The Missing Link in the Rehab Process


Forty percent of athletes who undergo ACL reconstructive surgery do not return to pre-injury performance levels, and 65 percent don’t return to competitive sport at all. Furthermore, those who do return to play have a high risk of re-injury.


So is it ACL reconstruction techniques that are the issue? Or are we failing to properly prepare athletes to return to their sport? I lean toward the latter.


Neuro-motor training (NMT) is the crucial and often missing link in athlete rehab, or even preventing ACL injuries—50-80 percent of all non-contact ACL injuries can be avoided with an injury prevention program that focuses on improving movement quality.


NMT involves targeting motor skills such as coordination, agility and proprioception. A new direction for NMT to optimize RTP (return to play) strategies involves focusing significantly on reforming correct movement patterns earlier in the rehab process.


One phenomenon of learning under extensive scientific investigative scrutiny is that of long-term potentiation, which refers to the increased efficiency of a synapse following a specific trained activity. This form of neural plastic training, or NMT, can be trained with activation techniques, such as performing Lateral Mini-Band Shuffles as part of a warm-up before a workout or game.


This band activates the glute medius and hip stabilizers to prevent dynamic knee valgus, a term for when the knee collapses inward—a primary cause of ACL injuries. This helps to re-educate these muscles and reinforces proper biomechanics to keep the body in a strong and stable position when dynamically moving on the court. The latter portion of a rehab program should make this type of exercise a primary focus to correct faulty patterns caused by the injury. [3]


This “missing” stage has been developed and equipped with the purpose of creating an elite re-education program to accelerate rehabilitation and reduce the risk of re-injury. Through a focused attention on movement, it is believed that factors, which may reduce the success of a rehabilitation program as well as enhance re-injury risk, can be corrected quickly and efficiently in a strategic manner to facilitate a timely and safe return to play.


Coordination can be trained. Muscle pre-activation strategies are crucial for prevention as part of a coherent strategy for RTP. One moves efficiently after an injury but one must learn to move correctly by NMT. It is vital to further develop advanced end-stage rehabilitation services to aid athletes in the attainment of their maximal functional recovery, and NMT is a bridge toward reaching this ambition; but what about performance? Well, that’s for another day.


Here is a step-by-step approach to implement an activation strategy to help enhance control and therefore help contribute to lowering the risk of injury or re-injury.


Identify the most crucial movement patterns in your sport. Once you understand the key biomechanics then those movements can be drilled. Here is an activation plan to get going:

Focus on pliability initially. Loosen the soft tissues around your joints and tendons. I recommend a vibration foam roller or trigger point ball to help enhance elasticity. We are trying to lengthen, soften and prime the muscles from a mechanical and neuromuscular standpoint.
Contract and relax rhythmically the primary muscle groups for 2 seconds on/2 seconds off for 20 to 30 seconds to awaken each muscle group.
Dynamic stretch: Adductors, psoas, quads, hamstrings, calves
Using a power band, focus on hip stability drills to counter the knee buckling in. Here are some exercise options: Banded Squat Internal/External Rotations, Banded March, Banded Lateral Shuffle. Do 3 sets of 20 reps each leg.
Activate transversus abdominus and deep core muscles for core stiffness. Dead Bugs and Pallof Press are two good options. Do 100 total reps.
Work lateral ankle stabilizers and foot intrinsics: Foot scrunches, Single-Leg Calf Raises, balance on one leg with eyes closed
Squats and Front and Lateral Lunges (20 each) to get gross movers going
Bear Crawls to activate upper body and trunk further (forward and backwards x10, sideways x5 each way)


You’re good to go! You’ve primed your muscles.



1. Sugimoto D, Myer G, Foss KDB, Hewett T. “Specific exercise effects of preventive neuromuscular training intervention on anterior cruciate ligament injury risk reduction in young females: meta-analysis and subgroup analysis,” BJSM 2015; 49: 282-289

2. Ardern CL, Webster KE, Taylor NF, Feller JA. “Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play,” BJSM 2011; 45(7): 596-606

3. Needle AR, Lepley AS, Grooms DR. “Central Nervous System Adaptation After Ligamentous Injury: a Summary of Theories, Evidence, and Clinical Interpretation,” Sports Med 2016; s40279: 016-0666




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