400

Physical Rehabilitation of the Injured Athlete

Table 19–9 Rehabilitation Protocol After Anterior Cruciate Ligament Reconstruction With a Bone–Patellar ­
Tendon–Bone Autograft

Week 1 Weeks 2-4 Weeks 5-8 3 Months 4-6 Months

Functional PWB with 2 crutches WB with 1 crutch or Advance strengthening Begin jogging Return to sport
progression FWB exercises

Criteria As postoperative pain Full knee extension No increase in effusion No increase in effusion No increase in
allows during gait AROM 0°-125° No pain effusion
SLR with no extensor Normal patellar mobility Full AROM Functional tests >85%
lag KT1000 <2 mm increase Eccentric control with Isokinetic tests >85%
No increase in effusion one-leg minisquat Pain free
Leg press strength >70% KT1000 unchanged
KT1000 unchanged Self-report functional
measures

Evaluation Pain Pain Pain Pain Pain

Effusion Gait Gait AROM Effusion
Patellar mobility AROM/PROM AROM/PROM Effusion Functional tests
AROM Effusion Effusion KT1000 Isokinetic tests
Passive extension Patellar mobility Patellar mobility Leg press strength test KT1000
Quadriceps Quadriceps Flexibility One-leg minisquat Self-report functional
recruitment recruitment Standing balance Lateral step-ups measures
Incision/portals Incision/portals KT1000 Self-report functional Proprioception tests
measures

Treatment Pain management Pain management Flexibility exercises Increase isotonic exercise Increase isotonic
Control effusion Control effusion Proprioception exercises Aerobic conditioning exercise
Patellar mobilization Patellar mobilization Endurance exercises Open chain quadriceps- Aerobic conditioning
Passive extension and AROM/PROM General strengthening strengthening full ROM Running progression
flexion Quadriceps NMES or (hamstrings, hip, etc.) Begin jogging progression Hop activities
Active flexion biofeedback Open chain quadriceps Begin hop progression Sport-specific
Quadriceps NMES Closed chain exercises strengthening from 60° Proprioception exercises activities
or biofeedback Gait training to 90° Proprioception
General strengthening Increase loads with closed exercises
(hamstrings, hip, etc.) chain exercises
Scar mobility

Goals PROM 0°-90° AROM 0°-100° Full AROM No pain or increase in Return to sport
50% WB 75%-100% WB Normal gait effusion with increased
SLR without extensor Increase strength and resistance through full
lag endurance ROM
No increase in effusion 85% with functional and
with 20-30 minutes of strength tests
biking or ambulating

Adapted from Mangine, R.E., Noyes, F.R. and DeMaio, M. (1992): Minimal protection program: Advanced weight bearing and range of motion after ACL reconstruction: Weeks 1 to 5. Orthopedics,
15:504-515; and DeMaio, M., Mangine, R.E., and Noyes, F.R. (1992): Advanced muscle training after ACL reconstruction: Weeks 6 to 52. Orthopedics, 15:757-767.
AROM, Active range of motion; FWB, full weight bearing; NMES, neuromuscular electrical stimulation; PROM, passive range of motion; PWB, partial weight bearing; ROM, range of motion;
SLR, straight leg raise; WB, weight bearing.

test scores, pain scores, and patient satisfaction scores. These
results are further supported by a systematic review of ­bracing
that found no benefit with the “routine” use of bracing follow-
ing ACL reconstruction.149 Additional consideration has to be
given to the evidence that bracing increases energy expendi-
ture, decreases maximal torque output from the quadriceps, and
increases the rate of fatigue.150
Based on the evidence just presented, the use of functional
bracing after ACL reconstruction should probably be reserved
for athletes who are having difficulty returning to sport because
of lack of confidence in the reconstructed knee. While keeping in
mind that the benefit associated with the brace is ­probably only
improved proprioceptive function and not control of ­physiologic
loads, the clinician and athlete must decide whether a custom-
made brace is worth the extra cost to the athlete given the off-
the-shelf alternatives. It has been the authors' experience that a
large percentage of athletes, even those who request one, stop
using a functional brace within a year.
Programs to Prevent Anterior Cruciate
Ligament Injury
A substantial number of ACL injuries occur in noncontact situa-
tions,151 especially in female athletes (see Chapter 9). A number of
factors have been proposed as potential causes of noncontact ACL
injuries, including lack of control of abduction/adduction forces
across the knee,152 hamstring weakness,81,152 ­electromechanical

Box 19-10
Accelerated Rehabilitation After Reconstruction of the Anterior Cruciate Ligament With a Patellar Tendon Graft
Preoperative Phase
Goals:
l Diminish inflammation, swelling, and pain
l Restore normal ROM (especially knee extension)
l Restore voluntary muscle activation
l Protect the knee from further injury—especially the meniscus
l Provide education to prepare the patient for surgery
Brace—Elastic wrap or knee sleeve to reduce swelling
Weight Bearing—As tolerated with or without crutches
Exercises:
l Ankle pumps
l Passive knee extension to 0°
l Passive knee flexion to tolerance
l Straight leg raises (three ways: flexion, abduction, adduction)
l Quad sets
l Closed kinetic chain exercises: minisquats, lunges, step-ups
Muscle Stimulation—Electrical muscle stimulation of the
quadriceps during voluntary quadriceps exercises (4-6 hr/day)
Neuromuscular/Proprioception Training:
l Eliminate quadriceps avoidance gait
l Retro stepping drills
l Balance training drills
Cryotherapy/Elevation—Apply ice for 20 min/hr; elevate the leg with
the knee in full extension (the knee must be above the heart)
Patient Education—Review the postoperative
rehabilitation program
l Review instructional video (optional)
l Select an appropriate surgical date
I. Immediate Postoperative Phase (Days 1-7)
Goals:
l Restore full passive knee extension
l Diminish joint swelling and pain
l Restore patellar mobility
l Gradually improve knee flexion
l Reestablish quadriceps control
l Restore independent ambulation
Postoperative Day 1
Brace—Brace/immobilizer applied to the knee locked in full
extension during ambulation and sleeping; unlock
the brace while sitting, etc.
Weight Bearing—Two crutches, weight bearing as tolerated
Exercises:
l Ankle pumps
l Overpressure into full, passive knee extension
l Active and passive knee flexion (90° by day 5)
l Straight leg raises (flexion, abduction, adduction)
l Quad sets
l Hamstring stretches
l Closed kinetic chain exercises: minisquats, weight shifts
Muscle Stimulation—Use muscle stimulation during active
muscle exercises (4-6 hr/day)
C H A P T E R 1 9     K n e e R e h a b i l i t a t i o n 401
Continuous Passive Motion—As needed, 0° to 45°/50°
(as tolerated and as directed by the physician)
Ice and Evaluation—Apply ice 20 min/hr and elevate the leg
with the knee in full extension
Postoperative Days 2-3
Brace—Brace/immobilizer locked at 0° degrees extension
for ambulation and unlocked for sitting, etc.
Weight Bearing—Two crutches, weight bearing as tolerated
Range of Motion—Remove the brace and perform ROM
exercises 4-6 times per day
Exercises:
l Multiangle isometrics at 90° and 60° (knee extension)
l Knee extension 90°-40°
l Overpressure into extension (knee extension should
be at least 0° to slight hyperextension)
l Patellar mobilization
l Ankle pumps
l Straight leg raises (three directions)
l Minisquats and weight shifts
l Quad sets
Muscle Stimulation—Electrical muscle stimulation of quadriceps
(6 hr/day)
Continuous Passive Motion—0° to 90°, as needed
Ice and Evaluation—Apply ice 20 min/hr and elevate the leg
with the knee in full extension
Postoperative Days 4-7
Brace—Brace/immobilizer locked at 0° extension for ambulation
and unlocked for sitting, etc.
Weight Bearing—Two-crutch weight bearing as tolerated
Range of Motion—Remove the brace to perform ROM exercises
4-6 times per day, knee flexion to 90° by day 5
and approximately 100° by day 7
Exercises:
l Multiangle isometrics at 90° and 60° (knee extension)
l Knee extension 90°-40°
l Overpressure into extension (full extension 0° to 5°/7°
hyperextension)
l Patellar mobilization (5-8 times daily)
l Ankle pumps
l Straight leg raises (three directions)
l Minisquats and weight shifts
l Standing hamstring curls
l Quad sets
l Proprioception and balance activities
Neuromuscular Training/Proprioception—OKC passive/active
joint repositioning at 90°, 60°; CKC squats/weight shifts
with repositioning
Muscle Stimulation—Electrical muscle stimulation
(continue 6 hours daily)
Continue Passive Motion—0°-90°, as needed
Ice and Elevation—Apply ice 20 min/hr and elevate the leg
with the knee in full extension
(Continues)
402 Physical Rehabilitation of the Injured Athlete

Box 19-10
Accelerated Rehabilitation after Reconstruction of the Anterior Cruciate Ligament with a Patellar Tendon Graft—cont'd
II.  Early Rehabilitation Phase (Weeks 2-3) Passive Range of Motion—Continue ROM stretching and
Criteria to Progress to Phase II: overpressure into extension (ROM should be 0°-100°/105°)
l Quadriceps control (ability to perform good quad l Restore patient's symmetric extension

set and SLR)
Exercises:
l Full passive knee extension
l Continue all exercises as in week 2
l PROM 0°-90°
l PROM 0°-105°
l Good patellar mobility
l Bicycle for ROM stimulus and endurance
l Minimal joint effusion
l Pool walking program (if incision is closed)
l Independent ambulation
l Eccentric quadriceps program 40°-100° (isotonic only)

Goals: l Lateral lunges (straight plane)

l Maintain full passive knee extension (at least 0° to 5°/7° l Front step-downs

hyperextension) l Lateral step-overs (cones)

l Gradually increase knee flexion l Stair Stepper machine

l Diminish swelling and pain l Advance proprioception drills, neuromuscular control drills

l Demonstrate muscle control and activation l Continue passive/active reposition drills (CKC, OKC)

l Restore proprioception/neuromuscular control

l Normalize patellar mobility
III. Progressive Strengthening/Neuromuscular
Control Phase (Weeks 4-10)
Week 2 Criteria to Enter Phase III:
l AROM 0°-115°
Brace—Continue locked brace for ambulation and sleeping
l Quadriceps strength >60% of contralateral side
Weight Bearing—As tolerated (goal is to discontinue crutches
10-14 days postoperatively) (isometric test at 60° of knee flexion)
l Unchanged KT test bilateral values (+1 or less)
Passive Range of Motion—Self-ROM stretching (4-5 times daily)
l Minimal to no full joint effusion
with emphasis on maintaining full PROM
l No joint line or patellofemoral pain
l Restore patient's symmetric extension
KT2000 Test—15-lb anterior-posterior test only Goals:
l Restore full knee ROM (5°-0° to 125°) symmetric motion
Exercises:
l Improve lower extremity strength
l Muscle stimulation superimposed on quadriceps exercises
l Enhance proprioception, balance, and neuromuscular control
l Isometric quadriceps sets
l Improve muscular endurance
l SLR (4 planes)
l Restore limb confidence and function
l Leg press (0°-60°)
l Knee extension 90°-40° Brace—No immobilizer or brace, may use knee sleeve to control
l Half squats (0°-40°) swelling/support
l Weight shifts Range of Motion:
l Front and side lunges l Self-ROM (4-5 times daily using the other leg to provide ROM)
l Hamstring curls standing (AROM) with emphasis on maintaining 0° of passive extension
l Bicycle (if ROM allows) l PROM 0°-125° at 4 weeks
l Proprioception training KT2000 Test—Week 4, 20-lb anterior and posterior test
l Overpressure into extension
l PROM 0°-100° Week 4
l Patellar mobilization Exercises:
l Well-leg exercises l Advance isometric strengthening program

l Progressive resistance extension program—start with 1 lb l Leg press 0°-100°

l Knee extension 90°-40°
and advance 1 lb/wk
l Hamstring curls (isotonics)
Proprioception/Neuromuscular Training: l Hip abduction and adduction
l OKC passive/active joint repositioning 90°, 60°, 30° l Hip flexion and extension
l CKC joint repositioning during squats/lunges l Lateral step-overs
l Initiate squats on tilt board l Lateral lunges (straight plane and multiplane drills)
l Lateral step-ups
Swelling Control—Ice, compression, elevation
l Front step-downs
Week 3 l Wall squats
Brace: l Vertical squats
l Discontinue locked brace (some patients use AROM brace l Standing toe/calf raises
for ambulation) l Seated toe/calf raises
l If the patient continues to use a brace, unlock for ambulation l Biodex stability system (balance, squats, etc.)
 C H A P T E R 1 9     K n e e R e h a b i l i t a t i o n 403

Box 19-10
Accelerated Rehabilitation after Reconstruction of the Anterior Cruciate Ligament with a Patellar Tendon Graft—cont'd
l Proprioception drills l
Quadriceps peak torque/body weight 65% at 180°/sec
l Bicycle in males and 55% at 180°/sec in females
l Stair Stepper machine l Hamstrings/quadriceps ratio 66%-75%
l Pool program (backward running, hip and leg exercises) l Hop test (80% of contralateral leg)
l Subjective knee scoring (modified Noyes system) of 80 points
Proprioception/Neuromuscular Drills:
or better
l Tilt board squats (perturbation)
l Passive/active OKC repositioning Goals:
l CKC repositioning on tilt board l Normalize lower extremity strength
l Enhance muscular power and endurance
Week 6 l Improve neuromuscular control
KT2000 Test—20- and 30-lb anterior and posterior test l Perform selected sport-specific drills

Exercises: Exercises:
l Continue all exercises
l May initiate running program (weeks 10-12) (physician's decision)
l Pool running (forward) and agility drills
l May initiate light sport program (golf) (physician's decision)
l Balance on tilt boards
l Continue all strengthening drills
l Progress to balance and ball throws
l Leg press
l Wall slides/squats
l Wall squats
l Hip abduction/adduction
Week 8
l Hip flexion/extension
KT2000 Test—20- and 30-lb anterior and posterior test
l Knee extension 90°-40°
Exercises: l Hamstring curls
l Continue all exercises listed in weeks 4-6 l Standing toe/calf raises
l Leg press sets (single leg) 0°-100° and 40°-100° l Seated toe/calf raises
l Plyometric leg press l Step down
l Perturbation training l Lateral step-ups
l Isokinetic exercises (90°-40°, 120°-240°/sec) l Lateral lunges
l Walking program l Neuromuscular training
l Bicycle for endurance l Lateral step-overs (cones)
l Stair Stepper machine for endurance l Lateral lunges
l Biodex stability system l Tilt board drills
l Training on tilt board l Sports RAC repositioning on tilt board

Week 10 Weeks 14-16

KT2000 Test—20- and 30-lb and manual maximum test l Advance program
Isokinetic Test—Concentric knee extension/flexion at 180° l Continue all drills above
and 300°/sec l May initiate lateral agility drills
l Backward running
Exercises:
l Continue all exercises listed in weeks 6, 8, and 10
V.  Return-to-sport Phase (weeks 17-22)
l Plyometric training drills
Criteria to Enter Phase V:
l Continue stretching drills
l Full ROM
l Progress strengthening exercises and neuromuscular
l Unchanged KT2000 test (within 2.5 mm of opposite side)
training l Isokinetic test that fulfills criteria
l Quadriceps bilateral comparison (80% or greater)
IV. Advanced Activity Phase (Weeks 11-16)
l Hamstring bilateral comparison (110% or greater)
Criteria to Enter Phase IV:
l Quadriceps torque–body weight ratio (55% or greater)
l AROM 0°-125° or greater
l Hamstrings-quadriceps ratio (70% or greater)
l Quadriceps strength 75% of contralateral side, knee extension
l Proprioceptive test (100% of contralateral leg)
flexor-to-extensor ratio 70%-75%
l Functional test (85% or greater of contralateral side)
l No change in KT values (comparable to contralateral side,
l Satisfactory findings on clinical examination
within 2 mm)
l Subjective knee scoring (modified Noyes system)
l No pain or effusion
l Satisfactory findings on clinical examination (90 points or better)
l Satisfactory results on isokinetic test (values at 180°)
Goals:
l Quadriceps bilateral comparison 75% l Gradually return to full unrestricted sports
l Hamstrings equal bilaterally l Achieve maximal strength and endurance

(Continues)
404 Physical Rehabilitation of the Injured Athlete

Box 19-10
Accelerated Rehabilitation after Reconstruction of the Anterior Cruciate Ligament with a Patellar Tendon Graft—cont'd
l Normalize neuromuscular control 6-Month Follow-up
l Advance skill training l Isokinetic test
Tests—KT2000, isokinetic, and functional tests before return l KT2000 test
l Functional test
Exercises:
l Continue strengthening exercises 12 Month Follow-up
l Continue neuromuscular control drills l Isokinetic test
l Continue plyometric drills l KT2000 test
l Advance running and agility program l Functional test
l Advance sport-specific training
l Running/cutting/agility drills
l Gradual return to sport drills

Copyright © 2011 by the Advanced Continuing Education Institute, LLC. All rights reserved. Any redistribution or reproduction of any materials herein
is strictly prohibited.
AROM, Active range of motion; CKC, closed kinetic chain; OKC, open kinetic chain; PROM, passive range of motion; ROM, range of motion; SLR, straight leg raise.

Box 19-11
Rehabilitation Protocol Following Reconstruction of the Anterior Cruciate Ligament with the Semitendinosus
I. Immediate Postoperative Phase Weight Bearing—Two crutches as tolerated
Goals: Range of Motion—Patient out of brace 4-5 times daily to perform
l Protect the ACL reconstruction self-ROM 0°-90°/100°
l Reduce swelling and inflammation
Exercises:
l Restore and maintain full extension
l Intermittent ROM exercises (0°-90°)
l Gradually restore knee flexion
l Patellar mobilization
l Activate the quadriceps muscle
l Ankle pumps
l Independent ambulation
l Straight leg raises (four directions)
l Patient education and protection of the graft harvest site
l Standing weight shifts and minisquats (0°-30° ROM)
l Knee extension 90°-40°
Day 1
l Continue quad sets
Brace—Locked at 0° extension for ambulation
Weight Bearing—Two crutches as tolerated (at least 50% WB) Muscle Stimulation—Electrical stimulation of quadriceps (6 hr/day)
Range of Motion: Continuous Passive Motion—0°-90°
l Full passive extension (0°-90°)
Ice and Elevation—Apply ice 20 min/hr and elevate the leg
l Obtain hyperextension if present on opposite side—goal is
with the knee in extension
symmetric motion
II. Maximum-Protection Phase (Weeks 2-8)
Exercises: Goals:
l Ankle pumps l Absolute control of external forces and protect graft
l Passive knee extension to 0° or equal to opposite side l Nourish articular cartilage
(hyperextension) l Decrease swelling
l Straight leg raise (flexion) l Prevent quadriceps atrophy
l Hip abduction/adduction
l Knee extension 90°-40° Week 2
l Quad sets Brace—Locked at 0° for ambulation only, unlocked for self-ROM
l No hamstring stretching (4-5 times daily)
Weight Bearing—As tolerated (goal to discontinue crutches 7-10
Muscle Stimulation—Stimulation of quadriceps (4-6 hr/day) during days postoperatively)
active exercises Range of Motion—Self-ROM (4-5 times daily) with emphasis on
Continuous Passive Motion—0°-90° maintaining 0° passive extension
Ice and Evaluation—Apply ice 20 min/hr and elevate the leg KT2000 Test—(15-lb anterior-posterior test only)
with the knee in extension
Exercises:
Days 2-7 l Multiangle isometrics at 90°, 60°, 30°

Brace—Locked at 0° extension for ambulation l Leg raises (four planes)

 C H A P T E R 1 9     K n e e R e h a b i l i t a t i o n 405

Box 19-11
Rehabilitation Protocol Following Reconstruction of the Anterior Cruciate Ligament with the Semitendinosus—cont'd
l No hamstring curls Week 10
l Knee extension 90°-40° Exercises:
l Mini squats (0°-40°) and weight shifts l Knee extension (90°-40°)
l Lunges l Leg press (0°-60°)
l Leg press (0°-60°) l Mini squats (0°-45°)
l PROM/AAROM 0°-105° l Lateral step-ups
l Patellar mobilization l Hamstring curls
l No hamstring and calf stretching l Hip abduction/adduction
l Proprioception training l Toe/calf raises
l Well-leg exercises l Bicycle
l PRE program—start with 1 lb, advance 1 lb/wk l StairMaster
l Wall squats
Swelling Control—Ice, compression, elevation
l Lunges

Week 4 l Pool running

Brace—Locked at 0° for ambulation only, unlocked for self-ROM l Proprioceptive training

(4-5 times daily) l Continue PRE progression (no weight restriction)

Range of Motion—Self-ROM (4-5 times daily) with emphasis on

Weeks 12-14
maintaining 0° passive extension
Exercise—Continue all above exercises
Exercises: Testing—Isokinetic test (180° and 300°/sec, full ROM, 10/15 reps)
l Same as week 2 KT2000 Test—Total displacement at 15, 20, and 30 lb, manual
l PROM 0°-125° maximal test
l Bicycle for ROM stimulus and endurance Maintain/Begin Running—If patient fulfills criteria
l Pool walking program, swimming
l Initiate eccentric quadriceps exercise 40°-100° (isotonic only) IV. Light-Activity Phase (Months 4-5)
l Leg press (0°-60°) Criteria to Enter Phase IV:
l AROM 0°-125°
l Emphasize CKC exercise
l Quadriceps strength 70% of contralateral side, knee flexor/
l StairMaster
l Elliptical extensor rated 70%-79%
l No change in KT scores (+2 or less)
KT2000 Test—(week 4, 20-lb anterior and posterior test) l Minimal/no effusion
l Satisfactory findings on clinical examination
Week 6
Brace—Discontinue use of drop locked brace Goals:
l Development of strength, power, endurance
Exercises:
l Begin gradual return to functional activities
l Same as week 4
l Hamstring curls (light resistance) Exercises—Initiate light straight line running
l Pool program (physician's decision)
l AROM 0°-115°
l PROM 0°-125°
Exercises:
l Emphasize eccentric quadriceps work
l Emphasize CKC exercises
l Continue CKC exercises, step-ups, minisquats,
l Bicycle
leg press
KT2000 Test—(week 6, 20- and 30-lb anterior and posterior test) l Continue knee extension 90°-40°
l Hip abduction/adduction
Week 8 l Initiate plyometric program
Brace—Consider use of functional brace
l Initiate running program

Exercises: l Initiate agility program

l Continue PRE program l Sport-specific training and drills
l Initiate light hamstring PREs l Hamstring curls and stretches
l Calf raises
KT2000 Test—(Week 8, 20- and 30-lb anterior and posterior test)
l Bicycle for endurance

III. Moderate-Protection Phase (Weeks 10-16) l Pool running (forward/backward)

Goals: l Walking program

l Maximal strengthening for quadriceps/lower extremity l StairMaster

l Protect patellofemoral joint l High-speed isokinetics

(Continues)
406 Physical Rehabilitation of the Injured Athlete

Box 19–11
Rehabilitation Protocol Following Reconstruction of the Anterior Cruciate Ligament with the Semitendinosus—cont'd
Testing: l Continue strengthening program for 1 year from surgery*:
l Isokinetic test (180° and 300°/sec, Full ROM, 10/15 reps) l For Quadriceps:
l KT2000 test—Total displacement at 15, 20, and 30 lb, l Knee extensions
manual maximal test l Wall squats
l Leg press
Criteria for Running:
l Step-ups
l Isokinetic test—>85% of opposite leg (quadriceps), >90%
l For Strength:
of opposite leg (hamstring)
l Hamstring curls
l Isokinetic test—Quadriceps torque/body weight (180°/sec)
l Calf raises
(60%-65% for males) (50%-55% for females)
l Hip abduction
l KT2000 test—Unchanged
l Hip Adduction
l No pain/swelling
l For Endurance:
l Satisfactory findings on clinical examination
l Bicycle
Functional Drills: l StairMaster
l Straight line running l Elliptical
l Jog to run l Swimming
l Walk to run l For Stability:
l High-speed hamstrings
V.  Return-to-sport Phase (Months 6-7) l High-speed hip flexion/extension
Goals: l Balance drills
l Achieve maximal strength and endurance
l Backward running
l Return to sport activities

Copyright © 2011 by the Advanced Continuing Education Institute, LLC. All rights reserved. Any redistribution or reproduction of any materials herein
is strictly prohibited.
*Pick one.
AAROM, Active assisted range of motion; ACL, anterior cruciate ligament; AROM, active range of motion; CKC, closed kinetic chain;
PRE, progressive resistance exercise; PROM, passive range of motion.

Table 19-10 Differences in Anterior Cruciate Ligament delay in ­hamstring activation,1535 reduced cocontraction of the
Rehabilitation Programs Between Patellar Tendon quadriceps and hamstring,81 muscle fatigue,153,154 reduced gastroc-
Autograft and Allograft or Hamstring Autograft nemius recruitment,153 and insufficient ankle and hip balance and
control.153,154
Patellar Bone- Several types of programs have been proposed to address
Tendon-Bone Allograft or Hamstring these factors, including plyometric programs,151,152 wobble
Autograft Autograft board training,81,154 and perturbation training.110 The results
WBAT (with crutches) NWB for 4 weeks of studies using plyometric151 or wobble board154 training pro-
immediately 25% WB from 4-5 weeks grams indicate that athletes participating in these training regi-
50% WB from 5-6 weeks mens have a reduced incidence of ACL injuries. A perturbation
100% WB at 6 weeks training study110 demonstrated that ACL-deficient athletes
or were more successful in returning to sports if their rehabilita-
PWB (with crutches) in brace locked tion included perturbation training. Wobble board and pertur-
in full extension for 1 week bation training programs progressively challenge the athlete's
WBAT (with crutches) in brace locked in balance and thereby train the athlete to develop strategies
full extension from 1-2 weeks
that maintain control of the ankle, knee, and hip. Plyometric
Full ROM unloaded Full ROM unloaded knee extension can training improves the athlete's ability to control abduction/­
knee extension can begin about 6 weeks postoperatively adduction forces, especially when landing from a jump.152
begin as early as 2 Plyometric training also improves hamstring strength152 and
weeks postoperatively hamstring activation time.81 It is important to note that all
Bilateral hopping can Bilateral hopping can begin around three types of training are performed functionally with weight
begin around 10 weeks 12 weeks bearing through the lower extremity and are controlled “high”-
speed activities rather than traditional strength-training exer-
Single-leg hopping can Single-leg hopping can begin around cises. Because of the benefits, these activities should not only
begin around 12 weeks 14 weeks
be used for ACL prevention programs but also be incorporated
NWB, Non–weight bearing; PWB, partial weight bearing; ROM, range of motion; WBAT, into the functional progression, as appropriate, after ACL inju-
weight bearing as tolerated; WB, weight bearing. ries or reconstruction.