CLINICAL COMMENTRY

IJSPT A TEN TASK-BASED PROGRESSION IN

REHABILITATION AFTER ACL RECONSTRUCTION:
FROM POST-SURGERY TO RETURN TO PLAY –
A CLINICAL COMMENTARY
Matthew Buckthorpe, PhD1,2
Antonio Tamisari3
Francesco Della Villa, MD1

ABSTRACT
There is a need to improve patient outcomes after anterior cruciate ligament reconstruction (ACLR). To do
this likely involves a strong focus on optimizing rehabilitation processes and practices. Movement
re-training is considered an important element of rehabilitation after ACLR, but there is a lack of knowl-
edge on the ‘how’ and ‘what’ movement re-training should occur after ACLR. In its basic form, movement
re-training after ACLR is about progressing a patient through gradually more demanding tasks from the
point of being able to walk to being able to perform highly complex sports movements. However, there is
a lack of guidance on when to implement certain tasks (e.g. when to begin running) and how to transition
between tasks. This paper presents a 10 task progressions system which can form an important aspect of
the movement-based re-training process, providing structure and patient autonomy. Monitoring knee func-
tion and movement and neuromuscular status to safely transition between these tasks is important.
Although this task-based progression is designed for patients following a rehabilitation program after ACLR,
it may have generalizability for all major lower limb injuries. The task-based progression was formed by
combining theory, the best available evidence, and significant practice experience applied to movement
re-training after ACLR. This approach supports patient autonomy, medical team communication and col-
laboration and can provide structure to the movement re-training process.
Keywords: Biomechanics, criterion-based progressions, movement system, performance rehabilitation,
screening

CORRESPONDING AUTHOR
1
Education and Research Department, Isokinetic Medical Matthew Buckthorpe
Group, FIFA Medical Centre of Excellence, Bologna, Italy
2
Isokinetic Medical Group, FIFA Medical Centre of Excellence, Isokinetic Medical Group
London, UK 11 Harley Street
3
Isokinetic Medical Group, FIFA Medical Centre of Excellence, London,
Bologna, Italy.
WG1 9PF
Conflict of interest: The authors report no conflicts of
interest and no external funding was received for the writing Tel - 0207 486 5733
of this manuscript. E-mail: [email protected]

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 611
DOI: 10.26603/ijspt20200611
BACKGROUND AND PURPOSE if they are running at that time. The ability though,
Outcomes following injuries such as anterior cruci- to perform specific tasks like running is not related
ate ligament (ACL) rupture are unsatisfactory, with to healing times, but more specifically to functional
lower than optimal return to sport (RTS) rates1 and return. But, in the decision to return to running after
high re-injury risk.2,3 To optimize patient outcomes ACLR, function is rarely assessed.17 Conversely,
after ACL reconstruction (ACLR) and limit long- there is a current practice-based trend regarding the
term associated problems which can follow injury implementation of functional tasks earlier than per-
(e.g., knee osteoarthritis),4 there is a need to opti- haps advisable. Such functional tasks are more excit-
mize the rehabilitation and RTS approach. One area ing than traditional, simple, isolated tasks, which
which is becoming increasingly important is move- may become boring to the patient. However, after
ment re-training or ‘functional’ training. Movement ACLR, patients are often ill-prepared for some func-
dysfunction is thought to be a risk factor for both tional tasks, which may increase athlete re-injury
primary and secondary ACL injuries.5-7 Disruption risk or result in joint overload, substitutions during
to the native ACL after injury, leads to mechanical performance, and/or complications in the rehabili-
instability of the knee, and can alter neuromuscular tation process.
control due to disrupted mechanoreceptors within
Therefore, the aim of this clinical commentary is to
the ligament8 and altered somatosensory input and
provide an easily implementable task-based progres-
joint proprioception. Multiple authors have identi-
sion, with specific criteria and monitoring suggestions
fied altered movement quality in both the involved
as a guide during rehabilitation after ACLR. These
and uninvolved limbs after ACLR during various
task-based progression are expected to offer clarity to
functional tasks.9-14 It appears that an ACL injury
the process for all, autonomy to the patient, and pro-
results in altered movement bilaterally, when com-
vide clinicians with an evidenced informed approach
pared to pre-injury movement quality.11 As such,
to optimize their functional recovery approach.
it would appear that targeting the restoration of
normal movement patterns is one of the priorities
LOAD MANAGEMENT CONSIDERATIONS
during rehabilitation and requires both single and
In terms of task-based progressions, it is important
bilateral limb activities.15
to initially establish the level of loading that a task
Although most clinicians and researchers under- may place on the body and have a clear understand-
stand that retraining movement after ACLR is impor- ing of the different total loading demands of each
tant (e.g., the ‘why’), there is often a disconnect with task. Loading can be considered as:
understanding the ‘how’ and ‘what’ of movement
– peak loading (e.g., peak ground reaction forces),
re-training post ACLR. There is a need to bridge the
gap between theory and practice to provide practitio- – volume load (e.g., load times repetition) and
ners who work with ACLR patients’ clear guidelines
– rate of loading (e.g., time over which it is
on ‘how’ to train movement and ‘what’ exercises to do
delivered/experienced)
and when. Establishing clear task based goals have
been suggested for athletes after ACLR to provide It is important to plan and prepare for all types of
structure and clarity to the process.16 One key task loading and develop load tolerance to particular
after ACLR is return to running, which is typically tasks. Load is dissipated via the neuromuscular sys-
recommended based on time as opposed to func- tem and absorbed passively via the tendons, liga-
tion, with recommendations being around 12 weeks ments and joints. Deficits in strength would mean
after surgery.17 In terms of graft healing and matu- insufficient neuromuscular capacity to eccentrically
ration, the often cited reason for determining this absorb forces during high load tasks, with greater
time frame, this is an irrelevant date.18,19 However reliance on joint complexes (tendon, ligament and
this becomes a fixed point in the athlete, coaches, joint structures) for passive force absorption.20
surgeons and rehabilitation specialists minds with
the athlete feeling as though they are “failing” if It is also important to understand how the load is
they cannot run at that point and feeling “on track” distributed throughout the body and specifically the

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 612
knee in particular. The extent of load will depend on MONITORING OF THE ATHLETE
the kinematics and the specific torques elicited at It is important to monitor the athlete to ensure that
each joint. Typically, loading is distributed through- the response to the exercise is appropriate, but also
out the joints of the lower limbs, with acceptance/ that they are progressing optimally and have the
torque development occurring at the ankle, knee appropriate function. The quality of movement and
and hip depending upon the tasks and adopted level of stress is important. The authors propose
movement strategy. Altered movement quality monitoring:
would result in differing joint torque loads being
1. The response to the exercise
shared by the movement system, which could either
increase knee joint loads (e.g., knee dominant pat- 2. Movement quality during the task
tern) or reduce the loads (e.g., knee avoidance strat-
egy). A key element for task-based progressions is 3. Strength and
to understand the tensile load experienced via the 4. Muscle soreness
ACL to provide ‘optimal loading’.21 This entails pro-
tecting the ACL-graft from excessive loads which Monitoring the response to exercise
could lead to graft attenuation or even failure, but Any task-based progression must consider the biolog-
sufficient enough load to encourage neuromuscular ical healing and ability of the joint to withstand the
adaptations and graft remodeling/strengthening. loading demands. Pain and swelling can be used to
An example of ACL loading during athletic activi- determine task-based progressions, as these factors
ties was described by Laughlin et al.22 using mus- will relate to the loading stress experienced by the
culoskeletal modelling to provide an estimate of knee.28 Optimal loading may be defined as the load
ACL tensile forces during single-leg landings (30 cm applied to structures that maximizes physiological
height) in a group of recreationally active females. adaptation.21 All exercises should typically be pain-
Peak ACL load during the landing was ~0.7 × body free. If not specific adaptation to training or in regard
mass, equating to 440 N for the female cohort in the to exercise quality has to be considered to continue
study. While this value is clearly below the ~1300 N to train function without affecting the knee joint
threshold which might be expected to rupture the homeostasis. Progression through tasks is allowed
female ACL,23 sagittal plane motion is only one com- only when there is no pain (numeric rating scale) or
ponent influencing the resultant ACL load. The addi- swelling (stroke test) increase as a response to previ-
tion of altered tibial and/or femoral rotation due to ous tasks, as these would indicate excessive previous
poor biomechanics may exacerbate the load on the loading levels to the knee joint and an adverse reac-
ACL24 during landing, bringing it closer to the injury tions, which may limit optimal adaptation.
threshold. So, assessing and controlling for altered
frontal and transverse plane control is an important Movement quality – Is the task too difficult?
aspect of movement re-training. The authors believe that rehabilitation needs to
be geared at least in part to regaining symmetrical
Finally, it is important to minimize excessive patel- motion and appropriate movement strategies in
lofemoral joint stress, given the high prevalence of order to reduce risk of re-injury and improve func-
patients who go on to develop patellofemoral pain tion. For this to be achieved, a means of monitoring
syndrome after ACLR.25-27 Understanding the extent limb alignment during functional tasks is required.
of load which may be placed on the patellofemoral Inability to maintain alignment may indicate the
joint is important. In closed kinetic chain exercises task is potentially too challenging. The assessment
(e.g., most functional tasks) such as lunges and the of movement quality is a matter of debate. 3-D cam-
leg press, quadriceps muscle force and patellofem- era motion tracking is considered the gold-standard
oral joint stress are highest near full flexion.25,26 As method for motion analysis,5 but is clinically not
such, it is recommended initially to restrict high commonly available. In terms of optimal movement
load functional exercise to between flexion angles training, there is a need to have information on move-
of 0-80°. ment quality during the tasks at hand, and to be able

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 613
to provide feedback to the patient, to create a con- force (e.g., strength).29 As discussed, various tasks
tinuous learning environment to solve the task and will place differing loads on the movement system,
optimally progress. This should be easy to obtain, not both in terms of the whole system and as well as
require expensive equipment and also not require joint specific (e.g., knee dominant or hip dominant).
time consuming analysis. Clinically, it needs to be Inability of the neuromuscular system to produce or
simple enough to be understood by the patient, to be accept force may result in either movement compen-
effectively coached and adopted so the patient can sations and/or acceptance of passive loading via ten-
learn to self-correct (a valuable stage of motor learn- dinous, joint, ligament, and potential joint overload.
ing). Herrington et al.16 suggests a qualitative move- Additionally, muscle strength imbalances will result
ment assessment system based on a series of criteria in altered movement quality, which may result in
including the ability to maintain control of the arms, further movement compensations and reinforce
trunk, pelvis and lower limbs in the sagittal plane. inappropriate patterning.30 As such, it is important
Here it is advised to adopt a similar approach, which to assess, monitor and use assessment of strength
focuses on teaching and monitoring the patient’s abil- to guide task progressions. This also provides objec-
ity to maintain control of the body utilizing teaching tive information to support shared decision making
and training of optimal frontal plane (pelvis, trunk as a team on important functional milestones (e.g.,
and lower limb, Figure 1a) and sagittal plane control initiating running, jumping and/or plyometric type
(Figure 1b), depending upon the specific task. Task- tasks).
based progression should be based on movement
quality or technical proficiency during the tasks. If Knee extensor strength is a major barrier to func-
the task cannot be performed with sufficient quality, tional progressions.30 It is advised to assess knee
then it should be simplified, or the load is reduced extensor strength (respecting the time after surgery
(e.g., no or less weight, or add support). and possible ACL graft loading) and use this infor-
mation to plan when to implement certain tasks or
Strength – Are they strong enough transition into different phases of rehabilitation. In
to do this task? addition, functional tasks require large force produc-
The ability to perform functional tasks is dependent tion for absorption from the whole kinetic chain. For
on the neuromuscular systems ability to produce example, bilateral landing, treadmill based running

Figure 1. 1a, an easy to utilise and teach model of movement analysis based on three lines in the frontal plane, with a line to
assess trunk stability/ alignment, pelvis stability/alignment and limb stability/alignment. 1b, depicts the sagittal plane view
which is dependent upon the task but a function of ankle to knee and knee to hip alignments.

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 614
and single limb plyometric tasks typically involve the task after attainment of the previous task. These
ground reaction forces of 1-1.5,31 2-332 and 2-631,33,34 can be used to support optimal progression between
times body mass, respectively. So, understanding tasks.
the ability of the lower limbs to produce and accept
force can provide a measure by which the “when” 1. Normal walking gait
a patient may be ready to begin practicing these The first milestone and task target (Figure 2) is typi-
potentially dangerous tasks after ACLR. cally to walk normally after surgery without aids
Assessing knee extensor strength using concentric (e.g., crutches). Following ACLR, a patient cannot
or isometric assessment via the isokinetic dyna- not fully weight bear or walk without crutches for
mometer or recording knee extension loads used in a period of time, often two to four weeks.40 Abnor-
rehabilitation (hand held dynamometry), or using mal gait patterns have been associated with muscle
the leg press 8 or 10 repetition maximum (RM) can weakness,41 decreased functional performance,42
provide an indication of strength and be used to low patient satisfaction with outcome after surgery43
regularly monitor the patients to support task-based and post-operative complications including osteoar-
progressions.16 In addition, although there is limited thritis.44 The abnormal gait patterns often become
research attention, assessing unilateral and/or bilat- further exacerbated when the patient returns to run-
eral squat strength isometrically using force plate ning.28 Thus, re-establishing normal gait early and
analysis could provide an useful objective measure safely after surgery is a key priority.
of work/load distribution to support task-based
Normal or optimal gait biomechanics cannot occur
progressions.35,36
without normal or optimal joint motion45 and so the
Muscle soreness- was the loading too high? restoration of joint range of motion is essential to
After unaccustomed exercise, there may be muscle target the restoration of optimal gait. After ACLR,
soreness referred to as delayed onset of muscle sore- patients should achieve full extension (and control
ness, that occurs following exercise induced muscle in extension) prior to ‘leaving’ the crutches. To be
reaction.37 The degree of muscle reaction depends able to achieve full terminal extension, the ability
on many factors including exercise type, duration, to recruit the quadriceps and maintain active exten-
intensity and habituation to the exercise.38,39 Tasks sion is essential. Quadriceps inhibition can prevent
that are too strenuous will result in significant mus- recovery of quadriceps muscle strength and the safe
cle reaction, which may take substantial time to and expedient progression of rehabilitation.46,47 Per-
recover and may limit the ability to train in the sub- sistent quadriceps lag on single leg raise has been
sequent days. Monitoring the muscle soreness can shown to indicate an inability to actively fully extend
provide an indication of the muscle specific loading the knee. If this is not achieved by week five post
and required recovery time, which can then support ACLR, it would be considered a predisposing fac-
subsequent training modifications. tor for significant quadriceps weakness at 6-months
post-operation.48 Prior to leaving the crutches, it is
SUGGESTED TASK-BASED MOVEMENT suggested to achieve full active knee extension, con-
PROGRESSION FROM THE BEGINNING TO trol of effusion and no ‘joint overload’ (e.g., clinical
THE END – THE 10 TASKS increase of swelling [> 1 cm, at the patella], or pain
Below is presented the 10 tasks, from the beginning [+1 point]) and no quadriceps lag on active straight
to the end of the functional recovery process after leg raise.
ACLR. These tasks are developed based on the load
and movement skill requirements and in line with 2. Bilateral squat
the progressive functional recovery process that is Neitzel et al.49 found some patients after ACLR failed
important after ACLR. Within each task, there are to symmetrically load their legs during squatting up
specific criteria to achieve prior to undertaking the to 12 months post-op and this was related to poor
task. Additionally, each task typically has sub-task functional outcomes. A bilateral squat is a founda-
progressions, which can be used to progress towards tion exercise, involving triple flexion and extension

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 615
Figure 2. The ten tasks progressions after ACLR, 1) walking, 2) bilateral squat, 3) single leg squat, 4) bilateral landing, 5) run-
ning on treadmill, 6) bilateral drop jump, 7) single leg deceleration, 8) single leg drop jump, 9) 90º cut maneuver, 10) sport-specific
change of direction.

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 616
of the lower limbs, while maintaining optimal trunk authors suggest the use of progressions to single leg
control. It provides a framework for developing squat to include: split squat, reverse lunge, walking
compound strength (e.g., squat training) as well as lunge, step up and single leg squat.
serving as the motor patterning for other tasks (e.g.,
bilateral landing, jumping, plyometrics). So, its res- Bilateral landing
toration early after surgery is a priority. Bilateral Bilateral landing represents the first landing task,
squat progressions can begin with squat, wall squat, where the patient leaves the ground in the air and
goblet squat, back squat, front squat and overhead must accept the potentially high ground reactions
squat. These should all initially be performed with- forces with the neuromuscular system, which can
out additional load and then with gradually increas- result from acceleration to the ground due to grav-
ing amounts of load, to aid functional strength ity. Typical forces during bilateral landings can be
development. Considering PFJ loading is impor- around 1.5-2 times body mass31 depending upon the
tant, an initially targeting lower knee flexion angles height of the landing (which represents around one
(< 90º), recommended. Optimal squat technique times body mass per limb delivered at high rates
is a great precursor to single leg progressions (e.g., of loading). Prior to initiating landing tasks on the
split squat). Importantly, there are times where ground, it is also recommended that the athlete
squat activities are limited or when range of motion have attained at least one times body mass (single
may be protected, such as after meniscal repair. limb) and two-times body mass (double limb) for set
of eight repetitions on the leg press. Bilateral land-
Unilateral foundation exercises – ing allows for the training of eccentric control at the
Single leg squat required speed, to prepare for single limb accep-
The single leg squat represents probably the most tance drills (e.g., single leg landing, running). Varia-
functional foundation movement, involving triple tions and progressions include landing from a box,
flexion and extension with optimal control and mini- landing from running on the spot, landing from a
mal support on one leg. Single leg exercises are com- jump. These can also be vertical, horizontal or even
plex movements with lots of degrees of movement rotational. Use of different surfaces can support the
freedom. A single leg squat represents the foun- reduction in peak landing forces, such as use of the
dation movement for progression to many tasks, pool, sand or trampolines or a mat (e.g., synergy
which require acceleration, deceleration and land- mat).
ing on one leg, representing the fundamental move-
ment pattern for all sports type activity. A single leg Running –Run on treadmill
squat also requires supporting and moving full body Running represents a functional task which all peo-
weight. As the single leg squat requires balance and ple should do and is often considered a milestone
control, it is advised to be able to leg press nearly mark for the ACLR patient. It is perhaps the most
100% body weight to have the necessary strength prioritized task and is the foundation for all sport-
to tolerate body weight during the single leg squat. ing type tasks (virtually all sports require you to be
Progressing to single leg squats can be done through able to run). Running is a high load task and requires
various tasks, with increasing complexity and load substantial strength and neuromuscular control.
(e.g. body weight applied to the limb). For example, a Each step taken during running represents weight
split squat is more complex than a bilateral squat and acceptance of around 2-3 times body mass.32 Effec-
requires the pelvis to stabilize in the frontal plane. tive implementation of running can serve as a use-
The split squat will have roughly 60% body weight ful training stimulus for developing strength and
on the front limb and 40% of the back limb. Adding neuromuscular control. Ensuring optimal move-
load to the tasks is advised prior to progressing to the ment quality in the running gait is important before
more complex or higher load task (e.g., adding 20 kg advancing to more high-risk complex sporting type
of load, should add around 12 kg of additional load movements. Assessing running gait training on a
to the training limb, representing around 60 kg or treadmill may allow the clinician to provide feed-
around 75% body weight for an 80 kg athlete). The back (visual or immediate or delayed feedback with

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 617
video recording) cues to support the improvement importance of optimal technique during the tasks
of the athletes running technique.28 Key aspects and re-learning optimal technique prior to progress-
entail normalization the range of motion of joints ing to more challenging tasks. Again, it is vital to rec-
of the involved and uninvolved limbs which can ognize many of the measurable parameters will not
be examined via video recording. Further analysis normalize during the first year following an ACLR.50
of stride length, contact times and force absorption
by force plate embedded treadmills can facilitate Unilateral landing/ deceleration –Single
more in-depth analysis and support optimal progres- leg deceleration
sions. Pain free symmetrical gait at near maximal ACL injuries typically occur during deceleration and
sprint speeds should be a key aim of gait retrain- landing tasks, and these movements represent a dan-
ing (this occurs towards end-stage rehabilitation). gerous progression for the ACLR patient. They are
Optimal gait at slower running speed (8 km.h-1) is also psychologically challenging for the patient due
requisite for progression to unilateral deceleration to their nature. The ability to absorb forces eccentri-
and landing training. It is essential that treadmill cally and dissipate these via the neuromuscular sys-
mechanics be restored prior to progression to out- tem is an essential aspect of functional performance.
door running or agility drills. It is important to note Single leg landing and deceleration tasks represent a
that many measurable parameters of function do transition to loading of 2-3 times body mass on each
not normalize during the initial year following an limb.59 As such, prior to initiating single leg landing
ACL reconstruction.50 tasks on the ground, it is recommended that the ath-
lete restore knee extension strength to within 20%
Bilateral plyometrics – Bilateral drop jump of the contralateral limb (e.g., 80% LSI, assessed via
Lower extremity plyometric exercises are com- isokinetic or hand-held dynamometry) and have
monly used by athletes to develop explosive speed, attained good single leg strength. It is advised the
strength, and power. They involve a stretch-short- patient attain the ability to push 1.5 times body mass
ening cycle, where eccentric muscle contraction is (or 2 times body mass for eccentric strength) in the
quickly followed by concentric contraction of the single leg press exercise prior to progressing to single
same muscle (or muscles). During the eccentric limb decelerations for optimal progression. Following
phase (pre-stretch), the musculotendinous unit is the attainment/ practice of landing control drills it is
stretched, which stores elastic energy, and the mus- important to practice these movements during more
cle spindles activate the stretch reflex. Plyometric natural deceleration tasks from running. Initially,
training has been reported to be superior to more single leg landings/decelerations should be practiced
traditional resistance training for development of on a surface which absorbs forces (e.g., mats, trampo-
explosive lower limb performance51,52 and can con- lines, sand) to reduce potentially high impact forces,
tribute to improvements in lower limb strength and with a progressive increase in height (e.g., 20, 30 and
power, increased joint awareness, and overall pro- then 40 cm landings from step) or gradually progres-
prioception.51,53-55 Performance of high-intensity ply- sive speeds prior to initiating deceleration actions.
ometric exercise often produces muscle damage, due The focus task for progression to the subsequent task,
mainly to the eccentric component of the muscle should be optimal control and kinematics in a single
action, and excessive joint loading (ligament, joint limb deceleration from straight line run.
structures, tendon), which could result in injury.56
Typical impact forces during plyometric exercise Unilateral plyometrics –Single leg drop jump
when performed on land is between 2-6 times body Sporting movements that include change of direc-
mass.31,33,34 Performance in the bilateral drop vertical tion mimic the nature of unilateral plyometrics. Ply-
jump, specifically control of dynamic knee valgus ometric drills can improve neuromuscular control
has been shown to be associated with ACL injury/ in athletes, which can become a learned skill that
re-injury risk.5 High knee abduction moments seen in transfers to sporting competitive movements.60 It is
adolescents during drop jump57 are not seen in more important to progress from uni-planar to multi-planar
elite older/ established athletes.58 This indicates the plyometrics as a progression and foundation for the

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 618
practice of sport-specific tasks. It is recommended sport-specific scenarios. This includes a gradual pro-
that satisfactory movement quality be achieved in gression to more challenging tasks at higher speeds,
the unilateral drop jump, with optimal force absorp- to high speed reactive multi-directional tasks and
tion prior to progression to rotational plyometrics then sport-specific tasks with more challenging
or change of direction tasks. Unilateral plyometrics visual-motor requirements (e.g., greater number
have typical landing forces between 2-6 times body of choices).61,63 Reactive movements can challenge
mass.31,34 Thus, representing a potentially dangerous movement quality and increase knee loads more
activity for both possible injury and/ or joint over- than planned movements.62 Thus, delaying reactive
load. The eccentric nature can also result in high movement training until the athlete has achieved
levels of muscle soreness, as such careful monitor- safe movement quality in pre-planned tasks, and
ing and implementation is needed. restoring and confirming safe movement quality in
reactive movements prior to RTS, are crucial aspects
Change of direction ability/coordination – 90º of movement based re-training process. Injuries to
cut maneuver the ACL typically occur in sporting activity, involv-
Regaining symmetry in high load sporting tasks may ing complex stimuli and an external focus of atten-
be associated with lower re-injury risk.6,7 Multidirec- tion.64 It is important to transition from the conscious
tional movements and higher movement speeds controlled movements with limited external distrac-
place greater load on the knee, so it is important tion and pre-planned nature to the highly chaotic
to gradually increase movement speeds61 and com- and reactive nature of movement requirements in
plexity.62,63 Knee abduction loads in side-step cutting
are five times greater in handball elite players than
the knee abduction loads in drop vertical jumps.58
Beginning with simple movements and short angle
changes is encouraged to limit the loading on the
knee. Furthermore, learning the technique with a
slow change of directions (e.g., two movements,
with a slight pause in between movements) can
allow safe introduction and training. Coaching the
discrete movement (e.g., step-cut), training coordi-
nation and technique with a single or two steps into
the movement (as such with lower approach speeds
and body momentum to deceleration), prior to then
gradually increasing the speed running speeds prior
to cutting, once the optimal technique has been prac-
ticed and learnt is recommended. Optimal control
in a 90º cut maneuver (Figure 2) is recommended
before transitioning to sport-specific (reactive, con-
tact, skills training) movement training.

Sport-specific movements – Movement

control under sport specific change
of direction
Training neuromuscular control in sport-specific
movements and during skill-based training ses-
Figure 3. Perturbation training on the field to prepare an
sions helps the athlete prepare for safe participa-
athlete for contact upon return to play. The athlete must aim
tion in sports like soccer. To do this, a program of to maintain optimal control and kinematics as well as ball
progressive sport-specific movements must be cre- contact with contact using swiss ball or another devise, such
ated, supporting transfer of movement patterns into as player-to-player contact.

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 619
sporting activity.65 Evidence suggests that an exter- appreciate the role and importance of perception/
nal focus of attention with movement training cognition in movement and ensure this process is
results in superior retention of tasks.66 Ecological trained in the movement specific drills. The pro-
dynamics states that skilled performance arises from gram entails gradually exposing newly acquired
performer-environment interaction. It is essential to movement patterns to sport-specific situations

Table 1. Ten task progressions after ACL reconstruction, with the specific tasks, exercise
group and the required strength and knee range of motion to allow unrestricted practice of the
tasks. Strength is measured with isometric or isokinetic knee extension and leg press and/or
squat strength testing. Squat strength reported is the force expressed as a percentage of body
mass measured isometrically with force plate and isometric testing rig and not the additional
load lifted during free weight squat.

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 620
with increasing complexity, decision making (e.g., 6. Paterno MV, Schmitt LC, Ford KR, et al.
choices) and environmental stimuli to support the Biomechanical measures during landing and
transfer and preparation for application of their postural stability predict second anterior cruciate
ligament after anterior cruciate ligament
motor skills in their sport-environment. In addition, reconstruction and return to sport. Am J Sports Med.
incorporating perturbation/ contact training (Figure 2010;38(10):1968-78.
3) is important to prepare for team sports such as
7. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett
soccer which involve player to player contact. TE. Incidence of second ACL injuries 2 years after
primary ACL reconstruction and return to sport. Am
SUMMARY J Sports Med. 2014;42(7):1567-73.
Establishing clear task-based progressions can pro- 8. Dhillon MS, Kamal B, Sharad P. Differences among
vide structure to a rehabilitation approach and give mechanoreceptors in healthy anterior cruciate
autonomy and motivation to a patient after ACLR. ligaments and their clinical importance. Muscles
This clinical commentary presents 10 task-based pro- Ligaments Tendons J. 2012;2(1):38-43.
gression which can be used by clinicians for their 9. Decker MJ, Torry MR, Noonan TJ, Riviere A, Sterett
patients who intend to return to sporting activity after WI. Landing adaptations after ACL reconstruction.
Med Sci Sports Exerc. 2002;34(9):1408-13.
ACLR. Progression through a task and between tasks
is based on respecting the joint, strength, movement 10. de Fontenay BP, Argaud S, Blache Y, Monteil K.
quality and muscle soreness. Many aspects of func- Motion alterations after anterior cruciate ligament
reconstruction: comparison of the injured and
tion do not typically normalize within the first year uninjured lower limbs during a single-legged jump. J
after ACLR and stronger attention to achieving opti- Athl Train. 2014;49(3):311-6.
mal and symmetrical movement quality is needed.
11. Goerger BM, Marshall SW, Beutler AI. Anterior
The presented task-based framework is evidence cruciate ligament injury alters preinjury lower
informed and based on applying theory into practice. extremity biomechanics in the injured and uninjured
leg: the JUMP-ACL study. Br J Sports Med.
REFERENCES 2015;49:188-95.
1. Ardern CL, Webster KE, Taylor NF, et al. Return to 12. Lee SP, Chow JW, Tillman MD. Persons with
pre-injury level of competitive sport after anterior reconstructed ACL exhibit altered knee mechanics
cruciate ligament reconstruction surgery: two-thirds during high speed maneuvers. Int J Sports Med.
of patients have not returned by 12 months after 2014;35(6):528-33.
surgery. Am J Sports Med. 2011;39:538-43. 13. Paterno MV, Ford KR, Myer GD, Heyl R, Hewett TE.
2. Webster KE, Santamaria LJ, McClelland JA, Fellar Limb asymmetries in landing and jumping 2 years
JA. Effect of fatigue on landing biomechanics after following anterior cruciate ligament reconstruction.
anterior cruciate ligament reconstruction surgery. Clin J Sports Med. 2007;17(4):258-62.
Med Sci Sports Exerc. 2012;44(5):910-6. 14. Sterns KM, Pollard CD. Abnormal frontal plane knee
3. Wiggins AJ, Granhi RK, Schneider DK, et al. Risk of mechanics during sidestep cutting in female soccer
secondary injury in younger athletes after anterior athletes after anterior cruciate ligament
cruciate ligament reconstruction: a systematic reconstruction and return to sport. Am J Sports Med.
review and meta-analysis. Am J Sports Med. 2013;41(4):918-23.
2016;44(7):1861-76. 15. Dingenen B, Gokeler A. Optimization of the return-
4. Culvenor AG, Patterson BE, Guermazi A, et al. to-sport paradigm after anterior cruciate ligament
Accelerated return to sport after anterior cruciate reconstruction: a critical step back to move forward.
ligament reconstruction and early knee Sports Med. 2017;47:1487-1500.
osteoarthritis features at 1 year: an exploratory 16. Herrington L, Myer G, Horsley I. Task-based
study. PM R. 2018;10(4):349-56. rehabilitation protocol for elite athletes following
anterior cruciate ligament reconstruction: a clinical
5. Hewett T, Myer G, Ford K, et al. Biomechanical
commentary. Phys Ther Sport. 2013;14(4):188-98.
measures of neuromuscular control and valgus
loading of the knee predict anterior cruciate 17. Rambaud AJM, Ardern CL, Thoreux P, et al. Criteria
ligament injury risk in female athletes a for return to running after anterior cruciate ligament
prospective study. Am J Sports Med. 2005;33: reconstruction: a scoping review. Br J Sports Med.
492-501. 2018;52(22):1437-44.

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 621
18. Claes S, Verdonk P, Forsyth R, Bellemans, J. The 31. Cleather D, Goodwin J, Bull A. Hip and knee joint
“ligamentization” process in anterior cruciate loading during vertical jumping and push jerking.
ligament reconstruction: what happens to the Clin Biomech. 2013;28:98-103.
human graft? A systematic review of the literature. 32. Cavanagh PR, Lafortune MA. Ground reaction forces
Am J Sports Med. 2011;39:2476-83. in distance running. J Biomech. 1980;13:397-406.
19. Woo S, Abramowitch S, Kilger R, Liang R. 33. Colado JC, Garcia-Masso X, Gonzalez L-M, et al.
Biomechanics of knee ligaments: injury, healing and Two-leg squat jumps in water: an effective
repair. J Biomech. 2006;39:1-20. alternative to dry land jumps. Int J Sports Med.
20. Hewett TE, Ford KR, Hoogenboom BJ, Myer GD. 2010;31:118-22.
Understanding and preventing ACL injuries: Current 34. Donoghue OA, Shimojo H, Takagi H. Impact forces
biomechanical and epidemiologic considerations – of plyometric exercises performed on land and in
Update 2010. N Am J Sports Phys Ther. 2010;5:234-51. water. Sports Health. 2011;3:303-9.
21. Glasgow P, Phillips N, Bleakley C. Optimal loading: 35. Nuzzo J, McBride J, Cormie P, McCauley G.
key variables and mechanisms. Br J Sports Med. Relationship between countermovement jump
2015;49:278-9. performance and multijoint isometric and dynamic
22. Laughlin WA, Weinhandl JT, Kernozek TW, et al. The tests of strength. J Strength Cond Res. 2008; 22(3):
effects of single-leg landing technique on ACL 669-707.
loading. J Biomech. 2011;44(10):1845-51. 36. Spiteri T, Cochrane JL, Hart NH, Haff GG, Nimphius
S. Effect of strength on plant foot kinetics and
23. Chandrashekar N, Mansouri H, Slauterbeck J,
kinematics during a change of direction task. Eur J
Hashemi J. Sex-based differences in the tensile
Sport Sci. 2013;13(6):646-52.
properties of the human anterior cruciate ligament.
J Biomech. 2006;39(16):2943-50. 37. Cleak MJ, Eston RG. Muscle soreness, swelling,
stiffness and strength loss after intense eccentric
24. Mokhtarzadeh H, Ng A, Teow CH, et al. Restrained exercise. Br J Sport Med. 1992;26:267–71.
tibial rotation may prevent ACL injury during
landing at different flexion angles. Knee. 38. Connolly DAJ, Sayers SP, McHugh MP. Treatment
2015;22(1):24-29. and prevention of delayed onset muscle soreness.
J Strength Cond Res. 2003;17:197–208.
25. Culvenor AG, Collins NJ, Vicenzino B, et al.
39. Tee JC, Bosch AN, Lambert MI. Metabolic
Predictors and effects of patellofemoral pain
consequences of exercise-induced muscle damage.
following hamstring-tendon ACL reconstruction. J Sci
Sports Med. 2007;37:827–36.
Med Sport. 2016;19:518-23.
40. Della Villa S, Boldrini L, Ricci M, et al. Clinical
26. Culvenor AG, Øiestad BE, Holm I, et al. Anterior
outcomes and return-to-sports participation of 50
knee pain following anterior cruciate ligament
soccer players after anterior cruciate ligament
reconstruction does not increase the risk of
reconstruction through a sport-specific rehabilitation
patellofemoral osteoarthritis at 15- and
protocol. Sports Health. 2012;4:17-24.
20-year follow-ups. Osteoarthritis
Cartilage. 2017;25:30-3. 41. Bush-Joseph C, Hurwitz D, Patel R, et al. Dynamic
function after anterior cruciate ligament
27. Feller JA, Webster KE. A randomized comparison of reconstruction with autologous patella tendon. Am J
patellar tendon and hamstring 300 tendon anterior Sports Med. 2001;29:36-41.
cruciate ligament reconstruction. Am J Sports Med.
42. Decker M, Torry M, Noonan T, Sterett W, Steadman
2003;31:564-73.
J. Gait re-training after anterior cruciate ligament
28. Myer G, Brent J, Ford K, Hewett T. A pilot study to reconstruction. Arch Phys Med Rehabil. 2004;85:
determine the effect of trunk and hip focused 848-56.
neuromuscular training on hip and knee isokinetic
43. Kocher M, Steadman J, Briggs K, Sterett W, Hawkins
strength Br J Sports Med. 2008;42:614-9.
R. Relationship between objective assessment of
29. Siff M. Biomechanical foundations of strength and ligament stability and subjective assessment of
power training. In Zatsiorsky V (Ed) Biomechanics in symptoms and function after anterior cruciate
Sports; Blackwell Sci Ltd. 2001:103-39. ligament reconstruction. Am J Sports Med.
30. Palmieri-Smith RM, Lepley LK. Quadriceps strength 2004;32:629-34.
asymmetry following ACL reconstruction alters knee 44. Dye S, Staubli H, Biedert R, Vaupel G. The mosaic of
joint biomechanics and functional performance at pathophysiology causing patellofemoral pain:
time of return to activity. Am J Sports Med. therapeutic implications. Oper Tech Sports Med.
2015;43:1662-9. 1999;7:46-54.

The International Journal of Sports Physical Therapy | Volume 15, Number 4 | August 2020 | Page 622
45. Clark NC. The role of physiotherapy in rehabilitation 57. Hewett TE, Myer GD, Ford KR, et al. Biomechanical
of soft tissue injuries of the knee. Orthop Trauma. measures of neuromuscular control and valgus
2015;29:48–56. loading of the knee predict anterior cruciate
46. Hopkins JT, Ingersoll CD, Edwards JE, et al. ligament injury risk in female athletes: a prospective
Cryotherapy and TENS decrease arthrogenic muscle study. Am J Sports Med. 2005;33(4):492-501.
inhibition of the vastus medialis following knee joint 58. Kristianslund E, Krosshaug T. Comparison of drop
effusion. J Athl Train. 2002;37:25-32. jumps and sport-specific sidestep cutting:
47. Lynch A, Logerstedt D, Axe M, Snyder-Mackler L. implications for anterior cruciate ligament injury
Quadriceps activation failure after anterior cruciate risk screening. Am J Sports Med. 2013;41(3):684-8.
ligament rupture is not mediated by knee joint doi: 10.1177/0363546512472043.
effusion. J Orthop Sports Phys Ther. 2012;42:502–10. 59. Norcross MF, Lewek MD, Padua DA, et al. Lower
48. Potter H, Foo L, Magnetic reasonance imaging of extremity energy absorption and biomechanics
joint arthroplasty. Orthop Clin North Am. 2006; during landing, part I: sagittal-plane energy
37:361-73. absorption analyses. J Athl Train. 2013;48(6):748-56.
doi: 10.4085/1062-6050-48.4.09.
49. Neitzel J, Kernozek T, Davies G. Loading response
following anterior cruciate ligament reconstruction 60. Myer G, Ford K, McLean SG, et al. The effects of
during the parallel squat exercise. Clin Biomech. plyometric versus dynamic stabilization and balance
2002;17:551-4. training on lower extremity biomechanics. Am J
Sports Med. 2006;34:445-55.
50. Agarwalla A, Puzzitiello RN, Liu JN, et al. Timeline
for maximal subjective outcome improvement after 61. Vanrenterghem J, Venables E, Pataky T, Robinson
anterior cruciate ligament reconstruction. Am J MA. The effect of running speed on knee
Sports Med. 2019;47(10):2501-9. mechanical loading in females during side cutting.
J Biomech. 2012; 45(14):2444-9.
51. Miller M, Berry C, Bullard S, Gilders R. Comparison
of land-based and aquatic-based plyometric 62. Besier TF, Lloyd DG, Ackland TR, et al. Anticipatory
programmes during 8-week training period. J Sport effects on knee joint loading during running and
Rehabil. 2002;11:268-83. cutting maneuvers. Med Sci Sports Exerc.
2001;33(7):1176–81.
52. Potteiger JA, Lockwood RH, Haub MD, et al. Muscle
power and fiber characteristics following 8 weeks of 63. Wolpert DM, Diedrichsen J, Flanagan JR. Principles
plyometric training. J Strength Cond Res. 1999;13: of sensorimotor learning. Nat Rev Neurosci.
275–9. 2011;12:739–51. doi: 10.1038/nrn3112.
53. Fatouros IG, Jamurtas AZ, Aggelousis N, et al. 64. Waldén M, Krosshaug T, Bjorneboe J, et al. Three
Evaluation of plyometric exercise training, weight distinct mechanisms predominate in non-contact
training, and their combination on vertical jumping anterior cruciate ligament injuries in male
performance and leg strength. J Strength Cond Res. professional football players: a systematic video
2000;14:470–6. analysis of 39 cases. Br J Sports Med. 2015;49:1452-60
54. Martel GF, HarmerML, Logan JM Parker CB. Aquatic 65. Buckthorpe M, Della Villa F, Della Villa S, Roi GS.
plyometric training increases vertical jump in On-field rehabilitation – Part 2: A 5-stage program for
female volleyball players. Med Sci Sport Exerc. the soccer player focused on: linear movements,
2005;37:1814-9. multidirectional movements, soccer-specific skills,
soccer-specific movements, and modified practice.
55. Robinson LE, Devor ST, Merrick MA, et al. The
J Orthop Sports Phys Ther. 2019; 49(8):570-5.
effects of land vs aquatic plyometrics on power,
torque, velocity, and muscle soreness in women. 66. Gokeler A, Benjaminse A, Welling W, et al. The
J Strength Cond Res. 2004;18:84-91. effects of attentional focus on jump performance
and knee joint kinematics in patients after ACL
56. LaStayo PC, Woolf JM, Lewek MD, et al. Eccentric
reconstruction. Phys Ther Sport. 2015;16:114-120.
muscle contractions: their contribution to injury,
prevention, rehabilitation, and sport. J Orthop Sports
Phys Ther. 2003;33:557-71.

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