Neuromuscular Training to Target Deficits Associated With Second Anterior Cruciate Ligament Injury

Abstract

Synopsis Successful return to previous level of activity following anterior cruciate ligament (ACL) reconstruction is not guaranteed, and the prevalence of second ACL injury may be as high as 30%. In particular, younger athletes who return to sports activities within the first several months after ACL reconstruction may be at significantly greater risk of a second ACL rupture compared to older, less active individuals. Significant neuromuscular deficits and functional limitations are commonly identified in athletes following ACL reconstruction, and these abnormal movement and neuromuscular control profiles may be both residual of deficits existing prior to the initial injury and exacerbated by the injury and subsequent ACL reconstruction surgery. Following ACL reconstruction, neuromuscular deficits are present in both the surgical and nonsurgical limbs, and accurately predict second-ACL injury risk in adolescent athletes. While second ACL injury in highly active individuals may be predicated on a number of modifiable and nonmodifiable factors, clinicians have the greatest potential to address the modifiable postsurgical risk factors through targeted neuromuscular interventions. This manuscript will (1) summarize the neuromuscular deficits commonly identified at medical discharge to return to sport, (2) provide the evidence underlying second-ACL injury risk factors, (3) propose a method to assess the modifiable deficits related to second-ACL injury risk, and (4) outline a method of intervention to prevent second ACL injury. The program described in this clinical commentary was developed with consideration for the modifiable factors related to second-injury risk, the principles of motor learning, and careful selection of the exercises that may most effectively modify aberrant neuromuscular patterns. Future validation of this evidence-based, late-phase rehabilitation program may be a critical factor in maximizing return-to-activity success and reduction of second-injury risk in highly active individuals. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2013;43(11):777–792. Epub 10 October 2013. doi:10.2519/jospt.2013.4693

Visual-Motor Control of Drop Landing After Anterior Cruciate Ligament Reconstruction

“…68,69 Using a visual-disruption technology, such as stroboscopic glasses, provides an opportunity to supplement traditional interventions and may more closely mimic the cognitive stress of sport in the clinic. [59][60][61] …”

Report of the Primary Outcomes for Gait Mechanics in Men of the ACL-SPORTS Trial: Secondary Prevention With and Without Perturbation Training Does Not Restore Gait Symmetry in Men 1 or 2 Years After ACL Reconstruction

“…Therefore, although neither of the rehabilitation paradigms tested in the present study (SAP or SAP+PERT) restored gait symmetry or altered gait mechanics 1 or 2 years after ACLR, there may be other benefits to these programs. Previous work suggests neuromuscular training programs may be efficacious in improving functional performance and patient-reported outcomes [7,31,33,35,39] and facilitating return to sport while lowering second injury risk [11,23,44]. Future work should not only further investigate the functional, clinical, and biomechanical outcomes of SAP versus SAP+PERT training and compare them with outcomes of other programs and no additional training, but also explore new interventions to improve gait mechanics and ameliorate gait asymmetry in athletes after ACLR.…”

International Epidemiology of Anterior Cruciate Ligament Injuries

“…For example, the range of motion of knee abduction was found to have a significant predictive value for post-ACL injury status [17]. As a result, specific neuromuscular retraining intervention programs have been developed, including the HarmoKnee program in Sweden for soccer players and the Sports metrics program in the United States for such sports as basketball and volleyball [18].…”