ORIGINAL RESEARCH
The Effects of Neuromuscular Training on Knee Joint
Motor Control During Sidecutting in Female
Elite Soccer and Handball Players
Mette K. Zebis, cand.scient, PhD,* Jesper Bencke, PhD, Lars L. Andersen, cand.scient,*
Simon Dssing, MD, Tine Alkjr, PhD, S. Peter Magnusson, DMedSci,
Michael Kjr, MD, DMedSci, and Per Aagaard, PhD
Objective: The project aimed to implement neuromuscular training
during a full soccer and handball league season and to experimentally
analyze the neuromuscular adaptation mechanisms elicited by this
training during a standardized sidecutting maneuver known to be
associated with non-contact anterior cruciate ligament (ACL) injury.
Design: The players were tested before and after 1 season without
implementation of the prophylactic training and subsequently before
and after a full season with the implementation of prophylactic
training.
Participants: A total of 12 female elite soccer players and 8 female
elite team handball players aged 26 6 3 years at the start of the study.
Intervention: The subjects participated in a specific neuromuscular
training program previously shown to reduce non-contact ACL
injury.
Methods: Neuromuscular activity at the knee joint, joint angles at
the hip and knee, and ground reaction forces were recorded during
a sidecutting maneuver. Neuromuscular activity in the prelanding
phase was obtained 10 and 50 ms before foot strike on a force plate
and at 10 and 50 ms after foot strike on a force plate.
Results: Neuromuscular training markedly increased prelanding
activity and landing activity electromyography (EMG) of the semi-
tendinosus (P , 0.05), while quadriceps EMG activity remained
unchanged.
Conclusions: Neuromuscular training increased EMG activity for
the medial hamstring muscles, thereby decreasing the risk of dynamic
valgus. This observed neuromuscular adaptation during sidecutting
could potentially reduce the risk for non-contact ACL injury.
Submitted for publication December 4, 2007; accepted May 4, 2008.
From the *National Research Centre for the Working Environment; Institute of
Sports Medicine; Gait Laboratory, Hvidovre University Hospital; Depart-
ment of Neuroscience and Pharmacology, University of Copenhagen; and
{Institute of Sports Sciences and Clinical Biomechanics, University of
Southern Denmark, Copenhagen, Denmark.
The authors state that they have no financial interest in the products mentioned
within this article.
Reprints: Mette Kreutzfeldt Zebis, cand.scientist, PhD, Institute of Sports
Medicine Copenhagen, Bispebjerg Hospital, Bispebjerg Bakke 23, Building
8, DK-2400 Copenhagen NV, Denmark (e-mail: mettezebis@hotmail.com).
Copyright 2008 by Lippincott Williams & Wilkins
Clin J Sport Med
Volume 18, Number 4, July 2008
Key Words: hamstrings, quadriceps, gluteus medius, prevention, ACL,
test-retest, prophylactic intervention, surface EMG, CMJ, dynamic
valgus
(Clin J Sport Med 2008;18:329337)
INTRODUCTION
Female soccer and team handball athletes have a reported
4- to 8-fold higher incidence of anterior cruciate ligament
(ACL) injury than their male counterparts,1,2 causing increased
focus on the prevention of ACL injury in female athletes. An
important issue in this respect is the identification of risk
factors. Many of the factors related to the gender prevalence37
are linked to differences in knee joint anatomy and circulating
hormones and are therefore difficult to affect. In contrast,
specific neuromuscular control strategies and movement pat-
terns in female athletes can be modified by prophylactic
training.
Non-contact ACL injuries typically occur during run-
ning, cutting, and jumping tasks when the knee is slightly
flexed and in valgus.8 Compared to male athletes, female
athletes seem to display distinct neuromuscular strategies and
knee motion patterns in motor tasks in which there is a high
risk of ACL injury.6,9,10 Specifically, female athletes tend
to land in more extended knee joint positions11,12 and with
increased knee valgus angles during running and sidecutting.
During isolated knee extension, quadriceps contraction force
can produce substantial anterior directed shear of the tibia
relative to the femur, especially at extended knee joint
angles.1315 The shear force is counteracted not only by the
ACL but also by means of hamstring coactivation.13 Thus,
coactivation of the hamstring muscles is needed to balance
contraction of the quadriceps,16 compress the joint, and control
high knee extension and abduction torques.
There is a synergistic relationship between the ACL and
hamstring muscle group,15,1719 which in humans exhibits a
complex behavior.20 Although the latency of the ACL ligamento-
muscular reflex arc (.100 ms) seems too long to provide
a protective mechanism per se for the ACL in acute situations,20
afferent feedback from the ACL potentially plays an important
role in the updating and formation of preprogrammed motor
patterns for optimizing knee joint stabilization.21 These findings
suggest that a change (re-programming) in movement pattern and
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Zebis et al
neuromuscular activity by means of training might reduce the
incidence of ACL injury among female athletes.2228
In fact, employment of neuromuscular training was
recently shown to reduce the incidence of ACL injuries in
female elite handball players.24 A prophylactic neuromuscular
training program was developed to focus on risk-reducing
movement strategies during landing, deceleration, and side-
cutting maneuvers.24 Despite the success of this program, the
underlying neuromuscular adaptation mechanisms elicited by
this type of training remain unknown. The well-established
effect of neuromuscular training in reducing the incidence of
ACL injuries in female sports24,28,29 may thus be related to
a remodeling of existing motor programs towards movement
and activation patterns that reduce ACL strain.
Therefore, the purpose of this study was to investigate
the effect of neuromuscular training on the specific neural
activation pattern of the hamstring and quadriceps muscles
during standardized sidecutting maneuvers, a movement clos-
ely associated with non-contact ACL injury.8
The main aim of the present study was to investigate the
effects of prophylactic neuromuscular training on neuromus-
cular function at the knee joint during sidecutting in female
elite athletes at risk for ACL injury.
It was hypothesized that neuromuscular training would
significantly change the pattern of neuromuscular activation
for the lower limb muscles in a manner that potentially reduces
specific risk factors predisposing for ACL injury among
female elite team handball and soccer players.
MATERIALS AND METHODS
Study Design
A test-retest study was used to separately evaluate
reproducibility of EMG, goniometer, and force plate measure-
ments during sidecutting in 8 individuals (see Subjects for
more details). Furthermore, the reproducibility of EMG nor-
malization procedure relative to peak amplitude during side-
cutting or relative to peak amplitude during MVC was
examined. For this purpose, the EMG activity during maximal
isometric quadriceps and hamstring contraction (MVC) was
obtained.
Neuromuscular activity at the knee joint was measured
during sidecutting before and after a 6-month period (control
season) of regular training (ie, without prophylactic training).
Furthermore, the players were tested for jump performance
expressed by countermovement jumps (CMJ).
After the control season, 12 months of prophylactic
neuromuscular training was implemented, and the effect of
neuromuscular training on neuromuscular activity during the
sidecutting maneuver was evaluated. In addition, changes in
jump performance were measured.
Subjects
Test-retest Study
Eight female elite team handball players (age, 28 6 5
years; height, 172 6 6 cm; weight, 71 6 9 kg) were tested on
2 separate days for selected biomechanical and neuromuscular
330
Clin J Sport Med
Volume 18, Number 4, July 2008
parameters (see below) with a period between tests of 9 6
4 days.
Intervention Study
Twenty female elite handball and soccer players
(2 teams) (age, 26 6 3; height, 174 6 6; weight, 70 6 9)
participated in the training study after a previous control
period. One team (n = 8) participated in the best national
handball league, whereas the other team (n = 12) participated
in the best national soccer league in Denmark.
Ethical approval was obtained from the local ethics com-
mittee, and informed consent was obtained from all players.
ACL Intervention Injury Prevention Program
The neuromuscular training program was originally
developed at the Oslo Sports Trauma Research Center (www.
klokavskade.no). We modified the program to include 6 levels,
each consisting of 3 exercises. Each of the 6 levels had to be
followed 2 times per week for 3 weeks before progressing to
the next level. After completing the program (18 weeks), the
6 levels were performed again with increasing difficulty of
the exercises. The main focus of the exercises was to improve
awareness and neuromuscular control of the hip, knee, and
ankle muscles during standing, running, cutting, jumping, and
landing tasks with simultaneous ball handling and included
exercises on wobble board (disc diameter, 38 cm; Norpro,
Notoddon, Norway, 2000) and balance mat (40 3 50 cm2;
7-cm-thick; Alusuisse Airex, Sins, Switzerland, 2000). The
program was performed twice weekly, and each exercise
session lasted 20 minutes. After careful supervision, the
involved team physiotherapists and physical trainers were
involved in the coaching of the neuromuscular training
program. The principal examiner conducted successive
follow-ups every second week.
Data on injury, match exposure and training frequency,
and type of training were recorded for each week.
Outcome Measures
The electrode sites were shaved with a hand razor and
carefully cleaned with ethanol before electrode placement on
the dominant leg. During the first visit, transparent paper was
placed over the leg, and recognizable anatomical landmarks
were identified and drawn on the paper together with the sites
of the electrodes for each subject. This was done to ensure
precise and standardized placement of the electrodes at each
visit. Bipolar surface EMG electrodes (Medicotest M-00-S)
with a 2.0-cm interelectrode distance were placed on the
medial portion of the vastus lateralis (VL), vastus medialis
(VM), and rectus femoris (RF) muscles of the quadriceps
femoris muscle, on the biceps femoris caput longus (BFcl) and
semitendinosus (ST) muscles of the hamstring muscles, and
finally on the superficial, anterior part of the gluteus medius
(GT) muscle and the muscle belly of gastrocnemius lateralis
(GL) and medialis (GM).
The EMG electrodes were connected directly to small
preamplifiers, and the signals were led through shielded wires
to custom-built differential instrumentation amplifiers with
a bandwidth of 10 to 10,000 Hz and a common mode rejection
ratio .100 dB.16,30,31 It was previously documented with this
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Volume 18, Number 4, July 2008
experimental set-up that the amount of EMG crosstalk is
negligible (2 to 6%).16 Knee and hip joint positions were con-
tinuously measured with flexible goniometers (G180; Penny &
Giles, Christchurch, United Kingdom) that were positioned
laterally over the left knee and hip joint. Calibration of the
goniometer signal was performed at anatomical knee and hip
joint angles of 0 and 90 degrees using a geometric retractor.
The EMG, ground reaction forces, and goniometer position
signals were sampled synchronously at 1000 Hz using an exter-
nal A/D-converter (dt2801-A, Data Translation, Marlborough,
USA) and stored on a personal computer for later analysis.
A sampling frequency of 1000 Hz for surface EMG
was used in numerous previous studies30,3234 because most
of the surface EMG signal is concentrated in the band between
20 and 200 Hz, and only negligible content occurs beyond
500 Hz.35
EMG Signal Treatment
All EMG signals were highpass filtered (5 Hz cutoff)
and smoothed by a symmetrical moving RMS filter (30 ms
time constant).31 RMS EMG activity (mean average ampli-
tude) was obtained in predefined time intervals and sub-
sequently normalized to the peak RMS EMG amplitude
recorded during the sidecutting maneuver. This procedure of
EMG normalization was chosen on the basis of the test-retest
results (see below). Onset of EMG was determined by an
automated signal algorithm, being the instant at which the
rectified EMG amplitude exceeded the mean of the preceding
50 data points by more than 5% of the peak rectified EMG
amplitude. This procedure ensured that premature short-
lasting bursts of EMG activity were not identified as the onset
of EMG (Figure 1).
EMG activity was obtained during maximal voluntary
isometric muscle contraction (MVC) (KinCom, Kinetic Com-
municator; Chattecx Corp., Chattanooga, TN).31 The reli-
ability and validity of the dynamometer have previously been
described in detail.36
Sidecutting and CMJ measurements were performed on
a force plate (AMTI, Advanced Mechanical Technology, Inc.)
with simultaneous EMG recordings. Goniometry (see above)
was used to record the knee and hip joint angles during side-
cutting movements. Countermovement jump was performed
with the hands placed at the hip (akimbo), and maximal jump
height was calculated from the flight time:
h g 3 t2 =8
where h is height of rise of body center of mass, g is
acceleration of gravity, and t is the flight time. The stand-
ardized sidecutting maneuver was performed with a fixed in-
step distance to the force plate (2 m). Instructions were given
to the subjects to perform the sidecutting as fast and forceful as
possible to simulate a match situation. In each test session, 5
sidecutting and 5 CMJ trials were performed by each subject,
respectively, and the average of these 5 trials was calculated for
all parameters examined.
Neuromuscular activity refers to the magnitude of nor-
malized RMS EMG amplitude in the given time intervals
examined. Neuromuscular activity during sidecutting was
obtained in the 10- and 50-ms time intervals before foot strike
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Neuromuscular Training Changes Knee Joint Motor Control
(prelanding phase), and in the 10- and 50-ms time intervals
after foot strike (landing phase), respectively.
The test-retest study was mainly executed to test repro-
ducibility of the sidecutting maneuver. Further, the test-retest
study made it possible to examine 2 normalization procedures
for highest reproducibility in the present study.
Normalization to Peak Amplitude Obtained
During Sidecutting
For each sidecutting maneuver trial, the average RMS
EMG amplitude in the predefined time intervals was nor-
malized to the peak amplitude measured in the same trial. This
normalization procedure was done for each muscle examined
(Example: Trial 1, vastus lateralis)
RMS EMG amplitudei
Neuromuscular activityi ;
Peak EMG amplitudeTRIAL 1
where i denotes time interval.
Normalization to Peak Amplitude Obtained
During MVC
For each sidecutting maneuver trial, the average RMS
EMG amplitude in the predefined time intervals was nor-
malized to the highest peak amplitude obtained from 3 trials of
MVC. This was carried out for each examined muscle except
gluteus medius, where no standardized MVC was attainable
(Example: Trial 1, vastus lateralis).
RMS EMG amplitudei
Neuromuscular activityi ;
Peak EMG amplitudeMVC
where i denotes time interval.
For both procedures, the neuromuscular activity in
a given time interval for each player was then calculated as the
average of the 5 trials performed at each test session (ie, base-
line, before, and after).
Statistical Methods
Data are presented as means 6 standard deviation (SD).
Longitudinal changes were evaluated by the Friedman 2-way
analyses of variance by ranks (related samples) in which chan-
ges were localized by multiple comparisons. Differences
between 2 tests were evaluated by Wilcoxon signed rank test
for paired samples. Test-retest reliability was assessed by
Spearman rank correlation, intraclass correlation coefficients
(ICC), and coefficient of variation (CV).
All tests were performed as 2-tailed tests at a 5% level of
significance.
RESULTS
Test-retest Study
Test-retest data are shown in Tables 1 through 3. Mod-
erate to high reproducibility was demonstrated for most of
the examined parameters,37 indicating that the sidecutting
maneuver test was highly reproducible.
A higher reproducibility for most of the examined
muscles were observed when normalizing to the peak EMG
amplitude obtained during sidecutting maneuver rather than
peak EMG amplitude obtained during MVC. Therefore,
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Volume 18, Number 4, July 2008

FIGURE 1. An example of raw EMG

activity during sidecutting in 1 subject.
The dotted lines represent the defined
onset of EMG. Full lines represent the
ground contact phase of the sidecut-
ting, named the landing phase.

normalization to peak EMG amplitude obtained during values (0 to 10 ms before landing) for mm. semitendinosus and
sidecutting was chosen. For example, when normalizing to biceps femoris were 0.861 and 0.963, respectively (Table 1).
peak EMG amplitude measured during sidecutting, the ICC In comparison, the ICC values were 0.532 and 0.609 for mm.

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Volume 18, Number 4, July 2008 Neuromuscular Training Changes Knee Joint Motor Control

TABLE 1. Test-retest Reliability of Normalized EMG Activity During Sidecutting (10 ms Pre-landing)
Test Mean (6SD) Retest Mean (6SD) Wilcoxon P Values ICC Spearmans Rho CV %
Normalized to peak amplitude
during MVC
Vastus lateralis (% of max) 42 6 19 45 6 14 0.889 0.675* 0.420 26.04
Vastus medialis (% of max) 54 6 11 52 6 13 0.779 0.389 0.526 18.50
Rectus femoris (% of max) 35 6 14 41 6 19 0.093 0.925* 0.857* 19.09
Gluteus medius (% of max)
Biceps femoris (% of max) 36 6 14 38 6 34 0.483 0.609* 0.790* 49.75
Semitendinosus (% of max) 51 6 21 31 6 13 0.025* 0.532* 0.476 47.12
Gastroc. lateralis (% of max) 74 6 34 68 6 28 0.401 0.791* 0.786* 25.27
Gastroc. medialis (% of max) 71 6 28 63 6 23 0.575 0.728* 0.635 24.94
Normalized to peak amplitude
during sidecutting
Vastus lateralis (% of max) 39 6 12 45 6 12 0.128 0.811* 0.713* 18.33
Vastus medialis (% of max) 46 6 11 52 6 12 0.401 -0.039 -0.048 24.23
Rectus femoris (% of max) 34 6 13 38 6 16 0.116 0.917* 0.946* 16.80
Gluteus medius (% of max) 55 6 19 50 6 19 0.441 0.803* 0.467 20.51
Biceps femoris (% of max) 43 6 14 42 6 16 0.396 0.963* 0.857* 9.06
Semitendinosus (% of max) 56 6 19 49 6 20 0.183 0.861* 0.738* 19.52
Gastroc. lateralis (% of max) 36 6 13 35 6 10 0.833 0.635 0.419 22.50
Gastroc. medialis (% of max) 32 6 9 33 6 16 0.612 0.854* 0.826* 19.71
*Denotes P , 0.05.

semitendinosus and biceps femoris, respectively, when nor-
malizing to peak amplitude obtained during MVC (Table 1).
The low reproducibility of the neuromuscular activity of
vastus medialis regardless of normalization procedure is not
unexpected and could be due to its function as a stabilizer of
patella (Table 1).
Control Season
Two ACL injuries were observed during the control
season. Neuromuscular pre-activity (Table 4) and landing acti-
vity, onset of EMG, knee joint angle, and hip joint angle
remained unchanged in the sidecutting maneuver during the
control season. Furthermore, no change was observed in jump-
ing performance as measured by maximal CMJ.
Intervention Season (Prophylactic Training)
No ACL injuries were observed in the intervention
season.
Neuromuscular Activity in the
Prelanding Phase
Pre- to post-training neuromuscular activity in the time
interval 50 ms before toe down of the m. semitendinosus
increased significantly from 41 6 12% to 52 6 16% (P ,
0.01). Furthermore, in the very initial time interval before
landing (10 ms), neuromuscular activity of m. semitendinosus
increased from 32 6 15% to 44 6 19% (P , 0.01; Table 4;
Figure 2, left), whereas the 10-ms pre-activity level for m.
gluteus medius decreased from 62 6 15% to 51 6 14% (P ,
0.05; Table 4; Figure 3).
Neuromuscular Activity in the Landing Phase
Neuromuscular activity measured in the 10-ms time
interval after foot strike increased for semitendinosus from
29 6 12% to 39 6 20% (P ,0.05; Figure 2, right). However,
in the 50-ms interval after foot strike, neuromuscular activity
remained unchanged in semitendinosus, whereas biceps

TABLE 2. Test-retest Reliability of Absolute EMG Activity During Sidecutting (Mean Average RMS Amplitude)
Preactivity (10 ms) Test Mean (6SD) Retest Mean (6SD) Wilcoxon P Value ICC Spearmans Rho CV %
Vastus lateralis (uV) 208 6 109 208 6 96 1.000 0.951* 0.810* 14.12
Vastus medialis (uV) 193 6 36 243 6 109 0.208 0.640 0.690 29.89
Rectus femoris (uV) 154 6 76 147 6 79 0.674 0.921* 0.595 18.70
Gluteus medius (uV) 199 6 176 171 6 88 0.674 0.841* 0.571 38.39
Biceps femoris (uV) 137 6 46 127 6 75 0.484 0.837* 0.690 23.79
Semitendinosus (uV) 258 6 87 176 6 76 0.017* 0.901* 0.548 30.44
Gastroc. lateralis (uV) 144 6 78 149 6 92 1.000 0.930* 0.833* 19.84
Gastroc. medialis (uV) 190 6 65 176 6 78 0.327 0.674* 0.881* 26.35
*Denotes P , 0.05.

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Volume 18, Number 4, July 2008

TABLE 3. Test-retest Reliability of Selected Parameters During Sidecutting

Variables Test Mean (6SD) Retest Mean (6SD) Wilcoxon P Value ICC Spearmans Rho CV %
Knee angle at landing (deg) 27 6 10 31 6 14 0.123 0.851* 0.857* 20.21
Hip angle at landing (deg) 47 6 19 47 6 14 0.889 0.922* 0.881* 12.90
Fz Peak (N) 1774 6 394 1836 6 365 0.484 0.851* 0.857* 10.32
Contact time (ms) 343 6 48 316 6 60 0.036* 0.934* 0.881* 7.99
CMJ (cm) 24.5 6 3.0 23.9 6 2.6 0.018* 0.988* 1.000* 2.93
Onset of ST EMG (ms) 151.2 6 27.1 134.2 6 20.7 0.067 0.806* 0.611 12.34
*Denotes P , 0.05.

femoris activity decreased from 42 6 14% to 32 6 11% (P , for magnitude and timing of the neuromuscular activity, which
0.01). Neuromuscular activity in gluteus medius decreased at indicates that the sidecutting maneuver is a consistent motor
the 10-ms and 50-ms time intervals after foot strike from 65 6 program that the player has developed during years of training.
16% to 52 6 13% and 68 6 13% to 58 6 12%, respectively The main finding in the present study was that neuro-
(P , 0.05). muscular training induced a change in the pattern of neuro-
muscular activation of the hamstring muscles during sidecutting.
Onset of EMG Activity The selective increase in semitendinosus activity in the pre-
EMG activity onset changed in semitendinosus from landing phase and the initial landing phase in parallel with the
168 6 70 ms before foot strike to 140 6 26 ms after the unchanged neuromuscular activity of the quadriceps muscles
intervention period (P , 0.05). The instant of EMG activity may represent an important adaptation in response to neuromus-
onset remained unchanged for all other muscles examined. cular training. During rapid movements like sidecutting, which
The order of onset of EMG activity for the examined muscles involve substantial eccentric quadriceps forces,38 it seems
during sidecutting was identical before and after intervention. essential to have adequate neural preactivation of the hamstring
The order was as follows: (1) gluteus medius; (2) hamstring muscles just before ground contact to protect the ACL. In
muscles; (3) gastrocnemius lateralis and medialis; and finally response to the present intervention, neuromuscular preactivity in
and closest to the time of landing (4) quadriceps (Table 5). the semitendinosus was increased during sidecutting from 41 6
Joint Angles 12% to 52 6 16% of maximal EMG. In accordance with our
findings, a previous study found that the hamstrings are not
Knee and hip joint angle at landing remained unchanged
activated maximally during rapid sidecutting, and it was spec-
(before, 30 6 11 degrees; after, 31 6 9 degrees; Figure 4).
ulated that increased coactivation of the hamstring muscles would
Jumping Performance result in a nonoptimal execution of the sidecutting maneuver.38
CMJ jump height increased from 27 6 4 cm to 29 6 4 This latter notion was not confirmed by the present results
cm (P , 0.001) after training (Figure 5). because duration of the sidecutting (ground contact time) was not
affected, despite increased neuromuscular activity in the semite-
ndinosus muscle.
DISCUSSION A study by Hewett et al39 identified dynamic valgus of
The sidecutting maneuver is a movement that the player the knee as a predisposing factor for ACL injury in female
is able to perform in match situations when the time for athletes. The balance between medial-lateral hamstring recruit-
decision-making about posture correction is extremely limited. ment seems highly important for the control of dynamic val-
The present study demonstrated high test-retest reproducibility gus. Female athletes have a disproportionately greater EMG
activity in their lateral hamstrings (biceps femoris) than male
TABLE 4. Neuromuscular Activity During Sidecutting
(10 ms Pre-landing) TABLE 5. Onset of EMG During Sidecutting
Normalized to Peak Time for
Amplitude During Pre Post Onset (ms) Before Pre Post Order of
Sidecutting Baseline (6SD) Mean (6SD) Mean (6SD) Foot Strike Mean (6SD) Mean (6SD) Onset (Pre/Post)
Vastus lateralis 44 6 15 45 6 17 48 6 12 Vastus lateralis 111 6 44 103 6 24 7/7
Vastus medialis 49 6 18 55 6 12 54 6 12 Vastus medialis 114 6 46 119 6 46 6/8
Rectus femoris 37 6 21 42 6 17 45 6 17 Rectus femoris 103 6 39 99 6 38 8/6
Gluteus medius 63 6 16 62 6 15 51 6 14* Gluteus medius 193 6 70 214 6 67 1/1
Biceps femoris 38 6 16 37 6 15 32 6 14 Biceps femoris 171 6 78 146 6 41 2/2
Semitendinosus 33 6 14 32 6 15 44 6 19* Semitendinosus 168 6 70 140 6 26* 3/3
Gastroc. lateralis 31 6 15 33 6 14 34 6 15 Gastroc. lateralis 125 6 35 132 6 39 5/4
Gastroc. medialis 34 6 14 32 6 15 32 6 15 Gastroc. medialis 129 6 25 131 6 27 4/5
*Significant difference, P , 0.05. *Significant difference, P , 0.05.

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Volume 18, Number 4, July 2008
FIGURE 2. Neuromuscular activity
recorded for the medial (ST) and lat-
eral (Bfcl) hamstring muscles before
and after neuromuscular training.
(Left) Mean average EMG amplitude
in the 10-ms time interval before foot
strike during sidecutting. (Right) 0- to
10-ms interval after landing. *Signifi-
cant difference between pre and post,
P , 0.05.
athletes when landing from a jump.6 Increased lateral ham-
string motor unit firing potentially leads to a more open medial
joint space and thereby potentially contributes to increased
dynamic valgus. Furthermore, Myer et al10 found that female
athletes demonstrated a reduced medial-to-lateral (VM-to-VL)
quadriceps EMG ratio compared to male athletes; this factor
could also contribute to dynamic valgus in high-risk man- still before the onset of quadriceps EMG (VL, VM, RF). In
euvers. During sidecutting, medial hamstring muscle contrac-
tion therefore seems very important in compressing the medial
knee joint compartment and thereby counteracting the risk of
dynamic valgus. Notably, the present intervention regime
resulted in an elevated ratio of preactivation EMG between
medial hamstring and quadriceps muscles during sidecutting.
Neuromuscular preplanning allows feed-forward re-
cruitment of the musculature that controls knee joint stability
during landing and pivoting maneuvers.40 The female athletes
in the present study displayed a muscle activation pattern
FIGURE 3. Neuromuscular activity (mean average EMG
amplitude) for gluteus medius in the 10-ms time interval before
foot strike during sidecutting, before and after neuromuscular
training. *Significant difference, P , 0.05.
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Neuromuscular Training Changes Knee Joint Motor Control
recommended by Kain et al, whereby the hamstring muscles
were activated before the quadriceps muscles and before initial
ground contact41 both before and after intervention. A main
finding in this study was that a selective change in EMG onset
was observed for the semitendinosus muscle after training.
Thus, EMG onset occurred closer to the time of landing but
addition to the increased neuromuscular preactivity of semi-
tendinosus, the present observation may reflect a further
optmization of the motor program. Interestingly, similar
changes in semitendinosus EMG onset during sidecutting
was previously seen in male team handball players after
a period of neuromuscular training.42 In support of an opti-
mization theory, Cowling and Steele43 found that during
a deceleration task, the semimembranosus EMG onset occurred
closer to the time of toe-down contact in males compared to
females, which may have enabled hamstring muscle activity to
better coincide with the high tibiofemoral shear forces generated
just after initial ground contact.43
Decreased activation of proximal stabilizing muscles
may lower the load-bearing capacity of the leg. Surprisingly,
we found a decrease in gluteus medius activity after the period
of neuromuscular training. Our finding could be explained
by the role of the anterior part of gluteus medius to act as
an internal hip rotator when the hip joint is flexed.44 Internal
femoral rotation during the sidecutting maneuver potentially
increases knee valgus moments during the landing phase,
which potentially increases strain and stress in the ACL. In a
3-dimensional study examining the kinetics of the sidecutting
maneuver, Bencke et al found that hip extensors, outward
rotators, and hip adductors are the most loaded muscle groups
around the hip joint during the crucial early part of the
sidecutting maneuver.45 This finding could indicate that high
neuromuscular activity of gluteus medius is not beneficial
during sidecutting maneuvers. In contrast to landing from a
jump, the sidecutting maneuver involves a change in direction,
which makes the forces in the frontal plane highly important.
The role of gluteus medius during sidecutting maneuvers may
therefore be different from its role in movements involving
1-leg landings in the sagittal plane.45
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Zebis et al
FIGURE 4. Knee joint angle at the instant of landing before and
after neuromuscular training. The dotted line represents a knee
joint angle at 30 degrees. (0 degrees = full knee extension).
In support of our findings, Pollard et al46 found that a
season of soccer practice combined with neuromuscular injury
prevention training in females led to reduced hip internal rota-
tion during a standardized landing task.
Knee and hip joint angles remained unchanged with
training. The average knee joint angle at landing for the players
after the intervention training (31 degrees) was still in the
range (0 to 30 degrees) where most non-contact ACL injuries
are observed to occur.8,47
Hewett et al48 observed a 10% increase in vertical jump-
ing performance after plyometric intervention training in
female athletes. Interestingly, the present neuromuscular train-
ing regime also produced an increase in jumping performance,
FIGURE 5. Maximum CMJ jump height, before (black bar) and
after (white bar) neuromuscular training. *Significant differ-
ence (P , 0.001).
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Clin J Sport Med
Volume 18, Number 4, July 2008
although plyometric exercises were used less than in the
program by Hewett et al.48
CONCLUSIONS
An increased ratio between m. semitendinosus and m.
biceps femoris neuromuscular activity may help to prevent
excessive external rotation of the tibia and lateral joint com-
pression during instep and sidecutting maneuvers, thereby
decreasing the risk of dynamic valgus. After neuromuscular
training, semitendinosus EMG activity was selectively in-
creased during sidecutting, which likely represents an impor-
tant adaptation mechanism because it potentially decreases the
risk of dynamic valgus. Jumping performance was additionally
enhanced as a result of the neuromuscular training.
ACKNOWLEDGMENTS
This study was supported by grants from the Danish
Ministry of Culture Committee for Sports Research, the Team
Denmark Elite Sports Association, and FIFA.
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