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Outcomes following anterior cruciate ligament reconstruction (ACLR) need improving, with poor return-to-sport rates and a high risk of secondary re-injury. There is a need to improve rehabilitation strategies post-ACLR, if we can support enhanced patient outcomes. This paper discusses how to optimise the early-stage rehabilitation process post-ACLR. Early-stage rehabilitation is the vital foundation on which successful rehabilitation post-ACLR can occur. Without high-quality early-stage (and pre-operative) rehabilitation, patients often do not overcome major aspects of dysfunction, which limits knee function and the ability to transition through subsequent stages of rehabilitation optimally. We highlight six main dimensions during the early stage: (1) pain and swelling; (2) knee joint range of motion; (3) arthrogenic muscle inhibition and muscle strength; (4) movement quality/neuromuscular control during activities of daily living (5) psycho-social-cultural and environmental factors and (6) physical fitness preservation. The six do not share equal importance and the extent of time commitment devoted to each will depend on the individual patient. The paper provides recommendations on how to implement these into practice, discussing training planning and programming, and suggests specific screening to monitor work and when the athlete can progress to the next stage (e.g. mid-stage rehabilitation entry criteria)., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

It is important to optimise the functional recovery process to enhance patient outcomes after major injury such as anterior cruciate ligament reconstruction (ACLR). Restoring movement quality during sporting-type movements is important prior to return-to-sport (RTS) after ACLR. Alterations in movement quality during an array of functional tasks are common amongst ACLR patients at or near the time of RTS and are associated with worse outcomes after ACLR. The inability to correct movement issues prior to RTS is likely due to the use of incomplete programmes or a lack of volume and intensity of movement re-training programmes. Although most clinicians and researchers understand that re-training movement after ACLR is important (e.g., the 'why'), there is often a disconnect with understanding the 'how' and 'what' of movement re-training post ACLR. The aim of this paper was to discuss factors relevant to movement dysfunction and re-training after ACLR and provide recommendations for clinicians to restore movement quality of patients after ACLR, prior to RTS. The paper recommends: (i) considering the factors which influence the expression of movement quality, which revolve around individual (e.g., neuromuscular, biomechanical, sensorimotor and neurocognitive factors), task-specific and environmental constraints; (ii) incorporating a three-staged movement re-training approach aligned to the ACLR functional recovery process: (1) addressing the neuromuscular and biomechanical and sensorimotor control factors which affect movement quality and motor learning, (2) including a progressive movement re-training approach to re-learn an array of functional tasks optimising coordination and motor learning (3) performing the final aspect of rehabilitation and movement training on the field, in realistic environments progressively simulating the sporting movement demands and environmental constraints; and (iii) effectively designing the movement programme for optimal load management, employing effective coach and feedback techniques and utilising qualitative movement analysis for transition between exercises, stages and for RTS., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

It is important to optimise the functional recovery process to enhance patient outcomes after major injury such as anterior cruciate ligament reconstruction (ACLR). This requires in part more high-quality original research, but also an approach to translate existing research into practice to overcome the research to implementation barriers. This includes research on ACLR athletes, but also research on other pathologies, which with some modification can be valuable to the ACLR patient. One important consideration after ACLR is the recovery of hamstring muscle function, particularly when using ipsilateral hamstring autograft. Deficits in knee flexor function after ACLR are associated with increased risk of knee osteoarthritis, altered gait and sport-type movement quality, and elevated risk of re-injury upon return to sport. After ACLR and the early post-operative period, there are often considerable deficits in hamstring function which need to be overcome as part of the functional recovery process. To achieve this requires consideration of many factors including the types of strength to recover (e.g., maximal and explosive, multiplanar not just uniplanar), specific programming principles (e.g., periodised resistance programme) and exercise selection. There is a need to know how to train the hamstrings, but also apply this to the ACLR athlete. In this paper, the authors discuss the deficits in hamstring function after ACLR, the considerations on how to restore these deficits and align this information to the ACLR functional recovery process, providing recommendation on how to recover hamstring function after ACLR.

Outcomes following anterior cruciate ligament (ACL) reconstruction need improving, with poor return-to-sport rates and high risk of secondary re-injury. There is a need to improve rehabilitation strategies after ACL reconstruction, if we can support enhanced patient outcomes. This paper discusses how to optimise the mid-stage rehabilitation process after ACL reconstruction. Mid-stage is a difficult and vitally important stage of the functional recovery process and provides the foundation on which to commence late-stage rehabilitation training. Often many aspects of mid-stage rehabilitation (e.g. knee extensors isolated muscle strength) are not actually restored prior to return-to-sport. In addition, if we are to allow time for optimal late-stage rehabilitation and return-to-sport training, we need to optimise the mid-stage rehabilitation approach and complete it in a timely manner. This paper forms a key part of a strategy to optimise the ACL rehabilitation approach and considers factors more specific to mid-stage rehabilitation characterised in 3 areas: (1) muscle strength: muscle and joint specific, in particular at the knee level, with the knee extensors and flexors and distally with the triceps surae and proximally with the lumbo-pelvic-hip complex, as well as closed kinetic chain strength; (2) altered basic motor patterning (movement quality) and (3) fitness re-conditioning. In addition, the paper provides recommendations on how to implement these into practice, discussing training planning and programming and suggests specific screening to monitor work and when the athlete is able to progress to the next stage (e.g. late-stage rehabilitation criteria).

Despite increased knowledge on anterior cruciate ligament (ACL) injury mechanisms, improved surgical techniques, improved understanding of ACL biomechanics and enhanced knowledge in rehabilitation practice, return-to-sport (RTS) rates and subsequent second ACL re-injury rates after ACL reconstruction are not optimal. This narrative review discusses factors that may be highly relevant for RTS training and testing after ACL reconstruction, but which have received limited research attention to date or do not form part of the standard approach to rehabilitation. These factors include (1) explosive neuromuscular performance; (2) movement quality deficits associated with re-injury risk, particularly the need to re-train optimal sport-specific movement patterns; (3) the influence of fatigue; and (4) a lack of sport-specific re-training prior to RTS, with particular attention to an insufficient development of chronic training load. In addition, incorporating performance re-training and ensuring an athlete has restored their sport-specific profile is important. The relevance of these variables for RTS training and testing is discussed, with a new recommended model of late-stage rehabilitation and RTS training presented. Additional testing to support RTS decision making is also presented. This paper contains important information for practitioners and researchers to support optimised late-stage rehabilitation and RTS programmes and RTS testing with a view to enhancing patient outcomes after ACL reconstruction.