Integrative Rehabilitation Using Acupuncture and Proprioceptive Training After ACL Reconstruction in an Elite Basketball Player: A Case Study with Psychological Follow-Up

Post-surgical complications such as pain, swelling, and proprioceptive deficits are common following anterior cruciate ligament (ACL) reconstruction. This case study examines the combined use of acupuncture with electrical stimulation and a structured rehabilitation program to address persistent knee symptoms and neuromuscular deficits. A 25- year-old male professional basketball player presented with chronic knee pain, limited range of motion, instability, and psychological distress six months post-ACL reconstruction. Initial evaluation revealed proprioceptive impairments and muscular weakness despite completing standard rehabilitation. A targeted six-week intervention, incorporating acupuncture at specific acupoints (ST35, SP9, GB34, ST36, ST40, SP10, ST34) and proprioception-focused rehabilitation, resulted in reduced pain (VAS: 5/10 to 1–2/10), improved knee flexion (left: 45° to 125°, right: 55° to 135°), increased strength (knee extension +4/5), and enhanced proprioception (single-leg stance: 8 ± 3.25 to 17 ± 6.31 seconds). Yellow Flag Risk scores decreased from 75 to 36 by the end of treatment, indicating psychological improvement. This case highlights the potential of integrative therapy to optimize recovery and support physical and psychological readiness for return to elite competition.

Introduction

Post-surgical complications are frequently seen in patients and pain is the most common symptom associated with it which will tends to cause chronic physiologic and psychological consequences (Apfelbaumet al., 2003). According to data from American College of Surgeons (ACS) clinical Congress, postoperative complications typically occur in about 30% of patient, and about half of all complications occur after patient leaves the hospital (Dharapet al., 2022). These complications are particularly common in athletic populations, especially among professional athletes. A dilemma for these athletes is how to balance the goal of getting fully rehabilitation and return to sport or competition as quickly as possible. In reality, many athletes tend to rush for returning before they are fully prepared for the physical demands, which increasing the risk of causing secondary injuries and chronic inflammation.

The anterior cruciate ligament is one of the most injured ligaments for knee joint in both male and female population (Wigginset al., 2016). Anterior cruciate ligament (ACL) reconstruction is a common surgical procedure seen in lot of basketball players who had ACL sprain. Basketball is a sport which involves consistent cutting and pivoting movements which places significant stress on the knee joint. Anterior knee pain following ACL surgery is a well-documented complication, often associated with muscular deconditioning and deficits in proprioception—an individual’s ability to perceive joint position and movement (Thomaset al., 2016). In a regular post ACL rehabilitation program, muscle strength, endurance, range of motion is the major key component. However, proprioception often receives limited attention. Such proprioceptive deficiencies are particularly pronounced after trauma, impacting knee stability and functional recovery (Dhillonet al., 2011). There is research associate with functional outcomes in terms of subjective feeling of stability in knee joint (Noyeset al., 1984).

Proprioception is specialized comprehensive results consist of sensation of joint movement and joint position. The detection of proprioception based on the activity of mechanoreceptors within fibers of ACL (Hanet al., 2020). Acupuncture treatment has demonstrated with benefits of improve muscle filament overlap and sensorimotor function (Mullinset al., 2021). Therapeutic exercise has been utilized widely in the later stage of post-ACL surgery rehabilitation. However, there are limited study on the combined use of acupuncture and rehabilitation exercises to improve overall recovery outcomes at late-stage rehabilitation program.

This case study evaluated the clinical presentation, objective findings, surgical procedures, and postoperative rehabilitation of a national basketball player with ACL tear. This case mainly focused on the effect of combining acupuncture treatment and a structured rehabilitation exercise program in the later stages of recovery. As a matter of fact, proprioception and balance are critical components of advanced rehabilitation, particularly for athletes striving for a full return to sport., This integrative approach showed a promising result in managing pain, enhancing proprioceptive abilities, and facilitating a more complete recovery.

Case Presentation

Patient History

A 25-year-old male, Chinese national basketball player presented to the clinic with persistent knee pain, swelling, and instability, which significantly impaired his ability to perform high-impact activities, such as running on and off court and jumping. The patient reported his pain level is 5/10 on the Visual Analog Scale (VAS) and he also expressed frustration with his limited recovery. These symptoms persisted despite undergoing surgical intervention and completing a six-month rehabilitation program at another facility.

Upon further discussion, the patient revealed that his initial symptoms began after a traumatic contact during one gameplay. Magnetic resonance imaging (MRI) conducted shortly after the game identified bone marrow edema in the proximal tibia and lateral femoral condyle, a complete anterior cruciate ligament (ACL) tear, a lateral collateral ligament (LCL) injury, joint effusion, and swelling of the soft tissues on the lateral side of the knee joint.

The patient underwent surgical intervention comprising three key steps. First, arthroscopic examination revealed synovial hyperplasia, unpolished cartilage surfaces, a narrowed intercondylar fossa, a complete ACL rupture, a longitudinal tear in the posterior corner of the medial meniscus, and a radial tear of the posterior root of the lateral meniscus. Second, ACL reconstruction was performed using semitendinosus and gracilis tendons, which were harvested, folded, and secured through a tibial tunnel with a 20 mm Endo button on the femoral side and a biodegradable screw on the tibial side. Finally, meniscal repairs were conducted, with the medial meniscus tear repaired using the FAST-FIX suture system and the lateral meniscus tear addressed with the TRUESPAN all-inside repair system. Postoperative stability was confirmed arthroscopically before wound closure.

Despite completing six months of rehabilitation focusing on knee stabilization and muscle strengthening, the patient continued to experience pain, swelling, and functional limitations. These challenges prompted him to seek further evaluation and treatment at our clinic.

Clinical Findings

Initial evaluation at our clinic revealed limited range of motion, measured using a standard goniometer, with left knee flexion at 45° and right knee flexion at 55°. Pain and swelling were evident around the knee joint, and functional tests indicated instability. Neurological examination showed normal sensory function and deep tendon reflexes bilaterally. Muscle strength testing revealed deficits in the injured leg, with right knee extension at +3/5 and right ankle dorsiflexion at +4/5, while plantarflexion strength was normal.

The Single-Leg Standing Test with Eyes Closed was conducted to assess proprioceptive ability. During the initial evaluation, the patient achieved a result of 8 ± 3.25 seconds. This indicated significant deficits in proprioception and neuromuscular control, which are critical for functional recovery and return to sport.

Psychological Assessment and Yellow Flag Monitoring

To assess the athlete’s psychological status and monitor emotional resilience throughout the rehabilitation process, the Yellow Flag Risk Assessment Form was administered at baseline and during follow-ups. At the initial evaluation, the athlete scored 75, indicating high psychological distress, with self-reported frustration and fear that his professional career might be at risk. He also expressed concern about potentially losing his position on the national team, a source of both pride and professional identity. These emotional challenges compounded his physical limitations, highlighting the need for a comprehensive, multidisciplinary intervention approach.

Acupuncture and Advanced Rehabilitation

A combined acupuncture and rehabilitation program was initiated to address the patient’s persistent symptoms and proprioceptive deficits. Acupuncture sessions were performed three times a week for the first week, twice weekly for the next two weeks, and once weekly during the final week.

During each session, the patient lay flat while the acupuncturist located acupoints. After skin disinfection, acupuncture needles (0.30 mm × 40 mm, Suzhou Medical Appliance Factory) were inserted to a depth of 30 mm. Acupuncture points utilize during therapy are Dubi medial and lateral (ST35), Yin Mound Spring (SP9), Yang Mound Spring (GB34), Zusanli (ST36), Fenglong (ST40), Xuehai (SP10), Liangqiu (ST34). Upon achieving the deqi sensation, two pairs of electrical acupuncture (EA) connectors were attached to the needles at ST35 medial–ST35 lateral and GB 34–SP 9, ST36–ST 40, SP10–ST 34. Electrical stimulation was applied using an SDZ-V electroacupuncture apparatus, set to a continuous waveform with a 2-Hz frequency and 1 mA–2 mA intensity for 20 minutes. This protocol aimed to reduce pain and swelling while enhancing proprioceptive and neuromuscular function. Detailed application see Figs. 1 and 2.

Fig. 1. Selected acupuncture point.

Fig. 2. Electrical stimulation with acupuncture.

Fig. 1: Selected acupuncture point (see attachment)

Rehabilitation exercises were designed to complement acupuncture, focusing on knee stabilization, muscle strengthening, and dynamic joint control. Specific exercises targeted flexion and extension strength while progressively challenging balance and proprioception through single-leg stance drills. Exercise progression was carefully monitored to prevent overloading the joint.

Outcome

The patient reported a significant reduction in pain levels after the treatment. Psychologically, they felt more confident in their ability to walk, especially trusting their injured leg and placing more weight on it without fear of instability or discomfort.

By the end of the treatment program, the patient demonstrated significant improvements. Pain levels decreased to 1–2 on the VAS, and the patient reported reduced discomfort during high-impact activities like jumping. Stability tests, including the Lachman and anterior drawer tests, were negative. Muscle strength improved, with right knee extension at +4/5 and right ankle dorsiflexion at +5/5.

The Single-Leg Standing Test with Eyes Closed showed marked improvement, with the post-treatment result increasing to 17 ± 6.31 seconds. This highlighted substantial gains in proprioceptive ability and neuromuscular control. Knee range of motion also improved, with goniometric measurements showing an increase from 45° to 90° in the left knee and from 55° to 110° in the right knee by the end of the program. Patient reported with increased confidence in the stability and functionality of his knee.

By the end of the six-week intervention, his Yellow Flag Risk score had decreased to 36, reflecting substantial improvement in psychological outlook.

Follow Up

Initial six-week integrative rehabilitation program, primarily via in clinic consultation. The athlete successfully returned to full competitive basketball within three months post-intervention. By this point, he had resumed high-impact activities including cutting, jumping, and rapid directional changes.

At six months post-treatment, the athlete reported only minor knee swelling following intense training sessions or prolonged competition, and occasional crepitus during deep squats. He continued with once-weekly acupuncture and electrical stimulation sessions for maintenance and adopted the use of a DonJoy knee brace during practices and games.

Functional assessments at follow-up demonstrated full range of motion and muscle strength (5/5) in the involved limb. The athlete reported feeling physically stronger and more confident in dynamic tasks. However, he expressed residual psychological hesitation during certain high-impact movements, such as jump landings, indicating a mild fear of reinjury. This highlights the potential need for integrated psychological readiness training during late-stage rehabilitation in elite athletes.

At one-month, three-month, and six-month follow-ups, scores were 44, 26, and 49, respectively. While the trend suggested overall improvement, the mild rebound at six months likely reflected the demands of returning to competitive play. These fluctuations underscore the importance of integrating psychological readiness strategies—such as fear avoidance retraining and mental performance coaching—into late-stage return-to-sport programs for elite athletes.

The summary of patient outcomes over time as follow in Table I.

Table I. Summary of Patient Outcomes Over Time

Outcome measure	Baseline	Post-treatment	1-Month	3-Month	6-Month
Pain level (VAS)	5/10	1–2/10	3/10	1/10	3/10
Left knee flexion (°)	45°	90°	100°	120°	120°
Right knee flexion (°)	55°	110°	120°	135°	120°
Knee extension strength (Right)	+3/5	+4/5	+4/5	+5/5	+4/5
Ankle dorsiflexion strength (Right)	+4/5	+5/5	+5/5	+5/5	+5/5
Single-leg stance (eyes closed)	8 ± 3.25 sec	17 ± 6.31 sec	20 ± 5.2 sec	23 ± 5.8 sec	20 ± 3.8 sec
Yellow flag score	75	36	44	26	49

Discussion

Acupuncture, when combined with proprioceptive training, offers synergistic benefits that extend beyond pain reduction. The stimulation of mechanoreceptors and afferent neural pathways through electroacupuncture may promote enhanced neuromuscular activation and motor learning, which is essential in restoring joint coordination after surgery. In this case, the concurrent application of acupuncture and proprioceptive drills not only improved balance and single-leg stability but also contributed to a substantial increase in knee flexion range of motion. The neuromodulatory effects of acupuncture likely facilitated improved muscle relaxation and joint mobility, enabling more effective execution of therapeutic exercises. This integrative approach appears particularly beneficial during late-stage rehabilitation when conventional therapy alone may plateau in addressing chronic stiffness and sensorimotor deficits.

Based on the neuroanatomy, proprioception is the ability to detect its position, movement, and orientation in adjacent space. The whole mechanism starts with different mechanoreceptors involved with knee joint. These receptors are Ruffini corpuscles, which located in joint capsules mainly function as responding to pressure and joint position changes. Pacinian corpuscles located in ligaments which function as detecting fast changes in pressure and vibration. Golgi tendon organs and muscle spindle is used for detecting tension of muscle and tendon. Last but not least, there are free nerve endings in the joint capsules, ligaments and muscles to detect pain and mechanical changes. After the stimuli are received by receptors, the information will be delivered to the central nervous system by afferent pathways (Proske, 2023).

Within the spinal cord, conscious proprioception follows the dorsal column medial lemniscal pathway, while unconscious proprioception travels through the spinocerebellar tract. These pathways culminate in higher-order integration centers such as the cerebellum and somatosensory cortex, coordinating movement, posture and balance (Warrenet al., 2018).

Acupuncture stimulates multiple mechanoreceptors and free nerve endings, generating afferent input that may enhance neuromuscular responsiveness. When combined with electrical stimulation, this input is amplified, supporting sensorimotor engagement. The resulting reduction in pain via gate control mechanisms also enables more effective participation in rehabilitation.

This case demonstrates that integrating acupuncture with proprioceptive rehabilitation can lead to meaningful improvements in joint stability, muscular strength, and neuromuscular coordination. Additionally, it highlights the interplay between physical and psychological domains. The significant reduction in the Yellow Flag Risk score from 75 to 36 by the end of the intervention suggests that targeted physical rehabilitation can contribute to mental recovery. Continued reductions in psychological distress during follow-ups—alongside mild rebound at six months—indicate a need for sustained psychosocial monitoring and support. Addressing both mental and physical readiness is essential for safe, confident return to sport in elite athletes.

Post ACL pain complication is common seen for many basketball athletes. Proprioception has been a neglected factor contribute to this pain complication. By utilizing acupuncture techniques combined with individualized rehabilitation program could greatly decrease the pain level, increase balance ability and proprioception ability. This case highlighted the complexity of managing severe knee injuries for basketball athletes and it also demonstrated the importance of addressing proprioceptive deficits during rehabilitation process. Combining acupuncture with electrical stimulation and targeted rehabilitation exercises proved efficacy in mitigating pain, managing swelling, and improving proprioceptive and neuromuscular control. The integration of these modalities facilitated dynamic balance recovery, a critical component for return to sport. Although six months of initial rehabilitation potentially provided a solid base, the persistent proprioceptive deficits brought back attention of the need for ongoing, multidisciplinary care to achieve full recovery and reduce the risk of reinjury.

Practical Applications

This case illustrates the value of incorporating acupuncture with proprioceptive training in advanced stages of ACL rehabilitation. Particularly for elite athletes, this integrative strategy may help resolve persistent neuromuscular deficits and support return to high-level competition. The inclusion of maintenance care and psychological readiness should be emphasized in return-to-sport protocols to prevent reinjury and enhance performance resilience.

Practical Application

This case illustrates the potential benefits of incorporating acupuncture into late-stage rehabilitation for athletes recovering from ACL injuries. The combined approach of acupuncture and advanced rehabilitation effectively addressed pain, swelling, and proprioception deficits, supporting the patient’s recovery and eventual return to professional basketball. Continued care and progression of proprioception-focused exercises are recommended to maintain long-term knee stability and performance.