Prehabilitation Before Anterior Cruciate Ligament Reconstruction

Introduction

Prehabilitation was coined in the 1980s, defined as the process enhancing functional capacity of the individual to enable them to withstand the stressor of inactivity . Although not initially used in the setting of anterior cruciate ligament (ACL) injury rehabilitation, its significance has been kindled when medium- and long-term studies showed significant decrease in functional, strength, and proprioceptive capabilities in the ACL-deficient knee. Noyes et al. was the first to propose the use of physiotherapy prior to ACL surgery, but relatively few studies have assessed the role of prehabilitation prior to ACL reconstruction (ACLR).

Lower limb weakness is prevalent in the knee extensors, knee flexors, and ankle plantarflexion in the ACL-injured patient and following ACLR. There is also evidence of hip flexor deficits post-ACLR. Quadriceps and hamstring deficits of 5%–40% and 9%–27%, respectively, in the injured limb with 21% and 14%, respectively, in the uninjured limb have been reported. This can persist post-ACLR at 3–6 years, which can be due to neuroplastic and neuromuscular effects. However, preoperative quadriceps strength is an important predictor of functional outcome following ACLR. Causes of quadriceps weakness after ACL injury would include decreased level of physical activity, reduced weight-bearing status, and immobilization. Factors such as decreased protein synthesis, increased plasma cortisol levels, arthrogenic inhibition, and altered afferent inflow may be the cause of atrophy following ACL injury and muscular disuse. Although regimens vary among surgeons, prehabilitation with targeted resistance and neuromuscular training may be useful following ACL injury and prior to ACLR.