Systematic Reviews
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Sep 18, 2017; 8(9): 726-734
Published online Sep 18, 2017. doi: 10.5312/wjo.v8.i9.726
Osteoarthritis action alliance consensus opinion - best practice features of anterior cruciate ligament and lower limb injury prevention programs
Thomas Trojian, Jeffrey Driban, Rathna Nuti, Lindsay Distefano, Hayley Root, Cristina Nistler, Cynthia LaBella
Thomas Trojian, Jeffrey Driban, Rathna Nuti, Lindsay Distefano, Hayley Root, Cristina Nistler, Cynthia LaBella, Division of Sports Medicine, Drexel University College of Medicine, Philadelphia, PA 19127, United States
Author contributions: Trojian T and Nuti R contributed to the main text writing; the other authors were equal part in the development and review of the manuscript; all performed the review, read and approved the final manuscript.
Supported by Cooperative Agreement Number DP006262 from the Centers for Disease Control and Prevention.
Conflict-of-interest statement: All the authors declare that they have no competing interests.
Data sharing statement: The technical appendix, statistical code, and dataset are available from the corresponding author at
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Thomas Trojian, MD, Chief Doctor, Professor, Division of Sports Medicine, Drexel University College of Medicine, 10 Shurs Lane Suite 206, Philadelphia, PA 19127, United States.
Telephone: +1-215-9671627 Fax: +1-215-9671601
Received: January 29, 2017
Peer-review started: February 13, 2017
First decision: May 11, 2017
Revised: July 25, 2017
Accepted: August 2, 2017
Article in press: August 3, 2017
Published online: September 18, 2017

To identify best practice features of an anterior cruciate ligament (ACL) and lower limb injury prevention programs (IPPs) to reduce osteoarthritis (OA).


This consensus statement started with us performing a systematic literature search for all relevant articles from 1960 through January 2017 in PubMed, Web of Science and CINAHL. The search strategy combined the Medical Subject Heading (MeSH) and keywords for terms: (1) ACL OR “knee injury” OR “anterior cruciate ligament”; (2) “prevention and control” OR “risk reduction” OR “injury prevention” OR “neuromuscular training”; and (3) meta-analysis OR “systematic review” OR “cohort study” OR randomized. We found 166 different titles. The abstracts were reviewed for pertinent papers. The papers were reviewed by at least two authors and consensus of best practice for IPP to prevent OA was obtained by conference calls and e-mail discussions. All authors participated in the discussion.


The best practice features of an IPP have the following six components: (1) lower extremity and core strengthening; (2) plyometrics; (3) continual feedback to athletes regarding proper technique; (4) sufficient dosage; (5) minimal-to-no additional equipment; and (6) balance training to help prevent injuries. Exercises focused on preventing ankle sprains, hamstring injuries and lateral trunk movements are important. Plyometric exercises should focus on correcting knee valgus movement. Exercises should focus on optimizing the hamstring to quadriceps strength ratio. In order for IPP to be successful, there should be increased education and verbal feedback along with increased athletic compliance. Additional equipment is not necessary. Balance training alone does not significantly reduce injuries, but is beneficial with other exercises. Not enough evidence to recommend stretching and agility exercises, with no ill effects identified. Therefore, we suggest making these optional features.


Best practice features for ACL and lower limb IPPs to help prevent OA contain six key components along with two optional.

Keywords: Anterior cruciate ligament, Lower limb, Injury prevention program, Knee injury

Core tip: Sports participation can provide health benefits, but also increase the injury risk to the lower limbs especially the anterior cruciate ligament. Many different types of injury prevention programs (IPPs) exist to train athletes to reduce inherent risk factors. The aim of this review is to provide a comprehensive analysis of both systematic and meta-analyses studies to identify the best practice features (lower extremity and core strengthening, plyometrics, continual feedback to athletes regarding proper technique, sufficient doses, minimal-to-no additional equipment, and balance training along with optional components of stretching and agility exercises) of an IPP to help protect the athlete.