Effect of upper limb isometric training (ULIT) on hamstring strength in early postoperative anterior cruciate ligament reconstruction patients: Study protocol for a randomized controlled trial

Abstract

Anterior cruciate ligament (ACL) injuries impact approximately 68.6 per 100,000 individuals annually, with ACL reconstruction (ACLR) being a common intervention for restoring knee stability in physically active individuals. Despite advancements in surgical techniques and rehabilitation protocols, patients often experience prolonged recovery, hamstring weakness, and neuromuscular deficits, increasing the risk of re-injury and osteoarthritis. Early-phase ACLR rehabilitation primarily focuses on managing pain, swelling, and quadriceps strength, frequently neglecting the critical role of hamstrings in knee stabilization. This leaves a gap in addressing imbalances that hinder functional recovery and return-to-sport timelines. Upper limb isometric training (ULIT) presents an innovative approach to enhance hamstring activation during the early rehabilitation phase. By leveraging the posterior myofascial kinetic chain (PMKC), ULIT indirectly stimulates hamstrings through bilateral static upper limb exercises, such as wall push up, shoulder extension and scapular retraction, promoting neuromuscular coordination and kinetic chain synergy. These exercises mitigate challenges associated with direct hamstring loading, such as arthrogenic muscle inhibition and graft protection needs. Preliminary research suggests upper limb resistance exercise at submaximal voluntary contraction facilitates inter-limb strength gains, improves core abdominals and hamstring activation, and reduces knee imbalances, supporting accelerated recovery and reduced re-injury risk. The ULIT demonstrates potential as an alternative warm-up exercise to promote hamstring activation and enhance overall readiness for physical activity. Emerging findings highlight ULIT as a safe and potentially effective supplementary intervention, but further research is essential to establish its role in ACLR rehabilitation and develop evidence-based protocols. This study aims to evaluate the effects of integrating ULIT into standard care rehabilitation on hamstring strength and physical function in early-phase postoperative ACLR patients with hamstring autograft. The findings could introduce a novel and effective strategy to optimize recovery, enhance functional outcomes, and support a safer return to sport. Trial registration number: ACTRN12624001445561 and available at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=388441&isReview=true.