A new study examining the outcomes of two different rehabilitation programs following anterior cruciate ligament (ACL) reconstruction was recently published in AJSM. The authors, from Oslo University in Norway, compared the outcomes from two groups of 74 patients (mean age 28 years old) after 6 months of rehabilitation.
Group one performed a neuromuscular exercise program consisting of what the authors defined as balance exercises, dynamic joint stability exercises, plyometric exercises, agility drills, and sport specific drills. The program was previously described in a JOSPT article here.
Group two consisted of a gradual progressive strengthening program for the lower extremity muscles, with specific emphasis on the quadriceps, hamstrings, gluteus medii, and gastrocnemii.
In general, the results show that:
- At 6 months, the neuromuscular group had higher Cincinnati knee scores and global function rating (this was actually previously published in Physical Therapy here).
- At 1 year, the neuromuscular group continued to have higher Cincinnati knee scores and global function scores. The neuromuscular group also had less pain at 1 year out.
- At 1 and 2 years, the strengthening group showed significantly stronger hamstrings
- This finding was not statistically significant, but thought it was worth mentioning that the neuromuscular group had greater laxity on KT testing at the 6 month, 1 year, and 2 year marks – up to 33% more laxity. There is some debate that accelerated rehab may lead to graft elongation.
There are several implications from this study. First and foremost, it appears that neuromuscular and strengthen exercise programs following ACL reconstruction are safe and effective in restoring function. Neuromuscular control exercises appear to lead to better functional outcomes, at least for the first year. This makes sense, as balance and proprioception will likely have significant carry over into everyday activities. But one thing keeps coming back to me when I look at these results:
The best rehabilitation program likely combines both strengthening and neuromuscular control exercises
This is how I have always approached ACL patients (and pretty much every injury). Why choose between optimal function vs. optimal strength when you can have both!?
As an aside, two things I learned about Norway – 1) Insurance routinely covers ACL rehab for 6 months, sweet! and 2) The mean time from injury to surgery was more than 46 weeks. So much for universal health care!
Risberg MA, & Holm I (2009). The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction: a randomized controlled clinical trial with 2 years of follow-up. The American journal of sports medicine, 37 (10), 1958-66 PMID: 19556470