Anterior Cruciate Ligament Reconstruction Rehabilitation Research Articles

Isometric Mid-thigh Pull Peak Force During Anterior Cruciate Ligament Reconstruction Rehabilitation

Isometric Mid-thigh Pull Peak Force During Anterior Cruciate Ligament Reconstruction Rehabilitation

Clinicians’ Attitudes, Perspectives, and Clinical Practices on Gait Retraining After Anterior Cruciate Ligament Reconstruction

Introduction: It has been shown that 45%–85% of patients with anterior cruciate ligament reconstruction (ACLR) will have early-onset arthritis within 10–12 years following surgery. Over the past two decades, the amount of literature regarding ACLR, gait maladaptations after ACLR and their potential link to early-onset arthritis, and rehabilitation techniques has grown exponentially; however, long-term patient outcomes remain modest. Methods: To evaluate current clinicians’ attitudes, perspectives, and clinical practice approach for rehabilitation of patients following ACLR, a survey questionnaire was designed using the Delphi technique. Results: Of the 263 respondents, 84.4% (n = 226) reported that they believed gait training to be “Very” or “Extremely Important.” However, only 35.7% (n = 94) reported objectively measuring gait during ACLR rehabilitation. Of the total respondents, only 6.8% (n = 18) assessed gait during rehabilitation using two-dimensional or three-dimensional motion capture technologies. Discussion: Our results suggest that while gait evaluation was perceived as important, most respondents did not objectively measure gait metrics as a clinical outcome during ACLR rehabilitation. These findings provide a prospective rehabilitation target to potentially mitigate a known risk factor of early-onset arthritis (gait maladaptations) in individuals following ACLR.

Crossover effect of knee and ankle joint training on knee mechanics after ACL reconstruction: A randomized controlled trial

BackgroundAnterior cruciate ligament (ACL) rehabilitation is a common intervention after ACL reconstruction. Since different types of exercise can influence muscle and kinematic parameters in diverse ways, the training order between the knee and ankle joints may also change gait parameters. PurposeThis study aimed to investigate whether the training sequence of the knee and ankle joints (knee followed by ankle training or vice-versa) in an ACL reconstruction (ACLR) rehabilitation program has any effects on knee extension and flexion torques. MethodsForty-two men (aged 20–30 years) with ACLR participated in this study. They were randomly allocated to receive one of two interventions: (A) knee joint training followed by ankle training or (B) ankle joint training followed by knee training. After five weeks (four weeks of intervention and one-week washout), participants crossed from one group to another for an additional four weeks. Knee extension and flexion torques were assessed during the stance phase of the gait cycle before and after the intervention program. ResultsTwo-way Mixed-design MANOVA showed that knee extension torque improved significantly in both groups after training (p = 0.001, Cohen’s D = 0.65), while the knee flexion torque increased significantly only in group B (p= 0.001, Cohen’s D = 0.97). When comparing both groups, patients of group B presented significant improvements in the post-training mean values of all tested variables compared with group A. ConclusionStarting a post-ACLR rehabilitation program with ankle training followed by knee training is better to improve knee flexion and extension torques during the stance phase of the gait cycle than starting the program by training the knee first, followed by the ankle. Future studies using a mixed-gender sample and different types of ACLR operations are necessary to examine whether similar improvements will happen as well as to test their effects on many sports activities.

Correlation between Anterior Cruciate Ligament-Return to Sport after Injury Score at 6 Months after Anterior Cruciate Ligament Reconstruction and Mid-Term Functional Test Results: An Observational Study at 5-Year Follow-Up.

Background/Objectives: Evaluations allowing patients to return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR) should be multimodal, including a psychological evaluation. The goal of this study was to determine if there is a correlation between the ACL-return to sport after injury (ACL-RSI) score at 6 months post-ACLR and mid-term functional results. Methods: A total of 498 patients were assessed 6 months after primary ACLR using a composite test including isokinetics, hops, and ACL-RSI. A minimum of 3 years of follow-up was necessary. At the last follow-up, each patient completed clinical and functional evaluations, including the subjective International Knee Documentation Committee (IKDC) score, Tegner Activity Scale, Self Knee Value (SKV), and ACL-RSI score. The results were compared overall and item by item. Results: At the last follow-up, the mean SKV, Tegner, IKDC, and ACL-RSI scores were 86.8 ± 14.3%, 6 ± 2.1, 77 ± 11.9%, and 68.8 ± 25.7%, respectively. A significant correlation existed between the 6-month ACL-RSI score and each functional test (respectively, ρ = 0.189 p < 0.001; ρ = 0.174 p < 0.001; ρ = 0.237 p < 0.001). The ACL-RSI score was significantly higher than at 6 months after surgery (p < 0.001). Over half (59.2%) of the cohort returned to an equal or greater level of activity, and there was a significant correlation between the 6-month ACL-RSI score and post-surgery level of activity. Conclusions: Patients with better ACL-RSI scores at 6 months post-ACLR have better functional results in the medium term and are more likely to RTS. Our results show a correlation between psychological factors at 6 months, measured through the ACL-RSI score, and activity level at mid-term follow-up. This study underlines the relationship between RTS and psychological effects, and the importance of ACLR rehabilitation to focus on decreasing apprehension and fear.

Repair potential of self-assembling peptide hydrogel in a mouse model of anterior cruciate ligament reconstruction.

Establishing zonal tendon-to-bone attachment could accelerate the anterior cruciate ligament reconstruction (ACLR) rehabilitation schedule and facilitate an earlier return to sports. KI24RGDS is a self-assembling peptide hydrogel scaffold (SAPS) with the RGDS amino acid sequence. This study aimed to elucidate the therapeutic potential of KI24RGDS in facilitating zonal tendon-to-bone attachment after ACLR. Sixty-four C57BL/6 mice were divided into the ACLR + SAPS and ACLR groups. ACLR was performed using the tail tendon. To assess the maturation of tendon-to-bone attachment, we quantified the area of mineralized fibrocartilage (MFC) in the tendon graft with demeclocycline. Immunofluorescence staining of α-smooth muscle actin (α-SMA) was performed to evaluate progenitor cell proliferation. The strength of tendon-to-bone attachment was evaluated using a pull-out test. The MFC and maximum failure load in the ACLR + SAPS group were remarkably higher than in the ACLR group on Day 14. However, no significant difference was observed between the two groups on Day 28. The number of α-SMA-positive cells in the tendon graft was highest on Day 7 after ACLR in both the groups and was significantly higher in the ACLR + SAPS group than in the ACLR group. This study highlighted the latent healing potential of KI24RGDS in facilitating early-stage zonal attachment of tendon grafts and bone tunnels post-ACLR. These findings may expedite rehabilitation protocols and shorten the timeline for returning to sports. Not applicable.

Blood Flow Restriction Therapy After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) rehabilitation necessitates restoration of quadriceps strength to minimize reinjury and optimize return to sport (RTS). Patients recovering from ACLR are limited by pain and activity restrictions, resulting in quadriceps muscle atrophy. Blood flow restriction (BFR) therapy involves performing exercises while a specialized blood pressure cuff is applied to the proximal aspect of the operative extremity and inflated to 40% to 90% of the arterial occlusion pressure, as determined using Doppler ultrasonography. BFR is theorized to induce an anaerobic environment and metabolic stress during exercise, promoting muscle hypertrophy and strength gains. Although the physiological mechanism has not been fully elucidated, it is theorized that BFR combined with low-load resistance training could yield muscle adaptations comparable to those of high-load resistance training. For ACLR patients with pain and restrictions precluding high-intensity strength training, incorporation of BFR into postoperative rehabilitation protocols could help mitigate quadriceps weakness and promote RTS. Randomized controlled trials report a prolonged, dose-dependent relation between BFR use and quadriceps and hamstring strength gains, improved bone and muscle mass, and earlier RTS, whereas other studies report no significant difference in quadriceps size, strength, or patient satisfaction compared with controls. Furthermore, although generally considered safe, there are rare reports of associated adverse events such as rhabdomyolysis, and BFR should be avoided in patients with a history of thromboembolic disease or peripheral vasculopathy. The literature examining BFR after ACLR is heterogeneous; lacks standardization; and contains broad variation in reported cuff pressures, as well as timing and duration of BFR use, among protocols. Although the use of BFR after ACLR shows promise, further study is necessary to elucidate the efficacy, safety, and optimal protocols.

Implementing Velocity-Based Training to Optimize Return to Sprint After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Clinical Commentary.

After anterior cruciate ligament reconstruction (ACLR), return to sprint is poorly documented in the literature. In soccer, return to sprint is an essential component of return to play and performance after ACLR. The characteristics of running in soccer are specific (velocity differences, nonlinear, intensity). It is important to address these particularities, such as curvilinear running, acceleration, deceleration, changes of direction, and variations in velocity, in the patient's rehabilitation program. Force, velocity, and acceleration capacities are key elements to sprint performance. Velocity-based training (VBT) has gained much interest in recent years and may have a role to play in optimizing return to play and return to sprint after ACLR. Force, velocity, and acceleration can be assessed using force-velocity-power and acceleration-speed profiles, which should inform rehabilitation. The purpose of this commentary is to describe a velocity-based return to sprint program which can be used during ACLR rehabilitation.

Go to the back before going forward: Addressing psychological responses in anterior cruciate ligament reconstruction rehabilitation

Go to the back before going forward: Addressing psychological responses in anterior cruciate ligament reconstruction rehabilitation

Changes in isometric mid-thigh pull peak force and symmetry across anterior cruciate ligament reconstruction rehabilitation phases.

Whether functionally relevant strength assessments, such as the isometric mid-thigh pull (IMTP), can be used either bilaterally or unilaterally to evaluate and guide rehabilitation progress in those with anterior cruciate ligament reconstruction (ACLR) is under-researched. This study assessed changes in peak force (PF) and asymmetry across 3 phases for bilateral and unilateral IMTP assessments in patients with ACLR. Peak isometric force from the IMTP was compared to peak torque from isokinetic dynamometry as well as against a cohort of healthy, uninjured individuals. Participants (ACLR, n = 15) completed bilateral and unilateral IMTP assessments at weeks 12 (baseline), 16 (phase 3), and 20 (phase 4) of rehabilitation to evaluate changes in PF and asymmetry. Asymmetry was evaluated using the asymmetry angle. Isometric data from the IMTP were compared to that from an isokinetic dynamometer as well as against a cohort of healthy, uninjured participants (n = 63) allowing for a detailed analysis of limb-specific force production. The PF during the bilateral IMTP increased for both the injured (0.94 N/kg) and uninjured (0.26 N/kg) limbs from baseline to phase 4, whereas the PF of the injured limb increased by 1.5 N/kg during the unilateral IMTP in the same time frame. Asymmetry values systematically reduced by ∼1% and ∼0.5% for the bilateral and unilateral IMTP tests from baseline to phase 4. Significant differences in PF of the injured limb were evident between those with ACLR and healthy controls across all phases (p = 0.022-0.001). The rate of progression in PF capacity was dependent on test type, amounting to 0.1 and 0.2 body weights per week for the bilateral and unilateral IMTP respectively. Small-to-large correlations (r = 0.12-0.88) were evident between IMTP PF and peak torque from the isokinetic dynamometer as well as between asymmetry metrics from both tests. The findings suggest that IMTP PF has potential for monitoring changes in PF and asymmetry during the ACLR rehabilitation progress. Both injured limb and uninjured limb show improvement in force-generating capacity, implying a positive adaptation to rehabilitation protocols. The findings highlight that ACLR is a unilateral injury that requires bilateral rehabilitation.

Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport

ObjectivesTo investigate current clinical practice of Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction (ACLR) from pre-operative rehabilitation until return to sport (RTS). We assessed optimisation strategies in daily practice and the perceived barriers to these optimisations, and evaluated whether there was a relevant difference in clinical practice for physiotherapists with post-graduate certification in sports physiotherapy or deep clinical experience and those without such experience. DesignCross-sectional survey. SettingOnline survey platform. ParticipantsSwiss physiotherapists. Main outcome measuresThe survey comprised six sections: participant information, pre-operative rehabilitation, post-operative rehabilitation, RTS, re-injury prevention, and optimisation strategies and barriers. ResultsA minority of physiotherapists treated ACLR patients pre-operatively. Overall, 91% included quadriceps open kinetic chain exercise in their treatment, 37% used patient-reported outcomes measures (PROMs) and 39% considered psychological criteria when making decisions about RTS. Most physiotherapists (67%) felt limited due to the time available, the number of prescriptions and the tariffication system. ConclusionThis study highlights areas within ACLR rehabilitation practice in Switzerland that could be improve. Improvements in understanding of the barriers to implementation of best evidence in practice and a redefinition of the clinical process around ACLR rehabilitation in Switzerland are necessary.

The Effect of Staged Versus Usual Care Physiotherapy on Knee Function Following Anterior Cruciate Ligament Reconstruction.

The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial. One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2weeks, 6weeks, 3months, and 6months. The staged group completed the ACLR rehabilitation protocol at home for the first 3months, followed by usual care in-person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing. There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval, 1.3 to 10.4; P = .01). A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups.

Improving the quality of rehabilitation following anterior cruciate ligament reconstruction surgery, in an outpatient physiotherapy department

Anterior cruciate ligament reconstruction (ACLR) is a type of orthopaedic knee surgery and physiotherapy rehabilitation is undertaken for several months postoperatively, often with the aim of returning the patient to...

Postoperative considerations based on graft type after anterior cruciate ligament reconstruction a narrative review.

Graft selection for anterior cruciate ligament reconstruction (ACLR) affects rehabilitation throughout the course of postoperative care. A search of PubMed and EBSCO was performed and abstracts independently reviewed by two authors. This search was also supplemented with additional evidence relevant to each phase of ACLR rehabilitation. Direct implications of graft type on clinical decisions vary throughout treatment phases, transitioning from potential differences in acute postoperative pain management immediately after surgery to facilitating sufficient and appropriate lower extremity loading in subsequent weeks. Regardless of graft type, surgical limb weakness persists throughout the course of rehabilitation; however, harvest site selection for autografts contributes to disproportionate weakness of the harvested muscle group and the potential for surgical-induced tendinopathy. In later phases of rehabilitation, as athletes are transitioning into return to sport (RTS), treatment decisions and protocols are less affected by graft type but expectations for meeting clinical milestones and the time required to do so does differ between graft types. Targeted strengthening interventions to address muscle weakness following graft harvest in autografts should be continued throughout the rehabilitation process. Lingering deficits in quadriceps strength symmetry may also influence time to meet progression and RTS criteria following graft harvest from the extensor mechanism.

Using a target as external focus of attention results in a better jump-landing technique in patients after anterior cruciate ligament reconstruction – A cross-over study

BackgroundImproving jump-landing technique during rehabilitation is important and may be achieved through different feedback techniques, i.e., internal focus of attention (IF) or external focus of attention using a target (EF). However, there is a lack of evidence on the most effective feedback technique after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to investigate the potential difference in jump-landing techniques between IF and EF instructions in patients after ACLR. MethodsThirty patients (12 females, mean age 23.26 ± 4.91 years) participated after ACLR. Patients were randomly assigned into two groups that each followed a different testing sequence. Patients performed a drop vertical jump-landing test after receiving instructions with varying types of focus of attention. The Landing Error Scoring System (LESS) assessed the jump-landing technique. ResultsEF was associated with a significantly better LESS score (P < 0.001) compared with IF. Only EF instructions led to improvements in jump-landing technique. ConclusionUsing a target as EF resulted in a significantly better jump-landing technique than IF in patients after ACLR. This indicates that increased use of EF could or might result in a better treatment outcome during ACLR rehabilitation.

Biomechanical Effects of Manipulating Preferred Cadence During Treadmill Walking in Patients With ACL Reconstruction.

Abnormal gait is common after anterior cruciate ligament reconstruction (ACLR) which may influence osteoarthritis risk in this population. Yet few gait retraining options currently exist in ACLR rehabilitation. Cueing cadence changes is a simple, low-cost method that can alter walking mechanics in healthy adults, but few studies have tested its effectiveness in an ACLR population. Here, we evaluated the acute effects of altering cadence on knee mechanics in patients 9 to 12 months post ACLR. Cueing larger steps will facilitate larger knee angles and moments, while cueing smaller steps would induce smaller knee angles and moments. Randomized cross-sectional design. Level 3. Twenty-eight patients with unilateral ACLR underwent gait assessments on a treadmill at preferred pace. Preferred walking gait was assessed first to obtain preferred cadence. Participants then completed trials while matching an audible beat set to 90% and 110% of preferred cadence in a randomized order. Three-dimensional sagittal and frontal plane biomechanics were evaluated bilaterally. Compared with preferred cadence, cueing larger steps induced larger peak knee flexion moments (KFMs) and knee extension excursions bilaterally (P < 0.01), whereas cueing smaller steps only reduced knee flexion excursions (P < 0.01). Knee adduction moments remain unchanged across conditions and were similar between limbs (P > 0.05). Peak KFMs and excursions were smaller in the injured compared with uninjured limb (P < 0.01). Frontal plane gait outcomes were unchanged across conditions suggesting acute cadence manipulations result in mainly sagittal plane adaptations. Follow-up studies using a longitudinal cadence biofeedback paradigm may be warranted to elucidate the utility of this gait retraining strategy after ACLR. Cueing changes in walking cadence can target sagittal plane knee loading and joint range of motion in ACLR participants. This strategy may offer high clinical translatability given it requires relatively minimal equipment (ie, free metronome app) outside of a treadmill.

Predicting readiness for return to sport and performance after anterior cruciate ligament reconstruction rehabilitation.

Determining readiness to return to sport after anterior cruciate ligament (ACL) reconstruction is challenging. To develop models to predict initial (directly after rehabilitation) and sustainable (one year after rehabilitation) return to sport and performance in individuals after ACL reconstruction. We conducted a multicentre, prospective cohort study and included 208 participants. Potential predictors - demographics, pain, effusion, knee extension, muscle strength tests, jump tasks and three sport-specific questionnaires - were measured at the end of rehabilitation and 12 months post discharge from rehabilitation. Four prediction models were developed using backward logistic regression. All models were internally validated by bootstrapping. All 4 models shared 3 predictors: the participant's goal to return to their pre-injury level of sport, the participant's psychological readiness and ACL injury on the non-dominant leg. Another predictor for initial return to sport was no knee valgus, and, for sustainable return to sport, the single-leg side hop. Bootstrapping shrinkage factor was between 0.91 and 0.95, therefore the models' properties were similar before and after internal validation. The areas under the curve of the models ranged from 0.74 to 0.86. Nagelkerke's R2 varied from 0.23 to 0.43 and the Hosmer-Lemeshow test results varied from 2.7 (p=0.95) to 8.2 (p=0.41). Initial and sustainable return to sport and performance after anterior cruciate ligament reconstruction rehabilitation can be easily predicted by the sport goal formulated by the individual, the individual's psychological readiness, and whether the affected leg is the dominant or non-dominant leg.

Survey of blood flow restriction therapy for rehabilitation in Sports Medicine patients

Blood flow restriction (BFR) therapy has demonstrated benefits across a spectrum of musculoskeletal injuries, including improved strength, endurance, function, and reduction in pain perception. There is, however, no standardized application of BFR therapy among orthopaedic surgeons within the United States (US). The indication and protocol for BFR therapy vary significantly across providers in the US. An online survey of 21 multiple-choice questions was sent to 3,281 surgeons listed on a large orthopaedic registry. A cross-sectional study was performed on all surgeons who successfully completed the questionnaire. Surgeons were queried on current or planned use of BFR, indications, contraindications, and peri-operative and non-operative management of sports-related injuries. Overall, 250 physicians completed the survey, with 149 (59.8%) reporting current BFR use and 75.2% initiating use in the last 1-5 years. Most protocols (78.8%) utilize the modality 2-3 times per week while 15.9% use it only once weekly. Anterior cruciate ligament reconstruction (ACLR) rehabilitation was the most reported indication for initiating BFR therapy (95.7%) along with medial patellofemoral ligament reconstruction (70.2%), multiligamentous knee reconstruction (68.8%), meniscus repair (62.4%), collateral ligament reconstruction (50.4%), Achilles tendon repairs (30.5%), and meniscectomy (27%). Only 36.5% reported using BFR after upper extremity procedures, such as distal biceps repair (19.7%), ulnar collateral ligament elbow reconstruction (17%), rotator cuff (16.8%), and shoulder labrum repair (15.3%). For non-operative injuries, 65.8% of surgeons utilized BFR. Of those not currently using BFR therapy, 33.3% intended to implement its use in the future. BFR therapy has increased in popularity with most physicians implementing its use in the last 5 years. BFR was commonly utilized after ACLR. BFR allows light-load resistance to simulate high-intensity resistance training. This study describes US orthopaedic surgeons' common practice patterns and patient populations that utilize BFR therapy.

Surface electromyography as a follow-up instrument in anterior cruciate ligament reconstruction rehabilitation

Surface electromyography as a follow-up instrument in anterior cruciate ligament reconstruction rehabilitation

Evaluation of raw segmental bioelectrical impedance variables throughout anterior cruciate ligament reconstruction rehabilitation

Background. Raw bioelectrical impedance analysis (BIA) variables are related to physical function in healthy and diseased populations. Therefore, BIA may be an insightful, noninvasive method of assessment to track following anterior cruciate ligament reconstruction (ACLR). Objectives. Evaluate phase angle, reactance and impedance at 50 kHz (PhA50, Xc50, and Z 50, respectively) in the operative (OP) and non-operative (NOP) limbs during ACLR rehabilitation. Approach. Seventeen patient (12 M, 5 F; 18.8 ± 4.8 years) clinic reports were evaluated prior to ACLR (PRE), two- (2 W), six- (6 W), and twelve-weeks (12 W) post-ACLR and at return to sport testing (RTS). Setting. All observations occurred during the participant’s physical therapy visits. Measurements. A multi-frequency BIA device measured segmental PhA, Xc, and Z. Linear mixed effects models were used to assess any leg and time interaction and changes over leg and time, independently. Any interactions or main effects were considered significant at p < 0.05. Main results. Significant leg x time interactions were observed for each variable. PhA50 and Xc50 of NOP were higher (p < 0.001) than OP at each time point by an average of by 0.9° and 4.9 Ω, respectively. In OP, PhA50 and Xc50 decreased from PRE to 2 W and increased from 6 to 12 W and 12 W to RTS (p < 0.01, for all). At RTS, PhA50 and Xc50 were similar to PRE in OP (p > 0.05). For Z 50, the OP leg did not change over time (p > 0.05). Z 50 was greater in NOP at 2 and 6 W (p < 0.01, for both). There were differences in PhA50 in NOP between PRE and 6 W and from 6 W to RTS (p < 0.05 for both). Xc50 did not change (p > 0.05), and Z 50 PRE was lower than at 2 W (p < 0.05). Significance. A multi-frequency BIA device can detect changes in segmental BIA variables following ACLR.

Return to Sport Following Anterior Cruciate Ligament Reconstruction: Women's Soccer

Soccer is largely recognized as the most popular sport in the world. It involves speed, agility and endurance, requiring its athletes to sprint, explode to the ball, change direction and maintain high thresholds of work for prolonged periods. In the United States, as many as 80,000 high school female athletes experience ACL injuries each year. Females tend to be more at risk for ACL injury for a multitude of reasons including biomechanical, neuromuscular activation patterns, strength imbalances and hormonal factors. Athletes and their families are becoming increasingly aware of this risk and the subsequent risk of not returning to their pre-injury level of play; thus, necessitating both preventative and post injury rehabilitation programs aimed at maximizing function and minimizing subsequent injury. A program that focuses on neuromuscular activation patterns, proprioception and balance training, functional strength, agility, landing techniques and quality of footwork is best for mitigating risk of ACL injuries in female soccer players. This post-surgical ACL reconstruction rehabilitation program for the female soccer player has been divided into five phases, each phase a progression and building upon its preceding phase. The phases range from early post-operative care to late stage, pre-clearance to return to sport guidance and have been constructed based on evidence informed guidelines focusing on maximizing function post operatively in a safe, efficient manner while minimizing risk for re-injury.