Functional rehabilitation strategies for enhancing neuromuscular control after ACL reconstruction: A systematic review.

BACKGROUND

Arthrogenic muscle inhibition (AMI) and altered neuromuscular control commonly arise after anterior cruciate ligament (ACL) injury and may persist both preoperatively and after anterior cruciate ligament reconstruction (ACLR), potentially impairing functional recovery.

OBJECTIVE

To synthesise randomised controlled trial (RCT) evidence on functional rehabilitation interventions targeting neuromuscular control after ACLR, using electromyography (EMG)-derived outcomes.

METHODS

PubMed, Cochrane Library, Embase, CINAHL, Web of Science, and SPORTDiscus were searched from January 1, 2015, to December 4, 2025; duplicates were removed ( n = 63 ). RCTs involving individuals undergoing ACLR (pre-operative) and/or following ACLR (post-operative) were included if they reported EMG-derived neuromuscular outcomes following functional rehabilitation. Due to heterogeneity in interventions, EMG normalisation, and outcome definitions, a structured narrative synthesis was performed.

RESULTS

Nine RCTs (total n = 263 ) were included. One trial examined preoperative blood flow restriction training (BFRT) preconditioning (5 sessions over 8 days before surgery), whereas the remaining interventions were delivered postoperatively. Jump training reduced quadriceps-hamstring co-contraction by 50% ( p < 0 . 001 ). Preoperative BFRT preserved quadriceps endurance at 4 weeks post-ACLR compared with sham (sham reduction: 97 ± 85 s) and increased root mean square (RMS) EMG amplitude by 54 ± 58 % at week 4. Aquatic proprioceptive training improved muscle activation similarity and magnitude ( p < 0 . 01 ). Sand-based training and cross-education interventions increased EMG activity during gait phases ( p < 0 . 05 ). Vibration therapy and postoperative BFRT produced mixed or non-significant effects. Evidence for several intervention types was limited to single trials and should be interpreted cautiously.

CONCLUSION

Functional rehabilitation strategies show limited but promising potential to improve neuromuscular outcomes following ACLR. Phase-specific approaches may be appropriate: early-phase interventions (e.g., BFRT preconditioning, vibration therapy, and cross-education) may help mitigate AMI and preserve neuromuscular capacity, whereas later-phase strategies (e.g., plyometrics and aquatic proprioceptive training) may support movement quality and motor control. Future RCTs should prioritise standardised EMG methodology and clinically meaningful endpoints (e.g., return-to-sport and reinjury).