups for soccer were not different (5.47 and 7.64, ing implementation. These previous results support our
respectively; F1,150 ¼ 1.92, P ¼ .17), as the trial was likely finding of an enhanced injury-prevention effect in younger
underpowered to examine individual sports. Given that athletes.
soccer was not a school-sponsored sport at the middle In research on a similar population, Barber Foss et al18
school level, our trial had a much smaller sample size for reported that the highest incidence of all new cases of
soccer than for the other 2 sports at this level. Therefore, patellofemoral pain occurred in middle school-aged
the conclusion that no effect was present for injury adolescent athletes. We found no differences between
incidence between intervention groups should be inter- intervention groups overall, by sport, or by level for ankle
preted with caution.34 With a larger sample size, the injuries. However, given that a small number of ankle
positive effects observed in basketball and volleyball injuries were reported, these results should be interpreted
might also be seen in soccer at this level, especially as a with caution.
reduction was evident in older female athletes.34 Replica- Our study had limitations, including the small sample
tion of this interventional study with a larger sample of size for middle school soccer players. Whereas we tested all
soccer athletes, particularly at this younger age level, is a sixth- through eighth-grade middle school teams in
worthy endeavor.35,36 basketball and volleyball, soccer was not a school-
Basketball continues to be a popular team sport in the sponsored sport at the middle school level. Only 1 middle
United States, and it is associated with the most sport- school offered a school-based soccer team, but the
related injuries: 40% more than boys’ American foot- competitions occurred through a community league. Future
ball.37,38 Researchers15,33,39,40 studying high school ath- research in which additional soccer teams at this age level
letes have indicated that ankle sprain is the most common are examined would be beneficial for determining if the
injury and injury location. Female athletes are also at a injury-incidence trend evident in our data holds true.

26 Volume 53  Number 1  January 2018

CONCLUSIONS 15. Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower
extremity injuries among U.S. high school athletes. Acad Emerg
Participation in the CORE intervention program reduced Med. 2007;14(7):641–645.
injury incidence compared with participation in a SHAM 16. Powell JW, Barber-Foss KD. Injury patterns in selected high school
intervention. Thus, the CORE intervention program sports: a review of the 19951997 seasons. J Athl Train. 1999;34(3):
offered protection against injury in young female athletes 277–284.
over the athletic season. Our data indicated that NMT 17. Schiff MA, Mack CD, Polissar NL, Levy MR, Dow SP, O’Kane JW.
implemented at the middle school and high school levels Soccer injuries in female youth players: comparison of injury
prevented injury in basketball and volleyball athletes. Of surveillance by certified athletic trainers and internet. J Athl Train.
particular interest was the knee-injury reduction observed 2010;45(3):238–242.
for middle school volleyball athletes. These data might 18. Barber Foss KD, Myer GD, Hewett TE. Epidemiology of basketball,
reflect an important window of opportunity for imple- soccer, and volleyball injuries in middle-school female athletes. Phys
menting injury-prevention strategies at younger ages to Sportsmed. 2014;42(2):146–153.
have the greatest effects on the susceptible female 19. Myer GD, Chu DA, Brent JL, Hewett TE. Trunk and hip control
population. neuromuscular training for the prevention of knee joint injury. Clin
Sports Med. 2008;27(3):425–448, ix.
ACKNOWLEDGMENTS 20. Myer GD, Paterno MV, Ford KR, Hewett TE. Neuromuscular
training techniques to target deficits before return to sport after
This study was supported by research grants R01AR049735, anterior cruciate ligament reconstruction. J Strength Cond Res. 2008;
R01AR055563, R01228AR056259, R03057551, R21AR065068- 22(3):987–1014.
01A1, and U01AR067997 from the National Institutes of Health/ 21. Sugimoto D, Myer GD, Bush HM, Hewett TE. Effects of compliance
National Institute of Arthritis and Musculoskeletal and Skin on trunk and hip integrative neuromuscular training on hip abductor
Diseases (Drs Hewett and Myer).
strength in female athletes. J Strength Cond Res. 2014;28(5):1187–
1194.
REFERENCES 22. Powell JW, Barber-Foss KD. Sex-related injury patterns among
1. Adirim TA, Cheng TL. Overview of injuries in the young athlete. selected high school sports. Am J Sports Med. 2000;28(3):385–391.
Sports Med. 2003;33(1):75–81. 23. Sugimoto D, Myer GD, Barber Foss KD, Hewett TE. Dosage effects
2. McGuine T. Sports injuries in high school athletes: a review of of neuromuscular training intervention to reduce anterior cruciate
injury-risk and injury-prevention research. Clin J Sport Med. 2006; ligament injuries in female athletes: meta- and sub-group analyses.
16(6):488–499. Sports Med. 2014;44(4):551–562.
3. Franklin CC, Weiss JM. Stopping sports injuries in kids: an overview 24. Sugimoto D, Myer GD, Barber Foss KD, Hewett TE. Specific exercise
of the last year in publications. Curr Opin Pediatr. 2012;24(1):64– effects of preventive neuromuscular training intervention on anterior
67. cruciate ligament injury risk reduction in young females: meta-analysis
4. Knowles SB, Marshall SW, Bowling JM, et al. A prospective study and subgroup analysis. Br J Sports Med. 2015;49(5):282–289.
of injury incidence among North Carolina high school athletes. Am J 25. Sugimoto D, Myer GD, Bush HM, Klugman MF, Medina McKeon
Epidemiol. 2006;164(12):1209–1221. JM, Hewett TE. Compliance with neuromuscular training and
5. Burt CW, Overpeck MD. Emergency visits for sports-related injuries. anterior cruciate ligament injury risk reduction in female athletes: a
Ann Emerg Med. 2001;37(3):301–308. meta-analysis. J Athl Train. 2012;47(6):714–723.
6. Ingram JG, Fields SK, Yard EE, Comstock RD. Epidemiology of 26. Sugimoto D, Myer GD, McKeon JM, Hewett TE. Evaluation of the
knee injuries among boys and girls in US high school athletics. Am J effectiveness of neuromuscular training to reduce anterior cruciate
Sports Med. 2008;36(6):1116–1122. ligament injury in female athletes: a critical review of relative risk
7. Gage BE, McIlvain NM, Collins CL, Fields SK, Comstock RD. reduction and numbers-needed-to-treat analyses. Br J Sports Med.
Epidemiology of 6.6 million knee injuries presenting to United States 2012;46(14):979–988.
emergency departments from 1999 through 2008. Acad Emerg Med. 27. Sugimoto D, Myer GD, Barber Foss KD, Pepin MJ, Micheli LJ,
2012;19(4):378–385. Hewett TE. Critical components of neuromuscular training to reduce
8. Louw QA, Manilall J, Grimmer KA. Epidemiology of knee injuries ACL injury risk in female athletes: meta-regression analysis. Br J
among adolescents: a systematic review. Br J Sports Med. 2008; Sports Med. 2016;50(20):1259–1266.
42(1):2–10. 28. Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee
9. Nelson AJ, Collins CL, Yard EE, Fields SK, Comstock RD. Ankle motion during non-contact anterior cruciate ligament injury in female
injuries among United States high school sports athletes, 20052006. athletes: lateral trunk and knee abduction motion are combined
J Athl Train. 2007;42(3):381–387. components of the injury mechanism. Br J Sports Med. 2009;43(6):
10. Robinson RL, Nee RJ. Analysis of hip strength in females seeking 417–422.
physical therapy treatment for unilateral patellofemoral pain 29. Hewett TE, Myer GD. The mechanistic connection between the
syndrome. J Orthop Sports Phys Ther. 2007;37(5):232–238. trunk, hip, knee, and anterior cruciate ligament injury. Exerc Sport
11. Fulkerson JP. Diagnosis and treatment of patients with patellofem- Sci Rev. 2011;39(4):161–166.
oral pain. Am J Sports Med. 2002;30(3):447–456. 30. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of
12. Fulkerson JP, Arendt EA. Anterior knee pain in females. Clin Orthop neuromuscular control and valgus loading of the knee predict anterior
Relat Res. 2000;(372):69–73. cruciate ligament injury risk in female athletes: a prospective study.
13. Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries Am J Sports Med. 2005;33(4):492–501.
in female athletes: part 2, a meta-analysis of neuromuscular 31. Myer GD, Ford KR, Brent JL, Hewett TE. Differential neuromus-
interventions aimed at injury prevention. Am J Sports Med. 2006; cular training effects on ACL injury risk factors in ‘‘high-risk’’ versus
34(3):490–498. ‘‘low-risk’’ athletes. BMC Musculoskelet Disord. 2007;8:39.
14. Borowski LA, Yard EE, Fields SK, Comstock RD. The epidemiology 32. Koutures CG, Gregory AJ; American Academy of Pediatrics,
of US high school basketball injuries, 20052007. Am J Sports Med. Council on Sports Medicine and Fitness. Injuries in youth soccer.
2008;36(12):2328–2335. Pediatrics. 2010;125(2):410–414.

Journal of Athletic Training 27

33. Leininger RE, Knox CL, Comstock RD. Epidemiology of 1.6 million 39. Gomez E, DeLee JC, Farney WC. Incidence of injury in Texas girls’
pediatric soccer-related injuries presenting to US emergency depart- high school basketball. Am J Sports Med. 1996;24(5):684–687.
ments from 1990 to 2003. Am J Sports Med. 2007;35(2):288–293. 40. Messina DF, Farney WC, DeLee JC. The incidence of injury in Texas
34. Gilchrist J, Mandelbaum BR, Melancon H, et al. A randomized high school basketball: a prospective study among male and female
controlled trial to prevent noncontact anterior cruciate ligament athletes. Am J Sports Med. 1999;27(3):294–299.
injury in female collegiate soccer players. Am J Sports Med. 2008; 41. Colvin AC, Lynn A. Sports-related injuries in the young female
36(8):1476–1483. athlete. Mt Sinai J Med. 2010;77(3):307–314.
35. Myer GD, Sugimoto D, Thomas S, Hewett TE. The influence of age
42. Shanmugam C, Maffulli N. Sports injuries in children. Br Med Bull.
on the effectiveness of neuromuscular training to reduce anterior
2008;86:33–57.
cruciate ligament injury in female athletes: a meta-analysis. Am J
43. Shea KG, Pfeiffer R, Wang JH, Curtin M, Apel PJ. Anterior cruciate
Sports Med. 2013;41(1):203–215.
ligament injury in pediatric and adolescent soccer players: an
36. Myer GD, Faigenbaum AD, Ford KR, Best TM, Bergeron MF,
Hewett TE. When to initiate integrative neuromuscular training to analysis of insurance data. J Pediatr Orthop. 2004;24(6):623–628.
reduce sports-related injuries and enhance health in youth? Curr 44. Hewett TE, Myer GD, Kiefer AW, Ford KR. Longitudinal increases
Sports Med Rep. 2011;10(3):155–166. in knee abduction moments in females during adolescent growth.
37. NEISS data highlights–2015. United States Consumer Product Safety Med Sci Sports Exerc. 2015;47(12):2579–2585.
Commission Web site. https://www.cpsc.gov/s3fs-public/ 45. Myer GD, Faigenbaum AD, Chu DA, et al. Integrative training for
2015%20Neiss%20data%20highlights.pdf. Accessed August 25, 2017. children and adolescents: techniques and practices for reducing
38. Cohen AR, Metzl JD. Sports-specific concerns in the young athlete: sports-related injuries and enhancing athletic performance. Phys
basketball. Pediatr Emerg Care. 2000;16(6):462–468. Sportsmed. 2011;39(1):74–84.

Address correspondence to Kim D. Barber Foss, MS, ATC, LAT, CCRP, The SPORT Center, Division of Sports Medicine, Cincinnati
Children’s Hospital Medical Center, 2800 Winslow Avenue, MLC 10001, Cincinnati, OH 45206. Address e-mail to kim.foss@cchmc.
org.

28 Volume 53  Number 1  January 2018