# Implementation effectiveness, barriers, and real-world outcomes of neuromuscular training programs for ACL injury prevention in female athletes: systematic review with narrative synthesis using SWiM framework

## TL;DR

This review finds that the success of ACL injury prevention programs for female athletes depends heavily on how well they are implemented, with strong support and stakeholder engagement leading to better outcomes.

## Contribution

The study provides a systematic synthesis of implementation effectiveness and barriers of NMT programs for ACL injury prevention using the SWiM framework.

## Key findings

- High-quality NMT programs delivered ≥2 times/week reduced ACL injury risk by 85% in amateur female soccer players.
- Implementation strategies with professional support achieved higher compliance (73.5–85.6%) compared to education-only approaches.
- Educational institutions had better implementation outcomes (89–100%) than community settings (52.5–85.6%).

## Abstract

ACL injuries disproportionately affect female athletes. Neuromuscular training (NMT) is effective in controlled studies, but real-world adoption and adherence remain poor.

To synthesize evidence on implementation effectiveness, barriers/facilitators, and real-world outcomes of NMT for ACL prevention in female athletes using narrative synthesis.

Following SWiM, we searched PubMed, SPORTDiscus, Scopus, and Web of Science (2014–2025) for controlled studies reporting implementation outcomes. NMT was defined as a multi-component intervention including ≥2 of: plyometrics, strength, balance/proprioception, agility, or sport-specific movement training. Barriers/facilitators were thematically analyzed using CFIR, and findings were organized within the RE-AIM framework. Study quality was assessed with MMAT 2018 and used for sensitivity and certainty appraisal rather than exclusion.

Thirteen studies (n = 2,847) were included. Implementation quality was consistently associated with program effectiveness. One high-quality study suggested that delivering NMT ≥ 2 times/week reduced ACL injury risk by 85% in amateur female soccer players (HR = 0.15, 95% CI 0.03–0.73, p = 0.019), though this threshold needs validation across settings. Implementation strategies showed a gradient: stakeholder-engaged models with professional support achieved higher compliance (73.5–85.6%) than education-only approaches. In one school-based study with limited professional support, coaches were an implementation bottleneck (52.5% compliance), despite high athlete compliance when programs were delivered (87.8%). Educational institutions showed higher implementation outcomes (89–100%) than community settings (52.5–85.6%). Key barriers were time constraints, competing priorities, and insufficient ongoing support; facilitators included professional supervision, organizational commitment, and systematic stakeholder engagement. ACL-specific outcomes were reported in 3 studies and broader injury outcomes in 6; compliance was measured in 12/13 studies (92%).

Implementation quality appears to be a major determinant of real-world effectiveness for ACL prevention, potentially as important as program selection. Comprehensive support strategies outperform passive dissemination, underscoring the need to prioritize implementation science and systematic professional development to sustain injury-prevention programs.

https://inplasy.com/inplasy-2025-6-0057/, identifier INPLASY202560057.