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Potential role of cross-education in early-stage rehabilitation after anterior cruciate ligament reconstruction
  1. Justin W Andrushko1,2,
  2. Joshua C Carr3,4,
  3. Jonathan P Farthing5,
  4. Lindsey K Lepley6,
  5. Jason M DeFreitas7,
  6. Stuart Goodall1,
  7. Ashlee M Hendy8,
  8. Glyn Howatson1,
  9. Dustin R Grooms9,
  10. Tjerk Zult10,
  11. Tibor Hortobagyi11,12,
  12. Gulcan Harput13,
  13. Maria Papandreou14,
  14. Kazunori Nosaka15,
  15. Richard G Carson16,
  16. Andrea Manca17,
  17. Franca Deriu17,18,
  18. David George Behm19,
  19. Dawson J Kidgell20,
  20. Nicholas C Clark21,
  21. Lara A Boyd2
  1. 1 Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
  2. 2 Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  3. 3 Department of Kinesiology, Texas Christian University, Fort Worth, Texas, USA
  4. 4 School of Medicine, Department of Medical Education, Texas Christian University, Fort Worth, Texas, USA
  5. 5 College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  6. 6 School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA
  7. 7 Applied Neuromuscular Physiology Laboratory, College of Education and Human Sciences, Oklahoma State University, Stillwater, Oklahoma, USA
  8. 8 School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
  9. 9 Division of Athletic Training, School of Rehabilitation and Communications Science, College of Health Sciences and Professionals, & Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, Ohio, USA
  10. 10 Vision and Eye Research Institute, School of Medicine, Faculty of Health, Education, Medicine, and Social Care, Anglia Ruskin University, Cambridge, UK
  11. 11 Kinesiology, Hungarian University of Physical Education, Budapest, Hungary
  12. 12 Institute of Sport Sciences and Physical Education, University of Pécs, Pécs, Hungary
  13. 13 Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
  14. 14 Physiotherapy, University of West Attica, Egaleo, Attica, Greece
  15. 15 School of Medical and Health Science, Edith Cowan University, Joondalup, Western Australia, Australia
  16. 16 Trinity College Institute of Neuroscience and School of Psychology, Trinity College Dublin, Dublin, Ireland
  17. 17 Department of Biomedical Sciences, University of Sassari, Sassari, Italy
  18. 18 Unit of Endocrinology, Nutritional and Metabolic Disorders, AOU Sassari, Sassari, Italy
  19. 19 School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
  20. 20 Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, Clayton, Victoria, Australia
  21. 21 School of Sport, Rehabilitation, and Exercise Sciences, University of Essex, Colchester, UK
  1. Correspondence to Dr Justin W Andrushko, Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne NE1 8SG, UK; justin.andrushko{at}

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Cross-education, which refers to the interlimb transfer of strength or motor skill following unilateral motor training, has demonstrated promise as a rehabilitation strategy for orthopaedic and neurological injuries, despite the limited number of clinical trials conducted. However, its application in anterior cruciate ligament reconstruction (ACLR) rehabilitation has recently been contested, primarily due to the perceived risk of increasing limb asymmetry.1 During ACLR rehabilitation, improved physical function is associated with the ability to restore compromised quadriceps strength and activation.2 Protocols that mitigate and restore quadriceps weakness and strength post-ACLR are a critical component of rehabilitation. Cross-education may attenuate the loss in neuromuscular function during disuse (online supplemental file), serve as an adjunct intervention for increasing quadriceps strength3 and enhance neuroplasticity in pathways known to be attenuated with ACLR (online supplemental file). This commentary reviews the potential role of cross-education in rehabilitation following ACLR and offers a summary of the physiological rationale for considering this intervention during early-stage ACLR rehabilitation.

Supplemental material


Facilitating early strength

Current clinical recommendations after ACLR delay externally loaded open kinetic chain exercises until the fourth week after surgery.1 Although this is advocated to reduce swelling and facilitate the early stages of healing, this process causes a decline in neuromuscular function and strength. When implemented effectively (online supplemental file), cross-education may be an adjunct intervention to mitigate a decline in neuromuscular function and help restore quadriceps strength in the first 3 weeks …

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  • Twitter @justinandrushko, @LindseyLepley, @goodall_stuart, @Tjerk_Zult, @DrNickCC

  • Contributors All authors contributed to the drafting and editing of the editorial.

  • Funding JWA is funded by a Canadian Institutes of Health Research (CIHR) postdoctoral fellowship and a Michael Smith Health Research British Columbia postdoctoral award.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.