n sports medicine update

Section Editor: Darren L. Johnson, MD

Current Rehabilitation Concepts for Anterior

Cruciate Ligament Surgery in Athletes
Chaitu Malempati, DO; John Jurjans, PT, ATC, SCS; Brian Noehren, PT, PhD; Mary L. Ireland, MD;
Darren L. Johnson, MD

reconstruction, the rehabilita- not compromise ligamentous

Abstract: The anterior cruciate ligament is the most com- tion of these injuries has also
monly disrupted ligament in the knee in high-performance evolved. Rehabilitation after
athletes. Most recently, advancements in surgical technique ACL reconstruction plays a
and graft fixation have enabled athletes to participate in early major role in the functional
postoperative rehabilitation, focusing on range of motion and outcomes of the extremity.2 In
progressing to patellar mobilization, strengthening, and neu- the early surgical management
romuscular control. Several rehabilitation protocols exist with of ACL injuries, full weight
variations in specific exercises, progression through phases, bearing without braces was
and key components. The ultimate goal of rehabilitation is not permitted for 6 to 8 weeks.
to return the athlete to preinjury performance level, includ- In 1983, the program of rigid
ing motion and strength, without injuring or elongating the immobilization was discarded
graft. Each athlete is unique; thus, safe return to play should in favor of immediate con-
be individualized rather than follow a particular postoperative tinuous passive motion, and
month or time line. This article provides an overview of the in 1990, Shelbourne and Nitz3
application and the scientific basis for formulating a rehabili- concluded that an “acceler-
tation protocol prior to and following anterior cruciate liga- ated” rehabilitation program
ment surgery. [Orthopedics. 2015; 38(11):689-696.] allowed athletes to return to
normal function and athletic
activities sooner than patients
stability and result in a lower
incidence of anterior knee pain
compared with non-weight
bearing.3-5 Current ACL reha-
bilitation approaches stress the
importance of immediate mo-
tion and early weight bearing,
immediate muscle exercises,
closed kinetic chain exercises,
early functional activities, and
an earlier return to sports. Pro-
prioceptive and neuromuscular
control drills are also important
for high-level athletes so that
they can regain the dynamic
joint and functional stabil-
ity needed in athletic competi-
tion.6,7
Numerous protocols exist

T he anterior cruciate liga-

ment (ACL) is by far the
most disrupted ligament in
ACL injuries is approximately
1 per 3000 Americans.1 As the
management of these injuries
in the conventional rehabilita-
tion program.
Most recently, advance-
for the rehabilitation of ACL
injuries before and after sur-
gery. The authors urge read-
the knee, with approximately has evolved from nonopera- ments in surgical technique ers to examine the variety of
200,000 isolated injuries an- tive treatment to extracapsu- and graft fixation have en- sources available but under-
nually. Epidemiologic studies lar augmentation and primary abled patients to participate in stand the importance of seeing
estimate that the prevalence of ligament repair to ligament early postoperative rehabilita- these materials as guidelines
tion, focusing on range of mo- because the unique circum-
The authors are from the Department of Orthopaedics—Sports Medicine, tion (ROM) and progressing stances of the patient may re-
University of Kentucky, Lexington, Kentucky. to patellar mobilization and quire adjustments, particularly
The authors have no relevant financial relationships to disclose. strengthening. Patients can if the protocol is somewhat
Correspondence should be addressed to: Chaitu Malempati, DO, Depart- bear weight on the affected time focused in its approach.8
ment of Orthopaedics—Sports Medicine, University of Kentucky, 740 S Lime-
stone, Ste K-401, Lexington, KY 40536-0284 (chaitu.malempati@uky.edu). limb immediately. Early weight An important concept is that
doi: 10.3928/01477447-20151016-07 bearing and rehabilitation do each athlete is unique; there-

NOVEMBER 2015 | Volume 38 • Number 11 689

n sports medicine update
application and the scientific
basis for formulating a reha-
bilitation protocol for athletes
prior to and following ACL
surgery. For athletes to return
to competition, they must re-
gain muscular strength and
neuromuscular control in their
injured leg while maintaining
static stability. This article fo-
cuses on some specific phases
and concepts of rehabilitation,
including presurgical reha-
bilitation, early postsurgical
rehabilitation, strengthening,
return to activity, and, ulti-
mately, return to play. Empha-
Figure 1: Prone hang. This is done by lying on the stomach and sliding down sis is on the most recent ACL
to the end of the table or bed where the thigh is supported and the lower leg reconstruction protocol used at
hangs off. A towel may be placed underneath the thigh, just above the patella, to
decrease pressure directly on the patella. This position should be held for 30 to
the authors’ institution as well
60 seconds, allowing gravity to pull the lower leg down toward the floor so that as that published by the Multi-
the knee straightens out. This exercise should be done for 5 to 10 repetitions. center Orthopaedics Outcomes
Network, which consists of a
fore, return to play should be low a rigid time line. This arti- comprehensive protocol based
individualized rather than fol- cle provides an overview of the on specific milestones.8
Table 1
Presurgical Rehabilitation
Aspect of
Rehabilitation Treatment Goal Treatment Intervention
Extension ROM Full extension equal to the op- Prone hangs, working up to more than
posite side 30 minutes per day
Flexion ROM 120° or more of flexion Heel slides, prone flexion stretching
Quadriceps function Straight leg raise without a lag Straight leg raise, quadriceps sets,
sign neuromuscular electrical stimulation
quadriceps, closed chain exercises
limited to 0° to 90°
Gait/brace Full weight bearing, brace un- Patient may ambulate with brace
locked unlocked if demonstrating a normal
gait pattern and not reporting instabil-
ity with activities of daily living; oth-
erwise, locked brace is recommended
Education Patient understands both pre- Integrated team approach with specific
surgical and early postoperative expectations and goals discussed
treatment goals/home exercise between the athlete, physician, ath-
program letic trainer, and physical therapist
Swelling Minimal to none Cryotherapy, compressive sleeve
(eg, Tubigrip [North Coast Medical,
Incorporated, Gilroy, California]),
limb elevation
Abbreviation: ROM, range of motion.
690 Copyright © SLACK Incorporated
Preoperative Phase
Before reconstructive ACL
surgery, emphasis should be
on establishing a normal gait
pattern and active range of mo-
tion of at least 0° to 90°. Only
1 to 3 physical therapy visits
are needed because patients
can transition to a home ex-
ercise program. Patients may
ambulate full weight bearing
with the brace unlocked if they
demonstrate a normal gait pat-
tern and no instability with
activities of daily living. Oth-
erwise, it is recommended that
the brace be locked to provide
support to an unstable knee.
Knee ROM in flexion and ex-
tension is an important predic-
tor of postoperative ROM and
therefore needs to be empha-
sized preoperatively. Prone
hangs (Figure 1), heel slides,
and prone flexion stretching
are some exercises that can
be used to re-establish a good
ROM base after the initial inju-
ry (Table 1). Also, quadriceps
sets and straight leg raises are
recommended in this phase to
maximize quadriceps function.
However, only closed chain
muscle strengthening exercises
should be used and limited to
ROM of 0° to 90°. Straight leg
raises are helpful for quadri-
ceps strengthening and should
be performed without a lag
sign. Neuromuscular electrical
stimulation is another func-
tional modality that can also
be used to improve quadriceps
muscle strength (Table 1).
Another important aspect
of this phase is reducing the
swelling and effusion in the
knee joint that occurs with
an ACL injury. Cryotherapy
(cold with compression and el-
 n sports medicine update

Table 2

Early Postoperative Phase (Weeks 0-4)

Aspect of
Rehabilitation Week 1 Week 4 Treatment Intervention
Extension ROM Symmetric to opposite side Symmetric to opposite side Prone hangs, working up to more than 30 min-
utes per day, extension mobilization in clinic;
splinting for patients unable to reach 0° after
1 to 2 weeks
Flexion ROM 90° 120° or more Heel slides, prone flexion stretching, station-
ary bike
Quadriceps function Able to isolate quadriceps Straight leg raise without lag Neuromuscular electrical stimulation quadri-
contraction sign ceps (home/clinic), quadriceps sets, straight
leg raise; if appropriate, open brace at week
2 in clinic to start 0° to 45° closed chain exer-
cises, including leg press, half squats, termi-
nal knee extensions
Weight bearing WBAT with both crutches Full weight bearing; discon- Progressive loading of involved limb with gait
tinue crutches on a weekly basis
Brace use Brace locked at 0° for weight Brace unlocked for gait Unlock brace at 4 weeks if patients demon-
bearing; otherwise, may be strate a straight leg raise without a lag and
unlocked can ambulate with a normal gait pattern;
patients still may be asked to lock their brace
for uneven terrain or inclement weather (eg,
ice and snow)
Patellar mobility Has active superior glide with Minimally restricted Teach the patient self-mobilizations at first
quadriceps set postoperative visit; therapist mobilizes patella
at all treatments
Swelling/wound care Incisions are clean, dry, intact Minimal swelling Swelling: cryotherapy, use of compression
stockings, including TED hose or Tubigrip
(North Coast Medical, Incorporated, Gilroy,
California); use of home units, including
Game Ready (CoolSystems, Incorporated,
Concord, California)
Abbreviations: TED, thromboembolic deterrent; WBAT, weight bearing as tolerated.

evation), compression sleeves,
and limb elevation can all be
used to attain this goal in prep-
aration for surgery. Further-
more, this phase should also
involve detailed and compre-
hensive education regarding
rehabilitation goals prior to
and immediately after surgery.
Patient education should also
include specific postoperative
exercises that are necessary
for successful rehabilitation,
the importance of compliance,
ambulation with crutches, and
wound care instructions.9 A
discussion of the postoperative
rehabilitation protocol, differ-
ent phases, and recommended
goals before eventual return to
play is imperative in managing
expectations and fostering a
safe and timely return to sport.
Early Postoperative
Phase
This phase consists of the
first 4 weeks (0-4 weeks) after
surgery. The goals during this
period are to minimize pain
and swelling, establish a nor-
mal gait pattern and eventually
discontinue crutch use, achieve
90° of flexion and full exten-
sion, and promote quadriceps
function and good quadriceps
control. It is important to en-
sure that the incisions are clean,
dry, and intact, and appropriate
wound care should be empha-
sized. Cryotherapy is recom-
mended for the first 24 hours or
until acute inflammation is con-
trolled and should be used ev-
ery hour for approximately 15
minutes. After acute inflamma-
tion is controlled, cryotherapy
can be used 3 times a day for 15
minutes and crushed ice can be
useful for reducing swelling af-
ter activity or physical therapy.9
Also, weight bearing as
tolerated with a brace and
both crutches should begin the
day of surgery. This should
include progressive loading
of the involved limb with im-
proved gait on a weekly basis.
Early weight bearing has been
shown to decrease patellofem-
oral pain after ACL surgery.9 A
brace should be applied at the
time of surgery and locked at 0°
for weight bearing initially, but
may be unlocked when seated.
At 4 weeks, the brace may be
shortened and unlocked if the
patient demonstrates a straight
leg raise without a lag and can
ambulate with a normal gait
pattern (Table 2). Crutches,
helpful for safe ambulation

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n sports medicine update
Figure 2: Patellar mobilization. This
exercise is done by simply pushing
the patella up and down and side to
side and holding that position. Move-
ment of the patella is essential when
restoring range of motion during an-
terior cruciate ligament rehabilitation.
If the patella cannot move within the
femoral groove, then the knee cannot
bend and extend.
initially, should only be dis-
continued when a normal gait
pattern without limp has been
established and the patient is
able to safely ascend/descend
stairs without noteworthy pain
or instability (reciprocal stair
climbing).
Furthermore, this phase
is important for establishing
ROM and quadriceps function,
and 2 to 3 physical therapy
visits per week along with a
focused daily home exercise
program is recommended. The
extension ROM goal by week
4 is for the limb to be sym-
metrical to the contralateral
side. For flexion, ROM should
progress from 90° initially to
approximately 120° by week
4. Specific ROM exercises that
are helpful in achieving these
goals include prone hangs
(Figure 1), heel slides, and
prone flexion stretching; a sta-
tionary bike can also be used.
692 Copyright © SLACK Incorporated
Figure 3: Correct method of step
downs. Note that the pelvic land-
marks appear symmetric on each
side and the patella is facing forward,
suggesting no excessive femoral ro-
tation. This athlete is demonstrating
good eccentric control of her knee,
suggesting that she may be ready to
progress her activity level.
Regarding quadriceps function
during this phase, neuromus-
cular electrical stimulation,
quadriceps sets, and straight
leg raises are important and
should be done with a brace
on and locked until the patient
can demonstrate performance
without a lag sign. The physi-
cal therapist should emphasize
closed chain exercises and the
patient should be able to iso-
late quadriceps contraction.
Additionally, “patellar mobil-
ity exercises” or “patellar mo-
bilizations” (Figure 2) are im-
portant for facilitating normal
active extension mechanics.
This includes attainment of a
symmetric superior glide of
the patella during quadriceps
Figure 4: Incorrect method of step
downs. The contralateral pelvis is
dropping down, and there is ipsilat-
eral valgus and femoral internal rota-
tion. This could suggest quadriceps
weakness, hip weakness, or just poor
neuromuscular control.
activation seen during quad-
riceps sets (Table 2). There
are also specific graft consid-
erations that are important to
note during this phase. Ante-
rior cruciate ligament recon-
structions with bone-patellar
tendon-bone autografts are
more prone to patellar hy-
pomobility; therefore, if the
wound is healing well, pro-
gressive patellar mobilizations
(Figure 2) are important. Pa-
tients with hamstring autograft
ACL reconstructions will be
limited in hamstring strength-
ening activities for the first
month.
Strengthening Phase
The strengthening phase
of ACL rehabilitation occurs
from 4 weeks until approxi-
mately 6 months postopera-
tively, but can last longer if
necessary. The brace should
be shortened and unlocked.
It is typically used outside of
the clinic, but can be removed
at the physical therapist’s or
physician’s discretion depend-
ing on the type of activity the
patient is performing. The
advancement of strengthen-
ing is dictated by the patient’s
response. There must be no
increase in either swelling or
articular pain. Short-term ar-
ticular soreness after exercises
should be limited to less than
6 to 12 hours in general and
should not require medication
for reduction. In this phase,
the primary focus should be on
proper technique and avoiding
substitution via compensa-
tory mechanisms. Full ROM
and patellar mobilization are
to be attained as early as pos-
sible if they were not achieved
in the first month postopera-
tively. There is a strict limit
on strengthening ROM dur-
ing closed chain activity to 0°
to 90°; however, earlier in the
phase, it may be best to limit
ROM to shallower depths such
as 45° to 60° to limit patello-
femoral stress.
Specific exercises that
should be stressed during
strengthening of the limb
include mini-squats, mini-
lunges, leg press, hamstring
curls, step downs (Figures
3-4), wall sits, one-legged
deadlifts, 4-way hip exercis-
es, TheraBand (Performance
Health, Akron, Ohio) hip ro-
tator exercises, shuttle, and
wall squats (Table 3). As a
general guideline, repetitions
are higher (10-15 per set) and

lower weights are used earlier
in the phase; later in the phase,
as strength improves, repeti-
tions may be reduced (6-8 per
set) with heavier weights. For
the best outcomes, weights
should be gradually increased.
Multidirectional movements
may also be incorporated to
mimic functional and athletic
activity.
Also, neuromuscular and
cardiopulmonary training are
important aspects of this phase.
Balance cushions or other pro-
prioceptive devices (wobble
board or roller board) can be
used during exercises to em-
phasize neuromuscular control
of the extremity and mimic
functional activities such as
catching, throwing, or kick-
ing. Regarding cardiovascular
endurance, straight line run-
ning on a treadmill or exercise
on a bike, elliptical machine,
or StairMaster (StairMaster,
Vancouver, Washington) in a
protected environment should
be performed (Table 3). To
protect the graft, there should
be no cutting or pivoting dur-
ing these exercises.
Return to Activity Phase
This phase starts at 3
months postoperatively and
continues until an athlete re-
turns to sport. Activity is pro-
gressed via patient response.
It is not unusual for patients to
experience mild joint discom-
fort after starting functional
activities; however, this sore-
ness should improve within 6
to 12 hours with cryotherapy
and without medication. The
presence of swelling indicates
how the knee is responding
to activity. There should be
NOVEMBER 2015 | Volume 38 • Number 11 693
n sports medicine update
Table 3
Strengthening Phase (Months 1-6+)
Aspect of
Rehabilitation Early Phase Advanced Phase
Strengthening Focus primarily on double limb Advance earlier phase activities with
exercises and progression to single gradual increase in weights or range of
limb exercises (eg, mini-squats, motion; may also attempt to incorporate
mini-lunges, leg press, hamstring multidirectional movements to mimic
curls, step downs, wall sits, band functional activity (eg, Y balance and
walks, one-legged deadlifts, 4-way lunge matrix); open chain leg extensions:
hip exercises, TheraBand [Perfor- 90° to 40° range of motion
mance Health, Akron, Ohio] hip
rotator exercises)
Cardiovascular/ Bike, elliptical machine, StairMaster Can start walking for exercise if normal gait
endurance (StairMaster, Vancouver, Washing- pattern and no swelling
ton), NordicTrack (Icon Health &
Fitness, Logan, Utah), retro tread-
mill
Proprioception Single limb stance, standing 4-way Use of balance cushions or other proprio-
TheraBand kicks ceptive devices during exercises; start to
mimic functional activity, including
catching, throwing, or kicking
little to no swelling follow- low-impact activity that en- fore return to sport. Full ROM
ing activity in this phase of courages double limb support. is needed and muscle strength
rehabilitation. During this Softer surfaces may be used to and balance must be achieved
phase, athletes must continue diminish joint reaction forces. to provide the required dy-
with their strengthening pro- Running progression should namic stability for high-level
gram in addition to perform- include walk/jog intervals, sports performance. Also, the
ing phase-specific exercises. agility ladder drills at 50% to athlete should have a greater
Throughout training, athletes 75% speed, dynamic activities than 90% score on the Limb
must receive proper instruc- with skipping and high knees, Symmetry Index, particu-
tion to ensure good form. Ad- and 90° to 180° turns in the larly the single leg hop, 6-m
ditional focus should be on air. Initial sport-specific drill timed hop, triple single leg
landing softly on the affected patterns can also be done with hop, crossover single leg hop,
extremity as well as maintain- 50% to 75% effort. Late in this and single leg vertical hop.
ing a neutral hip rotation to phase, cutting and pivoting Strength assessment should
minimize rotatory forces on training should be introduced also be greater than 90% of
the knee joint. as well as advanced plyomet- the opposite limb using ei-
Exercise suggested for this rics and team participation ther dynamometry or clinical
phase includes aggressive without contact (Table 4). tests such as the number of
strengthening with squats, The end of this phase in- step downs in 1 minute (Table
lunges, and plyometrics as volves the return to sport as- 4). Furthermore, the athlete
well as agility drills includ- pect of ACL rehabilitation. should be progressed to sport-
ing shuffling, hops, vertical Because each athlete is differ- specific activity and drills in
jumps, and running patterns. ent, safe return to play should a controlled environment at
Additionally, neuromuscular be individualized rather than full speed. If these activities
training should continue to follow a strict time line. An can be performed without
promote neuromuscular con- athlete should be able to per- pain, swelling, or instability
trol and proprioception. Early form maximal vertical jump complaints and athletes have
in this phase, the focus is on without pain or instability be- developed confidence with
n sports medicine update

mobilizations (Figure 2) are

Table 4 important and need to be em-
phasized in the rehabilitation
Return to Functional Activity Phase (Months 3-6+)
program. Also, with quadru-
Phase Functional Activities
pled hamstring autograft ACL
Early Focus is on low-impact activity that encourages double limb support; softer surfaces reconstructions, athletes are
may be used to diminish joint reaction forces (eg, Harvard stepping with a 6-in
step, straight plane agility ladder drills at 25% to 50% speed, jump rope, mini- limited in hamstring strength-
squat jumps, mini-scissor jumps, sport cord exercises) ening activities for the first
Middle Running progression including walk/jog intervals, agility ladder drills at 50% to 75% month. A quadriceps tendon
speed, unilateral hopping progression, dynamic activities including skipping and autograft ACL reconstruc-
high knees, more complicated double limb hops including 90° to 180° turns in the
air, participation in basic drills with team that do not involve cutting, pivoting, or tion will cause deficits in the
contact quadriceps musculature; this
Late Introduce cutting/pivoting training, participate with team but do not allow contact, should be expected and man-
agility drills at 75% to 100% speed, advanced plyometrics aged appropriately in reha-
Return to >90% Limb Symmetry Index on hop testing, including single leg hop, 6-m timed bilitation. Furthermore, the
sport hop, triple single leg hop, crossover single leg hop, and single leg vertical hop;
strength assessment >90% of opposite side using either dynamometry or clinical overall rehabilitation process
tests (eg, number of step downs in 1 minute); participation in sporting activity and is slower for allografts than
drills in controlled environment at full speed without pain, swelling, or instability autografts and therefore pro-
complaints
tocols should be modified to
account for the longer pro-
cess to return to play.6 Thus,
running, cutting, and jump- have been proven to improve thermore, full ROM is neces- athletes and physical trainers
ing at full speed, they can then athlete functional outcomes sary for a return to sports, as must be well educated about
return to sport with contact. and to result in fewer compli- decreased motion will place graft type used so that proto-
Some athletes may fear rein- cations.3,11,12 the extremity at a mechanical cols may be easily modified to
jury, and this should be ac- The authors believe that disadvantage and increase the achieve the best outcome.
counted for in the time line to knees undergoing ACL recon- risk for reinjury. A systematic Regarding return to sport,
return to play.10 struction ultimately require a rehabilitation program that no standard or objective criteria
comprehensive rehabilitation emphasizes the return to sym- are currently available to deter-
Discussion that emphasizes the return metrical motion aids in mus- mine when a patient is ready to
Rehabilitation of the ACL to symmetrical knee mo- cle strength and balance that return to competitive sport or
reconstructed knee is extreme- tion, symmetrical quadriceps must be achieved to provide unrestricted activity after ACL
ly important to athletes’ over- strength, and neuromuscular dynamic stability.14 reconstruction.10,16 Functional
all functional outcome. The control. Significant deficits in Current level I evidence testing provides an inaccurate
philosophy that has influenced quadriceps strength are evi- from randomized controlled marker for risk of injury be-
rehabilitation protocols has dent after ACL reconstruction. trials shows no overall dif- cause tests are performed un-
undergone a drastic change Kline et al13 found a lower ference in outcome between der nonfatigued conditions.17
in the past 15 years. The con- rate of torque developments bone-patellar tendon-bone In the protocol discussed here,
servative approaches that em- and a lower rate and timing of and quadrupled hamstring full ROM, limb strength sym-
phasized healing of the graft extensor moments after surgi- grafts in postoperative lax- metry, and neuromuscular con-
and stability of the knee were cal reconstruction. Therefore, ity, clinical outcome, return trol are important for an athlete
based largely on concepts that the quadriceps musculature to sport, one leg hop test, and to safely and effectively return
both time and control of the must be rehabilitated to im- ROM.15 However, regard- to full sport. However, it may
forces across the knee were prove the rate of torque de- ing rehabilitation, some dif- also be important to incorpo-
necessary for ligament healing velopments and prepare the ferences exist between the rate weight bearing and fatigue
and a good outcome.2 Long pe- limb for the demands of sport graft choices. Bone-patellar testing into the postoperative
riods of immobilization post- performance. This also serves tendon-bone autograft ACL rehabilitation program before
operatively have fallen out of to restore muscular balance reconstructions are more clearing patients for full return
favor and have been replaced in the extremity and aids in prone to patellar hypomobil- to activity.17,18 Currently, ath-
by accelerated protocols that neuromuscular control. Fur- ity; therefore, progressive letes’ rate of return to sport at

694 Copyright © SLACK Incorporated


the same level or higher is re-
ported to be between 70% and
90%.15,19,20
Some factors that can af-
fect rehabilitation after recon-
structive ACL surgery include
concomitant injuries, timing
of surgery, graft selection,
concomitant surgeries, quality
of rehabilitation, and the goals
and desire of the athlete. How-
ever, a comprehensive and ap-
propriate protocol with input
from the surgeon, athlete, and
physical trainer can lead to a
successful outcome where the
return to a high-performance
preinjury level is possible. The
authors believe that there are
several pearls for a successful
outcome in ACL reconstruc-
tion rehabilitation: (1) prevent
problems rather than treat
them whenever possible, (2)
obtain extension in the first
few days and be protective of
requestive function (do not
“beat” a dead extremity), (3)
know which graft is used and
possibly modify the rehabilita-
tion protocol, (4) quadriceps
activation is facilitated by
working in flexion and not at-
tempting to activate initially in
full extension, (5) do not have
patients discard assistive de-
vices until they are able to acti-
vate the quadriceps effectively
and demonstrate a normal gait,
(6) integrate both open and
closed chain exercises to gain
complete rehabilitation, and
(7) avoid large loads in ter-
minal extension (particularly
open chain) during the initial
months postoperatively.8
Conclusion
The concepts discussed
in this article provide an in-
NOVEMBER 2015 | Volume 38 • Number 11 695
tegrative and comprehensive
approach to the rehabilitation
of a reconstructed ACL in an
athlete. A variety of exercises
and protocols exist in the lit-
erature; however, there are
specific concepts that must
be emphasized to achieve a
successful outcome. Initial
knee flexion gains, followed
by full extension, and finally
terminal flexion is a guide to
achieving full ROM. Also,
the quadriceps and hamstring
musculature must be strength-
ened to achieve muscular bal-
ance in the affected extremity.
Furthermore, neuromuscu-
lar training and propriocep-
tion aid in returning athletes
to a high performance level
in their sport. Progression
through a protocol using
distinct phases allows for a
complete rehabilitation while
reducing the risk of reinjury.
Understanding that athletes
differ in rehabilitation and
progression is also important
in guiding a safe return to
play that accounts for a fear
of reinjury component.
An integrated approach
with input from the physician,
athlete, and physical trainer is
important to define the phas-
es, progression, and ultimate
goals of a rehabilitation pro-
gram. Education and commu-
nication are vital in managing
expectations and progressing
through a protocol safely and
successfully. Emphasis should
be on the rehabilitation of the
entire knee joint and not just
the ACL to achieve a success-
ful outcome. Further research
is needed to validate reliable
progression guidelines and
time lines to facilitate and
n sports medicine update
foster a safe return-to-play
process.
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