Integration of Postural Alterations in the Assessment and Neuromotor Rehabilitation after Anterior Cruciate Ligament Surgery: A Narrative Review

Article Information

Florian Forelli1,2 ?, Jean Mazeas1, Marc Linard1, Amaury Vandebrouck3, Pascal Duffiet3, Louis Ratte3, Maude Traulle1,2

1Researcher Physical Therapist in OrthoLab, Clinic of Domont, 85 route de Domont 95330 Domont, France

2Co-Director in OrthoLab, OrthoLab, Clinic of Domont, 85 route de Domont 95330 Domont, France

3Orthopaedic Surgeon, Clinic of Domont, 85 route de Domont 95330 Domont, France

*Corresponding Author: Florian Forelli, OrthoLab, Clinic of Domont, 85 route de Domont 95330 Domont, France

Received: 23 February 2020; Accepted: 04 March 2020; Published: 10 March 2020

Citation: Florian Forelli, Jean Mazeas, Marc Linard, Amaury Vandebrouck, Pascal Duffiet, Louis Ratte, Maude Traulle. Integration of postural alterations in the assessment and neuromotor rehabilitation after anterior cruciate ligament surgery : A narrative review. Journal of Orthopaedics and Sports Medicine 2 (2020): 29-34.

Share at Facebook


Vision is one of the main systems used to control movement and posture. However, ACL injury can lead to changes in motor control which can then entail risks which compromise the chances of patients having undergone ACL reconstruction to return to competition. Current data from the international literature highlight postural disorders associated with visiodependence after ACL surgery and agree that it is essential to assess this type of deficit. There is however no up to date consensus on the evaluation methods. Neuromotor rehabilitation must take into account these disorders which can persist over time in order to optimize the return to the field of patients. Taking postural disorders and visiodependence into account makes it possible to limit the factors and risks and therefore reduce the incidence of iterative ACL tears.


Neuromotor rehabilitation; Visiodependence; ACL; Postural disorders

Rehabilitation articles Rehabilitation Research articles Rehabilitation review articles Rehabilitation PubMed articles Rehabilitation PubMed Central articles Rehabilitation 2023 articles Rehabilitation 2024 articles Rehabilitation Scopus articles Rehabilitation impact factor journals Rehabilitation Scopus journals Rehabilitation PubMed journals Rehabilitation medical journals Rehabilitation free journals Rehabilitation best journals Rehabilitation top journals Rehabilitation free medical journals Rehabilitation famous journals Rehabilitation Google Scholar indexed journals Physical therapist articles Physical therapist Research articles Physical therapist review articles Physical therapist PubMed articles Physical therapist PubMed Central articles Physical therapist 2023 articles Physical therapist 2024 articles Physical therapist Scopus articles Physical therapist impact factor journals Physical therapist Scopus journals Physical therapist PubMed journals Physical therapist medical journals Physical therapist free journals Physical therapist best journals Physical therapist top journals Physical therapist free medical journals Physical therapist famous journals Physical therapist Google Scholar indexed journals Anterior cuciate ligament articles Anterior cuciate ligament Research articles Anterior cuciate ligament review articles Anterior cuciate ligament PubMed articles Anterior cuciate ligament PubMed Central articles Anterior cuciate ligament 2023 articles Anterior cuciate ligament 2024 articles Anterior cuciate ligament Scopus articles Anterior cuciate ligament impact factor journals Anterior cuciate ligament Scopus journals Anterior cuciate ligament PubMed journals Anterior cuciate ligament medical journals Anterior cuciate ligament free journals Anterior cuciate ligament best journals Anterior cuciate ligament top journals Anterior cuciate ligament free medical journals Anterior cuciate ligament famous journals Anterior cuciate ligament Google Scholar indexed journals ACL injury articles ACL injury Research articles ACL injury review articles ACL injury PubMed articles ACL injury PubMed Central articles ACL injury 2023 articles ACL injury 2024 articles ACL injury Scopus articles ACL injury impact factor journals ACL injury Scopus journals ACL injury PubMed journals ACL injury medical journals ACL injury free journals ACL injury best journals ACL injury top journals ACL injury free medical journals ACL injury famous journals ACL injury Google Scholar indexed journals Eye articles Eye Research articles Eye review articles Eye PubMed articles Eye PubMed Central articles Eye 2023 articles Eye 2024 articles Eye Scopus articles Eye impact factor journals Eye Scopus journals Eye PubMed journals Eye medical journals Eye free journals Eye best journals Eye top journals Eye free medical journals Eye famous journals Eye Google Scholar indexed journals Sport articles Sport Research articles Sport review articles Sport PubMed articles Sport PubMed Central articles Sport 2023 articles Sport 2024 articles Sport Scopus articles Sport impact factor journals Sport Scopus journals Sport PubMed journals Sport medical journals Sport free journals Sport best journals Sport top journals Sport free medical journals Sport famous journals Sport Google Scholar indexed journals Player articles Player Research articles Player review articles Player PubMed articles Player PubMed Central articles Player 2023 articles Player 2024 articles Player Scopus articles Player impact factor journals Player Scopus journals Player PubMed journals Player medical journals Player free journals Player best journals Player top journals Player free medical journals Player famous journals Player Google Scholar indexed journals Knee articles Knee Research articles Knee review articles Knee PubMed articles Knee PubMed Central articles Knee 2023 articles Knee 2024 articles Knee Scopus articles Knee impact factor journals Knee Scopus journals Knee PubMed journals Knee medical journals Knee free journals Knee best journals Knee top journals Knee free medical journals Knee famous journals Knee Google Scholar indexed journals Neuromuscular articles Neuromuscular Research articles Neuromuscular review articles Neuromuscular PubMed articles Neuromuscular PubMed Central articles Neuromuscular 2023 articles Neuromuscular 2024 articles Neuromuscular Scopus articles Neuromuscular impact factor journals Neuromuscular Scopus journals Neuromuscular PubMed journals Neuromuscular medical journals Neuromuscular free journals Neuromuscular best journals Neuromuscular top journals Neuromuscular free medical journals Neuromuscular famous journals Neuromuscular Google Scholar indexed journals Exercise articles Exercise Research articles Exercise review articles Exercise PubMed articles Exercise PubMed Central articles Exercise 2023 articles Exercise 2024 articles Exercise Scopus articles Exercise impact factor journals Exercise Scopus journals Exercise PubMed journals Exercise medical journals Exercise free journals Exercise best journals Exercise top journals Exercise free medical journals Exercise famous journals Exercise Google Scholar indexed journals Ligamententoplasty articles Ligamententoplasty Research articles Ligamententoplasty review articles Ligamententoplasty PubMed articles Ligamententoplasty PubMed Central articles Ligamententoplasty 2023 articles Ligamententoplasty 2024 articles Ligamententoplasty Scopus articles Ligamententoplasty impact factor journals Ligamententoplasty Scopus journals Ligamententoplasty PubMed journals Ligamententoplasty medical journals Ligamententoplasty free journals Ligamententoplasty best journals Ligamententoplasty top journals Ligamententoplasty free medical journals Ligamententoplasty famous journals Ligamententoplasty Google Scholar indexed journals ACL rupture articles ACL rupture Research articles ACL rupture review articles ACL rupture PubMed articles ACL rupture PubMed Central articles ACL rupture 2023 articles ACL rupture 2024 articles ACL rupture Scopus articles ACL rupture impact factor journals ACL rupture Scopus journals ACL rupture PubMed journals ACL rupture medical journals ACL rupture free journals ACL rupture best journals ACL rupture top journals ACL rupture free medical journals ACL rupture famous journals ACL rupture Google Scholar indexed journals

Article Details


ACL: Anterior Cruciate Ligament

EO: Eyes Opened

EC: Eyes Closed

COM: Center of Mass

1. Introduction

Vision is one of the main systems controlling movement and posture, along with the integration of proprioceptive information. Numerous studies have shown that neuromotor control depends on this visual system, and so any disturbance of vision automatically results in an alteration of posture [1]. However, in the case of ACL injury, the visual system seems to compensate for proprioceptive alterations and therefore disturbs neuromotor control. With a goal of returning to the field as optimally as possible, it is necessary to be able to assess the postural disorders associated with the reconstruction of the ACL and to develop a rehabilitation strategy aimed at reducing the risks of iterative rupture linked to sports practice.

2. Visual System and ACL Injury

In the context of an ACL injury, the proprioceptive system linked to the various local mechanoreceptors finds itself damaged, and also leads to a deficit in neuromotor control of the knee and of the posture as a whole [2, 3]. This deficit is partially compensated by the integration of visual information, we can then speak of an increase in visiodependence in this population. This visiodependence is mostly noticed on a postural evaluation by comparing the stabilometric parameters on a test with open eyes and closed eyes, with a more significant difference in subjects with an ACL lesion or repair compared to a healthy control population [4, 5]. Since ACL damage is mainly linked to sports practice, it is therefore important to take into account this visiodependence and its impact in return to sport: if the visual field is blocked, as it is very often the case in a sport context, neuromotor control of the player then loses the main sensory system to ensure stability and movement, in a situation where these two components are essential (contact with another player, shooting or pivot phase etc ...) [6]. Where vision plays a lesser role on knee stability in a healthy population [7], this same situation then becomes a risk of injury for players who have had an ACL injury, and dependence on vision presents itself as an additional factor which could partly explain the significant number of iterative ACL tears after initial injury [8]. It is therefore essential to take this factor into account in the neuromotor rehabilitation of these patients [9, 10].

3. Postural Alterations and ACL Surgery

Soltani and et al [11] studied the impact of an ACL ligamentoplasty on postural balance treated either by surgery or by functional treatment. The study highlighted the effect of the lesion on the static postural balance in bipodal for the two types of treatment compared to a control group, but showed no difference between the two treatments offered. The effect of the rupture is also found in unipodal but it would seem that the group having undergone a surgical operation has a more important postural imbalance. However, this study does not specify how long after injury or surgery the measures were taken. The reconstruction of the ACL by hamstring graft or Kenneth-Jones leads to muscular, neuromuscular, proprioceptive repercussions. These changes will have an impact in the regulation of bipodal [11-14] and unipodal [11, 13-21] posture in static and dynamic, which enlightens the importance of measuring and quantifying this imbalance via, for example, force platforms.

4. What Protocols in the Assessment of Postural ACL Disorders?

In their protocols Zouita Ben Moussa and et al [15] and Parus and al [12] offer patients a training session on the platform before measurements, while the other protocols do not offer it. It should be noted that there are some differences in the protocols for carrying out the measurements. First, the positioning of the patient on the platform may change. Indeed, the patient can perform the knee test in extension [12, 15, 17] or knee unlocked in flexion at 20 ° [12, 15, 18, 19, 21]. The flexed position at 20 ° adds an eccentric - isometric contraction of the quadriceps to accentuate the knee's destabilization. In addition, the exercises can either be done with EO [11-13, 16-19, 22] or EC [12, 13, 17, 18, 20]. Four studies performed the same exercises with both EO and EC. In his study Dauty and et al [5] reveals that in bipodal support EC, the values ??of the displacements of the COM in the sagittal and frontal planes, the size of the ellipse and the total value of the displacement of the COM are greater compared to the EO bipodal support test in patients with ACL but also in healthy patients. Tookuni and et al [17] and Pahnabi and et al [18] also highlight this point. Visual control would then be important to allow patients with ACL injury or healthy patients to maintain their stability. The time required to maintain the position to acquire the measurements on a stabilometric balance varies according to the study protocols. Generally, the exercises are maintained between twenty and thirty seconds [10, 11, 12, 16, 18, 19] but some articles propose a duration of ten seconds [15, 17] or as long as possible [13]. To allow a relevant acquisition, it is necessary to have a sufficient hold time but not too important so as not to have the impact of fatigue during the measurement. To limit the onset of fatigue, break times are made between each exercise (between 30s and 1 min) [11, 13, 15].

5. Long-Term Postural Changes

Different articles deal with postural balance at different stages after ACL ligamentoplasty. Dauty and et al [13] studied postural balance two weeks after ACL surgery in unipodal and bipodal. His study evokes a greater ellipse and variation of the COM in bipodal. However, unipodal tests reveal a higher failure rate and the results must be analyzed with caution. In addition, failure to test highlights the difficulty of performing the exercise after a short period of time following a ligamentoplasty and could mean an altered unipodal balance. Pahnabi and et al [18] studied unipodal postural balance in footballers with or without an ACL rupture. His study highlights that at seven months after surgery remains a postural imbalance on the operated but also non-operated leg in subjects with ligamententoplasty. Henriksson and et al [21] also studied the static postural equilibrium three years after rupture of the ACL. The study highlights a greater postural imbalance in the sagittal plane than a control group without ACL rupture. These different studies highlight the effects of ligamentoplasty in the more or less long term on postural balance. Thus, the importance of taking this aspect into account in postoperative rehabilitation seems important to allow recovery of a good balance and therefore return to a sporting activity identical to the one before the injury.

6. Impact on Rehabilitation after ACL Surgery

Studies have been carried out to enable various rehabilitation criteria to be proposed in order to find the most optimal sports recovery possible. Postoperative rehabilitation includes three distinct phases [10] where different conditions will have to be met in order to move from one phase to another. The second phase is often seen as the end of rehabilitation for patients (after five months). As seen above, there remains a postural imbalance several months or even years after the injury. Melick and et al [22] and Kruse and et al [23] highlight in their writings the main axes of rehabilitation after ligamentoplasty. The rapid loading and eccentric muscle work from the third week seem to improve the recovery of muscle strength and the improvement of neuromotor parameters. Neuromuscular rehabilitation must be carried out in conjunction with other rehabilitation techniques. The resumption of sport must be done gradually by combining rehabilitation adapted to the sport practiced. Rehabilitation exercises linked to resumption of sport must use the visual system wisely. Neuromotor practice with eyes closed seems archaic given the current data in the international literature. It is necessary to use the gaze without it becoming a means of postural control. Thus, the use of stroboscopic glasses, blackout, or exercises aimed at excluding the articulation of the visual field seem to decrease the visiodependency of patients having undergone an ACL reconstruction. Gokeler and et al [10] proposes in his analysis various criteria including the use of high-performance technological materials such as gait analysis with cameras, electromyography or even the use of pressure plates. However, the use of these tools is not standardized and would require a large database of healthy patients to better analyze the results of patients with ligamentoplasty.

7. Conclusion

If the various studies agree on the fact that postural disorders are associated with visiodependence after reconstruction of the ACL, it seems difficult for the moment to obtain a standardized evaluation of practices. On the other hand, it seems appropriate to build neuromotor rehabilitation around these disorders, even in the early phases of rehabilitation, in order to reduce the risk of iterative ruptures and allow a resumption of competition in optimal conditions.


  1. Goh KL, Morris S, Lee WL, et al. Postural and cortical responses following visual occlusion in standing and sitting tasks. Exp Brain Res 235: 1875-188.
  2. Wikstrom EA, Song K, Pietrosimone BG, et al. Visual Utilization During Postural Control in Anterior Cruciate Ligament– Deficient and –Reconstructed Patients: Systematic Reviews and Meta-Analyses. Archives of Physical Medicine and Rehabilitation 98 (2017): 2052-2065.
  3. Pahnabi G, Akbari M, Ansari NN, et al. Comparison of the postural control between football players following ACL reconstruction and healthy subjects. Medical Journal of the Islamic Republic of Iran 28 (2014):101.
  4. Okuda K, et al. Effect of vision on postural sway in anterior cruciate ligament injured knees. J Orthop Sci 10 (2005): 277-283.
  5. Lehmann T, Paschen L, Baumeister J. Single-Leg Assessment of Postural Stability After Anterior Cruciate Ligament Injury: a Systematic Review and Meta-Analysis. Sports Med Open 3 (2017): 32.
  6. Grooms DR, Chaudhari A, Page SJ, et al. Visual-Motor Control of Drop Landing After Anterior Cruciate Ligament Reconstruction. J Athl Train 53 (2018): 486- 496.
  7. Louw Q, Gillion N, van Niekerk SM, et al. The effect of vision on knee biomechanics during functional activities: a systematic review. J Sci Med Sport 18 (2015): 469-474.
  8. Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med 38 (2010): 1968-1978.
  9. Grooms D, Appelbaum G, Onate J. Neuroplasticity following anterior cruciate ligament injury: a framework for visual-motor training approaches in rehabilitation. J Orthop Sports Phys Ther 45 (2015): 381-393.
  10. Gokeler A, Dingenen B, Mouton C, et al. Clinical course and recommendations for patients after anterior cruciate ligament injury and subsequent reconstruction: A narrative review. EFORT Open Rev 2 (2017): 410-420.
  11. Soltani N, Rahimi A, Naimi SS, et al. Studying the Balance of the Coper and Non-Coper ACL-Deficient Knee Subjects. Asian J Sports Med 5 (2014): 91-98.
  12. Parus K, Lisinski P, Huber J. Body balance control deficiencies following ACL reconstruction combined with medial meniscus suture. A preliminary report. Orthopaedics and Traumatology: Surgery and Research 101 (2015): 807-810.
  13. Dauty M, Collon S, Dubois C. Change in posture control after recent knee anterior cruciate ligament reconstruction? Clin Physiol Funct Imaging 30 (2009):187-191.
  14. Howells BE, Ardern CL, Webster KE. Is postural control restored following anterior cruciate ligament reconstruction? A systematic review. Knee Surg Sports Traumatol Arthrosc 19 (2011): 1168-1177.
  15. Zouita Ben Moussa A, Zouita S, Dziri C, et al. Single-leg assessment of postural stability and knee functional outcome two years after anterior cruciate ligament reconstruction. Annals of Physical and Rehabilitation Medicine 52 (2009): 475-84.
  16. Hoffman M, Schrader J, Koceja D. An Investigation of Postural Control in Postoperative Anterior Cruciate Ligament Reconstruction Patient. Journal of Athletic Training 34 (1999): 130-136.
  17. Tookuni KS, Neto RB, Pereira CAM, Desouza DR, Andrea Greve JM, Agosto Ayala A, Comparative Analysis of postural control in individuals with and without injuries on knee anterior cruciate ligament.ACTA ORTOP BRAS 13 (2005): 115-119.
  18. Pahnabi G, Akbari M, Nakhostin Ansari N, et al. Comparison of the postural control between football players following ACL reconstruction and healthy subjects. Med J Islam Repub Iran 28 (2014).
  19. Lyshoim M, Ledin T, Odkvist M, et al. Postural control-a comparison between patients with chronic anterior cruciate ligament insufficiencv and healthy individuals. Scad J Med Sci Sports 8 (1998): 432-438.
  20. Sugimoto D, Howell DR, Micheli LJ, et al. Single-leg postural stability deficits following anterior cruciate ligament reconstruction in pediatric and adolescent athletes. Journal of Pediatric Orthopaedics 25 (2016): 338-342.
  21. Henriksson M, Ledin T, Good L. Postural Control after Anterior Cruciate Ligament Reconstruction and Functional Rehabilitation 29 (2001): 359-366.
  22. Melick N, Cingel REH, Brooijmans F, et al. Evidence-based clinical practice update practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. BJSM 18 (2016): 1-13.
  23. Kruse LM, Gray B, Wright RW. Rehabilitation after Anterior Cruciate Ligament Reconstruction A Systematic Review. J Bone Joint Surg Am 94 (2012): 1737-1748.

© 2016-2024, Copyrights Fortune Journals. All Rights Reserved