Statistics from Altmetric.com
ACL ruptures are rapidly increasing.1 ACL injuries can have a profound impact on an athlete’s physical and psychological functioning, and sporting career. Current standard of care following ACL injury is neuromuscular rehabilitation to help athletes regain motor skills. Optimising how rehabilitation is delivered has the potential to further enhance motor relearning and reduce the risk of secondary knee injuries.2
ACL injury rehabilitation programmes aiming to reduce secondary injury risk often involve explicit learning strategies to improve biomechanics and increase neuromuscular control.3 Athletes are mostly instructed to consciously control movements using internally focused, verbal cues that prescribe desired movement patterns (eg, ‘do not bring your knees over your toes’ during squatting). Only with sustained practice does explicit learning result in consistent, fluent, and automatic, motor performance.
Recently, practitioners have been encouraged to minimise explicit learning during ACL injury rehabilitation, and use implicit learning interventions such as external focus cues.2 We contend that implicit interventions are not a panacea, and that explicit interventions remain important in ACL injury rehabilitation. We discuss key individual characteristics and contextual constraints that warrant the use of explicit interventions.
Why would implicit learning be beneficial to ACL rehabilitation?
The theoretical advantage of implicit learning interventions is that athletes reach automaticity earlier in the learning process. Accordingly, implicit learning should reduce the risk of reinjury as:
Athletes will have more attentional resources available to deal with high cognitive–perceptual demands of events that often precipitate ACL injuries (eg, an approaching defender or incoming ball).
Athletes will be less likely to fall back on using verbal rules to consciously control movement, especially when anxious or fatigued. This enables them to ‘self-organise’ and flexibly adapt to quickly changing task demands (eg, a rapid change in direction of movement).
Evidence for implicit learning in the context of ACL injury
There is evidence that interventions that aim to induce implicit learning can improve preliminary outcomes associated with ACL injury risk (eg, knee biomechanics in standardised laboratory tasks).4 However, changes in biomechanics may not readily translate to actual changes in injury risk. It is also unclear whether improved biomechanics can be attributed to implicit learning per se, as researchers generally do not provide evidence to confirm whether implicit learning indeed occurred (eg, through self-report). For example, Welling et al4 attributed positive effects of a video-instruction intervention on jump landing technique to implicit learning. However, participants almost exclusively reported to have focused internally on movement technique—suggesting explicit learning had occurred.
Moreover, the effects of a purely implicit or explicit ACL injury rehabilitation programme on actual secondary knee injury incidence rates have never been examined. Explicit verbal feedback on movement has, however, been identified as a key active ingredient in primary ACL injury risk reduction.5
It may be best to hedge our bets and avoid putting all our money on implicit learning strategies in the ACL rehabilitation context!
Reappraising explicit motor learning
Tailoring to the individual
Individual differences in proprioception, working memory and motor learning preferences could influence the effectiveness of prescribing implicit or explicit learning interventions for ACL injury rehabilitation (see table 1)6–9:
Proprioceptive deficits are common following ACL injury.10 Proprioception is key to effective automatic movement control,6 and people with proprioceptive deficits benefit from explicit, rather than implicit, motor learning interventions.7
Explicit learning is a cognitively demanding learning method. An individual needs to be able to process verbal instructions, keep these in mind and use these to guide movement execution. There is evidence that individuals with greater verbal working memory capacity benefit from explicit learning. Implicit learning seems more beneficial for individuals with poorer verbal working memory capacity.8
Implicit or explicit learning appears most effective when it is aligned with an individual’s preference.9
While not yet tested in the context of ACL rehabilitation, the above findings strongly warrant against an isolated, one-size-fits-all approach to motor learning. Screening these factors (table 1) may help guide decision-making for the prescription of implicit and explicit motor learning interventions during ACL injury rehabilitation.
Explicit learning strategies to correct suboptimal movement patterns
Context in which athletes perform after ACL injury is also important. Explicit control is necessary for high-level, complex motor performance in cognitively demanding scenarios11 —those in which most non-contact ACL injuries occur. Explicit control allows the performer to intentionally correct inappropriate automatic motor responses, making small changes to technique as required.11 Elite athletes have shown to successfully use explicit interventions to de-automate, and subsequently improve, problematic movements.11 We therefore recommend caution against eradicating explicit motor learning interventions from ACL rehabilitation.
Motor learning to regain sports-specific motor skills after ACL injury is not a ‘one-size-fits-all’ exercise. Coaches and healthcare practitioners need to blend implicit and explicit interventions, and tailor them according to personal and contextual factors. We argue that a blended approach has strong potential to improve outcomes of ACL injury rehabilitation.
Twitter @elmar_kal, @marinuswinters
Contributors EK wrote the first draft. TE, JD, MW and JvdK provided important intellectual input. All authors consented to the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
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.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.