Search tips
Search criteria 


Logo of jathtrainLink to Publisher's site
J Athl Train. 1999 Apr-Jun; 34(2): 177–193.
PMCID: PMC1322907

Rehabilitation After Anterior Cruciate Ligament Reconstruction in the Female Athlete

Kevin E. Wilk, PT,* Christopher Arrigo, MS, PT, ATC, James R. Andrews, MD,§|| and William G. Clancy, Jr, MD§||



To discuss the rehabilitation program after anterior cruciate ligament (ACL) reconstruction in the female athlete. In addition, we will discuss 8 unique characteristics identified in the female athlete and specific training drills to address and correct the potentially deleterious effects of these unique characteristics.


The female athlete appears to be more susceptible to noncontact ACL injuries than the male athlete. There seem to be many differences between the female and male athlete that may contribute to the increased injury rate in the female athlete. These variations include anatomical and neuromuscular considerations and differences.


Based on the unique characteristics of the female athlete and the anatomical and neuromuscular dissimilarities, a specially designed rehabilitation program has been established for the female athlete after ACL surgery.

Clinical Advantages:

The rehabilitation drills discussed in this article challenge the neuromuscular system through proprioception, kinesthesia, dynamic joint stability, neuromuscular control, and perturbation training activities. Improving the female athlete's neuromuscular system will, we believe, expedite the injured athlete's recovery after ACL injury or surgery. Although the concepts discussed are part of a postoperative rehabilitation program after ACL surgery, these concepts may also be implemented as a preventive program to assist in reducing the incidence of ACL injuries in the female athlete.

Full text

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (5.0M), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Lindenfeld TN, Schmitt DJ, Hendy MP, Mangine RE, Noyes FR. Incidence of injury in indoor soccer. Am J Sports Med. 1994 May-Jun;22(3):364–371. [PubMed]
  • Ferretti A, Papandrea P, Conteduca F, Mariani PP. Knee ligament injuries in volleyball players. Am J Sports Med. 1992 Mar-Apr;20(2):203–207. [PubMed]
  • Komi PV, Karlsson J. Skeletal muscle fibre types, enzyme activities and physical performance in young males and females. Acta Physiol Scand. 1978 Jun;103(2):210–218. [PubMed]
  • Häkkinen K. Force production characteristics of leg extensor, trunk flexor and extensor muscles in male and female basketball players. J Sports Med Phys Fitness. 1991 Sep;31(3):325–331. [PubMed]
  • Komi PV, Karlsson J. Physical performance, skeletal muscle enzyme activities, and fibre types in monozygous and dizygous twins of both sexes. Acta Physiol Scand Suppl. 1979;462:1–28. [PubMed]
  • Bell DG, Jacobs I. Electro-mechanical response times and rate of force development in males and females. Med Sci Sports Exerc. 1986 Feb;18(1):31–36. [PubMed]
  • Viitasalo JT, Komi PV. Interrelationships between electromyographic, mechanical, muscle structure and reflex time measurements in man. Acta Physiol Scand. 1981 Jan;111(1):97–103. [PubMed]
  • Winter EM, Brookes FB. Electromechanical response times and muscle elasticity in men and women. Eur J Appl Physiol Occup Physiol. 1991;63(2):124–128. [PubMed]
  • Komi PV. Physiological and biomechanical correlates of muscle function: effects of muscle structure and stretch-shortening cycle on force and speed. Exerc Sport Sci Rev. 1984;12:81–121. [PubMed]
  • Beard DJ, Dodd CA, Trundle HR, Simpson AH. Proprioception enhancement for anterior cruciate ligament deficiency. A prospective randomised trial of two physiotherapy regimes. J Bone Joint Surg Br. 1994 Jul;76(4):654–659. [PubMed]
  • Häkkinen K, Pakarinen A, Kallinen M. Neuromuscular adaptations and serum hormones in women during short-term intensive strength training. Eur J Appl Physiol Occup Physiol. 1992;64(2):106–111. [PubMed]
  • Zhou S, Carey MF, Snow RJ, Lawson DL, Morrison WE. Effects of muscle fatigue and temperature on electromechanical delay. Electromyogr Clin Neurophysiol. 1998 Mar;38(2):67–73. [PubMed]
  • Vos EJ, Harlaar J, van Ingen Schenau GJ. Electromechanical delay during knee extensor contractions. Med Sci Sports Exerc. 1991 Oct;23(10):1187–1193. [PubMed]
  • Häkkinen K, Komi PV. Electromyographic and mechanical characteristics of human skeletal muscle during fatigue under voluntary and reflex conditions. Electroencephalogr Clin Neurophysiol. 1983 Apr;55(4):436–444. [PubMed]
  • Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med. 1996 Jul-Aug;24(4):427–436. [PubMed]
  • Renström P, Arms SW, Stanwyck TS, Johnson RJ, Pope MH. Strain within the anterior cruciate ligament during hamstring and quadriceps activity. Am J Sports Med. 1986 Jan-Feb;14(1):83–87. [PubMed]
  • Beynnon BD, Fleming BC, Johnson RJ, Nichols CE, Renström PA, Pope MH. Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med. 1995 Jan-Feb;23(1):24–34. [PubMed]
  • Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med. 1996 Nov-Dec;24(6):765–773. [PubMed]
  • Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med. 1996 Jul-Aug;24(4):427–436. [PubMed]
  • Wilk KE, Andrews JR, Clancy WG. Quadriceps muscular strength after removal of the central third patellar tendon for contralateral anterior cruciate ligament reconstruction surgery: a case study. J Orthop Sports Phys Ther. 1993 Dec;18(6):692–697. [PubMed]
  • Hardin JA, Voight ML, Blackburn TA, Canner GC, Soffer SR. The effects of "decelerated" rehabilitation following anterior cruciate ligament reconstruction on a hyperelastic female adolescent: a case study. J Orthop Sports Phys Ther. 1997 Jul;26(1):29–34. [PubMed]
  • Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990 May-Jun;18(3):292–299. [PubMed]
  • Ciccotti MG, Kerlan RK, Perry J, Pink M. An electromyographic analysis of the knee during functional activities. II. The anterior cruciate ligament-deficient and -reconstructed profiles. Am J Sports Med. 1994 Sep-Oct;22(5):651–658. [PubMed]
  • Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997 Jan-Feb;25(1):130–137. [PubMed]
  • Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991 Jul-Aug;19(4):332–336. [PubMed]
  • Shelbourne KD, Foulk DA. Timing of surgery in acute anterior cruciate ligament tears on the return of quadriceps muscle strength after reconstruction using an autogenous patellar tendon graft. Am J Sports Med. 1995 Nov-Dec;23(6):686–689. [PubMed]
  • Rubinstein RA, Jr, Shelbourne KD, VanMeter CD, McCarroll JR, Rettig AC, Gloyeske RL. Effect on knee stability if full hyperextension is restored immediately after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction. Am J Sports Med. 1995 May-Jun;23(3):365–368. [PubMed]
  • Herzog W, Read LJ. Lines of action and moment arms of the major force-carrying structures crossing the human knee joint. J Anat. 1993 Apr;182(Pt 2):213–230. [PubMed]
  • Zheng N, Fleisig GS, Escamilla RF, Barrentine SW. An analytical model of the knee for estimation of internal forces during exercise. J Biomech. 1998 Oct;31(10):963–967. [PubMed]
  • Delitto A, Rose SJ, McKowen JM, Lehman RC, Thomas JA, Shively RA. Electrical stimulation versus voluntary exercise in strengthening thigh musculature after anterior cruciate ligament surgery. Phys Ther. 1988 May;68(5):660–663. [PubMed]
  • Eriksson E, Häggmark T. Comparison of isometric muscle training and electrical stimulation supplementing isometric muscle training in the recovery after major knee ligament surgery. A preliminary report. Am J Sports Med. 1979 May-Jun;7(3):169–171. [PubMed]
  • Wigerstad-Lossing I, Grimby G, Jonsson T, Morelli B, Peterson L, Renström P. Effects of electrical muscle stimulation combined with voluntary contractions after knee ligament surgery. Med Sci Sports Exerc. 1988 Feb;20(1):93–98. [PubMed]
  • Morrissey MC, Brewster CE, Shields CL, Jr, Brown M. The effects of electrical stimulation on the quadriceps during postoperative knee immobilization. Am J Sports Med. 1985 Jan-Feb;13(1):40–45. [PubMed]
  • Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am. 1995 Aug;77(8):1166–1173. [PubMed]
  • Grood ES, Suntay WJ, Noyes FR, Butler DL. Biomechanics of the knee-extension exercise. Effect of cutting the anterior cruciate ligament. J Bone Joint Surg Am. 1984 Jun;66(5):725–734. [PubMed]
  • Lindahl O, Movin A. The mechanics of extension of the knee-joint. Acta Orthop Scand. 1967;38(2):226–234. [PubMed]
  • Beynnon B, Howe JG, Pope MH, Johnson RJ, Fleming BC. The measurement of anterior cruciate ligament strain in vivo. Int Orthop. 1992;16(1):1–12. [PubMed]
  • Arms SW, Pope MH, Johnson RJ, Fischer RA, Arvidsson I, Eriksson E. The biomechanics of anterior cruciate ligament rehabilitation and reconstruction. Am J Sports Med. 1984 Jan-Feb;12(1):8–18. [PubMed]
  • Wilk KE, Escamilla RF, Fleisig GS, Barrentine SW, Andrews JR, Boyd ML. A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med. 1996 Jul-Aug;24(4):518–527. [PubMed]
  • Jenkins WL, Munns SW, Jayaraman G, Wertzberger KL, Neely K. A measurement of anterior tibial displacement in the closed and open kinetic chain. J Orthop Sports Phys Ther. 1997 Jan;25(1):49–56. [PubMed]
  • Beynnon BD, Johnson RJ, Fleming BC, Stankewich CJ, Renström PA, Nichols CE. The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension. A comparison of an open and a closed kinetic chain exercise. Am J Sports Med. 1997 Nov-Dec;25(6):823–829. [PubMed]
  • Wilk KE, Andrews JR. The effects of pad placement and angular velocity on tibial displacement during isokinetic exercise. J Orthop Sports Phys Ther. 1993 Jan;17(1):24–30. [PubMed]
  • Wilk KE, Romaniello WT, Soscia SM, Arrigo CA, Andrews JR. The relationship between subjective knee scores, isokinetic testing, and functional testing in the ACL-reconstructed knee. J Orthop Sports Phys Ther. 1994 Aug;20(2):60–73. [PubMed]
  • Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991 Sep-Oct;19(5):513–518. [PubMed]
  • Barber SD, Noyes FR, Mangine RE, McCloskey JW, Hartman W. Quantitative assessment of functional limitations in normal and anterior cruciate ligament-deficient knees. Clin Orthop Relat Res. 1990 Jun;(255):204–214. [PubMed]
  • Markolf KL, Graff-Radford A, Amstutz HC. In vivo knee stability. A quantitative assessment using an instrumented clinical testing apparatus. J Bone Joint Surg Am. 1978 Jul;60(5):664–674. [PubMed]
  • Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D'Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988 Mar-Apr;16(2):113–122. [PubMed]
  • Perry J, Antonelli D, Ford W. Analysis of knee-joint forces during flexed-knee stance. J Bone Joint Surg Am. 1975 Oct;57(7):961–967. [PubMed]
  • McGown CM, Conlee RK, Sucec AA, Buono MJ, Tamayo M, Phillips W, Frey MA, Laubach LL, Beal DP. Gold medal volleyball: the training program and physiological profile of the 1984 Olympic champions. Res Q Exerc Sport. 1990 Jun;61(2):196–200. [PubMed]
  • Dufek JS, Bates BT. Biomechanical factors associated with injury during landing in jump sports. Sports Med. 1991 Nov;12(5):326–337. [PubMed]
  • Skinner HB, Wyatt MP, Hodgdon JA, Conard DW, Barrack RL. Effect of fatigue on joint position sense of the knee. J Orthop Res. 1986;4(1):112–118. [PubMed]
  • Lattanzio PJ, Petrella RJ, Sproule JR, Fowler PJ. Effects of fatigue on knee proprioception. Clin J Sport Med. 1997 Jan;7(1):22–27. [PubMed]
  • Lattanzio PJ, Petrella RJ. Knee proprioception: a review of mechanisms, measurements, and implications of muscular fatigue. Orthopedics. 1998 Apr;21(4):463–passim. [PubMed]

Articles from Journal of Athletic Training are provided here courtesy of National Athletic Trainers Association