ACL Reconstruction Rehabilitation – The Long Term Effects of 2 Postoperative Rehabilitation Programs


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.


Clinical Implications

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

8 replies
  1. theeverydayathletenews
    theeverydayathletenews says:

    When Talking Balance and Proprioceptive exercises are there any that are specific to the knee (ACL, lateral and medial compartments) Other than prescribing more global proprioceptive (ie single leg balance progressed to airex etc.)

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  3. Nick Pontifex
    Nick Pontifex says:

    Since your talking about ACL rehab Mike, still planning on a post for functional Knee braces?


  4. amy castillo
    amy castillo says:

    Good Point Christie. And since these are perhaps the non-copers, maybe greater neuromuscular control deficits?

  5. Christie Downing, PT, DPT, Dip MDT
    Christie Downing, PT, DPT, Dip MDT says:

    Echoing Kory,

    I agree, it seems logical. Utilize both. There's a study for you to do, Mike…repeat the study but with a third group.

    Here's a question I would have about the 46 weeks. After 46 weeks, how many of them were satisfied to NOT have surgery???

  6. Kory Zimney, PT
    Kory Zimney, PT says:

    Thanks for sharing Mike. I couldn't agree with you more. I get frustrated with therapist that get so focused on one thing and that it is the only thing that should be used.

    To me it's like painting a picture and saying you should use red and someone else thinks that blue is better. Why not use both not only do you get both colors, you can create a third color, purple!!!!

    We have to go back to realizing that it is the principle behind why we do something or not and not just the method we learned from someone, a journal article or saw on YouTube. One of my favorite quotes…"Study principles not methods, a mind that can grasp principles will create its own methods."

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