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Chapter 480Inclusion criteria were: 1) Age between 18-35 years old, 2) unilateral ACL rupture, 3) intact contralateral knee on physical examination, 4) no concomitant injury to bone, cartilage, meniscus, or other ligaments on magnetic resonance imaging (MRI). Participants were excluded if any of the following were present: 1) any history of fractures, osteotomy or previous ligament reconstructive surgery in the lower extremities or spine, 2) a neurological condition leading to musculoskeletal disorders, 3) any other musculoskeletal pathology of the lower limbs, 4) the inability to complete the questionnaires in Dutch. The menisci and anterolateral structures of the knee are known to play a role in the degree of tibial rotation.23 Accordingly, the degree of tibial rotation can be influenced by the presence or absence of any concomitant knee injury. Therefore only subjects without concomitant knee injury were included. Surgical procedureEvery subject underwent anatomic, single-bundle ACLR using a semitendinosus/gracilis graft. The tendons were doubled to create a fourstrand graft. The femoral tunnel was created inside-out in the anatomical position using the anteromedial portal technique. A suspension type fixation was used for the femoral fixation (Endobutton, Smith&Nephew, London, UK).The surgical procedures were performed by two orthopedic surgeons experienced in ACLR. Allocation was dependent on the site of inclusion.RehabilitationRehabilitation was performed according to the Dutch guidelines on ACL injury.45 ACLR rehabilitators went through several phases in which new exercises and movements were added progressively. This program initially focused on increasing range of motion and to decreasing effusion. First, mainly with isometric exercises and electrostimulation. Subsequently, concentric, and eccentric exercises were implemented using closed and open kinetic chain exercises. In addition to strength training, neuromuscular training was added, and attention was paid to proper movement quality to prevent reinjury. Mark Zee.indd 80 03-01-2024 08:56