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Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: 20 March 2026 | Viewed by 12970

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Dr. Young-Jin Seo

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Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
Interests: orthopedic surgery; anterior cruciate ligament reconstruction; osteotomy; knee; bone graft

Special Issue Information

Dear Colleagues,

Anterior cruciate ligament (ACL) injuries remain a prevalent challenge, particularly in athletic populations. Advances in clinical treatment and rehabilitation have transformed outcomes, but challenges persist. ACL reconstruction has seen significant technical evolution, emphasizing precision, durability, and optimized recovery. Innovations like lateral extra-articular procedures, all-inside techniques, internal bracing, slope reducing osteotomy, and biologic augmentation promise to enhance healing, graft integration, and biomechanical stability.

Rehabilitation plays a critical role in recovery and long-term success. A growing focus on injury prevention through neuromuscular training programs has demonstrated efficacy in reducing ACL injury rates, particularly in young athletes. However, addressing psychological readiness, particularly fear of reinjury, remains a vital yet underexplored dimension of recovery.

A multidisciplinary approach, combining surgical, rehabilitative, and preventive strategies, is essential for optimizing outcomes and reducing the long-term burden of ACL injuries.

This Special Issue aims to provide a thorough exploration of the challenges and advancements in clinical treatment and rehabilitation for ACL injuries. By featuring contributions from experts, it emphasizes clinical progress and long-term recovery outcomes, offering valuable knowledge to advance both research and practice.

Dr. Young-Jin Seo
Guest Editor

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Keywords

anterior cruciate ligament (ACL)
reconstruction
lateral extra-articular procedures
all-inside technique
internal bracing
slope reducing osteotomy
biologic augmentation
rehabilitation

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Published Papers (9 papers)

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Research

Jump to: Review, Other

11 pages, 1177 KB

Open AccessArticle

Short-Term Outcome of Combined Anterior Cruciate Ligament Reconstruction and Anterolateral Ligament Reconstruction with Suture Tape Augmentation

by Chieh-An Chuang, You-Hung Cheng, Cheng-Pang Yang, Chen-Heng Hsu, Chung-Yu Chen, Yi-Hsuan Lin and Huan Sheu

J. Clin. Med. 2025, 14(23), 8283; https://doi.org/10.3390/jcm14238283 - 21 Nov 2025

Viewed by 419

Abstract

Background: Persistent rotational instability and graft failure remain major challenges following anterior cruciate ligament reconstruction (ACLR). The addition of anterolateral ligament reconstruction (ALLR) and suture tape augmentation may enhance graft protection and early stability. This study aimed to assess the short-term clinical outcomes of combined ACLR and ALLR with suture tape augmentation, hypothesizing that this technique would yield favorable results in patients with ACL injury. Methods: Twenty-four patients (16 males, 8 females; mean age 30.8 years) with high grade pivot shift who underwent combined ACLR and ALLR with suture tape augmentation between 2022 and 2024 were retrospectively reviewed. Objective assessments included pivot-shift grading and anterior tibial translation (ATT) using a GNRB arthrometer. Patient-reported outcome measures (PROMs) comprised the International Knee Documentation Committee (IKDC), Marx activity score, and Single Assessment Numeric Evaluation (SANE) scores. Subgroup analysis compared graft diameters < 8 mm versus ≥8 mm. Results: The mean follow-up period was 23.4 months. Significant improvements were observed postoperatively in IKDC (45.9→83.7), Marx (4.4→9.9), SANE (49.2→85.2), and ATT (4.7→1.1 mm) (all p < 0.001). Full range of motion was regained at a mean of 3.2 months. Twenty-one patients presented no pivot shift and three with grade one postoperatively. No significant differences were found between the small (<8 mm) and large (≥8 mm) graft groups. MRI at one year showed intact grafts without adverse reactions. Conclusions: Combined ACL and anterolateral ligament reconstruction with suture tape augmentation demonstrated promising short-term stability and functional recovery without significant complications. This technique may enhance biomechanical reinforcement of both ACL and ALL grafts and represents a viable option for patients with smaller graft diameters. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

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13 pages, 1507 KB

Open AccessArticle

Can PRP Enhance Hamstring Recovery Post-ACL Reconstruction? Retrospective Insights from Non-Professional Athletes

by Roxana Mihaela Munteanu, Andrei Marian Feier, Bogdan Voicu, Arpad Solyom, Pia Simona Făgăraș and Tudor Sorin Pop

J. Clin. Med. 2025, 14(23), 8266; https://doi.org/10.3390/jcm14238266 - 21 Nov 2025

Viewed by 357

Abstract

Background and Objectives: Hamstring strength deficits are common after ACL reconstruction and may impair stability and increase reinjury risk. Despite structured rehabilitation, early postoperative asymmetries frequently persist. Platelet-rich plasma (PRP) has emerged as a potential biologic adjunct that may enhance tissue healing and facilitate muscle strength recovery. This study aimed to evaluate the efficacy of intra-articular PRP injections on hamstring strength restoration in non-professional athletes undergoing ACLR. Materials and Methods: This retrospective cohort study analyzed 68 non-professional athletes who underwent primary ACLR between 2020 and 2024. Participants followed a standardized, phase-appropriate rehabilitation program and were allocated to either a PRP group (n = 34; five intra-articular PRP injections every 4 weeks starting at week 4 postoperatively) or a control group (n = 34; rehabilitation alone). Data were analyzed with linear mixed-effects models to examine group, time, and group-by-time interactions. Results: Both groups improved over time, but PRP influenced faster hamstring strength recovery and greater symmetry. At 20 weeks, the PRP group achieved higher concentric strength (15.6 ± 4.3 vs. 13.6 ± 3.5; p = 0.040) and markedly reduced asymmetry (isometric: –1.1 vs. 0.6; p < 0.001; concentric: –0.6 vs. 1.9; p < 0.001). Conclusions: The addition of serial PRP injections to a structured rehabilitation protocol after ACLR influenced faster hamstring strength recovery and improved interlimb symmetry compared to rehabilitation alone. These findings suggest that PRP may serve as a potential biologic adjunct to optimize postoperative outcomes and facilitate a safer return to sport in non-professional athletes. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

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17 pages, 265 KB

Open AccessArticle

“Returning to Sport Is Not Just About the Knee”: Physiotherapists’ Experiences of the Management of Anterior Cruciate Ligament Injury: A Qualitative Study

by Sultan A. Alanazi, Samia A. Alamrani, Sarah S. Bajuaifer, Layan Alhammad, Nouf Alotaibi, Naif Z. Alrashdi, Msaad Alzhrani, Ahmad D. Alanazi, Ahmed M. Almansour, Abdulmajeed Alfayyadh and Aqeel M. Alenazi

J. Clin. Med. 2025, 14(20), 7301; https://doi.org/10.3390/jcm14207301 - 16 Oct 2025

Viewed by 1468

Abstract

Objectives: To explore sport physiotherapists’ perspectives and experiences on the management of anterior cruciate ligament (ACL) injuries in Saudi Arabia and to understand the key challenges that influence rehabilitation practice. Methods: A qualitative semi-structured interviews were conducted with sport physiotherapists recruited from different regions and clinical settings (Public, private and sport clubs) in Saudi Arabia. Eligibility criteria included ≥2 years’ post-qualification experience in ACL injuries management. Interviews were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis. A total of twenty-six sport physiotherapists (18 males; mean age 31 years, range 26–39) participated, including 13 working primarily as clinicians and 13 with combined clinical and research roles. Results: Five themes were identified: (1) disruptions of ACL injury in daily life and sport; (2) managing fear of re-injury and uncertainty in surgical vs. conservative care; (3) guiding rehabilitation through challenges of workload, progression, adherence and supportive tools; (4) variability in protocols, assessment tools, and available resources; and (5) returning to sport is more than just passing a test. These themes demonstrate that ACL injuries rehabilitation in Saudi Arabia is shaped by physical and psychological readiness, cultural expectations, and disparities in resources. Conclusions: Physiotherapists described ACL rehabilitation as a long-term process that needs an integration of physical, psychological, and contextual factors. This study’s findings highlight the need for resource-sensitive, standardized guidelines and the inclusion of psychological readiness assessments within rehabilitation processes. This study provides context-specific evidence that can be used to inform the development of culturally responsive, evidence-based approaches to strengthen ACL rehabilitation in Saudi Arabia. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

15 pages, 1166 KB

Open AccessArticle

Early Open Kinetic Chain Hamstring Exercise After ACL Reconstruction: A Retrospective Safety and Efficacy Study

by Roberto Ricupito, Rosalba Castellucci, Filippo Maselli, Marco Bravi, Fabio Santacaterina, Riccardo Guarise and Florian Forelli

J. Clin. Med. 2025, 14(19), 6871; https://doi.org/10.3390/jcm14196871 - 28 Sep 2025

Viewed by 2995

Abstract

Background: Hamstring tendon autografts are frequently used for anterior cruciate ligament reconstruction (ACLR), but they are associated with persistent hamstring strength deficits and delayed functional recovery. Current rehabilitation guidelines often delay open kinetic chain (OKC) hamstring exercises due to safety concerns, despite the limited supporting evidence. This uncontrolled, underpowered, and exploratory study aimed to evaluate the safety and effectiveness of introducing OKC hamstring strengthening exercises as early as three weeks after ACLR. Methods: An exploratory retrospective observational study was conducted at a single physiotherapy center on 13 patients (aged 18–35) who underwent primary ACLR with semitendinosus–gracilis grafts. Participants followed a standardized rehabilitation program including isometric leg curls at 60° and 90° knee flexion and long-lever glute bridges twice weekly, starting from postoperative week 3. Safety was assessed through predefined “safety flags” (pain > 4/10, hematoma, clinical hamstring strain). Strength outcomes, including isometric knee flexion strength at 60° and 90°, limb symmetry index (LSI), and endurance tests, were assessed at 6 and 12 weeks. Results: All participants completed the program without major adverse events. Pain remained consistently low (median 2.5/10), with only one transient episode exceeding the threshold. No other complications were recorded. Isometric knee flexion strength significantly improved between week 6 and week 12 at both 60° (p = 0.018) and 90° (p = 0.003), with large effect sizes. LSI at 90° also increased significantly (p = 0.006), whereas improvements at 60° did not reach significance. Endurance testing showed functional gains as early as 6 weeks. Conclusions: The early introduction of OKC hamstring strengthening exercises three weeks after ACLR with hamstring autografts appears safe and promotes clinically meaningful improvements in strength and endurance. These findings, while from a small uncontrolled study, challenge conservative rehabilitation protocols and support the reconsideration of early hamstring loading. Given the retrospective, uncontrolled, and underpowered design, these findings are hypothesis-generating and not generalizable beyond young adults with hamstring autografts; larger randomized trials are required. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

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15 pages, 2398 KB

Open AccessArticle

Propensity Score-Matched Comparison of Six-Strand All-Inside and Conventional Four-Strand Hamstring Autografts for ACL Reconstruction

by Young Jin Seo, Si Young Song and Dongju Kim

J. Clin. Med. 2025, 14(17), 6010; https://doi.org/10.3390/jcm14176010 - 25 Aug 2025

Viewed by 759

Abstract

Background/Objectives: All-inside ACL reconstruction has emerged as a minimally invasive alternative to conventional techniques, with potential advantages in graft configuration and reduced surgical trauma. This study aimed to compare the clinical outcomes of all-inside and full tibial tunnel ACL reconstruction, focusing on graft diameter, postoperative stability, and functional recovery. We hypothesized that the all-inside technique would allow for thicker grafts and yield superior postoperative knee stability and functional outcomes, with postoperative anterior laxity as a major outcome of interest. Methods: This retrospective comparative study reviewed patients who underwent ACL reconstruction between January 2020 and February 2024. From January 2020 to September 2022, a four-strand hamstring autograft with full tibial tunnel technique (FT-4) was used, while from September 2022, a six-strand hamstring autograft with the all-inside technique (AI-6) was adopted to enable thicker grafts and optimize fixation. Among a total of 103 patients, 1:1 propensity score matching (PSM) was performed based on age, sex, BMI, laterality, ALL reconstruction, meniscal lesion, and preoperative anterior laxity (SSD). Graft diameter and clinical outcomes, including knee stability and functional scores, were compared between the matched groups. Results: After PSM, two comparable groups of 29 patients each were established. Graft diameter was significantly larger in the AI-6 group (9.5 ± 0.7 mm) compared to the FT-4 group (7.8 ± 0.8 mm, p < 0.001), while other baseline characteristics remained well balanced between the groups. At the final follow-up, both groups exhibited significant improvements in anterior laxity, functional scores, and pivot shift grades (all p < 0.001). The AI-6 group demonstrated superior outcomes with a significantly higher Lysholm score (82.2 ± 6.7 vs. 75.6 ± 8.9, p = 0.002), lower WOMAC score (8.0 ± 4.3 vs. 12.9 ± 10.5, p = 0.023), and reduced anterior laxity (1.6 ± 1.1 mm vs. 2.5 ± 1.4 mm, p = 0.005) compared to the FT-4 group, whereas no significant differences were observed in the IKDC, Tegner, Korean knee score, or pivot shift test results. A simple linear regression revealed a significant negative correlation between graft diameter and postoperative anterior laxity (B = −0.398, p = 0.048). Conclusions: The present study demonstrated that the use of a six-strand hamstring graft configuration in the AI-6 technique resulted in significantly thicker grafts and was associated with reduced postoperative anterior knee laxity compared to the FT-4 technique. While interpretation of these findings requires caution in light of MCID thresholds, the AI-6 group showed favorable outcomes in anterior laxity and selected functional scores, such as the Lysholm and WOMAC. This technique may offer practical clinical value, particularly in populations prone to smaller graft diameters, as it facilitates adequate graft thickness through multifold preparation, with the all-inside approach accommodating the inherent graft shortening. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

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8 pages, 190 KB

Open AccessArticle

The Risk of Secondary Knee Procedures After Anterior Cruciate Ligament Reconstruction—A Nationwide Retrospective Cohort Study

by Han-Kook Yoon, Chang-Min Lee, Hyun-Cheol Oh, Taemi Youk and Sang-Hoon Park

J. Clin. Med. 2025, 14(11), 3823; https://doi.org/10.3390/jcm14113823 - 29 May 2025

Viewed by 1931

Abstract

Objectives: Some following up patients have poor clinical outcomes when they experience anterior cruciate ligament reconstruction. The patient will undergo progression of knee joint osteoarthritis or several secondary knee procedures such as high tibial osteotomy, total knee arthroplasty, menisectomy, meniscus repair, or meniscus transplantation on their knees after anterior cruciate ligament reconstruction. This may be related to the remaining instability of the knee joint, changes in the knee joint biomechanics, and progression of osteoarthritis. This study aims to determine which secondary knee procedures are performed over time after anterior cruciate ligament reconstruction. Methods: The National Health Insurance Service-Health Screening database analyzed 146,122 patients who underwent ACL reconstruction surgery between 1 January 2002 and 31 December 2021. Secondary knee procedures were investigated by categorizing them into revisional reconstruction, high tibial osteotomy, total knee arthroplasty, menisectomy, meniscus repair, and meniscus transplantation, respectively. Multivariable Cox Proportional Hazard model analysis was used. The significant predictors for complications (p < 0.05) were as follows. Results: Among a total of 146,122 patients with anterior cruciate ligament reconstruction, 1073 (0.7%) patients underwent HTO, 908 (0.6%) patients underwent TKA, 15,218 (10.4%) patients underwent meniscectomy, 7169 (4.9%) patients underwent meniscus repair, and 938 (0.6%) patients underwent meniscus transplantation. The hazard ratio differed according to graft type, gender, and age group. Conclusions: Patients who undergo ACL reconstruction may experience poor clinical outcomes, such as progression of osteoarthritis and undergoing secondary knee procedures several years after ACL reconstruction. It is important for decision-making, ongoing monitoring, and follow-up care for patients undergoing ACL reconstruction. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

Review

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13 pages, 256 KB

Open AccessReview

Biologic Augmentation in Anterior Cruciate Ligament Reconstruction and Beyond: A Review of PRP and BMAC

by Grant M. Pham

J. Clin. Med. 2025, 14(19), 6959; https://doi.org/10.3390/jcm14196959 - 1 Oct 2025

Viewed by 2091

Abstract

This narrative review synthesizes PubMed- and Scopus-indexed studies from 2020 to 2025, including preclinical animal models, prospective cohort studies, and level I and II randomized trials, to compare two leading biologic augmentation strategies: platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC). The review examines underlying mechanisms of action, delivery techniques, imaging biomarkers of graft maturation, patient-reported and functional outcomes, safety profiles, cost-effectiveness, and regulatory frameworks. PRP provides early anti-inflammatory and proangiogenic signaling, while BMAC delivers a concentrated population of mesenchymal stem cells and growth factors to the tendon–bone interface. Both modalities consistently enhance MRI-defined graft maturation, yet evidence of long-term functional or biomechanical superiority remains inconclusive. Emerging therapies such as peptide hydrogels, adipose-derived stem cells, and exosome delivery offer promising avenues for future research. Standardized protocols and large multicenter trials are needed to clarify comparative efficacy and inform personalized rehabilitation strategies. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

Other

Jump to: Research, Review

17 pages, 1340 KB

Open AccessSystematic Review

Does Adding LEAP to ACL Reconstruction Reduce Graft Failure? A Systematic Review and Meta-Analysis of Comparative Studies with Minimum Two-Year Follow-Up

by Simone Giusti, Angelo Matteucci, Simone Pavone, Ciro Mignano and Ezio Adriani

J. Clin. Med. 2025, 14(23), 8499; https://doi.org/10.3390/jcm14238499 - 30 Nov 2025

Viewed by 231

Abstract

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) is the gold-standard treatment for ACL rupture; however, graft failure remains a significant concern, particularly in young, active, or high-risk patients. The addition of a Lateral Extra-Articular Procedure (LEAP) has been proposed to enhance rotational stability and reduce the risk of graft rupture. This systematic review and meta-analysis aimed to determine whether adding LEAP to primary ACLR reduces graft failure rates compared to isolated ACLR, with a minimum follow-up of two years. Methods: A comprehensive literature search was conducted across PubMed, Scopus, Embase and Cochrane Library databases in accordance with PRISMA guidelines. Eighteen comparative studies with a minimum 24-month follow-up were included, encompassing 7336 patients (3857 undergoing isolated ACLR and 3479 undergoing ACLR with LEAP). The primary outcome was graft failure rate. Data were analyzed using the Mantel–Haenszel method with a fixed-effects model to calculate pooled risk ratios (RR) and 95% confidence intervals (CI). Results: Pooled analysis demonstrated a significant increase in graft rupture risk in the ACLR-alone group compared to ACLR + LEAP (RR 2.72; 95% CI: 2.23–3.32; p < 0.00001), with negligible heterogeneity (I² = 0%). LEAP was particularly beneficial in high-risk populations such as young athletes and individuals with high-grade pivot shift or ligamentous laxity. Secondary outcomes showed improved rotational stability and comparable patient-reported outcomes and complication rates between groups. Conclusions: ACLR alone presents a higher risk of graft failure in comparison with the ALCR + LEAP technique. Furthermore, the addition of LEAP to ACLR improves rotational stability without increasing complications. LEAP should be selectively considered in patients with high-risk profiles or persistent intraoperative instability. These findings support the incorporation of LEAP as a valuable adjunct in modern ACL reconstruction strategies. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

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17 pages, 3381 KB

Open AccessSystematic Review

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Shows Reduced Graft Failure Rates and Superior Residual Rotational Stability Regardless of Anterolateral Ligament Reconstruction Graft: A Systematic Review

by Joo Hyung Han, Sung-Hwan Kim, Min Jung, Hyun-Soo Moon and Kwangho Chung

J. Clin. Med. 2025, 14(7), 2237; https://doi.org/10.3390/jcm14072237 - 25 Mar 2025

Cited by 1 | Viewed by 1843

Abstract

Objectives: The aim of this study is to evaluate the literature for comparing clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with concomitant anterolateral ligament reconstruction (ALLR) versus isolated ACLR, with a primary focus on analyzing differences in outcomes based on the type of graft used for ALLR. Methods: We identified comparative studies involving primary ACLR performed in conjunction with ALLR. Graft failure rates, residual pivot shift, residual anterior–posterior (AP) laxity at follow-up, and patient-reported outcome measures were determined. Variables associated with isolated ACLR and ACLR combined with ALLR were compared based on the type of graft used for ALLR. Results: This systematic review included nine studies involving 2740 patients. Combined ACLR with ALLR using hamstring tendon (HT) autografts or tibialis allografts showed lower graft failure rates than isolated ACLR (HT autograft: rate, 0–5.9%, odds ratio [OR], 2.16–12.91; tibialis allograft: rate, 0%, OR, 2.00–5.27). Similarly, the combined procedure showed reduced residual pivot shift rates (HT autograft: rate, 0–9.1%, OR, 2.00–12.16; tibialis allograft: rate, 0%, OR, 7.65–15.33) compared to isolated ACLR. Residual AP laxity and patient-reported outcomes were similar or more favorable for the combined procedure; however, the results were heterogeneous. Complications related to the type of graft used for ALLR or the presence of ALLR itself were not reported. Conclusions: Regardless of the graft type used for ALLR, the combination of ACLR with ALLR showed better clinical outcomes, including reduced graft failure rates and superior residual rotational stability compared to isolated ACLR. However, the high heterogeneity observed across studies suggests that these findings should be interpreted with caution, and further research is needed to draw more definitive conclusions. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

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