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[ clinical commentary


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

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nterior cruciate ligament (ACL) rupture is one of the ACL reconstruction (ACLR) and
most physically, financially, and emotionally devastating postsurgical rehabilitation, but
reported success rates range from
sport-related knee injuries.24,34,49,141 Return to activity is
43% to 93%.4,17,19,76,88,138 Unfortu-
highly desired and expected for many athletes following nately, for those who do resume
their previous level of activity, the risk of
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

a second ACL injury may range from 6%
TTSYNOPSIS: Successful return to previous level neuromuscular interventions. This manuscript
will (1) summarize the neuromuscular deficits
to as high as 30%65,79,126,133,136,160 and can be
of activity following anterior cruciate ligament
(ACL) reconstruction is not guaranteed, and the commonly identified at medical discharge to associated with several factors, including
prevalence of second ACL injury may be as high return to sport, (2) provide the evidence underly- surgical technique,16,65,79,84 age,65,84,136,150
as 30%. In particular, younger athletes who return ing second–ACL injury risk factors, (3) propose a activity level,16,133 sex,125,136 time since sur-
to sports activities within the first several months method to assess the modifiable deficits related to gery,75,133,150 and biomechanical adapta-
after ACL reconstruction may be at significantly second–ACL injury risk, and (4) outline a method tions during dynamic tasks.126 Although
greater risk of a second ACL rupture compared of intervention to prevent second ACL injury. The
several of these factors are nonmodifi-
to older, less active individuals. Significant program described in this clinical commentary was
neuromuscular deficits and functional limitations developed with consideration for the modifiable able, the biomechanical components of
Journal of Orthopaedic & Sports Physical Therapy®

are commonly identified in athletes following ACL factors related to second-injury risk, the principles second–ACL injury risk may be effective-
reconstruction, and these abnormal movement of motor learning, and careful selection of the ex- ly addressed with targeted neuromuscu-
and neuromuscular control profiles may be both ercises that may most effectively modify aberrant lar training prior to unrestricted sports
residual of deficits existing prior to the initial injury neuromuscular patterns. Future validation of this participation.
and exacerbated by the injury and subsequent ACL evidence-based, late-phase rehabilitation program Aberrant neuromuscular and biome-
reconstruction surgery. Following ACL reconstruc- may be a critical factor in maximizing return-to-
tion, neuromuscular deficits are present in both chanical patterns are commonly seen up
activity success and reduction of second-injury
the surgical and nonsurgical limbs, and accurately risk in highly active individuals. to 2 years after ACLR54,55,108,123,126,130 and
may help explain the high rate of second
TTLEVEL OF EVIDENCE: Therapy, level 5.
predict second–ACL injury risk in adolescent
athletes. While second ACL injury in highly active ACL injury. Deficits in the neuromus-
J Orthop Sports Phys Ther 2013;43(11):777-
individuals may be predicated on a number of cular control of both lower extremities
792. Epub 10 October 2013. doi:10.2519/
modifiable and nonmodifiable factors, clinicians
jospt.2013.4693 following ACLR have been directly im-
have the greatest potential to address the modifi-
able postsurgical risk factors through targeted TTKEY WORDS: ACL, prevention, return to sport plicated in the risk for second ACL in-
jury126 and may not only be a result of

Sports Health and Performance Institute, The Ohio State University, Columbus, OH; Department of Orthopaedics, Division of Sports Medicine, The Ohio State University,
Columbus, OH. 2Sports Health and Performance Institute, The Ohio State University, Columbus, OH; The Sports Medicine Biodynamics Center and Human Performance
Laboratory, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Departments of Pediatrics and Orthopaedic Surgery, College of Medicine, University of Cincinnati,
Cincinnati, OH; Athletic Training Division, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH; The Micheli Center for Sports Injury Prevention,
Boston, MA. 3Sports Health and Performance Institute, The Ohio State University, Columbus, OH; Departments of Physiology and Cell Biology, Orthopaedics, Family Medicine,
and Biomedical Engineering and the School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH; The Sports Medicine Biodynamics Center and
Human Performance Laboratory, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. This work was supported in full or in part by the National Institutes of Health
grants R01-AR049735, R01-AR055563, and R01-AR056259. The authors acknowledge funding support from the National Football League Charities and resources from The
Orthopaedic Research and Education Foundation, The Sports Medicine Biodynamics Center, and Cincinnati Children’s Hospital Medical Center. The authors certify that they
have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address
correspondence to Dr Stephanie Di Stasi, The Ohio State University, Sports Health and Performance Institute, 2050 Kenny Road, Suite 3100, Columbus, OH 43221. E-mail: t Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy  |  volume 43  |  number 11  |  november 2013  |  777

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[ clinical commentary ]
the initial knee injury and subsequent are several times more likely to sustain letes may partially explain the relative sex
surgery,23,131,132 but may also characterize a primary ACL tear compared to their disparity in primary–injury risk.67 Peak
the athlete’s preinjury movement pat- equally active male counterparts,2,5 have hip adduction, dynamic knee valgus, and
terns.61,161,162 Therefore, identification and long been the cohort of scientific interest ankle eversion occurred earlier in women
subsequent targeted treatment of aber- to evaluate the mechanisms of ACL inju- than in men during a drop-jump landing
rant post-ACLR movement patterns are ry risk. In healthy adult volunteers, wom- task.67 In the same cohort of 10 male and
critical not only to maximize functional en demonstrated reduced dynamic knee female Division I college athletes, the fe-
recovery but also to reduce the risk for joint stiffness during both non–weight- males demonstrated knee valgus angular
a second ACL injury. Though neuromus- bearing51 and weight-bearing tasks.50,121 velocities that were nearly twice as high
cular training programs can effectively Specifically, reduced stiffness values in as those of the males.67
reduce primary–ACL injury prevalence women were identified despite higher To date, only 1 prospective study has
by between 43.8% and 73.4%,145 the ef- levels of lower extremity muscle activity measured and identified biomechani-
ficacy of similar programs for reduction when compared to men,51,121 highlighting cal variables predictive of primary–ACL
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of second–ACL injury risk has not been the likely role of sex-specific differences injury status.61 In this study,61 205 unin-
examined. To date, there is no validated in neuromuscular strategies in primary– jured adolescent female soccer, basket-
rehabilitation program that addresses ACL injury risk. ball, and volleyball players underwent
not only the residual neuromuscular Deficits in thigh muscle strength may preseason biomechanical assessment of
impairments following ACL injury and also be a key variable in the primary–ACL a drop-vertical jump task to determine
reconstruction, but also the known risk injury risk model of young female ath- potential factors predictive of future ACL
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

factors for second ACL injury. The pur- letes.96,100,101 In a prospective, matched- rupture. At the termination of the team’s
pose of this paper is to build on the theo- control study of 132 healthy athletes, injury-surveillance period more than 1
retical framework for second–ACL injury only the female athletes who went on year later, 9 athletes had sustained an
prevention set forth previously58 and to to sustain an ACL injury demonstrated ACL injury. Peak knee abduction angles
(1) summarize the neuromuscular defi- lower hamstrings strength when com- and external joint moments, as well as
cits that precede primary injury and per- pared to uninjured male controls.96 A initial contact values, significantly pre-
sist following injury, ACLR, and return low hamstrings-to-quadriceps strength dicted ACL injury status. Independently,
to activity; (2) provide the evidence for ratio is 1 of 5 clinically based measures the magnitude of the external KAM pre-
risk factors related to second ACL injury that combine to accurately predict high dicted ACL injury status with 73% speci-
Journal of Orthopaedic & Sports Physical Therapy®

and their link to previous neuromuscular knee abduction moment (KAM) status ficity and 78% sensitivity.61 In the same
impairments; (3) detail a method to as- in healthy adolescent female athletes.101 prospective sample, smaller peak knee
sess neuromuscular impairments follow- Importantly, a high KAM during 3-D flexion angles and larger vertical ground
ing ACLR; and (4) propose a method of analysis of a drop-vertical jump task was reaction forces and external hip flexion
intervention to address common neuro- the most accurate predictor of future moments were also identified in those
muscular deficits in this population. ACL injury in a cohort of 205 adolescent who went on to sustain an ACL injury,
female athletes.61 The clinical prediction further highlighting the multidimension-
ACL INJURY RISK FACTORS model for high KAM, which includes a al risk profile for primary ACL injury.61
low hamstrings-quadriceps strength ra- Risk for primary ACL injury is not
Neuromuscular Deficits Prior tio,101 has since been validated against solely related to neuromuscular deficits
to Primary ACL Injury 3-D motion analysis techniques.100 of the lower extremities,161,162 as impair-

rimary-injury risk factors pro- Sex-specific differences in kinemat- ments in the proprioception and neu-
vide an important window into the ics and kinetics during sport-related romuscular control of the trunk may
underlying neuromuscular deficits tasks provide additional insight into the also increase primary–ACL injury risk,
that may persist in athletes following mechanisms of risk for primary ACL particularly in female athletes.161 A co-
injury and ACLR. Active stabilization of injury.21,46,61,67,70,92,161 Uninjured females hort of 277 healthy college athletes were
the knee joint during vigorous sporting demonstrate altered peak hip and knee prospectively examined to determine
tasks depends largely on the coordinated flexion angles,21,61,70 increased frontal whether excessive trunk motion, errors in
coactivation and force generation of the plane motion of the hip and knee,46,61,70 repositioning accuracy, and history of in-
adjacent musculature,82,86,143 and variance and larger ground reaction forces61,70 jury could predict knee injury status over
in these dynamic joint-loading strategies during athletic tasks compared to their a 3-year period.161,162 Sex-specific knee
between sexes is theorized to explain the male counterparts. Differences in tem- injury prediction models were identified
differences in their relative risk for ACL poral components of dynamic movement both by assessment of the neuromuscular
rupture.50,51,60,63,96,121 Female athletes, who between high-level male and female ath- response of the trunk during a seated ac-

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116. kinesthetic acterize the acute postinjury phase.148.55 This concept is also evident injury.126 In tasks as basic as of these acutely injured athletes36.18 Deficits in the ham. Muscle Weakness Muscle weak.80 jury and reconstruction. tionships between muscle weakness.54. extension. a sufficiently adaptive motor control sys- reduced quadriceps strength are all com. the relationship to second–ACL injury predicted knee ligament or meniscal in.78.55.38 performance primary–ACL injury risk model. athletes who fail functional re- may be related to reduced dynamic knee symmetry with the uninjured contralat. deficits in the neuromus- these acute postinjury impairments can strength alone may not show a significant cular control of both lower extremities have significant negative implications for effect on knee function following ACL in. pass these criteria. Even after athletes have undergone mon impairments following ACL injury. tivity.25. efficient joint mechanics. alterations in force-atten- specific neuromuscular retraining. All rights reserved.120. tive trunk-repositioning task and a kneel. and colleagues126 prospectively examined tered early following ACL injury have ponent in neuromuscular control of the 56 athletes following ACLR who were the potential for significant positive ef. and kinetic asymmetries of the hips and functional limitations. ly translate to appropriate neuromuscular sition may also increase the risk for ACL tion.61 Good neuromuscular control is Abnormal neuromuscular patterns and After ACLR achieved by the intricate balance of ad- significant physical impairments char. reconstructed knee.130 abnormal neuro.151 Quadriceps uation and force-generation strategies. ACLR. turn-to-sport criteria demonstrate more joint at on November 5.162 explained a significant proportion of the sports activity.132 and are often cular control in athletes following ACL knees. covery of normal strength symmetry after failure. neu- provided the most accurate prediction tation (approximately 6 months).126 Paterno Rehabilitation programs adminis.91. returning to sports3.68. reinjury are still under investigation.89. the resumption of high-level.134 impaired dynamic joint awareness.31.47 one of several important indicators of knee and hip compared with those who Though some athletes are capable of re.137 While hamstrings Importantly.162 to restore high-level function in these in healthy athletic females who demon- athletes without surgery is unknown.56. 30. deficiencies in the months and years fol.87 Left untreated prior to surgery. in addition to age.45 and midterm non.18. compared to the contralateral ion displacements of the trunk during different study. While it is apparent that the neu.107.132 decreased thigh mus.64.69 hamstrings the risk for second ACL injury.123. strings-quadriceps torque production ra. ACL injury are adaptable to rehabilita.131. as well as multidimensional kinematic ence recurrent instability and significant ments of knee function and neuromus. strongest predictor of future knee liga.31 During sport-related turn to sport in the short term following for discharge to unrestricted sports activ.130 Strength walking.31. and flex.78.146 The rela- the kneeling sudden force-release task. symmetry in quadriceps and hamstrings quantified by lateral.45 the ity following ACLR.77.123. be at least 85%. in particular. Joint ness.20.100 but in the active repositioning of the trunk on functional tests following 10 physi. No other uses without permission. Prior to jury status with 86% sensitivity and 61% activity level.56. while as likely to return to their previous level patient-specific rehabilitation programs the magnitude of external frontal plane of sports activity as those athletes who and reduction of second-injury risk. initially classified as noncopers on the ba. as variance in the prediction of those ath.154 and difficulty tem. equate strength and mobility. that with prolonged nonsurgical rehabili.31.161. high-risk specificity only in female athletes. eral limb. and motion. limited range of motion.33.161 So.indd 779 10/16/2013 4:51:05 PM . cal therapy sessions. had initially been classified as potential Impaired Neuromuscular Control Re- lator of peak ACL strain at the time of copers. and Journal of Orthopaedic & Sports Physical Therapy® effusion.126. strength is strongly related to measure. strate high-risk biomechanical features Neuromuscular Deficits Following despite adequate leg-to-leg strength sym- ACL Injury Common Neuromuscular Deficits metry. muscular control. the optimal rehabilitation program control.96.jospt. medically cleared for sports participation fects on immediate39.132 and of formal rehabilitation.26. but whereas history of low back pain was the sis of poor function and knee instability an understanding of the interplay may be Downloaded from www. to document the movement characteris- journal of orthopaedic & sports physical therapy  |  volume 43  |  number 11  |  november 2013  |  779 43-11 Di Stasi.61. majority of athletes continue to experi.78. and often persist in spite are evident.161 Error In a study by Eitzen et al.134. is proposed as kinematic and kinetic asymmetries of the cle force.4 are all common ACLR and been cleared to return to ac- Episodes of giving way (knee joint sub.56.48 and abnormal joint loading.126 tion. many groups advise that Deficits in neuromuscular control. 2013. eventually. loading at the knee is a critical modu. In a strength. athletes romuscular control deficits. and episodes of giving way. during a screening examination were just critical to the development of effective. risk has not yet been assessed. deficits in neuromuscular control luxations) are not uncommon in many lowing ACLR.90 tio also appear to be a key variable in the ing sudden force-release task.57. return-to-sport readiness and. injury and those who have undergone after ACLR. surgical outcomes in this population.38. have been identified up to 4 years advised to undergo ligament reconstruc. following ACLR are highly predictive of postoperative outcomes.31.37. poor neuromuscular control of trunk po. ment injury in male athletes. letes who later underwent ACLR. 90 it was demonstrated limb. For personal use only. and risk for model for ACL injury in female athletes.69.146. jumping tasks.159 there is strong evidence that romuscular systems of athletes following ACLR unfortunately does not ubiquitous- Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. activation may be an important com.

When significant quadri.138 Within the first year Post-ACLR NM impairments Second-injury predictors following surgery. anterior cruciate ligament reconstruction. cantly increase the risk for contralateral same population. For personal use only. KAM.125. 780  |  november 2013  |  volume 43  |  number 11  |  journal of orthopaedic & sports physical therapy 43-11 Di Stasi.indd 780 10/16/2013 4:51:07 PM . effusion This model was shown to predict injury • Knee instability risk with excellent specificity (88%) and • Restricted knee motion/moments Downloaded from www.150 One of the most significant modifiable second ACL injury. athletes. effusion • Net hip internal rotator moment • Restricted knee motion/moments • Increased knee valgus motion post-ACLR who had been cleared for • Kinematic and kinetic asymme. and may be indicative of ond–ACL Injury Risk Several modifiable and revision was performed significantly residual and magnified asymmetries in and nonmodifiable factors have been re. • Asymmetrical external knee participation had not returned to their tries of the knee and hip moments competitive sport. in particular.136 The incidence rate of 50% of high school–level and collegiate. sensitivity (92%). re- Neuromuscular Impairments With Sec. ceps weakness persists.125.84 Age65. more often in those athletes with a graft neuromuscular control.79 Graft than second-injury rates in young male represent a significant component of post. Abbreviations: ACL. longitudi. graft inclination angles less lateral injury when compared to young. sex.6). Postinjury NM impairments and (4) deficits in postural stability. can significantly athletes.65.jospt. anterior cruciate ligament. their stronger counterparts.56)16 significantly increase an individ.136. neuromuscular.88.4 The low return-to-activity rates may be Second ACL injury explained. tries of the knee and hip ment patterns to second–ACL injury risk in athletic individuals. have a significantly er levels of activity that require cutting. second-injury risk. be at least twice that of graft rupture.15. Nonmodifiable fac. focused neuromuscular re-ed. size also appears to influence second. the surgical rehabilitation programs.58. One year following baseline testing. the risk for contralateral ACL rupture may Linking Presurgical and Postsurgical odds ratio for graft rupture in athletic in.125 Interestingly. (3) sagittal plane knee Primary ACL injury moment asymmetries at initial contact.83.107 injury risk.88 use of patellar tendon grafts may signifi. Sports-Related Function Recent prospective. (2) increased frontal plane knee motion during at on November 5. a second ACL injury in young female ath- level athletes indicated that they were able ual’s risk for graft rupture. gardless of sex.133 Return to high- and age of the patient. • Low hamstrings-quadriceps ratio jury.1.136. dividuals with a smaller graft size was 2. ACLR Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Neuromuscular impairments leading to primary and secondary ACL injury.126 and was the first • Kinematic and kinetic asymme- study of its kind to link deficient move. from which 4 predictive biomechan.134 Less than than 17°65 and use of allografts (odds ratio athletic males. 2013. whereas the letes is 16 times greater when compared to perform at their pre–ACL injury level.84. active female athlete’s activity level. NM. nal data sets highlight the varied return- to-sport success rate of highly active individuals.126 • Quadriceps weakness. in part. • Increased external KAM ical factors for second-injury risk were • Deficits in trunk proprioception • Increased trunk displacement identified: (1) a net internal rotator mo- ment of the uninvolved hip upon landing.160 ported to increase an athlete’s risk for a diameter of 7 mm or less.149 increased risk for a second17 and contra- functional-hop performance scores than Specifically. All rights reserved. rehabilitation. by the persistence of physical impairments even after formal FIGURE.125. within 4 years of ACLR. 13 Preinjury NM impairments athletes had sustained a second ACL in.3. including surgical technique. = 5.16. ACLR. after ACLR. two thirds of athletes • Quadriceps weakness. Deficits in High-Level. to primary–ACL injury incidence in the Therefore. and sex125.136 also play a significant role in predictors of a second ACL injury is the tors. and 4 times greater ucation and sports-related training should ACL rupture (odds ratio = 2.5 months following ACLR.3 A recent systematic • Reduced postural stability review found that only 44% of athletes successfully returned to sport after an Journal of Orthopaedic & Sports Physical Therapy® average of 41.2. Young. [ clinical commentary ] tics predictive of second ACL injuries. knee abduction moment. No other uses without permission. athletes who have undergone ACLR demonstrate poorer impact second-injury risk.

tests. phase rehabilitation program described patterns may be critical to maximizing light the biomechanical factors related to herein incorporates progressively more functional recovery following surgery and second–ACL injury risk126 and the over. In addi. abduction motion appears to be a key fac.126 In a study by Paterno et al.1. Although the effi. can vary widely. challenging tasks.134 Midterm knee function as mea- Downloaded from www.126 be critical modifiable factors of second. sured by single-leg hop tests 6 months multiplanar neuromuscular impairments injury risk. of information for treating clinicians as on the modification of the neuromuscular tion.123.66 knee function. Further. the use of symmetry after surgery demonstrated excellent ac- found in both the ACL-reconstructed and measures alone to capture important bi.54. Neu.1.29.110. and postsurgical but methods of assessing these deficits Identification and subsequent treat- status of athletes with a history of ACL in. reduction of primary. jury risk. Quadriceps strength deficits in ath- following ACLR are also characterized by nent in the calculation of external knee letes following ACLR are related to re- compensatory movement patterns and abduction loads. knee may be inadequate. The drop-vertical jump considered a plausible risk factor. serial Targeted neuromuscular training and and pain-free range of motion.78 lower asymmetries.1 and the ability to hop in place asymmetries but do not measure impor- rate of contralateral-limb ACL rupture without pain or apprehension. ing up to and following ACL rupture may tion. dards for postoperative reha.150 As the first several months variable126 and is an important compo.80 at on November 5.162 and additive effects of these neuromuscular proposed clinical testing battery. dynamic increase the risk of a second ACL injury tioning during athletic maneuvers.58 lapping profile with primary-injury risk.139 mini. objective reducing risk for a second ACL injury.indd 781 10/16/2013 4:51:08 PM . in young.31. All rights reserved. tion motion was a significant predictive return-to-sport readiness. maximize clinical testing can be an excellent source Journal of Orthopaedic & Sports Physical Therapy® re-education may have the greatest effect strength.146. of rehabilitation.7. For personal use only. as in. No other uses without permission. jective Knee Evaluation Form 1 year after C ing second–ACL injury risk has not been urrent evidence-based stan.8. postinjury. study of 79 athletes following ACLR.107 Targeted rehabilitation programs they progress their athletes through the components of second-injury risk. uninjured athletes ing ACLR. Thigh muscle contralateral-limb loading post-ACLR to that of the contralateral limb. vised that all patients demonstrate full sessed within the scope of the previously tion. therefore. the use of easily administered influence of trunk position and control adequately identify readiness for return qualitative tests that can capture perti- on second–ACL injury incidence has not to sport.126 mal joint effusion. Interestingly. and self-reported mea- between 5-fold16 and 10-fold. active individuals. including the frontal and sagittal plane motion of journal of orthopaedic & sports physical therapy  |  volume 43  |  number 11  |  november 2013  |  781 43-11 Di Stasi.8 The proposed late.125. the increased symmetry. Epidemiological data high. Taken together.jospt. increased knee abduc.81. pivoting. lateral physical performance deficiencies have normal knee function 1 year follow- ond ACL rupture with 92% sensitivity compared to matched.145 neuromuscular training to restore full 6 months after surgery.80 In a longitudinal outcomes and 88% specificity. specifically was not identified as a pre. it is ad. are likely most effective when tailored to phases of rehabilitation and back into romuscular dysfunction characterizes the patient-specific neuromuscular deficits. tant deficits in the quality of movement. multiple points throughout the late phase tional performance following ACLR. is advocated at time since surgery may not dictate func. toward functional goals and to determine significantly related to higher second-in.105 nor should it determine the nent deficits in neuromuscular control been empirically tested but may also be course of progression through each phase is warranted. objective measures of strength. To perform the a predictor of both primary–61. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. strength assessment and single-hop test- during sports-related activities.160 The Time since surgery alone does not Therefore. safely into this program. those who reported knee function within tor in both primary–61 and second–ACL PROPOSED ASSESSMENT normal ranges on the International Knee injury126 risk models.75. there is growing evidence for altered and pain-free knee range of motion equal described functional tests. jury risk. and achieve preinjury func.1 at least 70% strength ing identify quantitative performance which may explain.61 criteria should be used to enter patients While poor control of aberrant motion is suggesting that there may be negative.112.130 attention must data indicate that neuromuscular deficits limb-symmetry values on single-leg hop be given to the role of modifiable neu.161.133. symmetry values on the crossover test injury incidence using similar methods bilitation include exercises and and timed 6-meter hop test when tested has proven effective.126 it is not as- deficits on second-injury risk. OF IMPAIRMENTS POST-ACLR Documentation Committee 2000 Sub- cacy of neuromuscular training in reduc. curacy for prediction of athletes who will uninjured limbs combined to predict sec. in part. second–ACL injury risk.134 and poorer self-reported func- romuscular deficits in second–ACL in.133 Though While excessive knee abduction loading sures of knee function.105 an dictive component of the second–ACL of rehabilitation to document progress earlier time since surgery appears to be injury risk model. and jumping may substantially to be directly influenced by trunk posi. ment of aberrant post-ACLR movement jury (FIGURE). surgery had significantly higher limb- empirically tested.107 Use of a battery of can provide valuable information on creased knee abduction loading appears clinical tests and measures.58.79. these stricted knee motion during gait.17. 2013. of the lower extremities and trunk lead. preinjury. their sports activity.

102. L imb-symmetry indexes on single-leg hop for distance. triple hop for distance.74.126 Applying deficient at the time of return to sport. and (3) they elicit neuromuscular impairments that may tation program is presented that aims to movements that may replicate condi- be present in both limbs. and has been used as part of of the trunk and both limbs that reduce Programs that have been shown to a clinical nomogram to predict external sport-related function and increase sec. The use of reducing factors related to primary–ACL eo-capture technology. as well as These exercises. (side-to-side symmetry) demonstrated functional performance similar to uninjured quadriceps ratio control subjects134 2.110.145. in varying combinations. outcomes symptoms.126 and asymmetries ity of movement may allow clinicians joint loading considering multiplanar in athletes following ACLR appear to to identify neuromuscular impairments factors. and second ACL injury.indd 782 10/16/2013 4:51:09 PM . International Knee Documentation Committee Subjective Knee Evaluation Form. In combination programs that enhance control of 3-D injury risk and have been summarized in with strength assessments. sport-related and lowest in the athletes with strength asymmetries greater than 15%134 Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.103.116 a late.111.147 1.43 previous (2) they utilize surfaces and movements technique. These second–ACL injury risk profile.95. outlined in this manuscript were se- sessment. successfully reduce primary-injury risk knee abduction loads. jury movement deficits.161 be the product of bilateral limb adapta- 782  |  november 2013  |  volume 43  |  number 11  |  journal of orthopaedic & sports physical therapy 43-11 Di Stasi. both limbs.95. tests also require minimal time.101 The tuck jump ond–ACL injury risk (TABLE 1). and TO PREVENT SECOND ficulty. hop testing. is sub. A  thletes who underwent ACLR and had at least 90% quadriceps strength index dynamometry to-side symmetry. No other uses without permission.134 1. sports-related knee 90% or greater1. trunk. detail previously. ated ACL injury risk. 2013. and the work of others. disability 2.99 Both tests incorporate as. findings from our laboratory. points are deducted from the cular control postsurgery are a key lected for 3 specific reasons: (1) they total score for movement asymmetry.85.71. Use of self-reported outcomes is advised as part of a battery of tests to determine functional status following acute ACL injury36. S  agittal and frontal plane knee motion during a drop-vertical jump is part of a clini- mechanics separation distance7 cal algorithm that accurately predicts high external knee abduction loads101 Patient-reported Patient perception of function. of modifying mechanics theorized to be ment in the assessment.98. IKDC. Female athletes who went on to sustain a primary ACL rupture had decreased hamstrings-quadriceps ratios compared to male controls96 Single-leg hop tests Dynamic.152 and balancing frontal plane knee motion. and standard 2-dimensional vid.74. body positions9. Feedback provided on tuck jump technique reduces knee abduction motion during asymmetry and quality asymmetries or abnormalities)107 the drop-vertical jump109 of mechanics Drop-vertical jump Sagittal and frontal plane knee Greater than 60% normalized knee 1. hamstrings.9. hips. and a decline in the theories of motor learning. activate the muscles hypothesized to be increased frontal plane motion of the injury risk following ACLR. mechanisms.145. have been evaluated for their efficacy in space.127. anterior cruciate ligament.119. ACLR. anterior cruciate ligament reconstruction.jospt. regardless of address all modifiable components of the tions experienced during sport (TABLE 2). [ clinical commentary ] TABLE 1 Proposed Methods to Assess Neuromuscular Impairments After ACLR Assessment Method Impairments Assessed Clinically Important Cutoff Criteria Evidence for Clinical Applicability Thigh muscle Quadriceps and hamstrings side. 98. and function side-to-side symmetry crossover hop for distance differed between controls and athletes who had ACLR108 2. while emphasizing proper jump- is also linked to important reductions in ACL INJURY landing59. 90% or greater1. targeted neuromuscular rehabili. ersistent deficits in at on November 5.124 Because leg-to-leg and self-reported outcome measures. and knees.6. related to injury risk. the stantiated by literature that has evalu.127. 90% or greater1 1. For personal use only. Tuck jump Trunk and lower extremity Perfect score of 80 points (no 1. and incidence of ACL injuries have in- Journal of Orthopaedic & Sports Physical Therapy® assessment is another dynamic jumping corporated 3-D movement retraining test that is responsive to improvements PROPOSED INTERVENTION of progressively greater speed and dif- following neuromuscular training.109 Among the techniques.52. Symmetry on the triple hop for distance was the most strongly correlated to self- reported function of the 4 hop tests128 Downloaded from www. thus capturing phase.71.109 that elicit muscle coactivation capable pects of symmetry and quality of move.142 The exercises P 10 criteria for a successful tuck jump as.94. whether symmetry is present. IKDC scores were lower in athletes who underwent ACLR compared to controls.115.52. component of increased second.44 and readiness to return to sport following ACLR1 Abbreviations: ACL. limited common residual preinjury and postin. asymmetries greatly increase the risk of addition of clinical tests to assess qual. All rights reserved.

Lunge elicited greater than 75% vastus and dynamic knee function in athletes following medialis muscle activity40 ACLR57. gastrocne- activation ratios occurred with lateral mius.109. 1. 1. late-phase rehabilitation program is suc. proximally14 Lunge progression Gluteals. For personal use only. dius and maximus similarly and elicited away from knee during hopping versus controls117 hamstrings plyometric greatest gluteus maximus activation40 2. Progression to the next phase is depen.1.146 To of the trunk is also emphasized. describes evidence-based exercises that port leg are related to increasing external Each task or activity is evaluated in isola. Healthy athletes with increased knee valgus 2. Athletes with ACL deficiency shifted moments progression hamstrings ratios occurred with lateral hopping10 away from knee during hopping versus controls117 2.31. plyometric 1. Unstable surface shifted joint moments Downloaded from www. trunk muscula. the following section lean and trunk rotation toward the sup. E xternal obliques demonstrated high 1.130 this rehabilitation protocol To elicit the desired movement strat. unstable surface. and tibialis anterior activation122 hopping10 3. Ultimately. 1.53. quadriceps and Sagittal plane trunk and LE 1. each with a specific goal (TABLE ing should be implemented. may effectively target each of the 4 modi- knee abduction loads28. help guide the rehabilitation specialist in goal of optimal control and movement dent on the correct execution of each task devising a patient-specific neuromuscular symmetry.indd 783 10/16/2013 4:51:10 PM .42. Single-leg squat activated gluteus me. S  ingle-leg squat activated gluteus me. with the 3). Maximum lateral trunk displacement with secured lower extremities predicted ligament injury in females only162 Prone trunk stability Gluteals. cessful completion of each of the 4 phases. comprehensive functional test- both limbs. trunk musculature Sagittal and transverse plane 1. A  thletes with ACL deficiency shifted moments progression hamstrings joint motion. H  igh hamstrings-quadriceps coactivation 1. 1.126 the support leg may help athletes learn other and continue to be challenged at an better control of these risky knee loads. High hamstrings-quadriceps co. 2013.9°) reduction in the peak frontal plane angle on the drop-vertical jump task109 Lateral jumping Gluteals. Increased early lateral trunk displacement progression trunk motion levels of muscle activity in sidelying with secured lower extremities predicted knee flexion exercises73 ligament injury162 Journal of Orthopaedic & Sports Physical Therapy® 2. at on November 5. the goal for this Rotator Moment Upon Landing during high-level sports activities. quadriceps and motion. For example. incorporates bilateral training to address egies with progressively more advanced To determine return-to-sport readiness. trunk musculature Symmetry of LE movement.78. thus. All rights reserved. controlled tion.95. quadriceps and 3-D trunk and LE joint motion.54.58.105. risk.80 Tuck jump Gluteals. tions. plyometric dius and maximus similarly and elicited away from knee during hopping and their center greatest gluteus maximus activation40 of mass was more anterior versus controls117 Single-leg lateral Gluteals. quadriceps and 3-D LE joint motion. TABLE 2 Evidence for Selected Exercises Key Motions/ Exercise/Task Key Muscles Targeted Elements Targeted Direct Evidence for Targeted Effect Indirect Evidence for Targeted Effect Single-leg anterior Gluteals. given the specific skill set Exercises to Address the Net Hip Internal which may not be completely avoidable in each task. F orward lunge elicited high hamstrings. demonstrated higher hip adductor. A  thletes with ACL deficiency shifted moments progression ture.107. plyometric strated a 38% (up to 6. so that an athlete may progress more fiable predictors of second–ACL injury activities that elicit trunk motion toward quickly through one task compared to an. F emale athletes who received feedback None Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. neuromuscular deficits that may exist in tasks. Poor neuromuscular function of the pos- journal of orthopaedic & sports physical therapy  |  volume 43  |  number 11  |  november 2013  |  783 43-11 Di Stasi.jospt. P  rone bridge elicited high abdominal None trunk motion muscle activity40 2. appropriate level. Frontal plane trunk and LE joint 1. Trunk extension combined with hip extension elicited trunk extensor activa- tion up to 50%73 Table continues on page 784.106. Q  uadriceps strength was significantly correlated hamstrings plyometric quadriceps coactivation ratios10 with external sagittal plane knee moments117 2. Neuromuscular re-education 4 phases. and may vary based training program. progression frontal plane trunk and LE on their tuck jump mechanics demon- joint motion.126. greater torso in the prior phase. this program has been divided into however. on the individual abilities of each athlete. No other uses without permission. Increased lateral trunk motion increased external knee abduction moments66 Lateral trunk Trunk musculature Frontal and transverse plane 1.

hip extensors. and external rotators. trunk muscula. trunk muscula. terior and lateral hip musculature may affect generation of the optimal net hip TABLE 3 Goals of the 4 Exercise Phases joint moments required to control hip motion upon landing.80 Abbreviations: ACL. hamstrings unstable surface dius and maximus similarly and elicited proximally129 Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. and early stabilization116 medialis muscle activity40 2. All rights reserved. by way of task plane motions of extremities and trunk large hip flexion angles and avoidance of 2 Double. 1. LE. quadriceps and plyometric quadriceps coactivation ratios10 pulsive jumping forces. unstable surfaces response to perturbations and without feedback abductors. Therefore. Athletes with ACL deficiency shifted moments away from knee during hopping versus controls118 Journal of Orthopaedic & Sports Physical Therapy® 4. at on November 5. U  nstable surface shifted joint moments progression ture. anterior cruciate ligament. that is. 3-D trunk and LE joint motion. interventions improved dynamic hip strength93 and re- ther investigation of the influence of hip targeted at these deficits are indicated.157 Fur.indd 784 10/16/2013 4:51:11 PM . and multifidi activity40 Single-leg dead lift Gluteals. exer- Phase Common Task Components Goal cises that require large hip extension and 1 Usually a 2-legged task or a unidirectional single-leg Master basic component technique. neuromuscular system (ie. Maximum lateral trunk displacement with secured lower extremities predicted ligament Downloaded from www. [ clinical commentary ] TABLE 2 Evidence for Selected Exercises (continued) Key Motions/ Exercise/Task Key Muscles Targeted Elements Targeted Direct Evidence for Targeted Effect Indirect Evidence for Targeted Effect Kneeling trunk Gluteals. 1. in the interim. unstable None 1. trunk musculature 3-D trunk motion. 1. L ong-axis neuromuscular training increased pro- progression ture.155. greatest gluteus maximus activation40 2. hamstrings. Increased lateral trunk motion increased external knee abduction moments66 3. should of support surface. however.78. precise movements with rapid weakness of the hip external rotators. decreasing stability Integrate additional component of task without out-of-sagittal-plane hip motion. Airex plus ball catch) under perturbed conditions ductors. lower extremity. No other uses without permission. ab. For personal use only. anterior cruciate ligament reconstruction. U  nstable surface shifted joint moments stability surface proximally14 2. reduced joint velocities hamstrings 2. Lunge elicited greater than 75% vastus during landing phase. and extensors may not be and destabilizing perturbations from instructor strongly related to frontal plane hip and knee mechanics. Long-axis neuromuscular training increased knee flexion. posed training protocol has successfully control of the lower single-leg transition. trunk muscula. High hamstrings-quadriceps activation ratios with Romanian dead lift10 Lunge jump Gluteals. pilot work using the pro- links muscle activation deficits to poor lower extremity mechanics is warranted.156.158 recent evidence muscle strength and activation deficits on Furthermore. explosive.jospt. injury in females only162 Posterior chain Gluteals. hamstrings motion medius. longissimus thoracis. Quadriceps strength was significantly correlated with external sagittal plane knee moments117 and dynamic knee function in athletes following ACLR57. F orward lunge elicited low hamstrings. 1. narrowing base of support compromise of technique elicit powerful contractions of the target 3 Introduction of second perturbation to the athlete’s Athlete is able to avoid loss of balance or form musculature. S  ingle-leg bridge elicited high gluteus None progression ture. 3-D trunk and LE joint motion. Quick. control out-of- external rotation moments. changed timing of frontal plane peaks116 3. Although 4 Multidirectional tasks that demand explosive move. ments and quick repetition. Increased early lateral trunk displacement with secured lower extremities predicted knee ligament injury162 4. 2013. duced some of the neuromuscular deficits 784  |  november 2013  |  volume 43  |  number 11  |  journal of orthopaedic & sports physical therapy 43-11 Di Stasi. Transverse plane trunk and hip 1. S  ingle-leg dead lift activated gluteus me. increased gluteal muscle efficiency.

however. particularly in the late phases.101 Enhancement of should be incorporated into the rehabili- exercise progression.118 Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.97. C) and lunge jumping (APPENDIX K. tion of slight trunk flexion.140 Encouraging more upright lunge progression is to demand adequate motion in athletes following ACLR.126 Biofeedback and knee flexion movement. desired deep–knee flexion positioning proposed may be necessary to target fron. As the technique is perfected through proprioception and control of excessive sor moment symmetry early after initial the early phases and the athlete learns to trunk motion known to increase ACL in.123. online). mechanics during dynamic tasks. contact. ferring joint moment demands from the online).126 Exercises that en- equate trunk and lower extremity con. ize landing mechanics and thus mitigate progressions is to induce knee and hip ing an effective transfer of neuromuscular second-injury risk. online) stability training may be ef. control. Exercises to Address Sagittal Plane Knee generation as the activities become in- ment dominance.31. and leg dominance. online) petitive plyometric movements are used ing may also provide better frontal plane progression exercises introduce deep– to introduce high loading conditions at control at the knee during dynamic ac.106 cal sagittal plane knee joint torques are riceps torque ratio96 contribute to pri- Proper form on the tuck jump progres. online)40 may also thigh and hip musculature. eral (APPENDIX F. re. online) and lateral improved frontal plane knee mechanics extremities and trunk. The lunge progression (APPENDIX (APPENDICES I and J.109. prone (APPENDIX knee to the ipsilateral ankle and hip. not only elicit a functional upright trunk in athletes with neuromuscular deficien.13 reduces ver- emphasis on the deep–knee hold posi. The goal of the deep–knee flexion training using the tuck jump (APPENDIX D) creases knee and decreases hip extensor Downloaded from www. Deficits in the hamstrings-to-quad- be assessed using the tuck jump. tivities101 and improve its role as an ACL large joint torques to the reconstructed Journal of Orthopaedic & Sports Physical Therapy® agonist. mary–61 and second–ACL injury126 risk. Slower. may help normal- (APPENDIX B. with the on ACL injury risk. demand control of hamstrings and gluteal strength by way tation program to increase the athlete’s the frontal plane to execute proper tech. A combina- C) demands proximal muscle control by contribute to lowering second–ACL at on November 5. the effectiveness of neuromuscular train. fective for the enhancement of trunk position but also encourage knee exten- cy.3. precise completion of these early- of the lead limb. on concomitant hip and knee flexion. may be more force generation and attenuation of the Adequate trunk and hip strength may functional in terms of sports-specific proximal musculature to control out-of. mary–ACL injury risk but may also journal of orthopaedic & sports physical therapy  |  volume 43  |  number 11  |  november 2013  |  785 43-11 Di Stasi. online).161. Increased flexion of joint torques of increasing magnitude strategy that may have a direct influence the trunk leads to an increase in hip and during controlled movements.13. feedback flexion. online) replicate the extended lower-limb G. as well and specific prediction model for large also require deep–knee flexion holds and as the lateral jumping (APPENDIX E. No other uses without permission.162 Hamstrings strength train. Similarly. and also jury risk.61. the current evi.130 and risk. and kneeling trunk (APPENDIX The challenge is to employ exercises that posture known to induce valgus loading H. instruction provided during progressive tical ground reaction forces. with dynamic knee instability and can mechanism for ACL injury.103 while maintaining a functional Anterior (APPENDIX A) and lateral (APPENDIX are a component of a highly sensitive upright posture. The goal of the provided to athletes during the tuck jump transverse plane motions of the lower anterior (APPENDIX A. Low knee flexion angles during dynamic with the later phases of each exercise as previously described. of a progressive. while controlling frontal and plane segmental motion.41 Asymmetri. proposed to be related to second-injury sion.12.109 indicat. trunk posture.140 and in- tion.indd 785 10/16/2013 4:51:13 PM . courage greater and symmetrical knee trol to minimize frontal and transverse ing on high-risk biomechanics. 2013. Lack of control in the tal plane deficits associated with both pri. are associated tasks have been identified as a plausible progression. jury risk. weight-bearing protocol power and recruitment of the posterior nique. Cumulatively. with emphasis way of a narrow base of support. and produces large sagittal plane moments dence indicates that both plyometric and soft landings should address each theo- about the knee if the athlete utilizes the dynamic stabilization tasks such as those rized risk factor for second ACL injury.55.144 be indicative of superior neuromuscular predict second–ACL injury risk with an Single-leg activities necessitate ad. continued use of a strategy of increased sions may be manifested by excessive knee flexion and force attenuation and frontal plane motion at the knee. Tuck jump landings (APPENDIX D.117.jospt. may ing injury and surgery30. knee flexion holds as a way to introduce progressively greater velocities. quadriceps dominance. be necessary for proper lower extremity tasks but may keep athletes from trans- plane moments at the hip (APPENDIX C. online) single-leg exercise on the drop-vertical jump task. Lat. online) knee abduction loads. All rights reserved. Low hamstrings-to-quadriceps knee and can promote improved lower Exercises to Address Increased Frontal strength ratios are characteristic of young extremity side-to-side strength symme- Plane Knee Motion During Landing female athletes at risk for ACL injury and try22.109 In a previous study examining odds ratio of 3. squat jumps B) single-leg exercise progressions. Activities like the lunge (APPENDIX minimize non–sagittal plane motion. Liga. Moment Asymmetries at Initial Contact creasingly more dynamic and complex trunk dominance. phase landing tasks will help promote the anterior and lateral single-leg progres.126. and –hip flexion position during the may also reduce excessive frontal plane moments. also characteristic of athletes follow. For personal use only.

performance. cused on young.153 Future studies in Postural Stability the absence of asymmetry. as previously tion.39. neuromuscular deficits following ACLR late-phase post-ACLR rehabilitation that require prolonged single-leg holds while are based on the assumption that the can address the multifactorial nature of controlling lower extremity loads and restoration of limb symmetry and nor. [ clinical commentary ] influence second-injury risk. Single-leg hancement of dynamic lower extremity Return to Sport dead lifts demonstrate some of the high. of this proposed strategy in achieving though the primary–ACL injury biome- ation are emphasized and sport-specific functional symmetry.146 rehabilita. ing ACLR. male cohort follow- exercises (APPENDIX J). asymmetry as well as deficits in athletes the effectiveness of the exercise compo- ing tuck jump training (APPENDIX D) with following ACL injury compared to those nents described has not been empirically Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Limitations neuromuscular training. in healthy controls.144 reinjury rates and future function.153 To date. dynamic trunk in healthy athletes93. ACLR.126 and that return-to-sport training was not the fo- more dynamic movements that incorpo. highly position and avoiding loss of balance.45 far less from data describing the neuromuscular education with the prone trunk (APPENDIX is known about the ability of athletes who risk factors for ACL injury in a predomi- G) and kneeling trunk (APPENDIX H) pro.jospt.indd 786 10/16/2013 4:51:14 PM . All rights reserved. Postural stability may be improved tiveness of neuromuscular training in females and may not be directly trans- by advancement of quasi-static balance modifying risky neuromuscular patterns latable to an older. relative hamstrings strength. Specific increasing knee flexion. athletes were identified during a quasi. dition of on-field rehabilitation helps to letes recovering from ACLR should not address lingering deficits in the return- Exercises to Address Deficits be considered fully rehabilitated purely in to-sport phase. phase rehabilitation and preparatory ing (APPENDIX J) may help these muscles DISCUSSION return-to-activity program.60. the demands of the sport.109 and ath.124 Single-limb sport recommendations to fit individual The overall purpose of this clinical com- exercises. Furthermore. and neuromuscular re. providing dynamic control and ue to the known influence of tive care of these athletes in preparation increased force attenuation abilities with side-to-side limb asymmetry on for a safe return to sports activity. letes who are ACL deficient.11.102 as well as tion protocols should be tailored to ad. dress deficits identified in both limbs. generalizability to other populations mid-level and high-level phases of each programs. Transitions to second–ACL injury risk. combined with interventions. highly active adolescent knee. have undergone ACLR to improve aber.102.97. not only for short. thus.72. and minimizing abnormal with the second–ACL injury risk pro- phase training movements.72.103. No other uses without permission. how- lete in controlling frontal plane motion term functional performance but also for ever. 786  |  november 2013  |  volume 43  |  number 11  |  journal of orthopaedic & sports physical therapy 43-11 Di Stasi. stabilization102. concentrated feedback to guide the ath. residual bilateral neuromuscular deficits.126 these 2 profiles are not exactly and hold exercises. Much of the literature Specifically. excessive trunk movement maximize functional performance but on the effects of neuromuscular train- that affects the location of the body’s also mitigate future injury risk.103 Quadriceps dominance. 2013. Journal of Orthopaedic & Sports Physical Therapy® static task. similar exercises may not try to reduce second-injury risk by en. While ing on primary-injury risk has been fo- center of mass may impact loads on the there is strong evidence for the effec. as is This is especially important as we begin published for sports like soccer.27. result in all of the desired adaptations. may be employed to tively examined in athletes following the same.126 and are modifiable with will allow clinicians to tailor return-to. Specifically. like anterior (APPENDIX A) and needs. mal movement patterns will not only active individuals.98. For personal use only. end.102.10 Dynamic hamstrings strengthen. As this program was derived strengthening.61.11. maximizing sport chanical risk profile has some overlap tasks may be added.103 and improvement of Clinicians must consider the specific est hamstrings-to-quadriceps activation single-limb postural control. protocol. such as hop movement strategies must be prospec. and downhill skiing. several batteries of tests to determine cus of this paper but may be an important rate deep-hold requirements (APPENDIX E) return-to-sport readiness continue to component of return-to-activity prepa- have been successful for improvement of emphasize limb symmetry. tested on athletes following ACLR.88 and should be implemented Downloaded from at on November 5.62 may be addressed us. Ath. Specifically. file. nantly adolescent female athletic popula- gressions. Symmetry guidelines for the late-phase postopera- D traction. based on the needs of each athlete and side-to-side asymmetry in force dissipa. The goal of resist anterior tibial translation under this paper was to provide evidence-based conditions of forceful quadriceps con. recent reports indicate that the ad- at the knee. power generation and attenu.32. second–ACL injury risk in young. ration27. Our proposed methods to treat mentary was to detail a paradigm for lateral jumping (APPENDIX B) progressions. basket- common in young female athletes dur.124 needs of each athlete to tailor the late- ratios. targeted neuromuscular prediction of second-injury risk in young demands of each athlete. As athletes advance through rant movement strategies via similar tion. the effectiveness may be limited at this time. Consideration should focus on randomized controlled Postural deficits that contributed to the of the sport-specific and position-specific trials of specific. ing maturation. to better understand the implications of ball.

org at on November 5. T tiaxial support surfaces. Objective criteria proposed as an important component without disabling knee symptoms. 15. 2009. training. or on-field sport reintegration. construction in soccer athletes from the Multi- second–ACL injury risk. Sports Med. 13. Clin Biomech Axe MJ. landing Train. Arendt E. This program. Webster KE. Kaeding CC.doi. Smits-Engelsman BC.33:524-530. Anterior cruci. Br level and graft type as risk factors for anterior ACLR is likely dependent on a number J Sports Med. Barber-Westin SD. Pedroza A. factors.1519/JSC. Am ings in primary and revision anterior cruciate injury risk factors and to provide sports J Sports Med.2011. incidence is unknown and should be the ing a controlled drop landing. and Future research studies should focus on 9.47:396-405.39:538-543. Additional for anterior cruciate ligament reconstruction: a org/10. he goal of this review was to Return to the preinjury level of competitive Avon). 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Atroshi I. to sports participation following anterior JP.2519/jospt. 2001. Knee Surg after primary ACL reconstruction and return to after anterior cruciate ligament reconstruc. 2012.037200 153.1007/ Hewett TE.21:888-897. Williams GN.doi.doi. Reznichek Arthroscopy.125:614-621. Waters E.38:685-693. Am J http://dx. Am J Sports Med. J Electromyogr stability. Hägglund M. Br J Sports Med. Sell TC. BMJ. http://dx. et al. Zhou BH. and trunk correc. Arch Phys sition during single-leg landings influences the 2010. Evaluation of the effectiveness of neuro. Ford KR. Dynamic stability in the Alfredson H. Return to sport. 2000. Buchanan TS. 3rd. Braun C. Gray T. 2012. org/10.1177/0363546510376053 Sports Med. et al. Gluteal muscle activation org/10. Prevention of ante. Effects of patel. http://dx.04. 2012. Ford KR. 140. foam.1:236-241.doi. Jr.doi. 2009.doi. Kvist J.1177/0363546503262171 tors that influence the intra-articular rupture Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. lete. http://dx. strength on strength return after anterior cruci. Paterno MV. van Eck CF.4194 bjsports-2011-090895 Neuromuscular training improves single-limb 135. Snyder-Mackler L. Shelbourne KD. 144. J rior cruciate ligament injury in the female ath. Magnusson H.doi. Solomonow M.21:948-957.2012.44:1948-1953. prospective case control study of a preven.004 Kinesiol.doi. McKeon JM. ers: cluster randomised controlled trial. during running in females with and without 134. Heidt 155. Irr­ 128.6. in female soccer players? A prospective ran. Effects of task-specific aug.1007/s00167-011-1427-y org/10.38:1968-1978.doi. Working 2004. 126. 136. 1998. Johnson BC.1177/0363546511432545 s00167-011-1473-5 Am J Sports Med. Lorring D.e3042 org/10. 152. Hewett DA.42:326-336. Sipprell WH. van 129. compensate well for the injury and those who ment and thigh muscles in maintaining joint J Biomech. Urch SE. strength and hop performance criteria prior Sports Phys Ther. 2007.19:1795-1797.doi. 2012. Paterno MV. Incidence of s00167-011-1669-8 lateral anterior cruciate ligament (ACL) injury subsequent injury to either knee within 5 years 147. 2012. Return to basketball and soccer reconstruction.1016/j. graft rupture and contralateral rupture after performance of the tuck-jump exercise. Riemann BL. Ambegaonkar JP. 2008. Paterno MV.indd 791 10/16/2013 4:51:19 PM .19:1798-1805. Knee Surg Sports Traumatol Arthrosc. Myer GD. cal landing performance subsequent to ipsi- stability predict second anterior cruciate lar tendon width and preoperative quadriceps lateral semitendinosus and gracilis autograft ligament injury after anterior cruciate liga. Musgrove T. require operative stabilization. anterior cruciate ligament reconstruction with tion. Refshauge K. Shimokochi Y. http://dx.40:800-807. Harner CD.2004. Holla CJ. Balance board training: prevention cruciate ligament reconstruction: basketball. http:// ing anterior cruciate ligament injury. 1987.doi.22:7-18.doi.1136/ Biomech. Boden BP. 2005. http://dx. http:// tion with patellar tendon autograft.doi. Fac- 127. Sheehan FT.1177/0363546508325665 Lephart SM.2519/jospt.doi. Sugimoto No other uses without permission. Sullivan AN. bone-patellar tendon-bone autograft.2005. Scholz 142.1007/ radiographic arthritic changes after surgery. et al. http://dx. Evidence-based rehabilitation fol- Journal of Orthopaedic & Sports Physical Therapy® son of the ankle. http://dx. Knee Surg Sports Traumatol Arthrosc. Hop org/10.19:1806-1816. org/10. 2013.1007/ P. et al. knee. domized intervention http://dx. Am J to return to sports after ACL reconstruc- dx. Roewer BD.15:207-213.doi. Changing sagittal plane body po. Meyer EG. Kropf EJ. 148. Biome. Snyder. J Orthop Dynamic sagittal plane trunk control dur.84:90-95.1177/1941738109334275 gang JJ. bmj.344:e3042. Silvers HJ.1016/j. http://dx. Shelbourne KD.17:258-262. 2005. 139. Willson JD. http://dx.arthro.1177/0363546511423639 Loon anterior cruciate ligament reconstruction. Compari. Myers JB.305 Sports Med. Clin Biomech journal of orthopaedic & sports physical therapy  |  volume 43  |  number 11  |  november 2013  |  791 43-11 Di Stasi. Axe MJ. et al.16:2-14. A controlled org/10. sport. Rehabil. Rauh MJ. 2009. Davis IS.22:116-121. Knee Surg Sports Traumatol players: the German experience. jumping 2 years following anterior cruciate of quadriceps femoris strength asymmetry ligament injury in female athletes: a critical ligament reconstruction. et al. J Sport 2009. tion.doi.doi. 138. Neuromuscular and biomechani- Downloaded from at on November 5.34.1053/apmr. http://dx. Urch SE.46:979-988. http://dx.2004. Russell V.110 TE.1007/s00402-005-0793-7 Sports Health.doi. Eastlack ME. 2011. Hewett http:// 151. Schmitt LC. Freeman H. Bock W. Prospective analysis of failure tests correlate with IKDC and KOOS at mini.42:750. 2013. Mandelbaum BR. Schmitt LC. tion in competitive school-aged athletes.0b013e318246ef9e Sports Med. risk of non-contact anterior cruciate ligament s00167-009-1027-2 org/10. Trauma Surg. 125. Kernozek TW. van Eck CF. Myers JB. Muscle stability in young female athletes.jospt.1136/ 124. Mackler L. http://dx. Paterno MV.04. Engström B. http://dx. Schkrohowsky JG.doi. Brent JL. 759. Gray pattern of the ACL graft following single-bundle tion training program in female team handball T. Traumatol Arthrosc. Arndt RL. Wagner 130. Fu FH. Am J ate ligament reconstruction with ipsilateral Surg Sports Traumatol Arthrosc. Knee Surg Sports 154.34:305-316.32:1474-1478.0b013e31804c77ea http://dx.9:62-71.8:349-362.

org in the Info Center for Authors and submit your manuscript for peer review at http://mc.2011.00898 @ MORE INFORMATION Phys Ther.doi. For personal use only. http://dx. Wojtys EM. Clin Biomech (Bristol. http://dx. Am J org/10. and sports groups in 25 countries who provide online access either as a member benefit or at a discount. Ashton. J Bone Joint org/10. health.doi. http://dx. 158.doi. Cholewicki J. PUBLISH Your Manuscript in a Journal With International Reach Journal of Orthopaedic & Sports Physical Therapy® JOSPT offers authors of accepted papers an international audience. http://dx. Ipsilateral graft and contralateral ACL biomechanical-epidemiological study.1016/j. (Bristol.doi. Miller JA.08. Goldberg ity and lower extremity kinematics during org/10.012 valgus moment on in vitro relative ACL strain Sports Med. http://dx. Am J clinbiomech. No other uses without permission.clinbiomech. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. [ clinical commentary ] (Bristol. http://dx. Hewett TE.jospt. Please review our Information for and Instructions to Authors at www. 1 61. 2007.1016/j.001 B.2011. Withrow TJ. and during a single-leg squat.doi. All rights reserved. Wright RW.ORG Downloaded from www.35:1123-1130.manuscriptcentral. of the trunk predict knee injury risk: a prospec. The effect of a hip-strength. 792  |  november 2013  |  volume 43  |  number 11  |  journal of orthopaedic & sports physical therapy 43-11 Di Stasi.2012. 2011. Deficits in neuromuscular control 159.008 rupture at five years or more following ACL re. As a result. TW. Goldberg B. 2013. 2011.27:1052-1057.26:735-740. Sports Med.doi.1016/j. physical therapists and physicians at more than 1. Butler RJ. Zazulak BT. http://dx. 2011. Avon).2519/jospt.2106/JBJS. 162.JOSPT.35:368-373. WWW. The Journal is currently distributed to the members of APTA’s Orthopaedic and Sports Physical Therapy Sections and 31 orthopaedics.jospt.02. Clin Biomech org/10.21:977-983. Avon). Zazulak BT. Male and female gluteal muscle activ.clinbiomech. the Journal is now distrib- uted monthly to more than 28 500 individuals around the world who special- ize in musculoskeletal and sports-related rehabilitation. KP. Reeves NP. Willson JD.3470 Cholewicki J.250 institutions in 57 countries. construction: a systematic review. Huston LJ. and wellness. 2007. Reeves NP. In addition.2006. manual therapy. The effects of core pro- running. Petrowitz I.J. The effect of an impulsive knee tive biomechanical-epidemiologic study. Hewett TE. org/10. Davis IS. Willy RW. 2006. Kernozek during a simulated jump at on November 5. Spindler prioception on knee injury: a prospective 2012. JOSPT reaches students and faculty. Dunn WR.93:1159-1165. J Orthop Sports org/10.indd 792 10/16/2013 4:51:19 PM .com/jospt.41:625-632. Magnussen RA.doi.1177/0363546506297909 ening program on mechanics during running Surg Am. 160. Avon).

avoiding excessive non–sagittal plane motion of the lower extremities and trunk.indd 1 10/17/2013 12:21:25 PM . Progression to phase 2 should occur only after the athlete can demonstrate proper technique during phase 1. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. and the clinician should encourage jumping far- ther once the athlete has mastered the basic technique. APPENDIX A Single-Leg Anterior Progression Downloaded from www. Phase 1 focuses on symmetry during take-off and landing. 2013. Journal of Orthopaedic & Sports Physical Therapy® The clinician instructs the athlete to descend into a deep–knee flexion hold upon each take-off and landing. journal of orthopaedic & sports physical therapy | volume 43 | number 11 | november 2013 | A1 43-11 Di at on November 5. No other uses without permission.jospt. Single-leg jumping for distance with proper take-off and landing is the focus of phase 3. prior to repeated anterior jumps in phase 4 (phases 1-4: 3 × 10 repetitions bilaterally). For personal use only. All rights reserved.

No other uses without permission. A2 | november 2013 | volume 43 | number 11 | journal of orthopaedic & sports physical therapy 43-11 Di Stasi. Journal of Orthopaedic & Sports Physical Therapy® The clinician instructs the athlete to begin and end each hop hold with deep knee flexion. Phase 4 should incorporate lateral and medial jumping (phases 1-4: 3 × 10 repetitions bilaterally). In the later phases. avoiding excessive non–sagittal plane motion of the lower extremities and trunk during take-off and landing.indd 2 10/17/2013 12:21:25 PM . Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. [ CLINICAL COMMENTARY ] APPENDIX B Single-Leg Lateral Progression Downloaded from www.jospt. at on November 5. For personal use only. All rights reserved. the athlete should also be instructed to minimize the amount of rebound (or reverberation) of the BOSU under the foot.

No other uses without at on November 5. journal of orthopaedic & sports physical therapy | volume 43 | number 11 | november 2013 | A3 43-11 Di Stasi.indd 3 10/17/2013 12:21:26 PM . as this will assist the patient to drive off the lead leg. APPENDIX C Lunge Progression Downloaded from www. For personal use only. The athlete’s knee should never advance beyond the ankle during the exercise. The clinician should also cue the athlete to avoid pausing between the lunge and upright portions of the task (phase 1: 3 × 10 repetitions bilaterally.jospt. avoiding hyperextension of the trunk. A slight forward lean is acceptable. All rights reserved. Journal of Orthopaedic & Sports Physical Therapy® The clinician instructs the athlete to maintain most of the weight on the lead leg as they lunge forward into a deep knee flexion. 2013. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. phases 2-4: 10 m × 2 sets).

and to use a toe-to-midfoot rocker landing upon descent into a deep–knee flexion hold. The goal is to achieve a parallel position of both thighs in relation to the floor. and to try to take off and land in the same footprint in which the task started. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.org at on November 5.indd 4 10/17/2013 12:21:27 PM . All rights reserved.jospt. 2013. A4 | november 2013 | volume 43 | number 11 | journal of orthopaedic & sports physical therapy 43-11 Di Stasi. pulling their knees up as high as possible. extending arms behind body) prior to the vertical jump. [ CLINICAL COMMENTARY ] APPENDIX D Tuck Jump Progression Downloaded from www. Tuck jumps performed over an object should be completed only if the athlete completes repeated phase 3 jumps with proper technique (phases 1-2: 2 × 10 repetitions. As the athlete progresses from 2 consecutive jumps (phase 2) with proper technique to multiple consecutive jumps (phase 3). No other uses without permission. For personal use only. Journal of Orthopaedic & Sports Physical Therapy® The clinician instructs the athlete on the proper countermovement preparation (slight crouch downward. phases 3-4: 2 × 10 seconds). The vertical jump begins as the athlete vigorously swings the arms forward as they jump straight up. the clinician instructs the athlete to avoid excessive non–sagittal plane motion of the lower extremities and trunk.

All rights reserved. regardless of phase. rather. No other uses without permission. For personal use only. 2013. phase 4: 2 × 10 seconds bilaterally).org at on November 5.indd 5 10/17/2013 12:21:28 PM . phase 3: 2 × 10 repetitions bilaterally. APPENDIX E Lateral Jump Progression Downloaded from www.(phase 1) and then repeated double-leg landing (phase 2) (phases 1-2: 2 × 10 repetitions. increasing speed with good technique is the criterion by which the athlete will be progressed to the next phase. The height of the jump is not the focus. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Journal of Orthopaedic & Sports Physical Therapy® The goal of this exercise is to focus on minimizing the frontal plane motion of the trunk and lower extremities during lateral jumping. This exercise is progressed from double leg (phases 1 and 2) to single leg (phases 3 and 4) once the athlete can demonstrate symmetrical timing and proper alignment with single. A deep– knee flexion position is emphasized upon each take-off and landing. The clinician should encourage the athlete to jump “close to the line” in preparation for quicker lateral movements.jospt. journal of orthopaedic & sports physical therapy | volume 43 | number 11 | november 2013 | A5 43-11 Di Stasi.

The athlete should also maintain the arms in a crossed position over the chest. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. except when involved in a partner toss-and-catch activity. A6 | november 2013 | volume 43 | number 11 | journal of orthopaedic & sports physical therapy 43-11 Di Stasi.jospt. All rights reserved. For personal use only.indd 6 10/17/2013 12:21:29 PM . 2013. Progression should be implemented when the athlete can complete the current phase with proper form and full trunk motion (phases 1-4: 3 × 10 repetitions bilaterally). The clinician instructs the athlete to bend laterally at the waist during the crunch movement and avoid non–frontal plane motion of the trunk. No other uses without at on November 5. [ CLINICAL COMMENTARY ] APPENDIX F Lateral Trunk Progression Downloaded from www. Journal of Orthopaedic & Sports Physical Therapy® The clinician provides stabilization at the pelvis and lower extremities throughout the phases.

As the athlete progresses to the prone bridge position (phases 3 and 4). All rights reserved. the 2 to 3 contact points away from the center of mass further desta- bilize the athlete as they alternate extremity limb positions. For personal use only. APPENDIX G Prone Trunk Stability Downloaded from www.indd 7 10/17/2013 12:21:30 PM . No other uses without permission. especially during partner pertur- bations. The goal is to avoid excessive trunk rotation and flexion or hyperextension as they lift their limbs (phases 1-4: 3 × 10 repetitions bilaterally). journal of orthopaedic & sports physical therapy | volume 43 | number 11 | november 2013 | A7 43-11 Di at on November 5.jospt. Journal of Orthopaedic & Sports Physical Therapy® The clinician instructs the athlete to minimize the amount of rebound (or reverberation) of the BOSU under the trunk. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. 2013.

[ CLINICAL COMMENTARY ] APPENDIX H Kneeling Trunk Stability Downloaded from www.indd 8 10/17/2013 12:21:30 PM . No other uses without permission. A8 | november 2013 | volume 43 | number 11 | journal of orthopaedic & sports physical therapy 43-11 Di Stasi. especially when the clinician is providing perturbations to the support surface (phase 4). The clinician should avoid administering a subsequent destabilizing perturbation prior to the athlete restoring their equilibrium (phases 1. Excessive trunk flexion and upper extremity strategy (flailing of arms) should be avoided. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. For personal use only. and 4: 3 × 20 seconds.jospt. at on November 5. 3. Journal of Orthopaedic & Sports Physical Therapy® The clinician instructs the athlete to maintain slight hip flexion throughout the different phases. phase 2: 3 × 20 seconds bilaterally).

uncompensated motion. avoiding contralateral hip drop. the goal is to perform full. 2013. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. No other uses without permission. All rights reserved. journal of orthopaedic & sports physical therapy | volume 43 | number 11 | november 2013 | A9 43-11 Di Stasi. Journal of Orthopaedic & Sports Physical Therapy® The clinician instructs the athlete to avoid lumbar hyperextension during the bridging-task phases. As the athlete advances through stages. Phase 3 is designed to narrow the base of support and the number of contact points to increase the difficulty of the task. In phase 4. Manual and verbal cues may be necessary to ac- climate the athlete to a neutral pelvic position during this at on November 5. APPENDIX I Posterior Chain Progression Downloaded from www. For personal use only. the athlete should be instructed to minimize motion of the ball under their feet while achieving controlled hip flexion and extension (phases 1-4: 3 × 10 repetitions).indd 9 10/17/2013 12:21:31 PM .jospt.

A10 | november 2013 | volume 43 | number 11 | journal of orthopaedic & sports physical therapy 43-11 Di Stasi. with the knee slightly flexed and toes and foot relaxed. The clinician instructs the athlete to keep the muscles of the standing leg relaxed. No other uses without permission. All rights reserved. Journal of Orthopaedic & Sports Physical Therapy® The key component to this exercise progression is the ability of the athlete to minimize trunk deviation in the frontal and transverse planes while avoid- ing excessive cocontraction of the muscles of the lower at on November 5. Hip hinging with an erect spine should be emphasized throughout the phases (phases 1-4: 3 × 10 repetitions bilaterally). [ CLINICAL COMMENTARY ] APPENDIX J Romanian Dead Lift Progression Downloaded from www. For personal use only. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. 2013.indd 10 10/17/2013 12:21:32 PM .

jospt. No other uses without at on November 5. as well as the trunk. APPENDIX K Lunge Jump Progression Downloaded from www.indd 11 10/17/2013 12:21:33 PM . 2013. journal of orthopaedic & sports physical therapy | volume 43 | number 11 | november 2013 | A11 43-11 Di Stasi. phases 2 and 4: 3 × 20 seconds). The clinician instructs the athlete to descend into a deep–knee flexion hold upon each jump take-off and landing. For personal use only. avoiding excessive non–sagittal plane motion of the lower extremities and trunk (phases 1 and 3: 3 × 10 repetitions bilaterally. All rights reserved. Journal of Orthopaedic & Sports Physical Therapy® This is a plyometric advancement of the lunge progression in APPENDIX C. The clinician instructs the athlete to maintain more weight toward the lead limb to generate adequate power for the jump and maintain balance. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. and the same emphasis should be placed on the mechanics of the lead leg and trail leg.