Considerations for late stage acl rehabilitation and return to sport to limit re-injury risk and maximize athletic performance

Abstract

Purpose/background: Despite recent advances in anterior cruciate ligament reconstruction (ACL) surgical techniques, an improved understanding of the ACL's biomechanical role, and expanding research on optimal rehabilitation practices in ACL-reconstructed (ACLR) patients, the re-tear rate remains alarmingly high and athletic performance deficits persist after completion of the rehabilitation course in a large percentage of patients. Significant deficits may persist in strength, muscular activation, power, postural stability, lower extremity mechanics, and psychological preparedness. Many patients may continue to demonstrate altered movement mechanics associated with increased injury risk. The purpose of this clinical commentary and literature review is to provide a summary of current evidence to assist the rehabilitation professional in recognizing, assessing, and addressing factors which may have been previously underappreciated or unrecognized as having significant influence on ACLR rehabilitation outcomes.

Methods: A literature review was completed using PubMed, Medline, and Cochrane Database with results limited to peer-reviewed articles published in English. 136 articles were reviewed and included in this commentary.

Conclusions: Barriers to successful return to previous level of activity following ACLR are multifactorial.Recent research suggests that changes to the neuromuscular system, movement mechanics, psychological preparedness, and motor learning deficits may be important considerations during late stage rehabilitation.

Level of evidence: Level 5- Clinical Commentary.

Keywords: Anterior Cruciate Ligament (ACL); biomechanics; exercise; injury prevention; knee.

Figures 1A and 1B.

Cones or similar objects may be utilized to facilitate improved lower extremity mechanics with jumping (Figure 1A) and landing/squatting (Figure 1B). Use of these external cues in conjunction with visual and verbal feedback will facilitate increased hip and knee flexion to encourage improved force absorption at the lower extremities and increased hamstring activation.

Figures 2A and 2B.

CImprovements in jump height and jump distance may be observed during plyometric training using external attentional focus on objects such as cones, targets, etc. placed at increased distance.

Figures 3A and 3B.

The addition of competing environmental stimuli such as targets, balls, etc. during functional neuromuscular training may limit the overreliance on visual motor input for dynamic knee stability during sport‐specific tasks.