Prevention strategies for lower extremity injury: a systematic review and meta-analyses for the Female, woman and/or girl Athlete Injury pRevention (FAIR) consensus.
Level 1 - systematic review of randomized trials
Systematic review and meta-analysis of randomized and comparative trials.
PubMed 40645751 · doi:10.1136/bjsports-2025-109910
What was done
Authors conducted a systematic review and meta-analyses across eight data sources to evaluate interventions for preventing sports-related lower extremity (LE) injuries in female athletes. Eligible primary studies had a comparison group and included at least one female athlete per study arm. Study quality was evaluated using the Downs and Black tool, and certainty of evidence was graded using GRADE. The synthesis included 82 studies (48 randomized controlled trials, 16 quasi-experimental, 16 cohort, and 1 cross-sectional) with 154,561 total participants (84,915 female athletes).
What was found
Neuromuscular training (NMT) was the most evaluated intervention (n=60), followed by personal protective equipment (n=9), education (n=6), and policy/rule changes (n=4). Median Downs and Black quality score was 17 (range 5 to 24). For pooled outcomes: - ACL injury: NMT significantly reduced risk by 61% (0.39, 95% CI 0.25 to 0.60; high certainty evidence). - Overall LE injury: NMT (minimum 10 minutes, twice weekly) yielded a point estimate reduction of 19% across 9 studies (0.81, 95% CI 0.61 to 1.08; low certainty evidence). - Ankle sprain: NMT yielded a point estimate reduction of 39% across 6 studies (0.61, 95% CI 0.36 to 1.03; moderate certainty evidence).
Why it matters
This review provides high-certainty evidence that structured neuromuscular training directly prevents ACL tears in female athletes, supporting mandatory implementation in athletic programs.
Limits
Forty-one percent of included studies were non-randomized designs, and study quality varied widely (Downs and Black scores down to 5). Confidence intervals for overall lower extremity injuries and ankle sprains crossed 1.0. Interventions other than NMT (protective equipment, policy, education) had few studies, and quantitative data on unintended consequences were not reported in the abstract.
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