Neuroplastic and neuromechanical recovery after anterior cruciate ligament reconstruction: systematic review

Abstract

Background: Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures in sports medicine. Despite surgical and rehabilitation advances, patients frequently exhibit persistent neuromechanical asymmetries, proprioceptive deficits, and cortical maladaptation’s that compromise long-term functional outcomes. Objective: To systematically synthesize evidence regarding neuromechanical adaptations following ACLR, integrating findings on strength recovery, proprioception, cortical reorganization, and rehabilitation efficacy. Methods: Following PRISMA 2020 guidelines, a systematic search was conducted in PubMed, Scopus, Web of Science, PEDro, and Cochrane Library for studies published between 2015 and 2025. Boolean operators combined descriptors: (“Anterior Cruciate Ligament Reconstruction” OR “ACL Reconstruction”) AND (“Neuromechanics” OR “Proprioception” OR “Neuroplasticity” OR “Gait”) AND (“Rehabilitation” OR “Physiotherapy” OR “Biomechanics”). Inclusion criteria encompassed randomized, cohort, or case studies assessing neuromechanical outcomes post-ACLR. Fifty studies met eligibility criteria. Results: Evidence consistently indicates that neuromechanical recovery remains incomplete in most patients, with ongoing quadriceps inhibition, altered gait patterns, and impaired proprioception. Neuroplastic changes and asymmetrical activation persist despite conventional training. Multimodal rehabilitation integrating kinetic-chain coordination, plyometric and neurocognitive training, and exergaming enhances motor control and postural stability. Conclusion: Neuromechanical adaptation after ACLR is multifactorial and requires integrative approaches targeting both peripheral and central mechanisms. Proprioceptive retraining and neuroplastic interventions are essential to restore full sensorimotor control and prevent re-injury.