Which therapy program is best after ACL repair?

Q: I've been going to a rehab facility for training after having an ACL repair on my left knee six weeks ago. I'm very eager to get back into full sports participation (I'm on the volley ball team and cross country in college). I notice my therapist does an entirely different program with me than the other therapist in the clinic does with her patients. I'm wondering if I'm in the better group -- or if the other type of therapy would advance me faster. How do I go about finding out?

A: Despite more than 30 years of anterior cruciate ligament (ACL) repairs, therapists still haven't nailed down the best way to go about rehabilitating this injury. Traditional strength training programs have used resistive exercises to help patients regain motion, strength, and function.

But studies showed that there was something missing. Knee stability isn't always fine-tuned enough with this approach to get athletes back into action safely and without worry that the knee is going to give way underneath them.

So, a new approach was developed called neuromuscular exercise. This approach helps retrain the joint and all of the sensory and motor mechanisms needed to make sudden starts and stops and quick turns without buckling or otherwise slowing the athlete down.

You may be seeing the difference between these two types of programs. Some therapists are shifting from the traditional strength training more toward the neuromuscular approach. But there's some evidence that perhaps each of these treatment protocols contributes positive benefits to athletes post-ACL reconstruction.

It appears that the neuromuscular program has the most benefit in the first year after surgery. Patients receiving therapy with this emphasis have better overall knee function and less pain compared with the strength-training exercise. The strength-training program is more effective in improving knee flexion muscle strength after two years. It really looks like both exercise approaches contribute something a little different at different times in the recovery process. It may be that both should be used together for the best total results.

Mention your observations and questions to your therapist. It's possible the other patients you are seeing have a slightly different diagnosis than you do, which could explain the differences in treatment approaches. Or there may be some other explanation. There's never anything wrong with letting your therapist know your interest in progressing ahead as quickly as possible. You may or may not be a candidate for the other treatment approach -- the only way you'll find out is to ask!

May Arna Risberg, PT, PhD, and Inger Holm, PT, PhD. The Long-Term Effect of 2 Postoperative Rehabilitation Programs After Anterior Cruciate Ligament Reconstruction. In The American Journal of Sports Medicine. October 2009. Vol. 37. No. 10. Pp. 1958-1966.