The Effects of Neuromuscular Training and Additive Visual Biofeedback on Landing Biomechanics and Sensorimotor Brain Activity in Young Female Athletes

Introduction: Anterior cruciate ligament (ACL) injuries are debilitating, often requiring surgical reconstruction and prolonged recovery. Female adolescent athletes are at particularly high risk for ACL injury and display distinct neuromuscular control patterns during jump landing that further increase injury risk. Neuromuscular training (NMT) designed to reduce injury risk can be enhanced with automated movement corrective biofeedback to improve neuromuscular control and landing biomechanics, however the central nervous system responses to targeted NMT that underlie adaptative biomechanical responses are not well-understood. Purpose: This study aimed to identify the effects of NMT on landing biomechanics and task-related brain activity, examine the relationship of changes in these variables, and determine if additive visual biofeedback (augmented versus sham) provides meaningful impact on injury-related outcomes. Methods: This study included 55 female middle- and high-school athletes (age mean = 15.73 ± 1.40 years) who participated in ~6 weeks of NMT (3x/week; 18 sessions), which included up to 12 sessions of additive biofeedback (augmented: n = 28; sham: n = 27). Testing at pre- and post-NMT included a drop vertical jump task to assess landing biomechanics (sagittal and frontal plane hip and knee kinematics and kinetics) and a supine bilateral leg press task during functional magnetic resonance imaging to assess brain activity during a complex sensorimotor movement task. Results: NMT improved landing biomechanics (η 2 range = 0.04–0.41, P s < 0.049) and reduced task-related brain activity in sensorimotor regions ( P range = 0.015–0.032). Pre-post increases in postcentral gyrus brain activity predicted a reduction in left knee peak abduction moment (OR = 22.61, 95% CI 2.41, 212.21, P = 0.048). Additive biofeedback did not appear to influence outcomes of interest. Conclusions: NMT improved sensorimotor efficiency and landing biomechanics. However, increased somatosensory activity emerged as a critical predictor of improved landing patterns, highlighting the role of enhanced sensory processing in biomechanical risk reduction.