Search Results (139)

Background: Based on the available evidence, there are no published clinical trials that have analyzed the effectiveness of adding cross-education, mirror therapy, and virtual reality exercises (combined) to standard treatment to improve clinical outcomes in patients after anterior cruciate ligament (ACL) reconstruction. Methods: A total of 58 patients with ACL reconstruction, aged 18–50 years, will be randomized (1:1) to two treatment arms. The control group (n = 29) will receive a standard physiotherapy program based on a consensus developed by the Sport and Health Rehabilitation Guidelines. The experimental group (n = 29) will receive a novel physiotherapy program that includes cross-education exercise with visual biofeedback, mirror therapy, and virtual reality in addition to the standard exercise program. Five evaluations will be performed: at the beginning of physiotherapy treatment (baseline), at 6 weeks, 12 weeks, 24 weeks and 52 weeks after surgery. The primary outcome will be passive knee extension range of motion at 6 weeks (for sample size), assessed by goniometry; the remaining outcomes are secondary and exploratory. The secondary outcomes measures will be pain intensity, fear of movement, the level of anxiety, knee function, and isometric quadriceps strength. Discussion: We hypothesize that patients who receive a novel physiotherapy program that includes cross-education with visual biofeedback, mirror therapy, and virtual reality will show greater benefits in knee extension and other clinical outcomes than those who receive a standard physiotherapy program. Conclusions: The trial proposed in this protocol will provide new data on the effectiveness of the combination of cross-education, motor imagery, and virtual reality therapy added to a standard physiotherapy program compared with the standard physiotherapy program alone in patients who undergo ACL reconstruction. The findings will generate new insights into the effects of the interventions and expand the multimodal rehabilitation strategies available to patients who undergo this surgery. Full article

Background: Returning to sport (RTS) after anterior cruciate ligament (ACL) injury remains a complex challenge in sports medicine, requiring integration of physical recovery, functional performance, and psychological readiness. Although ACL rehabilitation and RTS outcomes have been extensively investigated, the intellectual structure and evolution of this research field have not been comprehensively synthesized. Objective: This study aimed to systematically map the global research landscape of ACL injury and RTS using bibliometric analysis. Methods: A total of 1368 Scopus-indexed publications published between 1997 and April 2026 were analyzed using performance analysis and science mapping. Results: The study identified leading authors, institutions, countries, funding agencies, and journals, and examined collaboration networks, thematic structures, and emerging trends. Scientific output grew substantially after 2012, with accelerated expansion between 2020 and 2025. The United States was the most productive country, and La Trobe University (Australia) the leading institution; the National Institutes of Health (NIH) was the principal funding source. Among 4652 authors, K.E. Webster was the most prolific contributor, and the Orthopaedic Journal of Sports Medicine was the most productive journal. Science mapping showed a shift from surgical and structural perspectives toward multidimensional frameworks emphasizing functional recovery, psychological readiness, neuromuscular performance, injury prevention, and athlete-centered outcomes. Emerging priorities include psychological and neurocognitive readiness, rehabilitation and performance optimization, biomechanical and functional assessment, surgical innovation, outcome validation, and machine learning applications. Conclusions: This bibliometric overview offers clinicians, rehabilitation specialists, and researchers an evidence base for guiding future investigation into functional recovery, re-injury risk reduction, and long-term athlete outcomes. Full article

Tibial spine avulsion injuries represent a distinct pattern of anterior cruciate ligament (ACL) injury in children and adolescents, reflecting the unique anatomical and biomechanical properties of the skeletally immature knee. Unlike midsubstance ACL ruptures, these injuries involve avulsion of the tibial insertion and pose specific diagnostic and therapeutic challenges. Management strategies remain heterogeneous, particularly for partially displaced fractures, with variation in surgical indications, fixation techniques, and rehabilitation protocols. This narrative review provides a structured synthesis of current evidence on the anatomy, biomechanics, clinical presentation, and management of pediatric tibial spine avulsion injuries. Nonoperative and operative approaches are compared, with attention to fixation strategies, complications, physeal considerations, and rehabilitation principles. Return-to-sport (RTS) outcomes are examined, with available evidence suggesting that RTS rates may be comparable between operative and nonoperative management in selected patients, although interpretation is limited by heterogeneous and predominantly retrospective data. Early mobilization appears important for reducing arthrofibrosis risk, while rehabilitation should be individualized. RTS decision-making remains inconsistent, with commonly used criteria largely extrapolated from ACL reconstruction literature and lacking validation in pediatric populations. Multifactorial assessment incorporating functional testing and patient-reported outcomes is increasingly advocated, although evidence for psychological readiness remains limited. Overall, the current literature is characterized by methodological heterogeneity and limited comparative data, restricting definitive conclusions. This review provides a clinically oriented synthesis while highlighting key uncertainties and priorities for future research. Full article

Background/Objectives: Previous studies have measured a limited number of biomechanical parameters during medical rehabilitation of an anterior cruciate ligament (ACL) rupture. This study aimed to quantitatively assess changes in gait biomechanics, knee function, and lower-extremity muscle activity during after ACL reconstruction. Methods: The study included 32 patients after arthroscopic ACL reconstruction. The patients were divided into three groups based on postoperative time points: 0.5 year (12 men), 1 year (7), and over 1 year (9). Gait analysis at both self-selected and fast speeds was performed using an inertial system. Statistical analysis was performed using rank models and full-factorial orthogonal designs. Results: After 0.5 year, the timing of the gait cycle at self-selected speed was within the control group’s range and showed no significant asymmetry. With increasing speed, a decrease in knee joint range of motion was observed in the 0.5 year and 1-year groups, without achieving a full physiological increase in range of motion at long-term follow-up. Multivariate analysis revealed the greatest biomechanical imbalance during fast walking at one year and a phase-dependent effect of time after surgery, speed, and limb status on kinematics and EMG, particularly in the quadriceps. Conclusions: Basic temporal gait parameters during self-selected walking were within the control range by 0.5 year, but load-dependent knee kinematic and EMG abnormalities persisted. The knee joint’s response to increased loads remained impaired for at least one year. The persistence of phase-specific compensatory changes in kinematics and muscle activity at later stages can be assessed using exercise testing. Full article

Background/Objectives: To analyse postoperative pain trajectories after anterior cruciate ligament (ACL) reconstruction using data from a digital rehabilitation system, and to determine (i) whether combined ligament injuries are perceived as more painful than isolated ACL tears, (ii) which patient characteristics are associated with clinically relevant pain (visual analogue scale [VAS] > 5), and (iii) whether higher early pain is associated with later discontinuation of digital monitoring. Methods: This retrospective cohort study used routine data recorded by a validated sensor-based home rehabilitation system in patients after ACL reconstruction. This approach has previously been used to analyse functional recovery trajectories. All patients with ACL-related indications who performed at least one postoperative test were included and classified into four groups: isolated ACL rupture, ACL + meniscus, ACL + collateral ligament, and ACL + collateral ligament + meniscus. Pain during exercises and tests was recorded on a 0–10 VAS. High pain was defined as VAS > 5. Group comparison between indication types, anthropometric and activity-related variables and the proportion of high-pain events were performed using chi-square tests. Early pain (first postoperative month) was analysed in relation to the presence of later tests (≥3 months) to explore associations with discontinuation of digital monitoring. Results: Combined ligament injuries showed a significantly higher proportion of high-pain events during rehabilitation compared with isolated ACL ruptures (5.8% vs. 2.4%, overall p < 0.001). In particular, combined ligament injuries with ACL + collateral ligament rupture were associated with a greater share of VAS > 5 ratings in the early rehabilitation phases. No relevant association was observed between sex or BMI category and the occurrence of high pain, while age group showed an overall association without a consistent directional pattern. Sport activity level showed a strong relationship with high pain (p < 0.001). Early pain demonstrated a small but statistically significant negative correlation with later test participation (r = −0.15, approximately 2% of variance, p = 0.0076); however, this association was attenuated and no longer statistically significant when analysed using mixed-effects models accounting for within-patient clustering, indicating that patients with higher early pain tended to discontinue digital monitoring. Conclusions: Digital routine data after ACL reconstruction suggest that (i) combined ACL–collateral ligament injuries are perceived as more painful than isolated ACL tears, (ii) high postoperative pain is more closely related to activity level and injury pattern than to sex or BMI, while age group shows an overall but non-directional association, and (iii) higher early pain shows a weak bivariate correlation with digital disengagement that was not confirmed in mixed-effects models. Pain is therefore an exploratory marker warranting further investigation, rather than a confirmed independent predictor of adherence in app-based rehabilitation. Full article

Background and Objectives: Persistent quadriceps weakness, muscle atrophy, and functional deficits are common following anterior cruciate ligament (ACL) reconstruction and may compromise return to sport and increase the risk of reinjury. Eccentric-oriented strength training has been widely used to enhance muscle strength and hypertrophy in various musculoskeletal conditions; however, its specific application within ACL rehabilitation remains insufficiently explored. The aim of this scoping review was to map the existing evidence on the use of eccentric-oriented strength training in ACL rehabilitation, identify gaps in the current literature, and provide suggestions for future research. Materials and Methods: A scoping review search was conducted in PubMed, Scopus, Web of Science, and PEDro from inception to February 2026 using the following keywords and Boolean operators: (“anterior cruciate ligament”, “ACL”, “anterior cruciate ligament reconstruction”, “ACLR”) AND (“eccentric training”, “eccentric exercise”, “eccentric loading”, “flywheel training”, “isoinertial training”). Eligible studies included studies that investigated eccentric exercises as part of ACL rehabilitation and reported outcomes related to muscle strength, muscle morphology, functional performance, or return to sport. Data were extracted and synthesized descriptively in accordance with the PRISMA-ScR extension for Scoping Reviews guidelines. Methodological quality and risk of bias were evaluated using the PEDro scale (RCTs) and the ROBINS-I tool (non-randomized studies). Results: Fifteen studies met the inclusion criteria. The included literature primarily examined isokinetic eccentric exercise, eccentric cycling, early progressive eccentric resistance training, Nordic hamstring exercise, eccentric ergometry, and flywheel strength training. Most studies reported improvements in quadriceps strength and muscle morphology, with additional benefits observed in functional performance measures (i.e., hop tests), gait mechanics, and limb symmetry. Evidence was unevenly distributed across rehabilitation phases, with relatively few studies focusing on the mid-phase of ACL rehabilitation. Conclusions: Eccentric-oriented strength training represents a promising but underexplored component of ACL rehabilitation. However, the existing literature lacks standardized protocols, comprehensive outcome measures, and phase-specific guidance, particularly during the mid and late stages of rehabilitation. Further high-quality studies are needed to clarify the optimal timing, dosage, and integration of eccentric training across rehabilitation phases. Full article

Background/Objectives: Anterior cruciate ligament (ACL) tears in children and adolescents are occurring at the intersection of skeletal growth and often early sports specialization, requiring a specialized approach, as pediatric ACL injury is not merely a scaled-down version of adult injury. Methods: This review synthesizes the current understanding of diagnostic protocols, evolution of knee morphology and neuromechanical risk factors characteristic of the pediatric population. It further examines the spectrum of specific management strategies including conservative approaches, primary repair and various reconstruction techniques, alongside rehabilitation, prevention and follow-up procedures. Results: In the diagnostic phase, pediatric-specific clinical and imaging findings must be carefully interpreted. Certain anatomical and neuromuscular characteristics seem to be linked to injury. Management remains complex, requiring a delicate balance between restoring stability and sparing bone growth. While conservative treatment may be attempted in specific cases, it must be promptly redirected toward surgical intervention if persistent instability occurs. Consensus on optimal surgical strategies remain impeded by the lack of robust evidence. Anterior cruciate ligament reconstruction (ACLR) still faces challenges such as growth disturbances, high graft failure, contralateral rupture rates and the biological process of graft remodeling. However, ACLR currently remains the gold standard compared to ACL repair. Tailored rehabilitation and robust prevention programs are needed. Conclusions: The management of ACL rupture in the pediatric population remains complex and constrained by important evidence gaps. Continued refinement of management strategies and future prospective, multicenter pediatric studies are needed. Full article

Background: No systematic review has yet been conducted simultaneously on the effectiveness of psychological interventions across multiple outcome measures during rehabilitation following anterior cruciate ligament reconstruction (ACLR). This study aims to assess the effects of such interventions on pain, psychological outcomes, patient-reported knee function, objective knee measures, and quality of life following ACLR. Methods: We searched PubMed, Medline, Embase, PsycINFO, and the Cochrane Library from inception to 20 April 2026 (PROSPERO CRD42023483889). Eligible randomized controlled trials compared psychological interventions with usual care in ACLR patients. Two reviewers assessed eligibility, risk of bias, and extracted data. Random-effects models were used; effect sizes were interpreted using Cohen’s guidelines. Results: Of 401 records screened, 11 RCTs (440 participants) were included. Psychological interventions significantly improved pain (six trials, SMD = −0.96, 95% CI −1.40 to −0.52, p < 0.001, I² = 47%; large effect), kinesiophobia (TSK-11: five trials, SMD = −0.48, −0.74 to −0.22, I² = 0%; small effect), knee self-efficacy (K-SES: three trials, SMD = 0.53, 0.19–0.86, I² = 0%, moderate effect), patient-reported knee function (IKDC: two trials, SMD = 0.58, 0.26–0.90, I² = 0%, moderate effect), and physical role function (SF-36: two trials, SMD = 0.41, 0.04–0.78, I² = 0%, small effect). No significant effects were found for KT1000, knee strength, SF-36 mental well-being, or ACL-RSI (all p > 0.05, with substantial heterogeneity for ACL-RSI). Particularly, imagery therapy reduced pain (three trials, SMD = −1.54, I² = 15%). Conclusions: This meta-analysis provides preliminary evidence that psychological interventions, especially imagery therapy, may improve pain, psychological outcomes, patient-reported knee function, and quality of life after ACLR. Adequately powered trials with standardized protocols are needed to confirm these findings. Full article

(1) Background: Asymmetry in strength, movement, and neuromuscular control is common in youth sports, yet its role in anterior cruciate ligament (ACL) injury risk in pediatric athletes remains underexamined. (2) Methods: This narrative review synthesized studies that examined lower-limb asymmetry, biomechanics, ACL injury or reconstruction (ACLR), and rehabilitation in participants younger than 18 years, supplemented by key mechanistic and methodological work. (3) Results: Evidence indicates that asymmetry is multifactorial and sometimes functional, arising from limb dominance, sport-specific loading, growth-related morphological change, and neuromuscular variability. However, asymmetry becomes concerning when it coincides with high-risk landing or cutting mechanics, growth-related coordination deficits, or incomplete recovery after ACL reconstruction. Persistent strength and loading asymmetries are linked to secondary ACL injury and early structural joint changes, whereas neuromuscular training and technique-modification programs can improve symmetry and reduce high-risk mechanics. Major gaps include the absence of pediatric-specific asymmetry norms, limited longitudinal and sex-specific data, and heterogeneous measurement approaches. (4) Conclusions: Clarifying when asymmetry is adaptive versus maladaptive, and integrating this knowledge into screening, rehabilitation, and return-to-sport decision-making, will be essential for optimizing performance and promoting lifelong knee health in pediatric athletes. Full article

Background: Children with juvenile idiopathic arthritis (JIA) exhibit gait abnormalities, postural instability, and compensatory movement strategies due to joint pain, inflammation, and reduced neuromuscular control. These alterations negatively affect functional mobility and movement efficiency. Although gait retraining is commonly recommended in rehabilitation, objective evidence on its short-term biomechanical effects remains limited. This study aimed to evaluate the immediate impact of a single-session standardized movement training intervention on gait biomechanics in children with JIA. Methods: Seventeen children with JIA underwent pre–post gait assessments using the Xsens MVN Awinda wearable motion capture system. The intervention focused on step symmetry, stride length, heel–toe progression, and upright trunk posture, delivered by an experienced physiotherapist following a standardized protocol. Scalar kinematic outcomes were analyzed using paired statistical tests, and time-normalized kinematic waveforms were compared with healthy reference data from 25 age-matched participants derived from the COMPWALK-ACL dataset. Results: Significant improvements were observed in multiple gait parameters following the intervention. Trunk lateral lean decreased significantly (p = 0.0002; d = −1.35), indicating enhanced postural stability. Significant changes were also found in ankle dorsiflexion–plantarflexion (p = 0.0081; d = 0.83) and knee flexion–extension (p = 0.0252; d = 0.68). Waveform analyses showed increased similarity to healthy patterns, particularly in trunk and knee kinematics. Spatiotemporal parameters reflected a slower, more controlled gait pattern, with increased stride time and stance duration. Conclusions: A single session of standardized movement training can produce immediate improvements in gait biomechanics in children with JIA, especially in trunk control and lower-limb kinematics. Wearable motion analysis provides a sensitive tool for detecting these short-term adaptations and supports the inclusion of structured movement training in pediatric JIA rehabilitation. Full article

Background/Objectives: Psychological barriers, particularly kinesiophobia and diminished psychological readiness, represent critical yet undertreated obstacles to a successful return to sport following anterior cruciate ligament reconstruction (ACLR). Scalable, preference-aligned educational interventions capable of addressing these barriers during early rehabilitation are lacking. We aimed to evaluate the effectiveness of structured educational content delivered via Snapchat, as an adjunct to standard ACLR rehabilitation, in reducing kinesiophobia (primary outcome) and improving psychological readiness and perceived knee function (secondary outcomes). Methods: A total of 120 adults with clinically elevated kinesiophobia (TSK-17 > 37) undergoing post-operative ACLR rehabilitation were enrolled in a quasi-experimental, two-arm study with non-randomized allocation at the clinic-branch level at two branches of the same sports rehabilitation clinic (Joint Clinics, Riyadh, Saudi Arabia). Branch allocation assigned 60 participants to each group (intervention and control). The intervention group received 12 weekly structured educational videos via Snapchat alongside standard rehabilitation; the control group received standard rehabilitation alongside general ACLR information videos via Snapchat. TSK-17, ACL-RSI, and IKDC were assessed at baseline and at 12 weeks. Primary analysis used ANCOVA covarying baseline scores, complemented by mixed repeated measures ANOVA and intent-to-treat analysis. Results: Both groups improved across all outcomes; the intervention group demonstrated significantly greater gains. ANCOVA revealed significant between-group differences favoring the intervention for TSK-17 (adjusted mean difference = −2.82; d = 0.54; p < 0.001; d represents Cohen’s d calculated from adjusted mean differences and pooled SD), ACL-RSI (+8.06; d = 0.77; p < 0.001), and IKDC (+8.90; d = 0.54; p = 0.002). Mean video completion was 82.8% among intervention participants. Intent-to-treat analyses using Multiple Imputation confirmed all findings. Conclusions: Snapchat-based structured education was associated with improvements in kinesiophobia, psychological readiness, and perceived knee function among the 102 analyzed participants (control n = 52; intervention n = 50) of the 120 enrolled. High engagement supports preference-based digital delivery as a scalable adjunct to standard rehabilitation. Full article

Background/Objectives: The optimal management of anterior cruciate ligament (ACL) rupture remains debated, especially regarding long-term outcomes after early ACL reconstruction (ACLR) versus rehabilitation-first with optional delayed ACLR. The interpretation of randomized evidence is complicated by frequent treatment crossover. This review synthesized evidence from randomized controlled trial (RCT) cohorts comparing surgical versus rehabilitation-first management strategies across available follow-up durations. Methods: A structured review based on a systematic literature search and narrative synthesis was conducted, with study identification and reporting guided by PRISMA 2020. MEDLINE (via PubMed) and Google Scholar were searched in February 2026 for English-language human RCTs (2000–2026) comparing early ACLR plus rehabilitation with rehabilitation-first management allowing delayed ACLR for persistent instability. A linked-report PubMed search using the KANON trial registration number (ISRCTN84752559) was additionally performed to identify cohort-derived follow-up publications. Reports were grouped by underlying RCT cohort. Data were extracted on crossover, follow-up, and clinical outcomes. Risk of bias for primary RCT reports was assessed with Cochrane RoB 2. Results: Twenty-seven reports representing three RCT cohorts (KANON, COMPARE, ACL SNNAP) were included; six index reports were prioritized for synthesis. In acute ACL rupture (KANON, COMPARE), early ACLR did not show a consistent long-term superiority in patient-reported outcomes versus rehabilitation-first with optional delayed ACLR, although COMPARE reported a statistically significant 2-year subjective functional difference favoring early ACLR; early ACLR more consistently improved mechanical stability and reduced instability episodes. Crossover from rehabilitation to delayed ACLR was common. In non-acute ACL injury with persistent symptomatic instability (ACL SNNAP), surgery-first improved 18-month patient-reported outcomes. Meniscal procedure rates and osteoarthritis-related outcomes did not consistently favor early ACLR. Conclusions: In acute ACL rupture, rehabilitation-first with timely access to delayed ACLR appears to provide long-term patient-reported outcomes comparable to an early ACLR strategy in many patients, while early ACLR more consistently improves knee stability. In non-acute symptomatic ACL deficiency, a surgery-first strategy appears more effective in the mid-term. These randomized trials should be interpreted as comparisons of management strategies rather than of “pure” operative versus nonoperative treatment approaches. Full article

Background and Objectives: The assessment of neuromuscular recovery after ACL reconstruction is crucial for safe return to sport (RTS) in professional soccer players. This retrospective cross-sectional study aimed to compare squat jump (SJ), bilateral countermovement jump (CMJ), and single-leg CMJ performance in three distinct groups: players at 6 months post-ACL reconstruction, players at 9 months post-ACL reconstruction, and healthy controls. Materials and Methods: Seventy-two male players (24 at 6 months post-ACL, 24 at 9 months post-ACL, 24 healthy controls) performed squat jump, bilateral countermovement jump, and single-leg CMJ tests using contact platforms following a controlled warm-up protocol. Results: Significant group differences were observed in all jump tests. At 6 months post-ACL reconstruction, players demonstrated significantly lower squat jump (45.13 ± 6.20 cm) and bilateral countermovement jump (49.67 ± 6.80 cm) heights compared to both 9-month players (SJ: 50.03 ± 5.30 cm; CMJ: 53.79 ± 4.85 cm) and controls (SJ: 51.12 ± 4.97 cm; CMJ: 55.49 ± 5.54 cm) (p ≤ 0.016, η² = 0.187 and η² = 0.156, respectively). No significant differences between 9-month and control groups were observed for the squat jump and the bilateral countermovement jump. Regarding the unilateral countermovement jump, the injured leg showed significant performance deficits compared to controls in both the 6-month and 9-month groups (p = 0.001, η² = 0.378). However, the non-injured leg exhibited deficits only in the 6-month group. Conclusions: Compared to the 6-month post-ACL reconstruction group, the 9-month group showed a marked improvement in bilateral jump performance, indicating substantial neuromuscular recovery over time. However, persistent unilateral deficits in the injured leg remained even at 9 months, underscoring the need for a routine and comprehensive jumping evaluation to identify residual neuromuscular impairments that may require targeted rehabilitation before returning to sport. Full article

Background/Objectives: Objective, non-invasive biomarkers are needed to track anterior cruciate ligament (ACL) graft maturation and support individualized return-to-sport decisions. This study evaluated a single-session multiparametric quantitative MRI (qMRI) protocol for longitudinal assessment of ACL graft microstructural evolution and its association with patient-reported outcomes. Methods: Twenty-eight patients undergoing primary ACL reconstruction with hamstring autografts underwent multiparametric qMRI (T1, T2*, R2*, and PD mapping) at 1, 3, 6, and 12 months. The contralateral native ACL served as a within-subject control. IKDC, Lysholm, and VAS scores were recorded at each visit. Linear mixed-effects models were used to test longitudinal changes. Correlations of baseline-normalized changes between adjacent visits were used to evaluate imaging–clinical associations. Results: All qMRI parameters changed significantly over time (all p < 0.001). At 1 month, T1, PD, and T2* were lower and R2* higher than the contralateral native ACL (all p < 0.001). Thereafter, T1, PD, and T2* increased and R2* decreased, with most metrics approaching contralateral values by 3–6 months (all p < 0.05), and changes entered a plateau after 6 months (all p > 0.05). IKDC, Lysholm, and VAS improved over time (all p < 0.001), mainly before 6 months. Greater early T2* increases and R2* decreases (1–3 months) were associated with less pain relief and smaller Lysholm improvement (p < 0.05); no significant associations were observed from 6–12 months. Conclusions: Single-session multiparametric qMRI sensitively captures ACL graft maturation and highlights 3–6 months as a critical remodeling window, providing objective biomarkers to complement clinical assessment for individualized rehabilitation monitoring and return-to-sport timing. Full article

Background: Musculoskeletal disorders (MSDs) are a major contributor to global disability. Exercise-based rehabilitation is widely recommended as first-line management; however, in clinical practice, it is frequently combined with adjunct therapeutic modalities, and the incremental effectiveness of these approaches remains unclear. The present review addressed the research question: Do adjunct modalities provide additional benefits beyond exercise-based rehabilitation alone in individuals with musculoskeletal disorders? Methods: This systematic review was conducted according to PRISMA 2020 guidelines and prospectively registered in the PROSPERO database (registration number CRD420261309183). Electronic searches were performed in PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials to identify controlled clinical trials evaluating exercise-based rehabilitation delivered alone or combined with adjunct modalities. Outcomes included pain, functional disability, physical performance, strength, structural or imaging-based measures, biomechanical variables, injury risk, and work-related outcomes. Due to methodological heterogeneity across studies, a structured narrative and tabular synthesis were performed. Results: Twenty-one controlled clinical trials were included, encompassing tendinopathies (n = 7), knee osteoarthritis (n = 5), post-ACL reconstruction (n = 2), chronic spinal pain (n = 3), sarcopenia (n = 2), low bone mass (n = 2), and occupational musculoskeletal conditions (n = 1), with sample sizes ranging from 22 to 823 participants. Pain outcomes were reported in 18 studies (86%) and functional outcomes in 16 studies (76%). Exercise-based rehabilitation consistently produced clinically meaningful improvements across studies, whereas adjunct modalities demonstrated short-term advantages in a limited number of trials but rarely showed sustained long-term superiority. Conclusions: Evidence from controlled clinical trials indicates that exercise-based rehabilitation is an effective primary intervention for improving pain, functional capacity, and physical performance across diverse musculoskeletal conditions. Adjunct modalities may provide condition-specific or short-term benefits but do not consistently enhance long-term outcomes beyond structured exercise programs. Full article