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.

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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 …