SYSTEMATIC REVIEW

IJSPT THE EFFECTS OF ANTICIPATION ON THE MECHANICS

OF THE KNEE DURING SINGLE-LEG CUTTING TASKS:
A SYSTEMATIC REVIEW
Thomas G. Almonroeder, DPT1
Erika Garcia, SPT2
Malerie Kurt, SPT2

ABSTRACT
Background: ACL injuries are common in sports, which has resulted in the development of risk screening
and injury prevention programs to target modifiable neuromuscular risk factors. Previous studies which
have analyzed single-leg cutting tasks have reported that the anticipation status of the task (pre-planned vs.
unanticipated) has a significant effect on the mechanics of the knee.
Hypothesis/Purpose: The purpose of this systematic review is to assess the effect of anticipation on the
mechanics of the knee in the sagittal, frontal, and transverse planes during tasks which athletes frequently
perform during competition.
Study Design: Systematic Review
Methods: The following databases were searched using relevant key words and search limits: Pub Med,
SPORTDiscus, CINAHL, and Web of Science. A modified version of the Downs and Black checklist was used
to assess the methodological quality of the articles by two independent reviewers.
Results: 284 articles were identified during the initial database search. After a screening process, 34 arti-
cles underwent further review. Of these articles, 13 met the criteria for inclusion in this systematic review.
Conclusions: It appears that tasks which do not allow a subject to pre-plan their movement strategy pro-
mote knee mechanics which may increase an athlete’s risk of injury.
Clinical Relevance: Clinicians involved in the development and implementation of ACL injury risk screen-
ing and prevention programs may want to consider incorporating tasks which do not allow time for pre-
planning. These unanticipated tasks may more closely mimic the demands of the sports environment and
may promote mechanics which increase the risk of injury.
Level of Evidence: Level 1b
Key Words: Anterior cruciate ligament, decision-making, knee biomechanics

CORRESPONDING AUTHOR
Thomas Gus Almonroeder, D.P.T.
Department of Kinesiology
1
Musculoskeletal Injury Biomechanics Laboratory, University of Wisconsin – Milwaukee
Department of Kinesiology, University of Wisconsin – P.O. Box 413
Milwaukee, Milwaukee, WI, USA
2
Doctorate of Physical Therapy Program, Carroll University, Milwaukee, WI 53201
Waukesha, WI, USA E-mail: tga@uwm.edu

The International Journal of Sports Physical Therapy | Volume 10, Number 7 | December 2015 | Page 918
INTRODUCTION to be factors which promote mechanics associated
Each year, there are as many as 200,000 anterior cru- with an increased risk of ACL injury.22 This is con-
ciate ligament (ACL) injuries in the United States sistent with the observation that the majority of ACL
alone, with the majority occurring in young athletes.1 injuries occur at the end of a half or the end of a
Unfortunately, the authors of a recent systematic game when athletes are fatigued.23-25 It appears that
review, which included a meta-analysis, determined assessing key biomechanical variables can provide
that only 63% of athletes will return to their prior level insight into the risk of ACL injury.
of function and only 44% will return to competitive
sports participation following an ACL reconstruction.2 The majority of ACL injuries are non-contact in
This is not the only reason for concern, as athletes nature and often occur in sports such as basketball
who have experienced an ACL injury also demon- and soccer26 which involve a relatively quick response
strate accelerated degenerative changes of the knee to an external stimulus such as a ball, teammate,
even when they have undergone a successful surgical or opponent which cannot be anticipated. In these
reconstruction.3 As a result of the high incidence of cases, an athlete is afforded limited time to identify
ACL injury and the potential long-term impact, ACL the relevant stimulus and perform the neurocogni-
injury prevention programs which target modifiable tive processing required to respond with a motor plan
neuromuscular risk factors have been developed.4-6 which will allow them to successfully complete a task
A recent systematic review was conducted to assess without putting themselves at risk of being injured.27
the effectiveness of these programs.7 Fortunately, this Interestingly, it has been previously reported that rel-
report indicated that three of the eight programs eval- atively poor performance on a test of neurocognitive
uated resulted in a significant reduction in the inci- processing is associated with an increased risk of non-
dence of ACL injury. However, the potential for these contact ACL injury.28 Due to the fact that the majority
programs to have a meaningful impact on ACL injury of ACL injuries occur in sports which require landing
rates may still be limited as even the most effective and cutting in response to unanticipated stimuli and
of these programs would require 70 athletes to par- the fact that an athlete’s neurocognitive processing
ticipate in order to prevent a single non-contact ACL appears to play a role in regard to their risk of injury,
injury, based on the number needed to treat metric. researchers have begun to investigate the effect of a
The authors also discussed the large degree of vari- task’s anticipation status (pre-planned vs. unantici-
ability in the training components included in these pated) on the mechanics of the lower extremity.27,29-31
programs. The limited effectiveness and significant Understanding the role that anticipation plays in
variability in ACL injury prevention programs may be regard to ACL injury risk is not just of interest to
due to an incomplete understanding of the important researchers trying to understand the ACL enigma, it
neuromuscular risk factors.8-10 This creates what has is also of great importance to clinicians involved in
been described as the “ACL injury enigma” as it has developing risk-screening and injury prevention pro-
been highlighted that an injury cannot be prevented grams. If unanticipated conditions promote injury
if it is not completely understood.11 risk in comparison to trials which allow for pre-plan-
ning, it is important that these types of unanticipated
tasks are integrated into these programs.
The identification of biomechanical risk factors for
ACL injury has been the result of a combination of Studies investigating the effects of anticipation have
studies which have predominantly involved human used a variety of tasks, subject groups, and methodol-
cadaver specimens,12-16 biomechanical analyses,17 or ogies and have also included various dependent vari-
musculoskeletal modeling.18-20 This work has iden- ables. This makes a systematic review on this topic
tified mechanics in the sagittal, frontal, and trans- of great importance in order to provide an unbiased
verse planes which contribute to ACL injury risk.21 overview which can help to guide future research
Understanding these mechanics has allowed for the and also inform clinicians who are interested in
identification of conditions or circumstances which preventing ACL injuries. Therefore, the purpose of
may promote the risk of ACL injury. For example, this article is to systematically review the literature
both central and peripheral fatigue have been found regarding the effect of anticipation on the mechanics

The International Journal of Sports Physical Therapy | Volume 10, Number 7 | December 2015 | Page 919
of the knee in the sagittal, frontal, and transverse article was assessed using items from a version of
planes during tasks which athletes frequently per- the Downs and Black checklist which was previ-
form during competition. ously modified for use in non-randomized biome-
chanical studies.22 This modified version includes 13
METHODS of the 27 items from the original checklist which was
A literature search was performed using the data- developed for use in randomized clinical trials.38 The
bases, key words and search limits provided in Table wording of some of the questions was also altered in
1. Articles which assessed the effect of anticipation order to provide clearer scoring criteria to improve
on the mechanics of the knee during a single-leg cut- the consistency among raters. Two reviewers inde-
ting tasks were included in this review. Only studies pendently evaluated each article. Their scores were
which included a single-leg land-and-cut or run-and- compared and a third reviewer was involved in the
cut task were included because these movements are case of any discrepancies.37 A data extraction form,
common in sports and ACL injuries typically occur developed specifically for this review process, was
during tasks of this nature.26,32 Some studies also provided to each reviewer involved in evaluating the
included a crossover cutting task. However, these were articles in order to ensure consistency in identifying
not included in this review as this activity is uncom- the key details (e.g. subject group(s), methods, task,
monly performed during sports.30,33 The authors also outcomes) which needed to be highlighted within
chose not to include studies which implemented a each study. This helped the reviewers determine
training program to alter cutting mechanics as the if an article was appropriate for inclusion in this
current review was only intended to describe ACL review and also allowed for analysis of the poten-
injury risk and studies that included training did not tial influence of additional factors (i.e. subject group,
allow for the delineation of the effects of anticipation task) on the results of a study.
independently of any training effects.34-36 Additional
Due to the heterogeneity of the tasks, methodology,
hand searching37 was conducted throughout the arti-
and outcomes assessed in the studies, it was deter-
cle review process and a search using the Cited Ref-
mined that a meta-analysis was not appropriate.37
erence Search tool provided by the Web of Science
The focus was specifically on the biomechanical
database was also performed.
variables (joint angles and moments) of the knee
Once the literature search was complete, each arti- as these are thought to have the most relevance to
cle title and abstract was screened to determine if ACL injury. All moments are expressed as externally
they were appropriate for inclusion in this system- applied moments as this was the most commonly
atic review.37 The methodological quality of each utilized convention among the articles included.

Table 1.
Database Key Word Search Search Limit s
PubMed [ACL OR knee] Human subjects,
AND [anticipation OR decision making] English language
AND [biomechanics OR kinematics OR kinetics]

SPORTDiscus [anterior cruciate ligament injury OR knee]

(EBSCO) AND [anticipation OR decision making]
AND [biomechanics OR kinematics OR kinetics]

CINAHL [knee OR anterior cruciate ligament OR lower extremity]

(EBSCO) AND [anticipation OR decision making]
AND [biomechanics OR kinematics OR kinetics]

Web of Science [ACL OR anterior cruciate ligament OR knee]

AND [anticipation OR decision making]
AND [biomechanics OR kinetics OR kinematics]

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 loads ranging from 6-40 kg during the trials in order
to simulate military field operations.40

A summary of the key details of the studies which

were included in the current review are provided in
Table 2. This includes the participant characteristics,
task, and outcomes of interest. The consensus scores
for the modified Downs and Black checklist are pro-
vided in Table 3. Both the overall scores and the
scores for each individual criterion are presented.37

Sagittal Plane Mechanics

The authors of four of the seven studies included in
this review, which analyzed the effect of anticipation
on the sagittal plane knee angles, reported a statis-
tically significant increase in the peak knee flexion
Figure 1. Flow diagram based on the recommendations of for the unanticipated trials in comparison to the pre-
the Preferred Reporting Items for Systematic Reviews and planned trials.27,30,41,42 The authors of the three remain-
Meta-Analyses (PRISMA) Statement. ing studies reported no significant differences.29,31,43
None of the authors reported a reduction in the knee
When summarizing the results of the studies, the flexion angle in the unanticipated condition. The
focus was on the peak angles and moments as these effect of anticipation on the sagittal plane moments
were most commonly reported. Studies that only was fairly inconsistent. The authors of two studies
looked at muscle activation patterns via electromy- reported a significant increase in the external knee
ography were not included as this was outside the flexion moment in the unanticipated condition,30,43
scope of this review. Khalid et al44 reported a significant decrease, the
authors of three studies reported no significant differ-
RESULTS ence between the conditions,29,31,41 and Besier et al27
reported an increase in the unanticipated condition
Search Results during a run-and-cut at 30°, but a significant decrease
The initial database search resulted in the identifi- when the angle of the cut was performed at 60°.
cation of 310 articles, with an additional 35 articles
identified using the Cited Reference Search tool Frontal Plane Mechanics
and through hand searching. After duplicates were The authors of each of the studies included in the
removed, 236 articles remained. The titles and current review reported the effect of anticipation on
abstracts were screened which resulted in the exclu- the mechanics (knee angles and/or moments) of the
sion of 201 of these articles. The remaining 35 arti- knee in the frontal plane. The authors of three of the
cles where read in full and evaluated for possible studies included in this review reported a significant
inclusion in the review. Thirteen of these articles increase in the peak knee abduction angle when tri-
met the criteria and were included. A flow diagram is als were unanticipated,30,41,42 while the authors of
provided in Figure 1 in accordance with the PRISMA three additional studies reported no significant dif-
Statement.39 This figure also includes the reasons for ference.29,31,45 The authors of two studies, which both
article exclusion. The primary reasons why articles included NCAA Division I athletes, reported a sig-
were excluded were 1) they did not include a single- nificant interaction between the effects of fatigue
leg cutting task, 2) they did not directly compare and anticipation on the peak knee abduction angles
pre-planned and unanticipated trials, and 3) they during a lateral cutting task, as the increase in the
implemented a training program. One study met all peak knee abduction angles for the unanticipated
of the criteria for inclusion in this review, but was condition became more prominent as the subjects
excluded because subjects were required to carry progressed through a general fatigue protocol.10,43

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 Table 2.
St u d y P a rt ic i p a n t Cha ra ct er i s t i c s T as k O u t com e s o f I nt er e s t
Besier 11 male soccer players Run-and-cut at 30° and 60° Sagittal angles
(2001) Adjusted timing of stimulus to subject Sagittal, frontal, and transverse moments

Borotikar 24 female NCAA athletes Land-and-cut laterally Sagittal, frontal, and transverse angles
(2008) (basketball, soccer, volleyball) Stimulus presented at 350 ms

Brown 13 males Land-and-cut laterally Sagittal, frontal, and transverse angles

(2009) 13 females Stimulus presented at 400, 500, and 600 ms

McLean 20 female NCAA athletes Land-and-cut laterally Sagittal, frontal, and transverse angles
(2009) (basketball, soccer, volleyball) Stimulus presented at 400 ms Sagittal, frontal, and transverse moments

McLean 20 female NCAA athletes Land-and-cut laterally Frontal moments

(2010) (basketball, volleyball, soccer) Stimulus presented at 650 ms

Cortes 13 female NCAA soccer players Run-and-cut at 45° Sagittal, frontal, and transverse angles
(2011) Stimulus presented at 450 ms Sagittal and frontal moments

Park 13 female college soccer players Run-and-cut at 45° Sagittal, frontal, and transverse angles
(2011)

Kipp 12 female recreational athletes Land-and-cut laterally Frontal angles

(2013) 18 female NCAA athletes Stimulus presented at 350 ms Frontal moments
(basketball, soccer, volleyball)
Lee 15 semipro male soccer players Run-and-cut at 45° Frontal and transverse moments
(2013) 15 amateur male soccer players Stimulus presented 450 ms

Weinhandl 20 female recreational athletes Run-and-cut at 45° Sagittal, frontal, and transverse angles
(2013) Stimulus presented at 600 ms Sagittal, frontal, and transverse moments

Kim 37 male middle school soccer players Run-and-cut at 45° Sagittal, frontal, and transverse angles
(2014) Sagittal, frontal, and transverse moments

Mornieux 13 male amateur soccer players Run- and-cut at 45° Frontal moments
(2014) Stimulus presented at 850, 600, 500 ms

Khalid 6 male soccer players Run-and-cut at 45⁰ Sagittal, frontal, and transverse moments
(2015) 6 female soccer players Adjusted timing of stimulus to subject

The authors of six of the included studies reported components analysis48-50 on the knee moment wave-
a significant increase in the peak knee abduction forms and compared the effects of anticipation
moment for the unanticipated condition,27,30,33,44,46,47 between the two groups of athletes and found a sig-
while Cortes et al41 reported a significantly lower nificant interaction (group x condition) for the fourth
peak knee abduction moment in the unanticipated retained principal component. This interaction indi-
condition, and Brown et al31 reported that the effect cated that the magnitude of the abduction moment
of anticipation was not significant.31 Kipp et al45 also during early stance (~20%) increased for the unan-
reported no significant effect of anticipation on the ticipated trials in the recreational athlete group, but
peak knee abduction moment in either a group of not for the group of NCAA Division I athletes. Simi-
recreational athletes or a group of NCAA Division I lar to the results reported for the peak knee abduc-
athletes. However, they also performed a principal tion angles, McLean et al43 also reported a significant

The International Journal of Sports Physical Therapy | Volume 10, Number 7 | December 2015 | Page 922
Table 3. (+) study met criteria (-) study did not meet criteria
Modified Downs and Black Criteria Besier Borotikar Brown McLean McLean Cortes Park Kipp Lee Weinhandl Kim Mornieux Khalid
(2001) (2008) (2009) (2009) (2010) (2011) (2011) (2013) (2013) (2013) (2014) (2014) (2015)

Clear Aim + + + + + + - + + + + + +
Outcomes described + + + + + + + + + + - + +
Subjects described - + - + + + + + + + - + +
Task(s) described + + + + + + - + + + + + -
Main findings clearly described + + + + + + + + + + + + -
Measures of random variability - + + + + + + + + + + + +
Reporting of probability values - - + - + + + - + + + + +
Subjects represent population - - - - - - - - - - - - -
Included subjects represent population - - - - - - - - - - - - -
Planned analysis + + + + - + - + + + + + +
Appropriate statistics + + + + + + + + + + + + +
Accuracy of outcome measures - + + + + + - + + + + + +
Sample size calculation - + + + + - - - + - - + -
Total Score 6 10 10 10 10 10 6 9 11 10 8 11 8

interaction between fatigue and anticipation as the The implications of the effects of anticipation on the
increase in the peak knee abduction moment in the mechanics of the knee in the sagittal plane were dif-
unanticipated condition became more prominent as ficult to ascertain. An increase in the external knee
subjects progressed through a fatigue protocol. flexion moment would likely require a greater inter-
nal knee extension torque, mainly from the quad-
Transverse Plane Mechanics riceps musculature. This could potentially increase
The effect of anticipation on the mechanics of the the risk of injury as force from the quadriceps has
knee in the transverse plane was less commonly been shown to increase ACL strain by promot-
analyzed than the effects in the sagittal and frontal ing anterior translation of the tibia relative to the
planes. However, the authors of four of the studies femur.12,13 In fact, DeMorat et al.12 reported that the
included in this review reported a statistically sig- application of a single quadriceps force of 4500 N at
nificant increase in the peak knee internal rotation 20° of knee flexion resulted in a rupture of the ACL
angles for the unanticipated trials,10,30,42,43 while the in over half of the cadaver specimens they included
authors of two studies reported that anticipation had in their analysis. However, many have begun to
no effect on the transverse plane kinematics of the question how this cadaver work translates to sports-
knee.29,31 Also, the authors of four of the included related tasks as the authors of multiple musculo-
studies reported an increase in the peak internal skeletal modeling studies have reported that sagittal
rotation moment of the knee for the unanticipated plane mechanics alone cannot produce forces which
condition,27,31,43,44 while the authors of two studies are high enough to rupture the ACL during landing
reported the opposite effect.30,47 and cutting.53,54 This is primarily due to the large pos-
teriorly directed ground reaction force vector dur-
DISCUSSION ing the initial landing phase which effectively limits
In general, anticipation had a prominent effect on the force which is transmitted to the ACL, as this
the mechanics of the knee during the cutting tasks, vector passes behind the knee joint and limits ante-
which would likely result in an increase in the risk rior translation of the tibia. Also, the increase in the
of an ACL injury. This finding was consistent with knee flexion angle reported in the unanticipated tri-
observational studies whose authors’ have reported als would most likely counteract the increase in the
that the majority of injuries occur during a landing force produced by the quadriceps. This is due to the
and cutting task32,51 performed while competing in fact that the hamstring musculature becomes more
sports such as basketball and soccer which do not effective at assisting the ACL in limiting the ante-
allow for pre-planning.26,52 rior translation of the tibia as the knee flexion angle

The International Journal of Sports Physical Therapy | Volume 10, Number 7 | December 2015 | Page 923
increases.13,20,55 However, Weinhandl et al29 used a knee in the transverse plane. The most consistent
musculoskeletal modeling approach to estimate the finding was an increase in the internal rotation
forces acting on the ACL and reported that anticipa- moment in the unanticipated condition. This is also
tion significantly increased ACL loading (combined concerning as Flemming et al56 found that applying
sagittal, frontal, and transverse plane forces). Inter- an internal rotation torque to the knee increased the
estingly, the increase in the ACL force was primar- ACL strain in a group of 11 subjects who had a trans-
ily due to an increase in the loading in the sagittal ducer implanted arthroscopically into their ACL. It
plane. It seems that further analysis is required in has also been reported that the effects of loading in
order to truly understand how the sagittal plane the frontal and transverse planes can have a com-
mechanics of the knee contribute to ACL injury risk. bined effect19,60 which may result in ACL strains
which are high enough to result in a rupture of the
In the frontal plane, the effects of anticipation were
ligament.19 In regard to ACL injury risk, it appears
relatively consistent as the results of multiple studies
that the most prominent effects of anticipation may
demonstrated an increase in the peak knee abduc-
occur in the frontal and transverse planes of motion.
tion angle and peak knee abduction moment. This is
concerning as these mechanics have been previously
From a research perspective, the results of this
shown to increase ACL strain18,19,56 and have also been
systematic review indicate that when performing
reported to prospectively predict ACL injury when
a study to investigate possible risk factors for ACL
observed during a land-and-jump task.17 The frontal
injury, the demands of the task must be carefully
plane mechanics of the knee for the unanticipated
considered, as anticipation appears to be a signifi-
trails also appear to be influenced by the athletes’
cant independent risk factor and may interact with
level of fatigue. In fact, some have proposed that
other risk factors for ACL injury. Also, if incorpo-
unanticipated tasks, performed when an athlete is
rating an unanticipated task, it is important to con-
fatigued, represent the “worst case scenario” in regard
sider the timing of the stimulus provided, as there
to ACL injury risk.10,43 The effects of fatigue appear,
appears to be a cutoff point (between 600-800 ms) in
at least in part, to affect central control mechanisms
regard to the presentation of the stimulus to the time
(suprapinal and spinal components) as McLean et al43
in which the subject must complete the task (i.e.
utilized a single-leg progressive fatigue protocol and
cut), where knee joint kinematics and kinetics are
found an interaction between the effects of antici-
affected. Times which are greater than this thresh-
pation and fatigue for the frontal plane mechanics
old are thought to allow participants time to success-
of the knee. The nature of the interaction indicated
fully develop a motor plan which will not increase
that the difference between pre-planned and unan-
their risk of injury.33 However, the specific cutoff
ticipated trials became more prominent with fatigue.
point may depend on the complexity of the task
Interestingly, they also found similar results in the
and the subject sample (recreational vs. elite ath-
non-fatigued limb. The authors concluded that this
letes).31 Finally, some have advocated for the imple-
inter-limb crossover supports the premise that the
mentation of stimuli which better reflect the sports
effects of fatigue are centrally mediated. While the
environment in an effort to improve the ecological
effects of central fatigue can occur anywhere in the
validity.41,47 While most studies used a relatively
nervous system from the cerebral cortex to the neu-
simple stimulus (e.g. alternating colors, arrows,
romuscular junction,57-59 future studies would likely
etc.) to direct movement10,27,29,43,46 others have begun
benefit from attempting to more precisely explain
to incorporate different stimuli which may more
the mechanism behind the relationship between
closely mimic sport participation.41,47 For example,
fatigue and anticipation. This is important as com-
Lee et al47 compared a traditional arrow stimulus to
bating the effects of fatigue at the spinal level would
a stimulus which required subjects to respond to a
likely require different intervention approaches than
video of a soccer defender and found that while both
at the supraspinal level.
significantly influenced knee mechanics, the game-
Similar to the frontal plane, anticipation was reported like soccer simulation had a more prominent effect.
to have significant effects on the mechanics of the While this is certainly a worthwhile endeavor, all

The International Journal of Sports Physical Therapy | Volume 10, Number 7 | December 2015 | Page 924
of the methods used to assess the effects of antici- which target neurocognitive processing should also
pation are still relatively controlled in comparison be investigated (e.g. mental imagery, choice reac-
to the demands of the sports environment as most tion tasks, dual task training) as these interventions
involve only two or three choices. Finally, studies would likely be very easy and relatively inexpensive
that include a run-and-cut task should be carefully to implement on a wide scale.46 Developing pro-
designed to control for the approach speed as two of grams which do not require trained personnel and
the studies reported significant differences between costly equipment may play a key role in reducing
the pre-planned and unanticipated trials.27,41 the rate of ACL injury. This is an area of research
that certainly merits further study.
For professionals interested in ACL risk screening
This systematic review does have some limitations,
and injury prevention, the results of this review
which need to be carefully considered. First, as with
support the integration of tasks that specifically
all systematic reviews there is a significant risk of
target central control mechanisms. Authors have
publication bias, as studies demonstrating statisti-
previously proposed the use of decision-making
cally significant differences in outcomes are more
tasks,27,45 neurocognitive training,45 virtual real-
likely to be published. No attempt was made to con-
ity training,31,43 and metal imagery43 as approaches
tact the authors of the studies in this review in order
which could potentially allow athletes to reduce
to address this limitation. Second, while the method-
their risk of injury in the dynamic sports environ-
ological quality of the articles included in this review
ment. The potential for training is supported by the
was assessed using a previously modified version
findings of Kipp et al45 where recreational athletes
of the Downs and Black checklist, no articles were
demonstrated greater differences between their pre-
excluded based on quality. Unfortunately, there is
planned and unanticipated trials than NCAA Divi-
not a well-developed checklist to evaluate the meth-
sion I athletes. These authors proposed that this
odological quality of studies which are not random-
is likely due to the fact that the NCAA Division I
ized control trials. While the authors of this paper do
athletes had improved their ability to perform in
have experience using these types of rating systems,
dynamic conditions as they may have more expo-
there is no training program available to ensure con-
sure to tasks which do not allow for pre-planning.
sistency as there is with other scales. Further devel-
However, it is impossible to determine from their
opment of tools to assess the methodological quality
cross-sectional design whether the elite athletes
of non-randomized trials, including the Downs and
improved performance under unanticipated condi-
Black checklist, appears warranted. Finally, while
tions was experience-driven or whether their innate
this review only analyzed the effects of anticipation
ability had contributed to them reaching their ath-
on the mechanics of the knee, the mechanics of the
letic status. Nonetheless, intervention studies do
hip and the ankle may also be affected29,41,47 and may
support the fact that the effects of anticipation may
contribute to the risk of ACL injury.
be modifiable with appropriate training.34-36 Current
training programs typically involve exposing athletes It is also important to note that a similar systematic
to unanticipated run-and-cut or land-and-cut tasks, review, which included a meta-analysis, was recently
similar to those included in the studies which have performed by Brown et al.61 However, these authors
analyzed the effects of anticipation. The basic prem- only included articles which assessed a run-and-cut
ise of this approach is that this training can improve task where the approach speed was between 3.0
an athlete’s neurocognitive processing within a rela- to 5.5 m/s in an attempt to allow for a comparison
tively controlled environment and that the effects among studies. However, in doing this they excluded
of this training will translate into improvements in any study which used a land-and-cut task. The arti-
motor control within the sports environment. Train- cles that Brown et al excluded provided valuable
ing studies have not typically involved any type of information within the current review and landing
progression. However, altering the timing of the and cutting is also a common task involved in sports.
stimulus and/or increasing the number of response As a result, they only included three of the thirteen
options seem like viable options. Other approaches articles that were included in the current review.

The International Journal of Sports Physical Therapy | Volume 10, Number 7 | December 2015 | Page 925
They also did not address how anticipation can inter- anterior cruciate ligament injury in female collegiate
act with fatigue and how there appears to be some soccer players. Am J Sports Med. 2008;36(8):1476-
experience-driven adaptations. Both of these factors 1483.
have important implications for both researchers and 6. Mandelbaum BR, Silvers HJ, Watanabe DS, et al.
Effectiveness of a neuromuscular and proprioceptive
clinicians and should be included in a review of this
training program in preventing anterior cruciate
nature. Finally, their systematic review was limited ligament injuries in female athletes: 2-year
in regard to their analysis of the effects occurring in follow-up. Am J Sports Med. 2005;33(7):1003-1010.
the frontal and transverse planes by only including 7. Noyes FR, Barber-Westin SD. Neuromuscular
a single study which analyzed the effect of anticipa- retraining intervention programs: Do they reduce
tion on frontal and transverse plane kinematics. noncontact anterior cruciate ligament injury rates in
adolescent female athletes? Arthroscopy.
CONCLUSION 2014;30(2):245-255.
In conclusion, the results of this systematic review 8. Bahr R, Krosshaug T. Understanding injury
mechanisms: A key component of preventing
indicate that anticipation has a significant effect
injuries in sport. Br J Sports Med. 2005;39(6):324-329.
on the mechanics of the knee in the sagittal, fron-
9. Kernozek TW, Torry MR, Iwasaki M. Gender
tal, and transverse planes during cutting tasks. It differences in lower extremity landing mechanics
appears that tasks which do not allow an athlete to caused by neuromuscular fatigue. Am J Sports Med.
pre-plan their movement promote mechanics which 2008;36(3):554-565.
may increase the risk of ACL injury. This has impor- 10. Borotikar BS, Newcomer R, Koppes R, McLean SG.
tant implications for both researchers and clinicians Combined effects of fatigue and decision making on
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