Prevention strategies for lower extremity injury: a systematic review and meta-analyses for the Female, woman and/or girl Athlete Injury pRevention (FAIR) consensus

Garrett S Bullock; Anu M Räisänen; Chelsea Martin; Maitland Martin; Jean-Michel Galarneau; Jackie L Whittaker; Justin M Losciale; Mario Bizzini; Matthew N Bourne; Hendrik Paul Dijkstra; Marc-Olivier Dubé; Alix Hayden; Michael Girdwood; Martin Hägglund; Shreya McLeod; Nonhlanhla Sharon Mkumbuzi; Andrea Britt Mosler; Myles Calder Murphy; Grethe Myklebust; Merete Møller; Juliana M Ocarino; Oluwatoyosi B A Owoeye; Debbie Palmer; Kati Pasanen; Ebonie Kendra Rio; Kristian Thorborg; Marienke van Middelkoop; Evert Verhagen; Stuart J Warden; Matthew Whalan; Kay M Crossley; Carolyn Emery

doi:10.1136/bjsports-2025-109910

Prevention strategies for lower extremity injury: a systematic review and meta-analyses for the Female, woman and/or girl Athlete Injury pRevention (FAIR) consensus

Br J Sports Med. 2025 Dec 3;59(22):1575-1586. doi: 10.1136/bjsports-2025-109910.

Authors

Garrett S Bullock^{1

2}, Anu M Räisänen³, Chelsea Martin⁴, Maitland Martin⁵, Jean-Michel Galarneau^{5

6}, Jackie L Whittaker^{7

8}, Justin M Losciale^{9

10}, Mario Bizzini¹¹, Matthew N Bourne¹², Hendrik Paul Dijkstra^{13

14}, Marc-Olivier Dubé^{15

16}, Alix Hayden¹⁷, Michael Girdwood¹⁸, Martin Hägglund¹⁹, Shreya McLeod²⁰, Nonhlanhla Sharon Mkumbuzi^{21

22}, Andrea Britt Mosler^{15

23}, Myles Calder Murphy²⁴, Grethe Myklebust²⁵, Merete Møller^{25

26}, Juliana M Ocarino²⁷, Oluwatoyosi B A Owoeye²⁸, Debbie Palmer^{29

30}, Kati Pasanen^{31

32}, Ebonie Kendra Rio³³, Kristian Thorborg³⁴, Marienke van Middelkoop³⁵, Evert Verhagen³⁶, Stuart J Warden³⁷, Matthew Whalan³⁸, Kay M Crossley³⁹, Carolyn Emery⁴⁰

Affiliations

¹ Department of Orthopaedic Surgery and Rehabilitation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA gbullock@wakehealth.edu.
² Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
³ Elon University, Elon, North Carolina, USA.
⁴ UNC-Chapel Hill, Chapel Hill, North Carolina, USA.
⁵ Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.
⁶ University of Calgary, Calgary, Alberta, Canada.
⁷ Faculty of Medicine, Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada.
⁸ Arthritis Research Canada, Vancouver, British Columbia, Canada.
⁹ Informatics, Decision-Enhancement, and Analytic Sciences Center of Innovation, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA.
¹⁰ Division of Epidemiology, The University of Utah School of Medicine, Salt Lake City, Utah, USA.
¹¹ Human Performance Lab, Zurich, Switzerland.
¹² Australian Centre for Precision Health and Technology, School of Health Sciences and Social Work, Griffith University-Gold Coast Campus, Gold Coast, Queensland, Australia.
¹³ Department of Medical Education, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.
¹⁴ Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
¹⁵ La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia.
¹⁶ Australian IOC Research Centre, La Trobe University, Melbourne, Victoria, Australia.
¹⁷ Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada.
¹⁸ La Trobe Sport and Exercise Medicine Research Centre, Bundoora, Victoria, Australia.
¹⁹ Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
²⁰ Discipline of Physiotherapy, School of Allied Health, Australian Catholic University Faculty of Health Sciences, North Sydney, New South Wales, Australia.
²¹ Department of Sports, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK.
²² Department of Human Movement Science, Nelson Mandela University, Port Elizabeth, South Africa.
²³ Australian IOC Research Centre, Melbourne, Victoria, Australia.
²⁴ School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.
²⁵ Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway.
²⁶ Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
²⁷ Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
²⁸ Translational Injury Prevention Lab, Physical Therapy and Athletic Training, Saint Louis University, Saint Louis, Missouri, USA.
²⁹ Edinburgh Sports Medicine Research Network, Institute for Sport, PE and Health Sciences, University of Edinburgh, Edinburgh, UK.
³⁰ UK Collaborating Centre on Injury and Illness Prevention in Sport, University of Edinburgh, Edinburgh, UK.
³¹ Integrative Neuromuscular Sport Performance Laboratory, University of Calgary, Calgary, Alberta, Canada.
³² Tampere Research Center of Sports Medicine, UKK-instituutti, Tampere, Finland.
³³ La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
³⁴ Department of Orthopedic Surgery, Copenhagen University Hospital, Rødovre, Denmark.
³⁵ General Practice, Erasmus Medical Center, Rotterdam, The Netherlands.
³⁶ Union of European Football Association, Nyon, Switzerland.
³⁷ Department of Physical Therapy, Indiana University Indianapolis, Indianapolis, Indiana, USA.
³⁸ Centre of Medical and Exercise Physiology, School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.
³⁹ La Trobe University-Bundoora Campus, Bundoora, Victoria, Australia.
⁴⁰ Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada.

PMID: 40645751
DOI: 10.1136/bjsports-2025-109910

Abstract

Objective: Examine the effectiveness and unintended consequences of prevention strategies for reducing female/woman/girl athletes' lower extremity (LE) injuries.

Design: Systematic review with meta-analyses and Grading of Recommendations, Assessment, Development and Evaluation.

Data sources: Systematic search of eight data sources.

Eligibility: Primary data studies with a comparison group(s) investigating injury prevention strategies for sport-related LE injuries with ≥1 female/woman/girl in each study group.

Results: Across 82 studies-including 48 randomised controlled trials (59%), 16 quasiexperimental studies (20%), 16 cohort studies (20%) and 1 cross-sectional study (1%)-a total of 154 561 participants were included, of whom 84 915 (55%) were females/women/girls. Neuromuscular training (NMT)-based programmes (n=60, 73%) were the most frequently studied intervention, followed by personal protective equipment (PPE) (n=9, 11%), policy/rule change (n=4, 5%) and education (n=6, 7%). The median Downs and Black score for all studies was 17 (range: 5-24). Point estimate from pooled results from nine studies revealed that NMT programmes, which include LE balance, strength, agility and change of direction exercises, with a minimum dose of 10 min two times per week, reduced female/woman/girl athletes' LE injuries by 19% (0.81, 95% CI 0.61% to 1.08%; low certainty evidence). Point estimate of pooled results from six studies uncovered that NMT reduced ankle sprains by 39% (0.61, 95% CI 0.36% to 1.03%; moderate certainty evidence). NMT significantly reduced anterior cruciate ligament (ACL) injuries by 61% (0.39, 95% CI 0.25% to 0.60%; high certainty evidence).

Conclusion: NMT programmes can reduce female/woman/girl athletes' ACL injuries by up to 61% and ankle sprains by 39%, highlighting the need for widespread implementation of NMT programmes. Evidence informing PPE, policy/rule changes and education to prevent female/woman/girl athletes' LE injuries is needed.

Prospero registration number: CRD42024486715.

Keywords: Education; Exercise.

Publication types

Systematic Review
Meta-Analysis

MeSH terms

Athletic Injuries* / prevention & control
Female
Humans
Leg Injuries* / prevention & control
Lower Extremity* / injuries
Personal Protective Equipment