Anterior Cruciate Ligament ACL Injury Hidden in The Complex Sensorimotor System

Review Article
Anterior Cruciate Ligament (ACL) Injury Hidden in the Complex

Sensorimotor System
Bartłomiej Kacprzak1, Mikolaj Stanczak2*, Jakub Surmacz3
1Orto
Med Sport, Łódź, Poland
2Sports Medicine, AECC University College, UK
3Rehab Performance, Lublin, Poland
*Correspondence author: Mikolaj Stanczak, Sports Medicine, AECC University College, UK; Email: [email protected]
Abstract
Citation: Kacprzak B, et al. Anterior
ACL injuries present significant challenges in sports medicine, particularly in restoring knee joint
Cruciate Ligament (ACL) Injury
Hidden in the Complexfunction and preventing further complications like subsequent injuries or post-traumatic
Sensorimotor System. J Ortho Sci osteoarthritis. Traditional rehabilitation techniques, which often rely on pre-planned exercises and
Res. 2024;5(2):1-23. standardized assessments, may not adequately prepare athletes for the unpredictable nature of
https://doi.org/10.46889/JOSR.2024.
sports. This paper argues for a comprehensive approach that recognizes ACL injuries as failures
5210
of complex nonlinear systems rather than merely biomechanical deficiencies.
Received Date: 02-08-2024 The complexity of ACL injuries involves a dynamic interplay of individual skills, team dynamics
Accepted Date: 20-08-2024
and external conditions. Traditional rehabilitation approaches that focus solely on biomechanical
factors overlook the critical role of interpersonal dynamics and sensorimotor control. The brain’s
Published Date: 27-08-2024
integration of sensory information to form a comprehensive environmental representation is vital
for motor actions. Disruptions in this sensorimotor feedback loop can impair motor control,
increasing the risk of ACL injuries.
Copyright: © 2024 by the authors. Effective rehabilitation should enhance sensory integration and feedback mechanisms, improving
Submitted for possible open motor control and reducing re-injury risk. Addressing proprioceptive deficits and Arthrogenic
access publication under the Muscle Inhibition (AMI) is crucial for successful rehabilitation. Neurocognitive training, focusing
terms and conditions of the on enhancing decision-making and motor responses, is essential for sports performance and injury
Creative Commons Attribution prevention. Techniques like neurofeedback training can optimize brain activity patterns, leading
(CCBY) license
to better motor responses and adaptation to dynamic environments.
(https://creativecommons.org/li
Psychological factors such as motivation, anxiety and fear significantly influence recovery.
censes/by/4.0/).
Integrating psychological support into rehabilitation programs can address these factors, leading
to more comprehensive and effective recovery strategies. Innovative rehabilitation approaches,
including EMG biofeedback, motor imagery and virtual reality-based training, can enhance reactive motor planning and
adaptability, preparing athletes for the demands of their sport.
The future of ACL rehabilitation lies in embracing the complexity of the sensorimotor system and developing multidisciplinary
interventions that promote beneficial neuroplasticity. Advances in neuroscience and technology, such as artificial intelligence,
can lead to more personalized and effective rehabilitation programs. Recognizing and addressing the multifaceted nature of ACL
injuries can significantly improve rehabilitation outcomes, ensuring athletes can safely and effectively return to their sports.
Keywords: Arthrogenic Muscle Inhibition; Neuroplasticity; Anterior Cruciate Ligament; Rehabilitation
Introduction
Our current therapeutic approaches fall short in adequately restoring knee joint function, preventing subsequent injuries and
staving off post-traumatic osteoarthritis. This shortcoming highlights a significant gap in our rehabilitation methods, which often
rely on largely pre-planned techniques and standardized test batteries. These methods, while systematic, fail to account for the
unpredictable and dynamic nature of sports, as emphasized by dynamic systems theory. The chaotic environment of sports
requires a more adaptive and responsive approach to rehabilitation, one that can quickly adjust to the varying demands placed
https://doi.org/10.46889/JOSR.2024.5210 https://athenaeumpub.com/journal-of-orthopaedic-science-and-research/
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on athletes.
As coaches, physiotherapists and healthcare professionals, it is imperative that we acknowledge and accept these limitations in
our current practices. Recognizing the complexity and multifaceted nature of this problem is the first step towards finding
effective solutions. The interplay between various factors such as biomechanics, physiology, psychology and even external
environmental influences means that a one-size-fits-all approach is inadequate. Each athlete's recovery process is unique,
influenced by their specific injury, personal health history, mental state and the particular demands of their sport.
To bridge this gap, we must adopt a holistic perspective, integrating insights and methods from multiple disciplines within
health and sports sciences. This includes not only traditional rehabilitation techniques but also innovations in sports science,
neurology, nutrition and mental health. By fostering a more interdisciplinary approach, we can develop more robust and resilient
rehabilitation protocols that better prepare athletes for the rigors and unpredictability of their sports. In doing so, we can enhance
recovery outcomes, reduce the risk of re-injury and promote long-term joint health, ultimately leading to better overall
performance and well-being for athletes.
Additionally, advancements in technology and data analytics offer promising avenues for improving rehabilitation strategies.
Wearable technology, for instance, can provide real-time feedback on an athlete's movements, enabling more precise adjustments
to their rehabilitation exercises. Data analytics can help identify patterns and risk factors for injuries, allowing for more
personalized and preventative care. Virtual reality and augmented reality can create immersive training environments that
simulate the chaotic conditions of actual sports, helping athletes better prepare for the demands of their activities.
Moreover, the psychological aspect of recovery cannot be overlooked. Mental resilience and confidence are crucial for an athlete's
return to sport. Psychological support, including mental health counseling and cognitive-behavioral techniques, should be
integrated into rehabilitation programs to address anxiety, fear of re-injury and other mental barriers that athletes may face. By
addressing both the physical and psychological aspects of recovery, we can provide more comprehensive care that supports the
whole athlete.
In conclusion, our current therapeutic approaches must evolve to meet the complex needs of athletes recovering from knee
injuries. By embracing a multifaceted, interdisciplinary approach and leveraging technological advancements, we can develop
more effective rehabilitation protocols. This will not only improve recovery outcomes but also enhance the overall health and
performance of athletes, ensuring they are better equipped to handle the challenges of their sports [1].
More Than Biomechanics

ACL injuries arise due to biomechanical flaws (e.g., excessive knee valgus, etc.), right? Well, sort of. As previously discussed by
Dr. Chaput and Harjiv Singh in the field of science, these injuries result from complex failures of nonlinear systems.
Biomechanical errors are necessary but insufficient on their own to cause injuries [2].
Sports are a complex system. The ultimate outcome of any game is determined by a multitude of factors beyond just the
individual skills and performance of players. Each player's interaction with teammates and the coach, the strategies employed
and the constantly evolving dynamics of the game all play critical roles. For instance, substitutions can alter the pace and energy
levels of a team, crowd noise can influence player focus and decision-making and refereeing decisions can impact the flow and
momentum of the game. Moreover, managing the game clock effectively is crucial for maximizing scoring opportunities and
defensive plays.
Two competing teams rarely play "perfectly." Instead, each team continuously adjusts to mistakes and unexpected events to
score points, maximize possession and ultimately win the game. This adaptive characteristic is a hallmark of all complex systems:
despite apparent flaws, complexity allows for variability in how systems operate. This means that even with biomechanical
imperfections, athletes can still perform effectively without necessarily sustaining injuries.
In this context, biomechanical flaws can be seen as "minor imperfections" in human movement. These flaws do not always lead
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to injuries because the body's natural variability and adaptability often compensate for them. For example, an athlete with a
slight knee valgus might adjust their movement patterns to reduce stress on the knee joint during play. Additionally, strength
and conditioning programs, proprioceptive training and sport-specific drills can enhance an athlete's ability to cope with these
imperfections [3].
The broader implication is that natural biomechanical variability should not be scapegoated for system failures. Instead, it should
be understood as part of the complex interplay of factors that influence injury risk. Addressing ACL injuries and similar issues
requires a comprehensive approach that considers the athlete's overall biomechanics, training environment, psychological state
and external influences. By embracing the complexity of sports and human movement, we can develop more effective injury
prevention and rehabilitation strategies that go beyond merely correcting biomechanical flaws.
In the realm of injury prevention, a multifaceted approach that includes education, technique refinement and conditioning is
crucial. Educating athletes about the risks and proper techniques for movements can significantly reduce the incidence of injuries.
For example, teaching proper landing techniques can help mitigate the forces on the knee during high-impact activities, reducing
the likelihood of ACL injuries.
Moreover, refining athletic techniques through personalized coaching can address individual biomechanical issues. Coaches can
work closely with athletes to modify their movements, ensuring they perform in ways that minimize undue stress on vulnerable
joints. This personalized attention can identify and correct subtle biomechanical flaws before they contribute to injury [4].
Conditioning programs that focus on strength, flexibility and neuromuscular control are also essential components of injury
prevention. Strengthening the muscles around the knee can provide better support and stability, reducing the strain on the ACL.
Flexibility exercises ensure that the muscles and ligaments can handle a wide range of motion without becoming overstretched
or damaged. Neuromuscular control exercises improve the body's ability to coordinate movements and maintain balance, which
is crucial for preventing falls and awkward landings that could lead to injury.
Psychological factors also play a significant role in injury prevention and recovery. Athletes' mental resilience, confidence and
stress levels can influence their risk of injury and their ability to recover. Psychological support, including mental health
counseling and techniques such as visualization and mindfulness, can help athletes manage anxiety, maintain focus and stay
motivated during rehabilitation.
Finally, the role of external factors, such as playing surfaces, equipment and environmental conditions, should not be
underestimated. Ensuring that athletes train and compete on well-maintained surfaces, using appropriate footwear and
protective gear, can reduce the risk of injury. Awareness of environmental conditions, such as weather and lighting, can help
prevent accidents that might lead to injury.
In conclusion, ACL injuries and other sports-related injuries cannot be attributed solely to biomechanical flaws. They result from
a complex interplay of factors within a dynamic system. By adopting a holistic approach that considers biomechanics, training,
psychological factors and external influences, we can develop more effective strategies for preventing and rehabilitating injuries.
This comprehensive perspective allows us to better support athletes in achieving optimal performance while minimizing the risk
of injury [5].
Sports Navigation
In sports, the interactions between two adaptive systems, such as teams, play a crucial role in disrupting each other's effectiveness
in scoring points. These interactions are not static; they contribute to the ongoing evolution of the larger system, which is the
game itself, over time. This dynamic nature of sports means that individual athletes must constantly adapt to changing
conditions. The motor options available to each athlete are influenced by a complex interplay of factors, including the dynamics
of the environment, the specific tasks they need to perform and their own physical and psychological states. This concept, rooted
in ecological psychology, emphasizes that the way a task is performed and initiated is contingent upon these interacting elements
[6].
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Suggesting that an athlete's injury risk can be determined solely by the presence of a biomechanical defect is overly simplistic. It
fails to consider the broader context of interpersonal dynamics during a game. For instance, an athlete's movements and decisions
are influenced by the actions of their teammates and opponents, as well as the immediate situational demands. These factors can
either mitigate or exacerbate the impact of any biomechanical issues [7].
To take these considerations into account, we must adopt a holistic approach to understanding and managing athletes'
performance and injury risks. This approach should integrate biomechanical assessments with an analysis of the athlete's
interactions within their sporting environment. By doing so, we can develop more effective training and rehabilitation programs
that address not only the physical aspects of performance but also the strategic and adaptive elements inherent in sports. This
comprehensive perspective can help in devising strategies that enhance performance while minimizing injury risks,
acknowledging that an athlete's success and safety depend on a multifaceted array of factors beyond mere biomechanics [8].
Furthermore, this approach should involve continuous monitoring and assessment of athletes during training and competition.
Advanced technologies, such as motion capture systems, wearable sensors and real-time analytics, can provide valuable data on
how athletes move and interact within the game context. By analyzing this data, coaches and medical professionals can identify
patterns that may indicate potential injury risks or areas for performance improvement.
Additionally, psychological factors play a significant role in how athletes navigate the complexities of their sport. Mental
resilience, decision-making under pressure and the ability to anticipate opponents' actions are all crucial components of athletic
performance. Training programs should, therefore, incorporate psychological skills training to help athletes develop these
mental attributes.
Injury prevention strategies should also be dynamic and adaptable, just like the sports environment itself. This includes
developing personalized training regimens that account for an athlete's unique physical and psychological profile, as well as
their role within the team and the specific demands of their sport. Regular feedback and adjustment of these programs are
essential to ensure they remain effective as the athlete and the game evolve [9].
In conclusion, the interplay between athletes, teams and the sporting environment is a complex and dynamic process that
requires a holistic and adaptive approach to performance and injury management. By considering the ecological context of
sports, incorporating advanced technologies and addressing both physical and psychological factors, we can better support
athletes in achieving their full potential while minimizing the risk of injury. This comprehensive perspective is crucial for the
ongoing development and success of athletes in the ever-evolving landscape of sports [10].
Interpersonal Dynamics: Nonlinear Pedagogy

More than two-thirds of ACL injuries result from non-contact mechanisms, many of which involve avoiding collisions such as
changing direction to evade a defender. Anecdotally, many of us believe that the interpersonal dynamics of sports contribute to
ACL injuries, which tend to occur more frequently in games than in training. This raises the question: do individuals at risk for
(or following) ACL injuries perform worse in reactive interpersonal coordination tasks? Can this be optimized through training?
If so, how?
The awareness that an opponent's actions disrupt movement patterns challenges the validity of traditional rehabilitation
approaches, which often focus on isolated skill development rather than the complex, dynamic interactions encountered in actual
sports scenarios. Traditional rehabilitation might emphasize strength, stability and controlled movements in a clinical setting,
but it may not adequately prepare athletes for the real-world demands where quick, unpredictable decisions are crucial. This
discrepancy raises important questions about whether we are effectively preparing athletes for the real demands of their sports
[11].
In sports, the ability to respond to the actions of others-teammates, opponents or even the movement of the ball—requires a high
level of coordination and agility. These reactive skills are crucial in preventing injuries like ACL tears, as they enable athletes to
make quick, safe movements in high-stakes environments. To better prepare athletes for these challenges, a deeper
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understanding of our patients' ability to adapt to environmental disruptions is essential. This involves exploring how the
sensorimotor system-the integration of sensory input and motor responses—can be trained to improve an athlete's readiness for
sports.
Research suggests that athletes who can effectively process and respond to complex stimuli are better equipped to handle the
dynamic nature of sports. Therefore, incorporating drills that mimic the dynamic, unpredictable nature of sports can help athletes
develop better reactive strategies, enhancing their ability to avoid injuries. This method of training not only aims to improve
physical readiness but also the cognitive aspects of sports performance, ultimately leading to a more holistic approach to injury
prevention and rehabilitation [12].
Key to this research is understanding how the sensorimotor system can be trained to improve an athlete's performance in real-
time, reactive situations. Nonlinear pedagogy, which emphasizes variability and adaptability in learning, can be particularly
beneficial in this context. Unlike traditional training methods that rely on repetitive, predictable drills, nonlinear pedagogy
involves exercises that are varied and mimic the chaotic environment of a real game. This approach helps athletes develop
flexibility and resilience, enabling them to better cope with unexpected changes and avoid injuries.
For instance, training sessions could include drills where athletes must react to the sudden movements of others, adjust their
trajectories on the fly or make quick decisions under pressure. These scenarios help simulate the stress and unpredictability of
actual gameplay, fostering better coordination and decision-making skills. By focusing on how athletes respond to the
unpredictable actions of opponents, we can develop more effective training protocols that better simulate game conditions [13].
Moreover, this approach to training emphasizes the importance of cognitive readiness. Athletes must be mentally prepared to
make split-second decisions, which can significantly impact their physical movements and overall performance. Therefore,
incorporating cognitive training elements, such as decision-making drills or situational awareness exercises, can further enhance
an athlete's ability to navigate the complexities of their sport [14].
In conclusion, to effectively reduce the risk of ACL injuries and enhance overall athletic performance, it is crucial to integrate
training methods that account for the dynamic, interpersonal nature of sports. By focusing on the sensorimotor system and
employing nonlinear pedagogy, we can better prepare athletes for the real-world challenges they face, ultimately leading to safer
and more effective sports participation.
Brains and Sprains

The brain is the director of sensorimotor control, orchestrating the intricate coordination between sensory input and motor
output. This central role involves processing information from various sensory systems, such as visual, auditory and
proprioceptive inputs and translating this data into precise and coordinated motor actions. Over the past two decades, extensive
research has increasingly highlighted the critical role that sensorimotor control plays in determining behaviors and
biomechanical deficiencies. These deficiencies can significantly contribute to the occurrence of anterior cruciate ligament (ACL)
injuries or emerge as a consequence of the injury's pathophysiology [15].
Sensorimotor control encompasses a range of complex processes that involve the brain, spinal cord, peripheral nerves and
muscles working together to ensure proper movement and stability. The sensorimotor system operates within a constantly
evolving environment, continually adapting to new stimuli and changes in the body's internal and external conditions. This
dynamic interaction underscores the complexity of the mechanisms involved in musculoskeletal rehabilitation. For instance,
when an individual sustains an ACL injury, the damage can disrupt normal sensorimotor control, leading to altered movement
patterns, reduced stability and an increased risk of further injury.
A deeper investigation into these mechanisms is essential for understanding and addressing the full scope of issues related to
sensorimotor control and its impact on injury prevention and recovery. By examining the intricate pathways and interactions
within the sensorimotor system, researchers and clinicians can identify specific factors that contribute to the development and
persistence of biomechanical flaws. Such insights are crucial for developing effective rehabilitation strategies that can mitigate
the risk of ACL injuries and improve outcomes for individuals recovering from these injuries. These strategies may include
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targeted exercises to enhance proprioception, neuromuscular training to improve coordination and interventions to correct faulty
movement patterns [16].
In conclusion, the brain's role as the director of sensorimotor control is fundamental to maintaining proper movement and
preventing injuries. As research continues to unravel the complexities of sensorimotor control and its influence on
musculoskeletal health, it will pave the way for more effective prevention and rehabilitation approaches. This ongoing
exploration holds the promise of reducing the incidence of ACL injuries and facilitating better recovery for those affected,
ultimately contributing to improved long-term outcomes and quality of life for individuals engaged in physical activities [17].
The Sensorimotor System is a Feedback Loop in Dynamic Systems

The sensorimotor system is a fundamental feedback loop within dynamic systems, intricately linking sensory input and motor
output in a seamless and continuous cycle. Our Central Nervous System (CNS) plays a crucial role by continuously integrating
sensory information from various modalities, such as visual, vestibular, somatosensory and auditory inputs. This integration
helps create a comprehensive and real-time representation of our environment, allowing us to navigate and interact with the
world effectively. Subsequent motor actions are then influenced by this sensory information, altering the sensory stimuli, which
in turn perpetuates the cycle. The continuous nature of this feedback loop is essential for successful motor behavior, enabling us
to perform complex tasks with precision and adaptability [18].
Beneath the surface of movement, the sensorimotor system must first distinguish between stimuli generated by the environment
and the anticipated feedback produced by our own actions. This process, known as sensory discrimination and prediction, is
crucial for maintaining accurate and coordinated movements. Impairments in sensory stimuli processing or sensory weighting,
such as visual dependency, can disrupt the accuracy of distinguishing between external environmental stimuli and self-
generated feedback. This distinction is critical because errors in sensory and motor predictions are believed to contribute to
injuries, such as those involving the Anterior Cruciate Ligament (ACL). For instance, an athlete who relies too heavily on visual
cues might not adequately process proprioceptive information from their joints and muscles, leading to poor movement patterns
and increased injury risk [19].
When we consider how individual variability and impairments, such as movement errors, can influence sensorimotor feedback
loops, the complexity of intra-personal coordination (i.e., the ability to control our body in space) becomes apparent. This
complexity is particularly pronounced in the dynamic context of sports, where precise control, rapid adjustments and adaptation
are paramount. Each individual's unique combination of sensory integration and motor response capabilities can lead to
significant differences in performance, coordination and susceptibility to injury.
In sports and other high-demand activities, the sensorimotor system's ability to adapt and accurately predict sensory outcomes
is continuously tested. Athletes must constantly adjust their movements based on sensory feedback to maintain balance,
coordination and optimal performance. Variations in an individual's sensory integration and motor response capabilities can
lead to differences in performance and injury risk. For example, a basketball player must rapidly integrate visual information
about the position of the ball and other players with proprioceptive feedback from their muscles and joints to execute precise
movements and avoid collisions.
Understanding the intricacies of the sensorimotor feedback loop and its role in motor control not only provides insights into
everyday movements but also highlights the importance of tailored training and rehabilitation programs to enhance performance
and reduce injury risk. Rehabilitation programs, for instance, often focus on improving sensory integration and motor control
through targeted exercises that challenge the sensorimotor system. By doing so, individuals can develop better coordination,
reduce the risk of injury and improve overall performance [20].
In essence, the sensorimotor system's feedback loop is a cornerstone of both our everyday functioning and our ability to excel in
complex physical activities. It underscores the importance of a well-coordinated CNS, capable of integrating and responding to
sensory information with precision and adaptability. This system's efficiency directly impacts our ability to perform tasks
ranging from simple daily activities to complex athletic maneuvers, highlighting the profound interconnectedness of sensory
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and motor processes in shaping human movement and behavior.
To further illustrate, consider the role of the vestibular system, which helps maintain balance and spatial orientation. It provides
crucial information about head movements and spatial orientation, enabling us to keep our balance while walking, running or
performing complex movements. When the vestibular system's input is integrated with visual and proprioceptive information,
it allows for smooth and coordinated movements. However, if the vestibular system is impaired, it can lead to dizziness,
imbalance and an increased risk of falls, underscoring the delicate balance required in sensorimotor integration [21].
Moreover, the auditory system also contributes to the sensorimotor feedback loop by providing information about the
environment, such as the location of sounds and changes in auditory stimuli. This information can influence motor actions, such
as turning the head towards a sound or adjusting movements in response to auditory cues. The integration of auditory
information with other sensory inputs enhances our ability to react and adapt to the environment.
In summary, the sensorimotor system's feedback loop is a dynamic and intricate process that integrates sensory information
from multiple modalities to guide motor actions. The ability to accurately discriminate and predict sensory stimuli is essential
for coordinated movement and injury prevention. Understanding the complexities of this system can inform the development
of effective training and rehabilitation programs, ultimately enhancing performance and reducing injury risk. This
comprehensive integration of sensory and motor processes is fundamental to human movement and behavior, highlighting the
importance of the sensorimotor system in our daily lives and athletic endeavors [22].
Intrinsic Dynamics
Consider a basketball point guard attempting to execute an effective lay-up. As the player approaches the basket, the
sensorimotor system manages an infinite number of degrees of freedom while simultaneously perceiving the evolving
environment. The player's brain must quickly process visual information about the position of the basket, the location of
defenders and the trajectory of the ball. Simultaneously, proprioceptive feedback from the muscles and joints informs the brain
about the body's position and movement. Such sports activities require the precise coordination of distributed muscle groups
and joints, which involves complex neuromuscular control. The player must constantly adjust their movements in response to
dynamic visual and proprioceptive feedback, ensuring a smooth and effective lay-up. This intricate coordination showcases the
remarkable adaptability of the human body, allowing athletes to perform under varying and often unpredictable conditions [23].
Several studies support this concept, showing that individuals with Anterior Cruciate Ligament Reconstruction (ACLR) exhibit
a reduced ability to adapt joint coordination during single-limb balance tasks. This reduction in adaptability often manifests as
increased joint stiffness, which can indicate a higher risk of re-injury. For instance, during a single-leg balance task, an individual
with ACLR might display more rigid and less fluid movements compared to a healthy individual, reflecting a compromised
ability to dynamically stabilize the joint. The same pattern of less variable joint coordination is also observed in gait, where ACLR
patients might demonstrate a more uniform and less adaptable walking pattern. Unfortunately, these disturbances in joint
coordination are less clinically tangible than more apparent issues like muscle weakness or a restricted range of motion, making
them harder to diagnose and address effectively in a clinical setting. Clinicians often rely on subjective assessments and
functional tests, which may not fully capture the subtle deficits in coordination and adaptability [24].
What modifiable factors contribute to these impairments and movement errors? How can we ensure we address them effectively?
It is believed that disruptions in sensory feedback within the knee joint, differences in perceptual and cognitive processing and
subsequent changes in muscle recruitment patterns significantly affect intrinsic coordination. These disruptions can stem from
altered proprioceptive signals following ACL injury or reconstruction, leading to compromised sensory integration and motor
output. For example, damage to the ACL can impair the sensory receptors in the knee, resulting in diminished proprioceptive
feedback and a reduced ability to sense joint position and movement. Consequently, the brain receives less accurate information,
affecting the precision and adaptability of motor responses [25].
As we navigate through the complexities of the sensorimotor system, it is crucial to remember that sensory stimuli and sensory
integration play vital roles in informing motor output and facilitating effective movement patterns. Addressing these issues
requires a comprehensive approach that incorporates proprioceptive training, cognitive-motor exercises and targeted
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rehabilitation strategies to enhance sensory feedback and coordination. Proprioceptive training might include exercises that
challenge balance and joint position sense, such as single leg stands on unstable surfaces. Cognitive-motor exercises could
involve tasks that require simultaneous cognitive processing and motor execution, like dribbling a basketball while solving
arithmetic problems. By focusing on these modifiable factors, we can develop more effective interventions to improve joint
coordination, reduce the risk of re-injury and enhance overall athletic performance. Moreover, advanced technologies like motion
capture systems and wearable sensors can provide detailed insights into movement patterns, enabling more precise assessments
and personalized rehabilitation protocols [26].
Ultimately, understanding and improving intrinsic dynamics in athletes, especially those recovering from injuries like ACLR,
can lead to better outcomes not only in terms of physical rehabilitation but also in achieving peak performance levels. Integrating
multidisciplinary approaches that combine insights from biomechanics, neuroscience and sports science will be essential in
advancing our ability to support athletes in their pursuit of excellence and long-term health.
Somatosensory Afferents: What Happens to ACL Mechanoreceptors After Injury?

Proprioception, the body's ability to sense its position, movement and effort, is generated by specialized receptors located in
ligamentous tissues, joint capsules and the muscle-tendon units throughout the body. These receptors, known as proprioceptors,
are essential for maintaining balance, coordination and overall bodily awareness. The signals from these receptors enable the
brain to perceive the position and movement of different body parts, as well as the amount of effort required to perform various
tasks. The integration of this diverse and distributed array of somatosensory afferents is a highly complex process, involving
multiple neural pathways and centers, including the spinal cord, cerebellum and higher-order central nervous system
(supraspinal level) [27].
The Anterior Cruciate Ligament (ACL) and surrounding structures of the knee joint collectively form one of the most significant
sensory organs in the human body. The ACL, which is crucial for stabilizing the knee joint, is densely packed with proprioceptors
that provide critical information about joint position and movement. Unfortunately, current neuroscience techniques are not yet
advanced enough to fully describe the specific information encoded in the afferent signals from these structures. However, it is
evident that the presence or absence of these signals can provide critical insights into knee function following an ACL injury. For
instance, individuals without an intact ACL tend to increase joint stiffness and hamstring tendon activity to compensate for the
lost ligament, thereby achieving a form of active stability. This compensatory mechanism helps to maintain some degree of
functionality and prevent further injury, even in the absence of the ACL [28].
Despite these compensatory mechanisms, the state of the proprioceptive pathway following ACL Reconstruction (ACLR)
continues to have significant functional and clinical implications. This is particularly relevant considering that all individuals
who have undergone ACLR initially experienced a period of ACL deficiency. The functional state of this pathway remains largely
unknown or unmeasured during the early postoperative stages. This raises important questions about the potential clinical
symptoms that could provide insights into the sensorimotor status of patients during recovery. Identifying these symptoms
could help in the development of better rehabilitation protocols and improve long-term outcomes for individuals undergoing
ACLR [29].
For example, clinical symptoms such as altered gait patterns, increased reliance on visual cues for balance and decreased
coordination may indicate deficits in proprioception. Additionally, subjective reports of instability or a sense of giving way in
the knee joint could also signal proprioceptive impairment. By closely monitoring these symptoms, clinicians can gain valuable
information about the sensorimotor status of their patients and tailor rehabilitation programs to address specific deficits.
Furthermore, advanced imaging techniques and biomechanical assessments could be utilized to measure changes in
proprioceptive function over time, providing a more objective evaluation of the recovery process [30].
In conclusion, proprioception plays a crucial role in maintaining bodily awareness and coordination and its impairment
following ACL injury and reconstruction has significant functional and clinical implications. While current neuroscience
techniques are not yet able to fully describe the information encoded in proprioceptive signals, the presence or absence of these
signals can provide valuable insights into knee function. By closely monitoring clinical symptoms and utilizing advanced
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assessment techniques, clinicians can develop more effective rehabilitation protocols to improve long-term outcomes for
individuals undergoing ACL reconstruction.
Disinhibition at the Spinal Level: Effective Therapies for Inhibiting the Quadriceps Muscles
Joint injury and surgical procedures cause swelling in the joint capsule, leading to a condition known as arthrogenic muscle
inhibition (AMI). AMI is a spinal-level dysfunction that disrupts the normal activation of muscles surrounding the injured joint,
resulting in a significant reduction in muscle strength and function. This phenomenon is particularly evident in the quadriceps
muscles following an Anterior Cruciate Ligament (ACL) injury and subsequent reconstruction surgery. Despite the absence of
direct muscle damage, patients often experience rapid and pronounced muscle atrophy due to AMI. This is a major concern
because it hampers the rehabilitation process and can delay a full recovery [31].
Arthrogenic muscle inhibition is primarily driven by altered sensory inputs from the swollen and injured joint capsule. These
abnormal inputs inhibit the motor neurons that control the quadriceps, preventing them from generating sufficient force. This
inhibition is a protective mechanism intended to prevent further injury, but it also leads to muscle weakness and atrophy [32].
Recent research has identified several disinhibitory interventions that target these altered sensory signals to mitigate the effects
of AMI. Techniques such as Transcutaneous Electrical Nerve Stimulation (TENS) and focal joint cooling have shown considerable
promise in addressing the underlying neuronal mechanisms that cause AMI. TENS involves the application of low-voltage
electrical currents to the skin, which stimulates sensory nerves and can modulate pain signals and muscle activation patterns.
Similarly, focal joint cooling or cryotherapy, reduces local inflammation and swelling, thereby normalizing sensory inputs and
reducing muscle inhibition.
By masking the inhibitory sensory stimuli with TENS or ice, these interventions create a temporary therapeutic "window of
opportunity." During this period, the excitability and strength of the quadriceps motor units are partially restored, allowing
patients to engage in more effective strengthening exercises. This temporary restoration is crucial for maximizing quadriceps
strengthening during the early stages of rehabilitation, often referred to as achieving a "quiet knee." A "quiet knee" is a state
where pain and inflammation are minimized and normal muscle function begins to return, facilitating better overall recovery
[33].
It is essential for clinicians to consider incorporating these disinhibitory techniques into their treatment protocols for patients
recovering from ACL injuries. By doing so, they can enhance muscle activation, improve strength gains and potentially expedite
the rehabilitation process. However, it is important to note that while these treatments have shown effectiveness in the short
term, the long-term impact on brain and central nervous system adaptations remains uncertain. Further research is needed to
fully understand the chronic effects of these interventions and their role in the overall rehabilitation strategy.
In conclusion, joint injury and surgical procedures can lead to significant muscle inhibition due to altered sensory inputs and
swelling. Disinhibitory interventions such as TENS and focal joint cooling offer promising solutions to mitigate these effects and
aid in the recovery process. Clinicians should consider these methods to enhance muscle strength and function during the critical
early stages of rehabilitation, although the long-term benefits and mechanisms still require further investigation.
Joint injury and surgical procedures cause swelling in the joint capsule, leading to a condition known as Arthrogenic Muscle
Inhibition (AMI). AMI is a spinal-level dysfunction that disrupts the normal activation of muscles surrounding the injured joint,
resulting in a significant reduction in muscle strength and function. This phenomenon is particularly evident in the quadriceps
muscles following an Anterior Cruciate Ligament (ACL) injury and subsequent reconstruction surgery. Despite the absence of
direct muscle damage, patients often experience rapid and pronounced muscle atrophy due to AMI. This is a major concern
because it hampers the rehabilitation process and can delay a full recovery [34].
Arthrogenic muscle inhibition is primarily driven by altered sensory inputs from the swollen and injured joint capsule. These
abnormal inputs inhibit the motor neurons that control the quadriceps, preventing them from generating sufficient force. This
inhibition is a protective mechanism intended to prevent further injury, but it also leads to muscle weakness and atrophy. Recent
research has identified several disinhibitory interventions that target these altered sensory signals to mitigate the effects of AMI.
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Techniques such as Transcutaneous Electrical Nerve Stimulation (TENS) and focal joint cooling have shown considerable
promise in addressing the underlying neuronal mechanisms that cause AMI. TENS involves the application of low-voltage
electrical currents to the skin, which stimulates sensory nerves and can modulate pain signals and muscle activation patterns.
Similarly, focal joint cooling or cryotherapy, reduces local inflammation and swelling, thereby normalizing sensory inputs and
reducing muscle inhibition.
By masking the inhibitory sensory stimuli with TENS or ice, these interventions create a temporary therapeutic "window of
opportunity." During this period, the excitability and strength of the quadriceps motor units are partially restored, allowing
patients to engage in more effective strengthening exercises. This temporary restoration is crucial for maximizing quadriceps
strengthening during the early stages of rehabilitation, often referred to as achieving a "quiet knee." A "quiet knee" is a state
where pain and inflammation are minimized and normal muscle function begins to return, facilitating better overall recovery.
It is essential for clinicians to consider incorporating these disinhibitory techniques into their treatment protocols for patients
recovering from ACL injuries. By doing so, they can enhance muscle activation, improve strength gains and potentially expedite
the rehabilitation process. However, it is important to note that while these treatments have shown effectiveness in the short
term, the long-term impact on brain and central nervous system adaptations remains uncertain. Further research is needed to
fully understand the chronic effects of these interventions and their role in the overall rehabilitation strategy [35].
In conclusion, joint injury and surgical procedures can lead to significant muscle inhibition due to altered sensory inputs and
swelling. Disinhibitory interventions such as TENS and focal joint cooling offer promising solutions to mitigate these effects and
aid in the recovery process. Clinicians should consider these methods to enhance muscle strength and function during the critical
early stages of rehabilitation, although the long-term benefits and mechanisms still require further investigation.
The Role of the Integrative Cortex and Neurocognition

"It appears that periods of deafferentation following ACL injury are sufficient to catalyze long-term neuroplastic changes in the
brain and functional differences in brain activity exist even before the injury." - Dave Sherman. Periods of deafferentation, which
refers to the loss of sensory nerve input, following an ACL injury can lead to significant and long-lasting changes in the brain’s
structure and function. This process of neuroplasticity involves the brain adapting to the new conditions by reorganizing its
neural pathways. Research suggests that these changes can result in functional differences in brain activity that may even predate
the injury, indicating that athletes with ACL injuries might have pre-existing neurocognitive vulnerabilities [36].
After sensory signals are initially processed and integrated in the spinal cord, they are transmitted to the brain where higher-
level sensory integration occurs. This integration is crucial for accurately predicting and responding to the dynamic environment
in which an athlete operates. During a game, an athlete must rapidly interpret a vast amount of sensory information to make
hundreds of motor decisions. This involves a complex interplay between visual, auditory and proprioceptive inputs that guide
movements and strategic decisions.
The key to athletic success lies in the athlete's ability to deliberately search for, interpret and anticipate relevant information
related to both the current and future dynamics of their tasks and environment. This perceptual-cognitive control is essential for
high performance. Performance is therefore constrained not only by the situational context and the athlete’s physical capabilities
but also by their ability to process and act on sensory information. For instance, individuals who suffer from ACL injuries often
exhibit slower neurocognitive processing speeds and delayed visuomotor reaction times even before the injury occurs. These
impairments likely persist and may worsen after the injury, further complicating the recovery and return-to-play processes [37].
Given these challenges, the question arises: can we train these perceptual-cognitive skills to enhance recovery and improve
performance? The answer is yes and there are several strategies that can be employed to achieve this: Neurocognitive training
programs aim to enhance brain functions such as attention, memory and decision-making. By using computerized cognitive
training, neurofeedback and virtual reality simulations, athletes can improve their ability to process information quickly and
make effective decisions under pressure. Visual training exercises improve visual skills such as tracking, depth perception and
peripheral vision, helping athletes better interpret fast-moving environments. Drills that focus on these areas can enhance eye-
hand coordination and overall visual processing speed.
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Dual-task training involves engaging in tasks that require simultaneous physical and cognitive effort, mimicking the demands
of athletic competition. For example, performing a physical exercise while responding to cognitive challenges can train the brain
to handle complex situations more efficiently. Mindfulness and focus training techniques like mindfulness meditation, focus
exercises and concentration drills can improve mental clarity and reduce the cognitive load during high-pressure situations,
helping athletes maintain optimal performance levels.
Sport-specific cognitive drills integrate cognitive challenges into sport-specific drills to ensure relevance and applicability to real-
game scenarios. These might include drills that require quick thinking, strategic decision-making and rapid adaptation to
changing conditions. Consistent monitoring and adaptation involve regular assessment of cognitive function using tools like
reaction time tests, neurocognitive evaluations and brain imaging to track progress and adjust training programs to meet the
evolving needs of the athlete.
Implementing these training methods effectively involves a structured approach: Start with a comprehensive evaluation of the
athlete's current neurocognitive abilities to identify specific areas of weakness. Develop a tailored plan that targets the identified
weaknesses while enhancing overall cognitive function. Combine cognitive and physical training regimens to create a holistic
development program. Monitor progress regularly through both subjective reports and objective measurements, making
necessary adjustments to the training plan. Recognize that cognitive training, like physical training, requires a long-term
commitment to achieve and maintain significant improvements [38].
By addressing the neurocognitive aspects of performance, athletes can improve their ability to process information quickly, make
better decisions and react more effectively during competition. This not only enhances performance but also reduces the risk of
re-injury, promoting a safer and more effective return to play. Training these perceptual-cognitive skills can also help athletes to
better anticipate the movements of their opponents, enhance their strategic thinking and adapt to the rapid changes in the game
environment. Additionally, it can help in developing mental resilience, enabling athletes to stay focused and composed under
pressure, which is crucial for peak performance.
Incorporating these neurocognitive training techniques into regular practice sessions can make them a natural part of an athlete's
routine, ensuring continuous improvement. It is also beneficial to use technology and data analytics to track progress and adjust
training protocols as needed, providing a more personalized and effective training experience. By integrating these methods,
coaches and trainers can help athletes reach their full potential, both physically and mentally, leading to improved overall
performance and a reduced likelihood of injury.
Neuronal Efficiency in Athletes

Neuronal efficiency refers to the ability of an individual to integrate a greater amount of perceptual-cognitive information
compared to another, assuming a similar capacity for neural abilities. This involves not only processing more information but
also executing motor actions more efficiently and exhibiting higher activity levels in the brain's sensorimotor areas. Essentially,
neuronal efficiency allows individuals to perform complex tasks with greater precision and less cognitive effort, making it a
critical factor in high-level performance across various domains [40].
Neuronal efficiency is demonstrated in various domains such as higher intelligence, musical abilities and specialized motor
skills. For instance, individuals with higher intelligence or advanced musical abilities often display enhanced neural processing
capabilities, enabling them to perform tasks with minimal neural effort. In these domains, experts require less neural activity to
complete standardized tasks compared to novices. This indicates a more efficient use of their brain's resources, allowing them to
perform at higher levels with less cognitive load. Musicians, for example, can play complex pieces with minimal conscious effort
due to their finely tuned neural pathways developed through extensive practice and experience.
However, in complex and dynamic environments such as sports, the scenario is different. Instead of showing reduced neural
activity, experts in sports utilize more neural activity. This increased activity is particularly evident in the mirror motor neuron
system, which is crucial for predicting and analyzing the movements of opponents. Highly skilled athletes show greater
activation of this system compared to their less skilled counterparts, enabling them to anticipate and respond to opponents'
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actions more effectively. This heightened neural activity helps them navigate the fast-paced and unpredictable nature of sports,
making quick decisions and executing precise movements [41].
These findings suggest that for athletes, neuronal efficiency involves a complex interplay of increased neural activity and efficient
information processing. By gradually reducing the cortical demand for simpler tasks, athletes can free up cognitive resources to
handle the more demanding aspects of their sport. This allows them to process more information simultaneously and respond
to the complexities and chaos inherent in sports environments more effectively. In essence, their brains become more adept at
managing and integrating the barrage of sensory inputs and motor outputs required for peak performance.
Currently, research has shown that individuals who have undergone ACL Reconstruction (ACLR) often exhibit increased fMRI
activity in visual and attentional networks during simple rhythmic tasks. This increase in neural activity indicates a state of
neuronal inefficiency, as their brains are working harder to perform tasks that would typically require less effort. This inefficiency
likely stems from disruptions in neural pathways and sensory-motor integration caused by the injury and subsequent surgery.
The increased demand on visual and attentional networks suggests that these individuals may be compensating for deficits in
proprioceptive feedback and motor control, leading to a greater cognitive load for tasks that should be more automatic [42].
These findings highlight the potential for neuromodulatory intervention practices aimed at enhancing neurocognitive and
integrative networks. Interventions such as neurofeedback, cognitive training and targeted physical therapy could help restore
neuronal efficiency by retraining the brain to process information more effectively and reduce unnecessary neural activity.
Neurofeedback, for example, can provide real-time feedback on brain activity, allowing individuals to learn how to regulate
their neural processes more efficiently. Cognitive training exercises can improve attention, memory and executive function,
which are crucial for processing complex information and making quick decisions. Targeted physical therapy can focus on
restoring proper motor patterns and proprioceptive feedback, reducing the cognitive load required for movement control.
In addition to these interventions, incorporating sports-specific cognitive drills into training can be beneficial. These drills can
simulate the high-pressure, fast-paced environment of competitive sports, helping athletes to improve their decision-making and
motor skills in a context that closely resembles actual gameplay. Techniques such as dual-task training, where athletes perform
cognitive tasks while engaging in physical activities, can further enhance the integration of cognitive and motor functions [43].
In summary, neuronal efficiency is crucial for optimal performance in both cognitive and physical domains. While it involves
reduced neural activity for simpler tasks, in complex environments like sports, it requires increased neural activity to handle the
additional demands. Understanding and improving neuronal efficiency through targeted interventions can lead to better
performance, quicker recovery from injuries and overall enhanced brain function. By focusing on enhancing perceptual-cognitive
skills and integrating them with physical training, athletes can achieve higher levels of performance and resilience, ultimately
improving their ability to compete at elite levels.
Mindfulness and Cognition

In general, selective attention prepares the cognitive system to distinguish between relevant and irrelevant features of the
environment. This ability is crucial for effective interaction with the world, enabling individuals to focus on important stimuli
while ignoring distractions. An increasing body of research suggests that goal-directed attention, known as external focus, results
in better performance compared to self-directed attention, known as internal focus. This distinction has significant implications
for ACL rehabilitation, where the focus of attention can impact recovery outcomes. Findings suggest that an external focus of
attention facilitates the ability to plan, select and execute actions with better environmental perception. This means that athletes
and patients who concentrate on external cues related to their movements, such as the trajectory of a ball or the position of an
opponent, perform more effectively. In contrast, an internal focus of attention, where individuals concentrate on their own
movements or body parts, can divert perception away from the surrounding environment, potentially leading to suboptimal
performance and slower recovery [44].
Following ACL Reconstruction (ACLR), fMRI results suggest greater cognitive demands during rhythmic motor tasks such as
the infinity walk. This indicates that patients recovering from ACLR may need to exert more cognitive effort to perform tasks
that would typically be more automatic. Additionally, healthy individuals at high risk of ACLR injury exhibit less variable
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cortical activity and cortical signs indicating less adaptive motor coordination. This lack of variability and adaptability in cortical
activity suggests that these individuals might struggle with adjusting their movements to changing environments, increasing
their risk of injury [45].
Although the relationship remains theoretical, neuromuscular training strategies based on attention are targeted at these
suboptimal cognitive-motor strategies. These strategies aim to enhance the adaptability and efficiency of motor coordination by
training individuals to focus their attention externally. This could involve exercises that require participants to respond to
external stimuli or navigate dynamic environments, thereby improving their ability to process and integrate sensory information
effectively.
But does this address all aspects of neurocognitive training? What implications does the premovement period of silence have?
The premovement period of silence or the brief moment of cognitive preparation before initiating a movement, is critical for
effective motor execution. During this period, the brain organizes and plans the forthcoming action, integrating sensory inputs
and motor commands. Understanding and optimizing this premovement phase can enhance the efficiency and accuracy of
movements, particularly in athletes recovering from injuries [46].
The neural processes of the limbic system, which encompass emotions and memory, are intricately intertwined with motor
behavior. Neuroplasticity in this system is theoretically linked to negative behavioral changes in models of lower back pain and
chronic pain and has been extended to the ACLR population. This connection suggests that emotional and psychological factors
can significantly impact motor control and recovery. For instance, athletes experiencing fear, anxiety or pain may exhibit altered
motor patterns and reduced coordination, hindering their rehabilitation progress. This means we need to consider the impact of
motivation, fear, anxiety, pain, memory and other factors on the motor control of our athletes. Addressing these elements through
comprehensive rehabilitation programs that include psychological support and stress management techniques can improve
outcomes.
Several recent articles highlight a wide range of psychological, social and contextual factors that affect our patients' recovery
from knee injuries. Critically important for mental and social health and well-being, psychological factors have also been directly
linked to quadriceps function and re-injury rates after ACLR. For example, athletes with higher levels of motivation and lower
levels of fear are more likely to engage fully in rehabilitation exercises and achieve better functional outcomes. Conversely, those
experiencing high levels of anxiety or depression may struggle with adherence to rehabilitation protocols and exhibit poorer
recovery [47].
Psychological, social and contextual factors evolve with the stages of recovery and should be prioritized in the management of
individuals post-ACLR. Early in the recovery process, patients may need more support to manage pain and anxiety, while later
stages might focus on rebuilding confidence and returning to sport-specific activities. By integrating these factors into
rehabilitation programs, clinicians can provide a more holistic approach that addresses both the physical and psychological
aspects of recovery, ultimately leading to better long-term outcomes for patients recovering from ACL injuries.
The Notorious 3 Sets of 10 Repetitions is a Myth

The basal ganglia and the connected motor cortex are crucial for action selection, initiation and task switching of motor activities.
These brain regions work together to coordinate and execute movements by integrating sensory information and motor
commands. In the context of rehabilitation and training, we often focus on largely pre-planned and intentional motor activities.
This approach involves repetitive exercises, such as the well-known "3 sets of 10 repetitions," which heavily rely on the
supplementary motor area (SMA). While this method can help in building strength and muscle memory, it also leads to an
overreliance on a specific motor system. This traditional method of training has been the cornerstone of many rehabilitation
programs due to its simplicity and effectiveness in structured environments [48].
However, differences in neural activation between control groups and individuals with ACL Reconstruction (ACLR) suggest a
decreased propensity for reactive motor control in the latter group. Reactive motor control, which involves adjusting movements
in response to unexpected changes or stimuli in the environment, is less utilized in traditional rehabilitation exercises. This type
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of movement is crucial in sports and other dynamic activities where athletes must constantly adapt to rapidly changing
conditions. The premotor areas of the brain, rather than the SMA, play a significant role in these reactive movements. The
premotor cortex is involved in the planning of movements, understanding the intentions of others and integrating sensory
information to guide actions [49].
Reactive movement is likely more important in sports and utilizes a different motor system, specifically the premotor areas. This
type of movement requires the brain to integrate sensory input and motor output quickly and efficiently, allowing for rapid
adjustments to new or unexpected situations. In sports, athletes need to respond to opponents' actions, changes in play and other
environmental factors, all of which demand high levels of reactive motor control. The ability to perform well under such
conditions is what often separates elite athletes from their peers. Their brain's ability to swiftly process information and execute
precise movements gives them a competitive edge [50].
This suggests the need for therapeutic exercises and research paradigms that focus on reactive motor planning in complex and
changing environments. Traditional "3 sets of 10 repetitions" may not sufficiently prepare athletes for the unpredictable nature
of sports. Instead, incorporating drills that simulate real-game scenarios can enhance an athlete's ability to make quick decisions
and adapt their movements accordingly. This includes exercises that require continuous adaptation of new movement
assumptions and learning from predictive errors. For instance, agility drills that involve reacting to a coach's commands or
unexpected changes in direction can help improve reactive motor skills. Such drills can include sudden stops, starts, changes in
direction and responding to visual or auditory cues, all of which mimic the unpredictable nature of sports competition.
Furthermore, incorporating technology such as Virtual Reality (VR) can create immersive environments where athletes can
practice reactive movements in a controlled yet dynamic setting. VR can simulate various sports scenarios, providing real-time
feedback and allowing athletes to refine their reactive motor skills. Additionally, neuromuscular training that emphasizes
balance, coordination and proprioception can support the development of reactive motor control by enhancing the brain's ability
to process and respond to sensory information. Tools like motion capture systems and force plates can also provide detailed
insights into an athlete’s movement patterns, helping to identify areas for improvement [51].
Cognitive training programs that include decision-making under pressure, multi-tasking exercises and memory tasks can also
play a role in enhancing reactive motor control. These programs can be designed to improve cognitive functions that are critical
for sports performance, such as attention, processing speed and working memory. For example, drills that require athletes to
remember a sequence of movements or make rapid decisions based on changing scenarios can enhance both their cognitive and
motor skills.
In summary, while pre-planned and repetitive exercises like "3 sets of 10 repetitions" are valuable for building foundational
strength and muscle memory, they should be complemented with training that enhances reactive motor control. By incorporating
exercises that simulate real-life sports scenarios and emphasize the importance of adaptability and quick decision-making, we
can better prepare athletes for the dynamic and unpredictable nature of their sports. This holistic approach to training not only
improves performance but also reduces the risk of injury by promoting a more responsive and adaptable motor system. It
acknowledges the complexity of human movement and the need for a comprehensive strategy that addresses both the physical
and cognitive aspects of athletic performance [52].
Integrating these advanced training methods into rehabilitation and athletic training programs can significantly enhance the
effectiveness of these programs. It ensures that athletes are not only physically prepared but also mentally equipped to handle
the demands of their sports. This comprehensive approach can lead to better performance, quicker recovery from injuries and a
lower risk of re-injury, ultimately contributing to the long-term success and well-being of athletes.
"All or Nothing" is a Bit Harder to Achieve

The descending corticospinal pathway is crucial for initiating voluntary muscle contractions and regulating descending motor
control. This neural pathway acts as a bridge between the brain and the spinal cord, transmitting signals that allow for precise
and controlled movements. Within this system, the balance between excitatory and inhibitory potentials determines the
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transmission and activation of motor neurons, following the "all or nothing" principle. When a sufficient level of excitatory input
is reached, motor neurons fire and initiate muscle contractions. However, reduced excitability of the corticospinal tracts
following ACL reconstruction means that a higher level of activation is required before movement can begin. This increased
threshold for activation can lead to delayed responses and decreased muscle efficiency, affecting the overall coordination and
timing of muscle contractions [53].
Despite ongoing treatment efforts, this impairment tends to worsen over time. The decreased excitability is not just a temporary
setback; it reflects an underlying degeneration of the pathway itself. This degeneration can result in a progressive decline in
motor function, making it increasingly difficult for patients to perform voluntary movements with the same ease and precision
they once had. The weakening of this critical pathway underscores the importance of early and effective intervention to prevent
long-term deficits. Over time, the continued degradation of the corticospinal tract can lead to chronic motor impairments, further
complicating the rehabilitation process and limiting the potential for full recovery [54].
Furthermore, corticospinal excitability is strongly linked to key characteristics of quadriceps muscle function, such as the rate of
torque development. The rate of torque development is essential for activities that require quick and powerful muscle
contractions, such as jumping, sprinting and sudden directional changes. A reduction in corticospinal excitability can therefore
lead to a decrease in these functional capabilities, hindering the overall recovery of motor functions. This relationship highlights
the importance of maintaining and enhancing corticospinal excitability as a central goal of rehabilitation programs. Reduced rate
of torque development not only impacts athletic performance but also daily activities, increasing the risk of falls and other injuries
due to compromised muscle function [55].
To address this challenge, it is crucial to develop and adopt treatment strategies that enhance the excitability of the corticospinal
system. EMG biofeedback is one promising option. This technique involves providing patients with real-time feedback on their
muscle activity, helping them to consciously improve their motor control and activation patterns. By visualizing their muscle
activity, patients can make adjustments to their movements, fostering greater awareness and control. Motor imagery, another
effective strategy, involves patients mentally rehearsing movements without actually performing them, which has been shown
to enhance motor pathway activation and improve physical performance. Imagery practice can stimulate similar neural
pathways as actual movement, promoting motor learning and recovery.
Ballistic exercises, which involve rapid and forceful muscle contractions, can also stimulate the corticospinal pathway and
enhance neuromuscular function. These exercises challenge the neuromuscular system to generate quick bursts of power, which
can improve the speed and efficiency of neural transmission. Eccentric exercises, which focus on the controlled lengthening of
muscles under tension, are known to be particularly effective in strengthening muscles and improving motor control. Eccentric
training helps in muscle hypertrophy and neuromuscular adaptation, providing a strong stimulus for recovery and rehabilitation
[56].
In addition to these specific interventions, a multi-faceted approach that combines various therapies may yield the best outcomes.
For example, integrating strength training, balance exercises and proprioceptive training with neuromuscular reeducation
techniques can create a comprehensive rehabilitation program. Using technology, such as virtual reality (VR) and robotic-assisted
therapy, can also enhance rehabilitation by providing immersive and interactive environments for patients to practice and refine
their motor skills [57].
Furthermore, understanding the psychological aspects of recovery is crucial. Motivation, fear and anxiety can significantly
impact the rehabilitation process. Psychological support, including motivational interviewing and cognitive-behavioral therapy,
can help patients overcome mental barriers and stay engaged in their recovery. Addressing these factors can improve compliance
with rehabilitation protocols and enhance overall outcomes [58].
Integrating these techniques into rehabilitation programs can create a more comprehensive approach to restoring motor function.
By focusing on enhancing corticospinal excitability, we can help patients regain their ability to perform voluntary movements
efficiently and effectively. This holistic approach not only addresses the physical aspects of recovery but also supports the neural
16
mechanisms underlying motor control, leading to more sustainable and long-term improvements in function. Ultimately, a well-
rounded rehabilitation program that combines physical, technological and psychological interventions will provide the best
chance for patients to achieve full recovery and return to their desired activities.
What Happens in the Muscle?

A primary clinical feature in individuals with ACLR (anterior cruciate ligament reconstruction) is quadriceps muscle atrophy.
This condition is characterized by a significant reduction in muscle mass and strength, which can severely impact the overall
functionality and performance of the affected leg. Clinicians struggle with persistent inhibition, atrophy and weakness of the
quadriceps muscle. These challenges are often compounded by the difficulty in fully reactivating the muscle and achieving pre-
injury levels of strength and control. Addressing quadriceps atrophy is crucial because the quadriceps play a vital role in knee
stability, shock absorption and overall lower limb functionality [59].
Denervation, which is the separation of nerve tissue from muscles, severely limits the ability to voluntarily contract muscles.
This condition disrupts the normal communication between the nervous system and the muscle fibers, leading to a cascade of
detrimental changes within the muscle tissue. One of the most noticeable changes is an increase in intramuscular fat deposits.
These fat deposits can interfere with muscle contraction and further weaken the muscle, making it less efficient and more prone
to fatigue. This accumulation of fat within the muscle tissue not only affects muscle strength but also its metabolic health,
potentially leading to further complications such as insulin resistance [60].
In addition to fat accumulation, denervation catalyzes fiber type transformations within the muscle. Typically, muscle fibers can
be classified into different types based on their contraction speed and endurance properties. Denervation often causes a shift
from fast-twitch to slow-twitch muscle fibers or vice versa, depending on the specific conditions and duration of denervation.
These changes can alter the muscle's performance characteristics, making it less suited for rapid, powerful movements or
sustained endurance activities. The loss of fast-twitch fibers, which are essential for explosive movements, can significantly
impair an athlete's ability to perform at high levels [61].
Furthermore, denervation enhances circulating atrophy mediators. These mediators, such as inflammatory cytokines and other
biochemical signals, promote muscle breakdown and prevent muscle growth. The presence of these mediators accelerates the
process of muscle atrophy, leading to a more rapid loss of muscle mass and strength. Chronic inflammation associated with these
mediators can further exacerbate muscle weakness and delay the healing process. The inflammatory response also affects
surrounding tissues and can contribute to pain and discomfort, complicating the rehabilitation process [62].
Another critical effect of denervation is the decrease in the number of satellite cells. Satellite cells are essential for muscle repair
and regeneration. They are a type of stem cell that resides within the muscle tissue and can differentiate into new muscle fibers
in response to injury or stress. A reduction in satellite cells compromises the muscle's ability to recover from damage, making it
harder to rebuild muscle mass and regain strength after ACLR. The depletion of these regenerative cells can lead to incomplete
or inadequate muscle repair, prolonging recovery times and reducing overall functional outcomes [63].
To address these myological disturbances, treatments such as Blood Flow Restriction (BFR) and eccentric exercises have been
developed. Blood flow restriction involves applying a constrictive device to the limb to partially restrict blood flow during
exercise. This technique creates a hypoxic environment within the muscle, which has been shown to stimulate muscle growth
and strength gains even with low-intensity exercises. BFR can enhance muscle protein synthesis, increase the recruitment of
muscle fibers and promote greater muscle hypertrophy. The hypoxic environment also encourages the production of growth
factors and other anabolic signals that facilitate muscle repair and growth [64].
Eccentric exercises, on the other hand, focus on the lengthening phase of muscle contractions. These exercises place a high level
of tension on the muscle, which can induce muscle damage and subsequently stimulate muscle repair and growth. Eccentric
training is particularly effective in increasing muscle strength and size, as it engages more muscle fibers and creates a more
significant adaptive response compared to concentric or isometric exercises. The mechanical stress from eccentric contractions
helps to realign muscle fibers, reduce intramuscular fat and improve overall muscle architecture [65].
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In addition to these specific interventions, a comprehensive rehabilitation approach that integrates various therapeutic
modalities can yield optimal results. For example, combining BFR and eccentric exercises with Neuromuscular Electrical
Stimulation (NMES) can further enhance muscle activation and strength. NMES uses electrical impulses to stimulate muscle
contractions, helping to maintain muscle mass and prevent atrophy during periods of reduced voluntary activity.
Moreover, incorporating functional training that mimics real-life movements can improve the transfer of strength gains to daily
activities and sports. Exercises that challenge balance, coordination and agility can enhance neuromuscular control and overall
functional performance. Plyometric exercises, which involve explosive movements like jumping and hopping, can also be
beneficial for rebuilding power and speed in the quadriceps [66].
Nutritional support plays a crucial role in muscle recovery as well. Adequate protein intake is essential for muscle protein
synthesis and repair. Nutrients such as omega-3 fatty acids, vitamin D and antioxidants can help reduce inflammation and
support muscle health. Hydration and overall dietary balance are also important for optimizing recovery and performance.
Psychological factors should not be overlooked in the rehabilitation process. Motivation, adherence to the rehabilitation program
and mental well-being significantly impact recovery outcomes. Providing psychological support and setting realistic, achievable
goals can help patients stay committed to their rehabilitation journey [67].
Integrating these techniques into rehabilitation programs can create a more comprehensive approach to restoring motor function.
By focusing on enhancing corticospinal excitability and addressing the multiple factors contributing to muscle atrophy and
weakness, we can help patients regain their ability to perform voluntary movements efficiently and effectively. This holistic
approach not only addresses the physical aspects of recovery but also supports the neural mechanisms underlying motor control,
leading to more sustainable and long-term improvements in function. Ultimately, a well-rounded rehabilitation program that
combines physical, technological, nutritional and psychological interventions will provide the best chance for patients to achieve
full recovery and return to their desired activities [68].
Neuromuscular Control as a Transistor to Understanding ACL Injuries

The term "neuromuscular control" encompasses a spectrum of human functions, ranging from afferent input, processing of this
input, generation of efferent output and overall system coordination. Neuromuscular control involves the ability to effectively
manage and execute movement by seamlessly integrating sensory information from the body with motor commands from the
brain (Fig. 1). This complex process is essential for maintaining balance, performing coordinated movements and adapting to
changing environments [69].
Neuromuscular control also has a temporal component in continuous feedback loops between sensory and motor processing
that contribute to the final measurable outcome. As muscles contract and body segments move, the afferent system continuously
sends new signals to the motor system to update position, generate force, represent the environment and account for other factors
related to the output signal. These feedback loops ensure that movements are precise, adaptable and efficient, allowing for real-
time adjustments to maintain optimal performance. This constantly updated system represents the profile of neuromuscular
control, which is crucial for movement control and the execution of motor tasks. Effective neuromuscular control enables
individuals to perform complex tasks, such as walking on uneven surfaces or catching a ball, with accuracy and confidence [70].
To experimentally capture the neuromuscular control system, a largely behaviorist and functionalist methodology has
dominated the field, relying on a postural-structural-biomechanical approach. This dominant method primarily concerns
measuring the final performance of the system in terms of joint biomechanics without quantifying the underlying mechanisms
driving this mechanics. While this approach provides valuable insights into movement patterns and joint function, it often
overlooks the intricate neural processes that underpin these behaviors. This behaviorist or outcome-oriented approach does not
consider the extensive neural computations involved in sensory processing along vestibular, visual and somatosensory
pathways, which in turn allow for stability and control in a changing environment. Proprioception, force control and the
kinesthetic input from the sensory system are crucial for organizing motor performance and maintaining the integrity of
neuromuscular control. Understanding these neural computations and their contributions to movement can lead to more
effective rehabilitation strategies and improved outcomes for individuals with movement disorders or injuries [71].
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The ACL is unique compared to most ligamentous structures because it has strong afferent connections to the spinal cord and
brain. This extensive neural connectivity allows the ACL to play a significant role in providing sensory feedback that influences
motor control and stability. This is due to the large number of mechanoreceptors, such as free nerve endings, Ruffini's endings,
Pacinian corpuscles and Golgi receptors in the synovial membrane of the ACL, which significantly contribute to its afferent
function. These mechanoreceptors detect changes in joint position, movement and load, sending critical information to the CNS
to help coordinate protective reflexes and conscious movement adjustments. Restoring these important neurological features has
not been well understood in clinical settings but may prove crucial for future functioning post-ACL injury. The interaction
between proprioceptive stimuli, such as those from the ACL and visual stimuli plays a key role in providing the overall afferent
signal to the CNS for regulating the movement control feedback loop. This integration ensures that movements are well-
coordinated and appropriately adjusted based on the current context and environmental demands [72].
The brain receives somatosensory information in the thalamus and primary somatosensory cortex (through Brodmann areas 3-
1-2), then integrates this afferent information in the posterior parietal cortex, in areas 5 and 7. These regions are involved in
processing sensory input and transforming it into spatial representations of the body and surroundings. The temporal lobe is
also involved here, playing a role in integrating sensory information with memory and other cognitive processes. Processed
vestibular and visual information integrates with somatosensory input before being transmitted to the premotor cortex (area 8)
and finally to the motor cortex (area 6) for motor drive. This hierarchical processing pathway allows the CNS to generate precise
and coordinated motor commands that account for the body’s position, movement and external environment [73].
Musculoskeletal injuries can alter the flow of somatosensory, vestibular and visual processing in the CNS to maintain motor
control. These injuries can disrupt the normal feedback loops and neural computations necessary for effective movement, leading
to compensatory changes in motor planning and control. To preserve neuromuscular integrity in the case of joint injury, the CNS
may compensate by altering motor planning, regulating integrated sensory information reaching motor areas, increasing reliance
on visual feedback or working memory, but also by changing corticospinal drive. This functional reorganization of the CNS is
most likely due to the loss of mechanoreceptors in the damaged tissue, contributing to reduced afferent input. This weakened
sensory function persists even years after injury and despite normalized strength in surrounding muscles [74].
It is a likely source of neuroplasticity following musculoskeletal injury; hence, studying methods that address the sensory-visual-
motor system along with the neuromuscular system in rehabilitation can improve patient function and reduce the risk of re-
injury. By leveraging neuroplasticity, we can develop targeted interventions that enhance the CNS's ability to adapt and
reorganize, leading to better recovery outcomes. This approach involves using advanced techniques such as proprioceptive
training, virtual reality environments and neuromuscular electrical stimulation to stimulate the sensory-motor pathways and
promote functional recovery. By integrating these methods into rehabilitation programs, we can create more effective and
comprehensive treatment plans that address the complex interplay between sensory input, motor output and neural processing.
This holistic approach can help patients regain optimal neuromuscular control, improve movement quality and reduce the
likelihood of future injuries [75].
19
Figure 1: Brain changes after ACL injury. Analysis revealed that the participants in the ACL group exhibited heightened brain
activity in regions associated with visual regulation of movements compared to the control group. This indicates that
individuals who underwent ACL injury and reconstruction depend more heavily on visual cues to modulate their knee
movements (visual motor control) rather than relying on sensory input from the muscles and joints (sensorimotor control).
What’s Next?
As trainers, we cannot continue doing the same thing and expect different results. Considering a single change in the
sensorimotor system, such as altered sensory afferentation following ACLR, the central nervous system (CNS) must gradually
adapt throughout its distributed network in a way that maintains key behavioral traits (e.g., balance, gait). This adaptation
process is essential for regaining functional abilities and preventing further injury. The complexity of the CNS makes it extremely
difficult to know where to intervene, but we cannot be afraid to try. The CNS is incredibly adaptable and neuroplasticity—the
brain's ability to reorganize itself by forming new neural connections—provides a foundation for recovery and rehabilitation.
Changes in the CNS are not permanently fixed and the potential to induce long-term neuroplastic changes has been
demonstrated in populations with much greater denervation (e.g., stroke, spinal cord injury). This plasticity offers hope that,
with the right interventions, we can facilitate significant recovery even in cases of severe injury [76].
The future of ACL injury rehabilitation must incorporate interventions that guide beneficial neuroplasticity through
neuromodulation. This approach involves using techniques that influence neural activity to promote healing and functional
recovery. Moving forward, it will be necessary to globally appreciate the embodied sensorimotor system to systematically and
scientifically test these theories. This holistic perspective acknowledges the intricate interplay between the body and the brain in
movement and rehabilitation. This will require diverse neurophysiological and neurochemical assessments, such as
Electromyography (EMG), functional Magnetic Resonance Imaging (fMRI) and blood biomarkers, to understand the underlying
mechanisms of recovery. With the most important aspect being the integration of clinical knowledge, consideration of patient
experience and utilization of available methods, we can develop more effective, personalized rehabilitation protocols [77].
Areas where we need deeper understanding include interpersonal dynamics, changes in neural networks, reactive motor control
and insights into psychological, social and contextual factors. Interpersonal dynamics, such as the interactions between patients
20
and therapists, can significantly influence rehabilitation outcomes. Understanding changes in neural networks will help us
identify which neural pathways are most affected by injury and how they can be rehabilitated. Reactive motor control is critical
for responding to unexpected changes in the environment, a skill that is especially important in sports. Psychological factors,
such as motivation and fear, as well as social and contextual influences, such as support systems and the rehabilitation
environment, also play vital roles in recovery. For now, there are interventions that exist and should be applied to induce
beneficial plasticity by targeting spinal reflex excitability, re-sensitization of the sensorimotor system, visuomotor dependency,
corticospinal excitability and local muscle growth factors. Techniques like EMG biofeedback, proprioceptive training, visual-
motor integration exercises and specific strength training protocols can be used to address these targets [78].
In summary, embracing a multifaceted approach that integrates neuromodulation and neuroplasticity principles can
significantly enhance ACL injury rehabilitation. By continually advancing our understanding of the CNS and its adaptability,
we can develop innovative and effective rehabilitation strategies that not only restore function but also optimize overall
performance and well-being.
Conflict of Interests
The author declares that he has no conflict of interest in this paper.
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Review Article

Anterior Cruciate Ligament (ACL) Injury Hidden in the Complex

Keywords: Arthrogenic Muscle Inhibition; Neuroplasticity; Anterior Cruciate Ligament; Rehabilitation

More Than Biomechanics

Interpersonal Dynamics: Nonlinear Pedagogy

Brains and Sprains

The Sensorimotor System is a Feedback Loop in Dynamic Systems

and motor processes in shaping human movement and behavior.

Somatosensory Afferents: What Happens to ACL Mechanoreceptors After Injury?

The Role of the Integrative Cortex and Neurocognition

Neuronal Efficiency in Athletes

Mindfulness and Cognition

The Notorious 3 Sets of 10 Repetitions is a Myth

"All or Nothing" is a Bit Harder to Achieve

What Happens in the Muscle?

Neuromuscular Control as a Transistor to Understanding ACL Injuries

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