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Recent Advances in the Prevention and Rehabilitation of ACL Injuries—2nd Edition

A special issue of Applied Sciences (ISSN 2076-3417). This special issue belongs to the section "Biomedical Engineering".

Deadline for manuscript submissions: closed (20 June 2026) | Viewed by 5792

Editor

Dr. Dimitris G. Mandalidis

E-Mail Website
Guest Editor
Department of Physical Education and Sports Science, National and Kapodistrian University of Athens, Athens, Greece
Interests: anatomical and functional asymmetries of the musculoskeletal system; postural control assessment; gait analysis; rehabilitation of musculoskeletal dysfunctions; prevention of sports injuries
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

The anterior cruciate ligament (ACL) is one of the most commonly injured knee ligaments in the athletic population. The treatment of this injury very often requires the implementation of appropriate surgical interventions and long-term physical rehabilitation programs, which are necessary to safely return to the pre-injury level of activity. However, despite improvements in the management of ACL injuries, many athletes worldwide are still injured each year, making it more imperative than ever to prevent the onset of the injury and minimize—if not eliminate—the adverse effects of re-injury.

The anatomy of the athlete’s musculoskeletal system related to lower-limb joint alignment, skeletal asymmetries or deviations, non-fatigued or fatigue-induced functional imbalances, postural control, and fitness deficits are only some of the intrinsic factors that have been under continuous research in recent years.

Research related to the biomechanical analysis of injury is also ongoing and undertaken by many investigators to identify the sports-related factors contributing to its provocation during the execution of athletic movements, such as cuts, jumps, and landings.

Clinical therapists continue to pursue effective and balanced rehabilitation programs with strength training and neuromuscular exercises that will increase athletes’ compliance while simultaneously seeking methods and tests that will optimally assess athletes’ readiness before returning to sports activities.

Furthermore, wearable technology, the use of fMRI to identify brain mechanisms underlying ACL injury risk and sports-related movements, and the application of virtual reality (VR) as well as augmented reality (AR) to identify deficits and enhance neuromuscular training consistently gain ground in individualized ACL injury prevention and rehabilitation.

This Special Issue addresses all working in these areas and welcomes original papers, review articles, and meta-analyses that provide insight into "Recent Advances in the Prevention and Rehabilitation of ACL Injuries—2nd Edition". We are looking forward to your contributions.

Dr. Dimitris G. Mandalidis
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-anonymized peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Applied Sciences is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2400 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • anatomic variations
  • musculoskeletal assessment
  • skeletal asymmetries
  • tibial torsion
  • valgus knee
  • medial knee displacement
  • foot overpronation
  • lower limb joints alignment/misalignment
  • postural control
  • fatigue-induced functional imbalances
  • injury-related biomechanics
  • cutting movements
  • jumping and landing
  • strength exercises/training
  • unsupervised/supervised preventive/rehabilitative programs
  • adherence/compliance with intervention programs
  • post-rehabilitation assessment
  • neuromuscular training
  • wearable technology
  • inertial sensors
  • injury-related brain function
  • virtual and/or augmented reality
  • augmented neuromuscular training
  • personalized rehabilitation

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Related Special Issue

Published Papers (5 papers)

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14 pages, 4268 KB  
Article
Kinematic and Muscle Activity Differences During Change of Direction in Female Second Division Football Players Following ACL Reconstruction Compared with Uninjured Controls
by Loreto Ferrández-Laliena, Lucía Vicente-Pina, Rocío Sánchez-Rodríguez, Mira Ambrus, Sofía Monti-Ballano, Julián Müller-Thyssen-Uriarte, César Hidalgo-García, José Miguel Tricás-Moreno and María Orosia Lucha-López
Appl. Sci. 2026, 16(13), 6631; https://doi.org/10.3390/app16136631 - 2 Jul 2026
Viewed by 178
Abstract
The high rate of reinjury after anterior cruciate ligament reconstruction (ACLR), persistent sex-related disparity, and increased susceptibility during transitional stages in female football players highlight the need for more specific strategies to identify biomechanical parameters associated with valgus collapse. This study aimed to [...] Read more.
The high rate of reinjury after anterior cruciate ligament reconstruction (ACLR), persistent sex-related disparity, and increased susceptibility during transitional stages in female football players highlight the need for more specific strategies to identify biomechanical parameters associated with valgus collapse. This study aimed to compare three-dimensional knee kinematic and synchronized electromyography (EMG) muscle activity of the medial and lateral thigh muscle complexes during a change of direction (COD) task, between ACLR and healthy controls players. A cross-sectional case–control study was conducted with 26 under-23 semiprofessional female football players (22.89 ± 2.68 years), divided into ACLR (n = 13) and control (n = 13) groups. The maximum and minimum peaks and range of knee angular velocity across three planes, along with the average and peak electromyography (EMG) muscle activity of the Biceps Femoris (BF), Semitendinosus (ST), Vastus Medialis (VM), and Vastus Lateralis (VL), were recorded during the preparation and load phases. Between-group differences were assessed using independent t-tests or Mann–Whitney U tests. Statistical significance after Holm–Bonferroni correction was established at p-Holm < 0.05. ACLR players demonstrated significant increased knee valgus angular velocity, alongside 4% reduced average ST muscle activity and 27% diminished peak BF muscle activity during the load phase, compared to controls. These findings indicate altered knee kinematic and muscle activity patterns during COD in ACLR players, suggesting persistent long-term functional adaptations in female football players after ACLR. Full article
(This article belongs to the Special Issue Recent Advances in the Prevention and Rehabilitation of ACL Injuries—2nd Edition)
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17 pages, 1622 KB  
Article
Comparison of Limb Symmetry Index Values Across Different Knee Flexor Strength Testing Conditions in Healthy Male Recreational Athletes
by Natalia Urban and Aleksandra Królikowska
Appl. Sci. 2026, 16(7), 3440; https://doi.org/10.3390/app16073440 - 1 Apr 2026
Viewed by 945
Abstract
Background/Objectives: Restoring lower-limb strength and symmetry is crucial after ACL injury and reconstruction. The limb symmetry index (LSI) is often used to assess strength symmetry for return-to-sport decisions, but various assessment methods can influence outcomes. This study aimed to compare LSI across [...] Read more.
Background/Objectives: Restoring lower-limb strength and symmetry is crucial after ACL injury and reconstruction. The limb symmetry index (LSI) is often used to assess strength symmetry for return-to-sport decisions, but various assessment methods can influence outcomes. This study aimed to compare LSI across common knee flexor testing methods in healthy male athletes and to examine associations between absolute strength outcomes, thereby establishing baseline reference values for LSI in a healthy population. Methods: Twenty-two healthy recreationally active males participated in this prospective cross-sectional study. Knee flexor strength was assessed bilaterally using three force plate isometric tests, a static dynamometer-based test (isometric), and isokinetic dynamometer-based tests. Absolute strength values were normalized to body mass. LSI values were calculated for each testing condition. Differences in LSI across modalities were analyzed with repeated-measures ANOVA, and associations between normalized strength outcomes were assessed using Pearson correlation coefficients. Results: LSI values ranged from 96.69 to 101.83 across the testing conditions, with no significant differences observed between measures. Normalized absolute strength outcomes demonstrated very strong correlations within the same measurement category (r = 0.86–0.94 for force plate tests and r = 0.88–0.96 for isokinetic tests). In contrast, correlations between isometric and isokinetic strength outcomes were moderate (r = 0.41–0.67). Conclusions: LSI values were consistent across knee flexor strength testing modalities, suggesting that symmetry assessment was relatively consistent across different measurement methods in the studied group. In contrast, normalized absolute strength outcomes showed only moderate and variable associations across modalities, indicating that different testing approaches assess related but not interchangeable aspects of muscle strength. Full article
(This article belongs to the Special Issue Recent Advances in the Prevention and Rehabilitation of ACL Injuries—2nd Edition)
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21 pages, 1016 KB  
Article
Test–Retest Reliability and Agreement of Postural Control Variables Within and Between Single-Leg Squat Variations
by Vasileios Chatziilias, Ioannis Kafetzakis and Dimitris Mandalidis
Appl. Sci. 2026, 16(2), 1147; https://doi.org/10.3390/app16021147 - 22 Jan 2026
Cited by 1 | Viewed by 1383
Abstract
Single-leg squats are commonly used to assess lower-limb strength and alignment; however, their application for evaluating postural control remains underexplored. This study assessed the reliability and agreement of postural control measures within and between unipedal squat variations. Twenty-eight physically active adults performed a [...] Read more.
Single-leg squats are commonly used to assess lower-limb strength and alignment; however, their application for evaluating postural control remains underexplored. This study assessed the reliability and agreement of postural control measures within and between unipedal squat variations. Twenty-eight physically active adults performed a conventional single-leg squat (CSLSQ), the anterior excursion of the Y-Balance Test (ANYBT), and a forward step-down (FRSTD) with both limbs on two occasions, 5–7 days apart. The mean values of five trials were analyzed for center-of-pressure (COP) 95% confidence ellipse area (95%CEA), path length (PL), velocity (VL), and mediolateral and anteroposterior variability (RMS-X and RMS-Y). Most COP variables demonstrated good-to-excellent reliability (ICC = 0.780–0.948), whereas RMS-X showed lower reliability (ICC = 0.367–0.803) and higher measurement error across limbs. The FRSTD demonstrated high ICCs (0.780–0.948) and low measurement error, comparable to the CSLSQ (0.794–0.940) and generally higher than the ANYBT (0.790–0.895), regardless of limb. Overall, the dominant limb exhibited higher ICCs and lower measurement error than the non-dominant limb. Inter-task agreement was greatest between the CSLSQ and FRSTD, primarily on the dominant limb, indicating greater potential interchangeability for selected COP metrics (95% CEA, VL, and RMS-Y). These findings may assist clinicians and sports scientists in selecting appropriate single-leg squat tasks and COP measures for assessment. Full article
(This article belongs to the Special Issue Recent Advances in the Prevention and Rehabilitation of ACL Injuries—2nd Edition)
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14 pages, 2433 KB  
Article
Evaluating the Functionality of a Field-Based Test Battery for the Identification of Risk for Anterior Cruciate Ligament Injury: An Exploratory Factor Analysis
by Charis Tsarbou, Nikolaos I. Liveris, Sofia A. Xergia, George Papageorgiou, Vasileios Sideris, Giannis Giakas and Elias Tsepis
Appl. Sci. 2025, 15(1), 167; https://doi.org/10.3390/app15010167 - 28 Dec 2024
Cited by 3 | Viewed by 2232
Abstract
(1) Background: A parsimonious test battery is deemed necessary to efficiently assess the functional performance of athletes avoiding redundant measurements. This study investigates the interrelationships between elements of an experimental field-based test battery during pre-season assessment (PA), with the purpose of enhancing comprehension [...] Read more.
(1) Background: A parsimonious test battery is deemed necessary to efficiently assess the functional performance of athletes avoiding redundant measurements. This study investigates the interrelationships between elements of an experimental field-based test battery during pre-season assessment (PA), with the purpose of enhancing comprehension of the underlying structure of the assessed variables and suggesting guidelines for the tests incorporated in a PA. (2) Methods: Sixty-two professional football athletes performed a PA, including isometric muscle strength, triple hop and core stability tests, the LESS, and evaluation of landing performance through kinetic and electromyographic data. (3) Results: For the dominant lower limb, the factor analysis resulted in six factors, explaining 79.04% of the variance including core stability, ground reaction forces, dynamic balance, hamstrings strength, quadriceps–hamstring EMG ratio, and quadriceps performance. For the non-dominant lower limb, factor analysis resulted in five factors, explaining 76.60% of the variance including core stability, dynamic balance, ground reaction force, quadriceps–hamstring EMG ratio, and quadriceps–abductors strength. The LESS was loaded with various factors. (4) Conclusions: Given the need for efficient field-based assessments that can be repeated throughout the season without sacrificing data quality, we suggest incorporating the LESS, the prone bridge test, and force-plate-based landing performance evaluation as key elements of the PA. Full article
(This article belongs to the Special Issue Recent Advances in the Prevention and Rehabilitation of ACL Injuries—2nd Edition)
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13 pages, 499 KB  
Case Report
Prehabilitation with Low-Load Blood Flow Restricted Resistance Exercise Training Attenuates Muscle Inhibition of Quadriceps Femoris Muscle in Polytraumatized Patient: A Case Report
by Matej Ipavec, Alan Kacin and Tina Tomc Žargi
Appl. Sci. 2026, 16(12), 6079; https://doi.org/10.3390/app16126079 - 16 Jun 2026
Viewed by 162
Abstract
Background: Severe knee trauma and chronic cruciate ligament insufficiency are commonly accompanied by marked quadriceps femoris (QF) atrophy and weakness. High-load strengthening is often poorly tolerated by patients with compromised joint stability; therefore, low-load blood flow restriction resistance training (LL-BFRT) may serve as [...] Read more.
Background: Severe knee trauma and chronic cruciate ligament insufficiency are commonly accompanied by marked quadriceps femoris (QF) atrophy and weakness. High-load strengthening is often poorly tolerated by patients with compromised joint stability; therefore, low-load blood flow restriction resistance training (LL-BFRT) may serve as an effective alternative. Case presentation: A 38-year-old male presented 27 months after motorcycle-related polytrauma with right knee pain, instability, complete anterior and posterior cruciate ligament ruptures, and partial QF denervation after femoral nerve injury. Before surgery, he completed a supervised 5-week LL-BFRT prehabilitation program (13 sessions). Results: Lean thigh circumference increased by 5.9% proximally and 17.7% distally. Voluntary activation increased from 87.2% to 92.5%, and maximal QF EMG median frequency decreased by 7.4%. Knee extensor isometric and concentric (60°/s) peak torque increased by 52.4% and 36.9%, respectively. QF isometric endurance time increased from 48.5 to 61.8 s. Stair-climbing time decreased from 18.9 to 10.6 s, repetitions in the step-down test increased from 10 to 17, and the Y-balance test composite score increased from 77.7% to 99.4%. Conclusions: Substantial physiological and clinical improvements in QF voluntary activation, maximal strength, endurance, and lower limb function were observed following a short-term LL-BFRT program in a patient with multiple ligament injuries. Changes in lean thigh circumference were consistent with possible improvements in muscle size; however, muscle hypertrophy was not directly assessed. Full article
(This article belongs to the Special Issue Recent Advances in the Prevention and Rehabilitation of ACL Injuries—2nd Edition)
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