Eitzen 2010

[ research report ]
Ingrid Eitzen, PT, PhD1 • Håvard Moksnes, PT, MSc2

Lynn Snyder-Mackler, PT, ScD3 • May Arna Risberg, PT, PhD4
A Progressive 5-Week Exercise Therapy

Program Leads to Significant Improvement
Downloaded from www.jospt.org at New York University on May 11, 2015. For personal use only. No other uses without permission.
in Knee Function Early After Anterior

Cruciate Ligament Injury
D
ue to differing clinical Recent studies from our own research injuries to perform a progressive exercise
practice in the management group have supported the underlying ra- therapy program. Moksnes et al45 dem-
Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tionale for advising all patients with ACL onstrated that patients with ACL injury,
of anterior cruciate
ligament (ACL) ruptures,
t STUDY DESIGN: Prospective cohort study the patient-reported questionnaires. In addition,
there is no universal agreement without a control group. absolute values and the standardized response
as to what is the ideal treatment t OBJECTIVES: Firstly, to present our 5-week
mean for muscle strength and single-leg hop tests
were calculated at pretest and posttest for the
algorithm for individuals progressive exercise therapy program in the early
injured and uninjured limb. Adverse events during
with ACL injury. 5,23,43
In our stage after anterior cruciate ligament (ACL) injury.
the 5-week period were recorded.
Secondly, to evaluate changes in knee function
outpatient clinic, our general after completion of the program for patients with t RESULTS: The progressive 5-week exercise
recommendation to individuals ACL injury in general and also when classified therapy program led to significant improvements
Journal of Orthopaedic & Sports Physical Therapy®
as potential copers or noncopers, and, finally, to (P.05) in knee function from pretest to posttest
with an acute ACL injury is examine potential adverse events. both for patients classified as potential copers and
to go through 10 sessions of t BACKGROUND: Few studies concerning
noncopers. Standardized response mean values
for changes in muscle strength and single-leg hop
a progressive exercise therapy early-stage ACL rehabilitation protocols exist. Con-
performance from pretest to posttest for the injured
program for a period of 5 weeks sequently, little is known about the tolerance for, limb were moderate to strong (0.49-0.84), indicating
and outcomes from, short-term exercise therapy
after initial impairments are programs in the early stage after injury.
the observed improvements to be clinically relevant.
Adverse events occurred in 3.9% of the patients.
resolved, before the final decision t METHODS: One-hundred patients were t CONCLUSION: Short-term progressive exercise
for either ACL reconstruction included in a 5-week progressive exercise therapy therapy programs are well tolerated and should
(ACLR) or further nonoperative man- program, within 3 months after injury. Knee func- be incorporated in early-stage ACL rehabilitation,
tion before and after completion of the program either to improve knee function before ACL recon-
agement is made. This is recommended,
was evaluated from isokinetic quadriceps and struction or as a first step in further nonoperative
independent of whether patients are clas- hamstrings muscle strength tests, 4 single-leg hop management.
sified as potential copers or noncopers.45 tests, 2 different self-assessment questionnaires,
and a global rating of knee function. A 2-way t LEVEL OF EVIDENCE: Therapy, level 2b.
Potential copers are characterized as hav-
mixed-model analysis of variance was conducted J Orthop Sports Phys Ther 2010;40(11):705-721.
ing good knee stability and the ability to doi:10.2519/jospt.2010.3345
to evaluate changes from pretest to posttest for
compensate well after injury, whereas
the limb symmetry index for muscle strength and t KEY WORDS: ACL, adverse events, copers, hop
noncopers have poor knee stability and single-leg hop tests, and the change in scores for tests, noncopers
less potential for compensation.25
Researcher, NAR, Department of Orthopaedics, Oslo University Hospital, Oslo, Norway; Physical Therapist, Hjelp24 Norwegian Sports Medicine Clinic (Hjelp24 NIMI), Oslo, Norway.
1
PhD student, Norwegian School of Sports Sciences, Oslo, Norway; Physical Therapist, Hjelp24 Norwegian Sports Medicine Clinic (Hjelp24 NIMI), Oslo, Norway. 3Alumni Distinguished
2
Professor, Department of Physical Therapy, University of Delaware, Newark, US. 4 Professor and Chair, NAR, Norwegian School of Sports Sciences, Oslo, Norway; Hjelp24 Norwegian
Sports Medicine Clinic (Hjelp24 NIMI), Oslo, Norway; Department of Orthopaedics, Oslo University Hospital, Oslo, Norway. This study was financed by RO1 HD 037985-04, RO1 HD
037985-05, and RO1 HD 037985-06 from The National Institutes of Health. The study protocol was approved by The Regional Ethical Committee, Health Region South-East, Norway
(Institutional Review Board). Address correspondence to Ingrid Eitzen, Hjelp24NIMI Ullevaal, Pb 3843 Ullevaal Stadion, 0805 Oslo, Norway. E-mail: ingrid.eitzen@hjelp24.no
journal of orthopaedic & sports physical therapy | volume 40 | number 11 | november 2010 | 705
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[ research report ]
who initially have poor knee function,
demonstrate good potential for function-
TABLE 1 Classification of Activity Level*
al improvement after rehabilitation. Fur-
ther, Eitzen et al17 found that preoperative
Level Sports Activity Occupational Activity
quadriceps strength was the single most
important predictor for knee function 2 I Jumping, cutting, pivoting (soccer, basketball, Demands comparable to level I sports activities
American football)
years after ACLR, and that preoperative
II Lateral movements (skiing, tennis) Heavy manual labor, working on uneven surfaces
deficits were persistent 2 years after sur-
III Light activity (running, weight-lifting) Light manual labor
gery. These findings seem to justify post-
IV Sedentary activity (housework, activities of daily living) Comparable to activities of daily living
poning the decision for ACLR for a short
* In accordance with Hefti et al.27
period, to optimize preoperative knee
function. Still, very few evidence-based
protocols for early-stage ACL injury man- self-assessment questionnaires; (2) pa- days after the date of injury, a quadriceps
agement, including explicit descriptions tients initially classified as noncopers muscle strength index less than or equal
of the rehabilitation programs and evalu- would improve knee function assessed to 70%, grade III or IV injury to collateral
ation of outcome, exist.11,56,65 As a conse- from isokinetic muscle strength tests, ligaments, injury to the posterior cruciate
quence, little is known about the tolerance single-leg hop tests, and self-assessment ligament, previous injuries of any kind to
for, and potential benefit from, short-term questionnaires significantly more than the injured or uninjured knee, cartilage
progressive exercise therapy programs in subjects classified as potential copers; (3) lesions affecting the subchondral bone
the early stage after ACL injury. early after injury, patients with ACL rup- (assessed from magnetic resonance im-
In the present study, our purpose was ture would tolerate a progressive exercise aging), fractures, or did not agree to the
to evaluate a 5-week progressive exercise therapy program without adverse events. compliance requirements of performing
therapy program either as a preoperative the exercise therapy program at least
optimization of knee function, or as the METHODS twice a week for 5 weeks.
first step in further nonoperative man- The study was designed and carried
P
agement, in patients with ACL injury. We articipants consisted of the out in accordance to the Declaration of
wanted to examine changes in general, first 100 included patients in an on- Helsinki and approved by The Regional
but, additionally, to analyze individuals going prospective cohort study. The Ethical Committee for Eastern Norway.
classified as potential copers or noncop- patients were enrolled between January Prior to inclusion, all patients signed a
ers in accordance to the criteria described 2007 and August 2009. Patients were written informed consent.
by Fitzgerald et al.19 The first aim of the referred to our outpatient clinic from
study was to present in detail our 5-week the emergency room or their physician, Outcome Measures
progressive exercise therapy program or they came on their own initiative. To Before testing, patients performed a stan-
for patients with ACL injury. Secondly, be considered eligible for inclusion, pa- dard 10-minute warm-up on a stationary
to evaluate changes in isokinetic quad- tients must have had a complete unilat- ergometer cycle. The test battery in this
riceps and hamstrings muscle strength, eral rupture of the ACL within the past study included isokinetic muscle strength
single-leg hop tests, and self-assessment 90 days. Complete rupture of the ACL tests for quadriceps and hamstrings28,29,35
of knee function from pretest to post- was confirmed by both magnetic reso- (Biodex 6000; Biodex Medical Systems
test after completion of the exercise nance imaging and at least 3 mm of bi- Inc, Shirley, NY), using 5 repetitions at
therapy program, including potential lateral difference in anterior knee joint 60° per second. This velocity is consid-
differences between patients classified laxity, as measured by a KT-1000 knee ered adequate for assessment of muscle
as potential copers and noncopers. The arthrometer (MED Metric, San Diego, strength after ACL injury.14,29,38,52 Patients
third and final aim was to examine the CA).70 Patients had to be between 13 and performed 4 repetitions for practice for
potential risk of adverse events for such 60 years of age, participate regularly in each limb before the test. Isokinetic ab-
an intensive program in the early stage pivoting sports, which is an activity level solute torque values were measured in
after ACL injury. We hypothesized the I or level II, as defined by Hefti et al27 (TA- newton meters (Nm) for both peak torque
following: (1) patients with ACL injury BLE 1), and be able to come to our clinic at and torque at 30° knee flexion angle,16
completing a 5-week progressive exercise least twice a week for participation in the and total work was expressed in joules
therapy program in the early stage after exercise therapy program. Patients were (J). Four single-leg hop tests15,19,47 were
injury would significantly improve knee excluded if they had symptomatic menis- included: the one-leg hop for distance,
function assessed from isokinetic muscle cal injuries, range-of-motion (ROM) the triple crossover hop for distance, the
strength tests, single-leg hop tests, and deficits that were not resolved within 90 triple-hop for distance, and the 6-meter
706 | november 2010 | volume 40 | number 11 | journal of orthopaedic & sports physical therapy
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timed hop test. A stopwatch was used for program represents phase 2. In the ini- importance for quadriceps strength im-
timing the 6-meter timed hop test. Sin- tial phase (phase 1), the goal is to resolve provement,44,62 and threaten unwanted
gle-leg hop tests have been considered to knee impairments related to swelling and anterior translation of the tibia less than
reflect both strength, coordination, and ROM deficits. As soon as knee joint ef- previously assumed.41,46,49 Specific single-
confidence after ACL injury.36,53 Patients fusion is eliminated and full ROM is re- limb exercises for the injured limb were
performed 1 practice trial for each limb to stored, phase 2 is initiated. Patients were performed on custom strength training
familiarize themselves with the tests. Two excluded from this study if impairments equipment (Technogym, Gambettola, It-
trials were performed for each hop test, were not eliminated within the first 3 aly), using leg press, knee extension, and
and the average score of the 2 trials was months of phase 1 rehabilitation after leg curl machines. The strength train-
used in the analyses. Absolute hop lengths their injury. ing program was individualized based
were measured in centimeters, and time The primary aim of phase 2 reha- on the specific needs of each patient. In
for the 6-meter timed hop test in seconds. bilitation is to restore muscle strength addition to progressive strength train-
Immediately after the hop tests, patients and adequate neuromuscular responses. ing, plyometric exercises were included
answered 2 self-assessment question- Consequently, this phase emphasizes in the program for enhancement of neu-
naires: the Knee Outcome Survey Activi- intensive muscle strength training, ply- romuscular performance and strength
ties of Daily Living Scale (KOS-ADLS)34 ometric exercises,9 and advanced neu- development.9,59 Plyometric exercises
and The International Knee Documen- romuscular exercises. Because specific were performed through variations of
tation Committee Subjective Knee Form evidence-based guidelines for strength single-leg hops and drills focusing on
(IKDC2000).31 These 2 questionnaires training in the early stage after ACL in- maintaining the knee-over-toe posi-
were selected due to the previously shown jury do not exist, the strength training tion with soft landings to avoid landings
reliability, validity, and responsiveness for part of our phase 2 program is developed with injurious dynamic loads.48 Further,
individuals with ACL injury.31-34 Patients based on the principles outlined in the neuromuscular challenges were assured
also stated their activity level, number American College of Sports Medicine po- through balance and proprioception
of episodes of giving way, and a global sition stand for progression models for exercises such as single-legged squats
rating of knee function from a numeric resistance training for healthy adults.40 on balance pads or the BOSU balance
visual analogue scale (VAS).21 Patients The strength training was standard- trainer. The basic strength, plyometric,
were classified as either potential copers ized and performed as multiple sets and neuromuscular exercises included in
or noncopers, according to the criteria of exercises for a minimum of 2 and a the program are presented in APPENDIX A.
described by Fitzgerald et al.19 To fulfill maximum of 4 sessions a week, with As a specific neuromuscular enhance-
the criteria of a potential coper, patients maximal effort for 3 or 4 sets of 6 to 8 ment, a sequence of 10 sessions with
had to have greater than or equal to 80% repetitions. These guidelines are consis- perturbation training was included in
score on the KOS-ADLS, a global rating tent with recent recommendations for the program. Perturbation training in-
numeric VAS score greater than or equal training frequency, recovery, and exer- cluded balance and stability exercises on
to 60, single-leg hop performance on the cise volume for recreational athletes at custom-made roller board, rocker board,
6-meter timed hop test of greater than or an intermediate level.40,50,54,69 Progression and platform, and involved perturbation
equal to 80%, and maximum 1 episode of was guided by a dose-response theoreti- of the support surface that allowed al-
giving way since the injury.19,45 cal framework, where the absolute load tered forces and torques to be applied to
Data collection procedures for the is increased from a targeted repetition the injured limb in multiple directions in
above tests are described in detail in a number in each set.40 To assure progres- a controlled manner.8 Progression of the
recent publication from our research sive overload, we used the “+2 principle.” perturbation training sessions was based
group.18 The baseline pretest, including This principle implies that the patients on the guidelines from the University of
the screening examination for classifica- are told to perform as many repetitions Delaware20 and is presented in APPENDIX
tion into potential copers and noncopers, as they can manage in the last of the B and instructional videos recently pub-
was performed as soon as initial impair- third or fourth sets. If they are able to lished online.26 Rehabilitation programs
ments were resolved, whereas the post- add 2 extra repetitions, load will be in- including perturbation training have
test was to be performed within 6 weeks creased in the next treatment session. previously been shown to enhance coor-
after the screening examination. Both single- and multiple-joint exer- dinated muscle activity and thus improve
cises, open and closed kinetic chain ex- the dynamic stability of the knee early af-
Exercise Therapy Program ercises, as well as concentric, eccentric, ter injury.8,20,25
ACL-rehabilitation in our outpatient and isometric strength exercises, were All patients were supervised at least
clinic is divided into 3 subsequent phases, included.40 Open kinetic chain exercises twice a week throughout the program to
where the described progressive 5-week have been shown to be of considerable assure that the intended quality of per-
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[ research report ]
Assessed for eligibility (n = 211) between January 2007

and August 2009
Inclusion criteria:
• Complete unilateral ACL rupture within the last 3 mo
(confirmed with MRI and KT-1000 side-to-side
difference 3 mm)
• Regular participation in pivoting sports (level I or II)
• 13-60 y of age
• No concomitant injuries
• Ability to come to our clinic at least 2 times per wk for 5 wk
Included (n = 100) Excluded (n = 111)

Baseline screening examination (n = 100): Reasons for exclusion:

• Isokinetic quadriceps and hamstrings strength • Symptomatic meniscal injuries and/or range-
• Single leg hop tests of-motion deficits (n = 41)
• KOS-ADLS • Compliance issues: unable to come to our
• IKDC2000 clinic at least 2 times per wk due to work or
• Numeric VAS function school obligations and/or travel distance to the
clinic (n = 40)
• Previous knee injuries (n = 12)
• Scheduled reconstruction within 3 wk after first
Exercise therapy program (n = 100): appointment at clinic (n = 7)
• Minimum 2, maximum 4, sessions per wk • Quadriceps strength index 70% after 3 mo (n = 3)

• Total of 10 sessions • Other reasons: more than 1 wk absence when
• On average completed within 5 wk scheduled for screening examination due to own
sickness or sickness in the family (n = 4), stopped
showing for appointments (n = 2), changed mind
regarding participation before the screening
Posttest (n = 98): examination (n = 2)
• Isokinetic quadriceps and hamstrings strength
• Single-leg hop tests (n = 93)
• KOS-ADLS
• IKDC2000
• Numeric VAS function
• Episodes of giving way Lost to follow-up (n = 2):
• Missed appointments (n = 1)
• Involved in a traffic accident, restricted from
all physical activities (n = 1)
Incomplete single-leg hops at posttest (n = 5):

• Giving way during posttest (n = 1)
• No hop tests at posttest due to symptoms of
swelling and pain when performing
plyometric exercises (n = 4)
FIGURE 1. Flow chart of the study. Abbreviations: ACL, anterior cruciate ligament; IKDC2000, The International Knee Documentation Committee Subjective Knee Form; KOS-
ADLS, Knee Outcome Survey activities of daily living scale; MRI, magnetic resonance imaging; VAS, visual analog scale.
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formance and correct level of difficulty
was achieved, as well as to perform the
TABLE 2 Characteristics of the Cohort
perturbation sessions. Because patients
were not supervised continuously during
Subject characteristics
each session, compliance was additional-
ly monitored through exercise diaries and Gender, males/females (%) 44/56
medical records. Each training session Age (y)* 26.1 (14-47)
was intended not to exceed 75 minutes, Body mass index females (kg/m2)* 23 (20-27)
including a 10- to 15-minute warm-up Body mass index males (kg/m2)* 24 (20-36)
on a stationary ergometer cycle, tread- Classification, potential copers/noncopers (%) 52/48
mill, or ellipse walker. Complications KT-1000 static laxity† 5.6  2.3
and adverse events were reported to the Injured side, left/right (%) 53/47
2 supervising physical therapists (I.E. or Activity level prior to injury, I/II (%) 70/30
H.M.) and noted in the medical records Activity when injured (n subjects)
of each subject. S
occer 33
After completion of the progressive Team handball 22
5-week exercise therapy program, pa- Alpine skiing 22
tients went through posttesting and the Basketball 5
final decision for reconstructive surgery Martial arts 4

or further nonoperative management was Other 14
addressed. The majority of the patients in * Data presented as mean (range).
our cohort had a preference for surgery,

†
Data presented as mean  SD.
based on their desire to return to pivoting

sports. The posttest results were incorpo-
rated when treatment options were dis- Changes from Pretest to Posttest for Limb
cussed with the patients, but not used as TABLE 3 Symmetry Indexes, Isokinetic Muscle Strength,
cut-off criteria in the final decision mak- and Single-Leg Hop Tests*
ing for surgery or further nonoperative
LSI Pretest LSI Posttest Difference Pretest-Posttest

management. Patients who were not re-
Quadriceps PT† 88.6%  9.7% 92.6%  9.8% 4.0%  9.4%
ferred to surgery continued rehabilitation
Quadriceps torque 30° flex† 84.4%  15.7% 92.5%  17.8% 8.1%  15.4%
in phase 3, whereas patients awaiting
Quadriceps TW† 88.4%  11.7% 92.0%  11.6% 3.6%  10.7%
ACLR continued progressive rehabilita-
Hamstrings PT† 94.0%  9.7% 96.9%  9.8% 2.9%  12.8%
tion in phase 2 with restrictions against
Hamstrings TW† 92.8%  14.6% 96.0%  9.8% 3.2%  15.3%
participation in pivoting sports. Of the
OLH‡ 90.4%  9.4% 90.0%  18.6% –0.4%  18.6%
100 included patients, 64 went through
TCH‡ 90.5%  13.3% 90.6%  17.9% 0.1%  16.5%
ACLR within the first 6 months after the
TH‡ 89.5%  12.6% 90.9%  18.3% 1.4%  14.8%
posttest, and 36 continued nonoperative
6MTH‡ 90.5%  15.6% 92.2%  17.9% 1.7%  18.4%
management.
Abbreviations: 6MTH, 6-meter timed hop test; LSI, limb symmetry index (side-to-side percentage
differences, injured versus uninjured limb); NC, noncopers; OLH, one-leg hop test for distance; PC,
Data Analysis potential copers; PT, peak torque; TCH, triple crossover hop test for distance; TH, triple-hop test for
Descriptive data characterizing the co- distance; TW, total work.
* Data are mean  SD. There was no significant time-by-group interaction effect for any of the variables.
hort was calculated from frequencies †
Significant main effect for time was found for all strength outcomes (P.001-.04), with large effect
and mean values with standard devia- sizes for quadriceps strength outcomes (0.15-0.22). Between-group (PC/NC) effects were significant for
tions. Changes in muscle strength and quadriceps strength outcomes (P.01) and for the TH and 6MTH (P = .02), with moderate to large
effect sizes (0.06-0.16).
hop performance limb symmetry in- ‡
No main effect for time was found for the single-leg hop tests (P.05).
dex (LSI) from pretest to posttest were
compared using a 2-way mixed-model
analysis of variance (ANOVA). LSI was pretest to posttest for the KOS-ADLS, noncoper) and time, as well as potential
expressed as the side-to-side difference IKDC2000, and VAS. The main effect differences in the observed changes be-
in percent using the uninjured limb as evaluated changes over time from pretest tween potential copers and noncopers,
control. The ANOVA was also utilized to posttest. Further, potential interaction were calculated. Additionally, we calcu-
for calculation of changes in score from effects between groups (potential coper/ lated the percentage changes from pre-
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[ research report ]
Peak Torque Total Work Torque at 30° Knee Flexion
96.00
100.00
95.00
94.00
95.00
Limb Symmetry Index
Limb Symmetry Index
Limb Symmetry Index

92.50
92.00
90.00
90.00
90.00 85.00
87.50
88.00 80.00
85.00
86.00 75.00
Pretest Posttest Pretest Posttest Pretest Posttest
Potential copers Noncopers
FIGURE 2. Main group and interaction effects between copers and noncopers, quadriceps strength.
test to posttest using the mean absolute Peak Torque Total Work
values of the isokinetic muscle strength

tests and the single-leg hop tests. To 97.00 97.00
evaluate whether percentage changes 96.00

96.00
Limb Symmetry Index

Limb Symmetry Index
could be regarded as clinically relevant,

95.00
the standardized response mean (SRM) 95.00
was calculated for changes in absolute 94.00
94.00
torque values, hop lengths (one-leg 93.00
hop for distance, crossover hop for dis- 93.00
92.00
tance, triple-hop for distance), and time
(6-meter timed hop test) from pretest to 92.00 91.00
posttest. The SRM was computed by di- Pretest Posttest Pretest Posttest
viding the mean change (posttest score
minus pretest score) by the SD of the Potential copers Noncopers
change.10 SRMs were regarded as moder-
ate between 0.5 and 0.8, and large above FIGURE 3. Main group and interaction effects between copers and noncopers, hamstrings strength.
0.8.4,10 The number of adverse events was
registered in the medical records for all examination for the included patients while injured, days from injury to pre-
patients. was 60.4 (range, 23-96) days, while the test screening, or days from pretest to
mean number of days from the baseline posttest between patients classified as
RESULTS pretest screening examination to post- potential copers or noncopers. Further,
test was 34.9 (range, 15-58) days. The there were no significant baseline dif-
Characteristics of the Cohort exercise therapy program incorporated ferences between those who later opted
A
flow chart of the study is 10 sessions, and the mean number of to have ACLR (64%) and those who
presented in FIGURE 1. To include completed sessions of the 98 patients continued nonoperative management
100 patients, 211 were considered that were included at follow-up was (36%), except for age (P = .005) and ac-
eligible for inclusion, and 111 were ex- 9.7 (range, 8-10) sessions. The sessions tivity level (P = .003). Those who opted
cluded. Reasons for exclusion are given were completed within a mean time for surgery were younger, with a mean
in FIGURE 1. There were no significant frame of 5 weeks. Subject character- age of 24.5 years, compared to 29.0
differences in age, gender, body mass istics are presented in TABLE 2. There years for those who elected not to have
index, or preinjury activity level be- were no significant baseline differences surgery. Among those who were surgi-
tween the included and excluded pa- on age, gender, preinjury activity level, cally treated, 81% were active at level I
tients. The mean number of days from KT-1000 static knee laxity, body mass and 19% at level II; whereas the activity
injury to the baseline pretest screening index, which side was injured, activity level was equally distributed, with 50%
40-11 Eitzen.indd 710 10/20/10 1:02 PM

at both level I and II among those who
continued nonoperative management. Muscle Strength Torque Improvement (%)
TABLE 4
Two patients were lost to follow-up From Pretest to Posttest*
at posttest (FIGURE 1). One subject did
Pretest† Posttest‡ Change (%) SRM
not show for his appointments week 2
Uninjured limb
after pretest screening, then came back
Quadriceps PT (Nm) 192.5  51.6 200.1  56.8 3.9% 0.27
6 weeks later, after he had reconstruc-
Quadriceps 30° flex (Nm) 118.8  30.9 121.2  32.7 0.2% 0.13
tive surgery at another clinic. The other
Quadriceps TW (J) 887.8  237.2 934.3  266.6 5.2% 0.35
subject was involved in a traffic accident
Hamstrings PT (Nm) 96.8  27.1 103.2  29.8 6.6% 0.37

and consequently did not complete the
Hamstrings TW (J) 545.1  165.8 591.8  182.3 8.6% 0.40
posttest. Both these patients were clas-
Injured limb
sified as potential copers at the pretest
Quadriceps PT (Nm) 169.8  45.8 183.8  52.5 8.2% 0.49
screening examination. Five additional
Quadriceps 30° flex (Nm) 100.9  34.7 112.1  36.2 11.1% 0.58
patients have incomplete data from the
Quadriceps TW (J) 784.1  225.8 856.4  264.0 9.3% 0.53
hop tests at posttest. Four of these expe-
Hamstrings PT (Nm) 90.4  25.6 99.7  29.3 10.2% 0.53
rienced adverse events with swelling and
Hamstrings TW (J) 499.8  148.9 564.7  170.5 12.9% 0.60
pain during the 5-week exercise therapy
program. The fifth had an episode of Abbreviations: PT, peak torque; SRM, standardized response mean; TW, total work.
* Torque values and percentage changes are presented as mean  SD.
giving way during the crossover hop for †
n = 100.
distance at posttest. However, this sub- ‡

n = 98.
ject had completed the exercise therapy
program without problems.
Hop Performance Improvement (%)
TABLE 5
Quadriceps and Hamstrings From Pretest to Posttest*
Muscle Strength
Changes from pretest to posttest for Pretest† Posttest‡ Change (%) SRM
quadriceps and hamstrings muscle Uninjured limb
strength are shown in TABLE 3. There were OLH (cm) 139.8  26.6 145.1  31.5 3.8% 0.27
no significant interaction effects between TCH (cm) 416.5  92.7 451.8  86.2 8.5% 0.51
groups (potential copers and noncopers) TH (cm) 460.3  100.9 481.9  84.6 4.7% 0.32
and time. The main effect for time was 6MTH (s) 1.84  0.29 1.79  0.27 2.7% 0.29
significant for quadriceps muscle peak Injured limb
torque, torque at 30° knee flexion, and OLH (cm) 126.9  25.0 136.0  28.2 7.2% 0.71
total work, as well as hamstrings muscle TCH (cm) 387.1  78.5 423.9  86.9 9.5% 0.84
peak torque and total work (P.05). The TH (cm) 423.5  82.9 449.3  87.7 6.1% 0.69
between-group main effect was signifi- 6MTH (s) 2.00  0.38 1.89  0.32 5.5% 0.50
cant for all 3 quadriceps muscle strength Abbreviations: 6MTH, 6-meter timed hop test; OLH, one-leg hop test for distance; SRM, standardized
response mean; TCH, triple crossover hop test for distance; TH, triple-hop test for distance.
outcome measurements (P.01) (FIGURE * Hop lengths, time in seconds and percentage changes are reported as mean  SD.
2) but nonsignificant for hamstrings mus- †
n = 100.
cle strength peak torque (P = .50) and to- ‡
n = 93.
tal work (P = .43) (FIGURE 3).
Changes in percent of absolute torque single-leg hop tests (TABLE 3). Further, for the one-leg hop for distance, triple-
values for quadriceps strength for the in- no significant main effect for time was hop for distance, and 6-meter timed hop
jured limb from pretest to posttest were found for either of the single-leg hops. test, and large for the crossover hop for
between 8.2% and 11.1% for the 3 out- For the triple-hop for distance and the distance (TABLE 5).
come measures, with moderate corre- 6-meter timed hop test, significant main
sponding SRM values (TABLE 4). effects for groups were present (P.05) Self-Assessment Questionnaires
(FIGURE 4). A significant interaction effect between
Single-Leg Hop Tests Changes in percent of absolute hop groups (potential copers and noncop-
There were no significant interaction length for the injured limb for the 4 hop ers) and time was evident for the KOS-
effects between groups (potential cop- tests were between 5.5% and 9.5%. The ADLS (P.01) (TABLE 6 and FIGURE 5), but
ers and noncopers) and time for the calculated SRM values were moderate not for the IKDC2000 or the VAS. Both
40-11 Eitzen.indd 711 10/20/10 1:02 PM

[ research report ]
the main effects for time and groups were
One-Leg Hop Triple Crossover Hop
significant (P.001) for the IKDC2000
and the VAS (TABLE 6 and FIGURE 5). 93.0 93.0
92.0 92.0
Tolerance for the Exercise
Limb Symmetry Index

Limb Symmetry Index
91.0 91.0
Therapy Program
Two patients were lost to follow-up at 90.0 90.0
posttest. Four of the remaining 98 pa- 89.0 89.0

tients (3.9%) experienced progressively
88.0 88.0
more swelling and pain during the sec-
ond or third week of the program, and 87.0 87.0
had to reduce exercise intensity to the Pretest Posttest Pretest Posttest

extent that they could not be considered
compliant with the program. Swelling Triple Hop 6-Meter Timed Hop
and pain occurred following the perfor- 96.0 96.0
mance of plyometric exercises for all 4
patients. None of the patients reported 94.0 94.0
Limb Symmetry Index

Limb Symmetry Index
pain during muscle strength exercises,

92.0 92.0
balance and stability exercises, or per-
turbation sessions. Two of the 4 patients 90.0 90.0

that had complications during the plyo-
88.0 88.0
metric exercises were noncopers and 2
were potential copers. These 4 individu- 86.0 86.0
als all later opted to have ACLR and also
Pretest Posttest Pretest Posttest
required a meniscus repair.
DISCUSSION
FIGURE 4. Main group and interaction effects between copers and noncopers, single-leg hop tests.
T
he purpose of this study was

to investigate whether a pro-
gressive 5-week exercise therapy Changes from Pretest to Posttest for
TABLE 6
program in the early stage after injury Self-Assessment Questionnaires*
before decision making for either ACLR
or further nonoperative management Pretest Score Posttest Score Difference Pretest-Posttest
could improve knee function and was KOS-ADLS† 81.4  10.7 86.4  8.8 5.0  9.0
tolerated by patients with ACL injury. IKDC2000‡ 69.7  11.7 77.2  10.2 7.5  11.0
The overall results confirmed our first VAS (global rating)‡ 78.3  12.9 83.7  12.5 5.4  12.5
hypothesis: that a progressive exercise Abbreviations: IKDC2000, The International Knee Documentation Committee Subjective Knee Form;
KOS-ADLS, Knee Outcome Survey activities of daily living scale; NC, noncopers; PC, potential copers;
therapy program conducted within a VAS, global rating of knee function on a visual analogue scale.
mean time frame of 5 weeks would lead * Data presented as mean  SD.
to significantly improved knee function †
For the KOS-ADLS, a significant interaction effect (P.01) was found, revealing that noncopers
improved more than potential copers.
in patients with ACL injury. This was ‡
For the IKDC2000 and VAS there was no interaction effect. Significant main effects (P.001) were
evident both for subjects initially classi- found for time and between groups (PC/NC). The effects sizes for the main effect for time and between
fied as potential copers and noncopers. groups (PC/NC) were large (0.16-0.35).
The second hypothesis, that noncopers
would improve significantly more than events among patients conducting the exist for the selection of exercises and
potential copers, was not confirmed. program, was partially confirmed, with exact dose-response in rehabilitation
An interaction effect implying larger only 3.9% of the patients attending the programs in the early stage after ACL
improvement in noncopers compared posttest having progressive swelling and injury. Our 5-week progressive program
to potential copers was only found for pain that required curtailing compliance combines strength training, plyometric
KOS-ADLS. Our third hypothesis, sug- with the 5-week program. exercises, general exercises for balance
gesting that there would be no adverse Currently, a clear consensus does not and stability, and perturbation train-
40-11 Eitzen.indd 712 10/20/10 1:02 PM

KOS-ADLS Numeric VAS Function IKDC 2000
90.0 90.0 85.0
80.0
85.0 85.0
75.0
Score
Score
Score
80.0 80.0
70.0
75.0 75.0
65.0
70.0 70.0 60.0
Pretest Posttest Pretest Posttest Pretest Posttest
FIGURE 5. Main group and interaction effects between copers and noncopers, self-reported knee function. Abbreviations: IKDC2000, The International Knee Documentation
Committee Subjective Knee Form; KOS-ADLS, Knee Outcome Survey activities of daily living scale; VAS, visual analog scale.
ing. The strength training regimen is ferences between patients are avoided. evaluating only LSI. Without a control
based on principles for heavy resistance But the potential disadvantage is that group, calculation of SRM values for
strength training for healthy individu- the status of the uninjured side may lead pretest to posttest changes in the injured
als with few repetitions in each series, to to misinterpretation of results4,7,30 due to limb may be of particular clinical inter-
increase the cross-sectional area of the possible bilateral neuromuscular changes est. While P values reflect whether an ob-
muscle and promote neuromuscular ad- after injury.1,48 In addition to evaluation served change is statistically significant,
aptation.40 Both closed and open kinetic of the LSI, we performed supplementary SRM values express the magnitude of the
chain exercises were included, as recent evaluations of the absolute values for the observed changes.4 Our SRM values em-
publications have shown that open ki- uninjured and injured side and examined phasize that patients with ACL tears in
netic chain exercises are important to re- changes in percent from pretest to post- the early stage after injury have potential
gain quadriceps muscle strength41,44 and test for both isokinetic muscle strength for clinically relevant functional improve-
also that open kinetic chain exercises can torques and single-leg hop lengths (one- ments, even from a short-term exercise
be conducted safely in patients with ACL leg hop for distance, crossover hop for therapy program consisting of only 10
injury.44,46,49 The neuromuscular exercises distance, and triple-hop for distance) training sessions.
in the program are intended to be of the and time (6-meter timed hop test). These When comparing our muscle strength
utmost challenge to the patient. Over analyses revealed changes in both quad- data to normative values presented by
the past few years, our exercise therapy riceps and hamstrings muscle strength Phillips et al,51 the mean posttest abso-
program has evolved in the direction of for the injured side (range, 8.2%-12.9%) lute peak torque values on the injured
higher loads, fewer repetitions, and less (TABLE 4), entailing a strength increase of limb were equivalent to normative val-
restrictions with regard to open kinetic 1.6% to 2.2% per week. The correspond- ues from the dominant limb of healthy
chain exercises, as well as more challenging SRM values for the injured limb subjects (183.8 versus 180.3 Nm, respec-
ing neuromuscular exercises. reflected changes of moderate clinical tively). However, the mean age of the
LSI is commonly used to express relevance (0.49-0.60), whereas the cor- subjects included in the normative study
both isokinetic muscle strength61 and responding SRM values for the uninjured was higher than for our cohort (44.2 ver-
single-leg hop performance,2 and a LSI limb were low (0.13-0.40). Evaluation of sus 26.1 years, respectively). However,
of greater than or equal to 90% is often absolute values (TABLE 5) for single-leg Danneskiold-Samsøe et al12 presented
considered to indicate normal limb sym- hop performance showed changes in normative values for a cohort with pa-
metry.2,24,25,61 However, the use of LSI percent in the injured limb from 5.5% tients age-matched to ours at 169.0 Nm,
alone may be ambiguous if the main pur- to 9.5%. The SRM values were moderate which further suggests that the patients
pose is to evaluate the response to exer- to strong (0.50-0.84) for all tests. Thus, in our cohort regained adequate muscle
cise and improvement of knee function analyses of the absolute values and cor- strength after the exercise therapy pro-
primarily in the injured limb. Using the responding SRMs for the injured lower gram. The limited amount of normative
uninjured limb as control has the meth- extremity revealed clinically interesting data for isokinetic knee muscle strength
odological advantage that biological dif- improvements that were concealed when should, nevertheless, be addressed in fu-
40-11 Eitzen.indd 713 10/20/10 1:02 PM

[ research report ]
ture studies. cohort indicate a mean score of approxi- the effect of neuromuscular training
Previous studies from our group16 and mately 89 points for men and 86 points programs for individuals with ACL-
Shirakura et al60 showed that there were for women. Previous studies have shown deficient knees, with variations both in
larger differences in quadriceps strength that ACL injury may lead to low self-ef- exercises included and the duration of
at knee flexion angles of less than 40°. ficacy64 and that self-efficacy and mental the programs. Still, it is concluded that
Thus, quadriceps torque values at 30° preparedness before ACLR may influ- exercises for proprioception and bal-
knee flexion angle were included in the ence the final outcome.5,63 The improve- ance may improve dynamic knee stabil-
analyses. The results confirm previous ments in the IKDC2000 may suggest the ity and thus the functional ability of the
findings that LSI differences were larger potential importance of increased self- patients. Further, there is some evidence
at angles closer to full knee extension evaluation scores in the early stage after suggesting that plyometric exercises will
(TABLE 3). This may have important clini- injury, before scheduled ACLR. This is enhance muscular strength and athletic
cal implications when using quadriceps of particular interest for noncopers, who performance,9,59 and that rehabilitation
strength LSI in the evaluation of treat- from the original screening examination programs, including specific perturba-
ment outcome. However, when evalu- algorithm were not regarded as candi- tion training, may lead to beneficial neu-
ating changes in absolute values and dates for rehabilitation.19 However, the romuscular adaptations.20,25,42 Without a
SRM values from pretest to posttest, the IKDC2000 does not assess self-efficacy comparison group, we cannot state that
deficits at 30° demonstrated the highest as such, and future studies investigating our findings document that combined
percentage improvement (11.1%) and the preoperative self-reported outcomes as approaches of both neuromuscular exer-
highest SRM value (0.58) of the included predictors for postoperative outcome are cises and strength training are superior
strength measures. This indicates that needed to verify this suggestion. to other exercise programs emphasiz-
even though larger at pretest, quadriceps Preoperative quadriceps muscle ing separate elements. However, we can
muscle strength weakness in the injured strength deficits have previously been from our findings state that it is possible
limb at angles closer to full extension assessed from isokinetic measurements to achieve significant and clinically im-
have good potential for improvement. As to be between 7% and 21%,13,36-38,55 and portant improvements in both muscle
a consequence, knee extension exercises have also been shown to be persistent af- strength and knee function even with a
targeting strength deficits throughout ter ACLR.17,37,68 As a consequence, there short-term exercise program, and that
the whole knee extension ROM should has been growing attention towards the this is true both for subjects initially clas-
be included in early stage rehabilitation importance of more aggressive strength sified as potential copers and noncopers.
programs. training of the quadriceps muscle after Future studies, including randomized
All self-assessments of knee func- ACL injury.6,25,41 Ingersoll et al30 suggest- controlled trials with groups that per-
tion significantly improved from pretest ed that strength deficits after ACL injury form different exercise therapy pro-
to posttest (P.001). The KOS-ADLS are the result of alterations to muscle grams, are needed to verify the potential
showed a significant interaction effect, activation patterns. The almost imme- effectiveness of our program.
implying that noncopers improved signif- diate development of weakness and the A crucial issue when introducing
icantly more than potential copers (FIG- often observed persistency of the deficit progressive exercise therapy programs
URE 5). Significant main effects for time despite rehabilitation suggest that ar- is the tolerance for the training load. In
and group were found for both the VAS throgenic muscle inhibition may play a this study, 3.9% of the patients experi-
and the IKDC2000 (P.001), revealing major role in quadriceps atrophy after enced adverse events during the period
that both potential copers and noncopers ACL injury.48 Furthermore, individu- of conducting the program that prevent-
improved but noncopers still had lower als with ACL injury who have muscle ed compliance with regard to progres-
scores at posttest (P.001). strength deficits often have overall poor sion of the plyometric exercises. Lack of
The IKDC2000 is used for assess- function.62,68 However, to what extent al- tolerance was demonstrated by progres-
ment of knee function with regard to tered neuromuscular strategies1,6,30,48,68 sively increasing symptoms of swelling
symptoms, function, and sports activity,3 and proprioceptive deficits22,57 contribut- and pain during or after training ses-
and may thus be considered to be of par- ing to reduced function after ACL injury sions. We attribute these complications
ticular relevance for our cohort of young, may be restored through rehabilitation to the performance of the plyometric
active individuals. The mean IKDC2000 is not well documented. Most systematic exercises. Recent studies have empha-
score for our cohort at pretest and post- reviews and randomized controlled tri- sized the challenges related to the cor-
test was 69.7 and 77.8 points, respec- als on ACL-injuries focus on individu- rect diagnosis of meniscus injuries.39,58,67
tively. According to the normative data als post ACLR. In 2 systematic reviews, We included both magnetic resonance
for IKDC2000 published by Anderson et Cooper et al11 and Risberg et al56 identi- imaging and a clinical examination
al,3 scores for subjects age-matched to our fied only a few high-quality studies on when evaluating individuals eligible for
40-11 Eitzen.indd 714 10/20/10 1:02 PM

inclusion in the study. Our definition of reminded to update a personal written It is, therefore, suggested to incorporate
a symptomatic meniscus injury implied exercise diary during the 5-week exercise a short-term period of intensive exercise
that patients should reveal symptoms therapy program. However, the compli- in ACL injury management, either before
during hopping exercises, and/or have ance of the patients to fill in these self- scheduled ACLR, or as a preparation for
evident knee joint effusion, and/or ROM reported data was not satisfactory. We further nonoperative management before
deficits that were not resolved within 3 did not register this information system- returning to preinjury activity without
months after the date of injury. The 4 atically when monitoring the patients, surgery. t
patients that experienced adverse events and, as a consequence, data showing
all later opted to have ACLR and were exact progression during each session KEY POINTS
found to require a concomitant menis- throughout the exercise period cannot be FINDINGS: A 5-week progressive exercise
cus repair. All patients in the study were provided. Future studies should include therapy program in the early stage after
advised not to participate in any pivoting closer monitoring of dose-response and ACL injury led to significantly improved
activities during phase 2. Further, they progress for each separate exercise that is knee function before the decision mak-
were monitored at least twice a week and included in the exercise therapy program, ing for reconstructive surgery or further
any complications and adverse events both for muscle strength and neuromus- nonoperative management. The compli-
were registered. No episodes of giving cular exercises. From our experience, this ance to and tolerance for the program
way were reported. Thus, it is unlikely should be registered as part of the patient was high, with few adverse events.
that any of the 4 patients had new inju- monitoring at each session and not be IMPLICATION: Short-term progressive
ries within the 5-week period, and their based on self-reporting. exercise therapy programs should be in-
symptoms were most probably related to Our cohort consisted of patients with corporated in the early stage after ACL
the increased demands posed on the knee isolated ACL-tears, including asymp- injury, to optimize knee function before
during phase 2 of the rehabilitation pro- tomatic meniscus lesions. A consider- ACLR or as a first step in the prepara-
gram. The remaining 94 patients were able amount of patients with ACL injury tion to return to previous activity with-
compliant with the demands for pro- have additional injuries to the menisci out surgery.
gression and exercises in the program. and/or collateral ligaments and related CAUTION: The participants in this study
Our results indicate that the majority of symptoms,66 which is also reflected in the had an ACL tear with no symptomatic
patients with isolated ACL-injuries are number of individuals excluded from our concomitant injuries; therefore, results
able to comply with progressive exercise cohort. Our results can, therefore, not be cannot be generalized to all patients
therapy programs. However, our results generalized to patients with symptomatic with ACL injury. The results of this
suggest that adverse events can be ex- concomitant injuries. Our high tolerance study are further dependent on moti-
pected to occur in 1 out of 25 patients. rate for the progressive exercise therapy vated patients with high compliance to
Thus, the responsible physical therapist program must be interpreted within this the exercise therapy program.
must monitor eventual adverse events context.
closely on an individual basis and never Finally, the patients included in this ACKNOWLEDGEMENTS: We would like to ac-
hesitate to adjust the program if unde- study were young, active individuals who knowledge the physical therapists Ida Svege,
sired symptoms appear. Based on our might have had higher motivation for ex- Espen Selboskar, and Karin Rydevik for as-
findings, symptoms of pain and swelling ercise and rehabilitation than other sub- sistance in data collection, and Line Hagen in
during the rehabilitation program may groups of patients with ACL injury. Our Exercise Organizer for providing illustrations
be an indicator of other intra-articular results are thus dependent on high com- for APPENDIX A.
pathology like a meniscus tear. pliance to, and low drop-out rates from,
the exercise therapy program.
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[ research report ]
appendix a
Sets by
Number of
Exercise Description Repetitions Figures
Stationary cycle Continuous warm-up at your preferred resistance 10 min
Treadmill Continuous warm-up at your preferred speed 10 min

Elliptical trainer Continuous warm-up at your preferred resistance 10 min
Single-limb squat Maintain knee-over-toe position 3×8

Step-up Maintain knee-over-toe position 2 × 10
Squat on BOSU Maintain knee alignment and core stability. Squat quickly down and up 2 × 20
Single-limb leg press Start in 90° knee flexion 3 × 6 (+2)
©2010 Exercise Organizer®
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appendix a
Sets by
Number of
Exercise Description Repetitions Figures
Single-limb knee Start in 90° knee flexion 4 × 6 (+2)
extension
Squats Squat slowly down to 90° knee flexion, stop, lift quickly up again 3 × 8 (+2)
Leg curl Lift quickly up, stop, and then slowly down to full extension 3 × 8 (+2)
Hamstring on Fitball One foot on top of the ball, lift back and pelvis up, pull ball towards you 3×6
Single-leg hop Hop up on step, stop, continue down and directly 1 hop forward with a soft 1 × 15
controlled landing
Sideways single-leg Start on 1 side of a board. Hop quickly sideways and stop after 3 hops. Con- 3 × 15
hop tinue and stop 5 times
Skating Start on 1 leg, hop sideways, perform a soft, deep and steady landing on 1 2 × 20
leg, hop back to the other side
All exercises are to be performed at each training session. Two to 3 series in each session. Training sessions minimum 2, maximum 4 times a week. Progression from increasing loads
on the strength exercises and for higher steps, longer/higher jumps, movement in several directions and more wobbly surfaces for the neuromuscular and plyometric exercises. ©2010
Exercise Organizer®
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[ research report ]
appendix b
Perturbation Training Protocol

Sessions 1-4. Early Phase
Progression by adding perturbations in all directions and minimizing of verbal cues
Activity
Session Rocker Board Roller Board/Platform Roller Board
1 • Bilateral stance • 2 sets with injured limb on roller board, anterior/posterior • Bilateral stance
• 2 sets, anterior/posterior • 2 sets with uninvolved limb on roller board, anterior/posterior • 2 sets anterior/posterior
• 2 sets, medial/lateral
2 • Unilateral stance • 2 sets with injured limb on roller board, anterior/posterior plus • Unilateral stance
• 2 sets anterior/posterior direction medial/lateral • 2 sets anterior/posterior
• 2 sets medial/lateral direction • 2 sets with uninvolved limb on roller board, anterior/posterior
plus medial/lateral
• 2 sets medial/lateral direction medial/lateral plus rotation • 2 sets anterior/posterior plus
• 2 sets diagonal direction • 2 sets with uninvolved limb on roller board, anterior/posterior medial/lateral

plus medial/lateral plus rotation

• 2 sets diagonal direction • 2 sets with uninvolved limb on roller board, anterior/posterior medial/lateral plus rotation
plus medial/lateral plus rotation
Sessions 5-7: Middle Phase

Progression by adding light sport-specific activity during perturbations
Activity

• 2 sets anterior/posterior direction medial/lateral plus rotation • 2 sets anterior/posterior plus
• 2 sets medial/lateral direction • 2 sets with uninvolved limb on roller board, anterior/posterior plus medial/lateral plus rotation
• 2 sets diagonal direction medial/lateral plus rotation • Ball against wall
• Ball against wall • Ball against wall
• 2 sets anterior/posterior direction medial/lateral • 2 sets anterior/posterior plus
• 2 sets diagonal direction
medial/lateral • Ball against wall/floor
• Ball against wall/floor • Ball against wall/floor
• 2 sets medial/lateral direction medial/lateral • 2 sets anterior/posterior plus
• 2 sets diagonal direction • 2 sets with uninvolved limb on roller board, anterior/posterior plus medial/lateral plus rotation
• Ball thrown by other
medial/lateral • Ball thrown by other
• Ball thrown by other
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appendix b
Perturbation Training Protocol (continued)

Sessions 8-10: Late Phase
Progression by adding sport-specific stances combined with sport-specific activity
Activity
• 2 sets anterior/posterior direction medial/lateral plus rotation • 2 sets anterior/posterior plus
• 2 sets diagonal direction medial/lateral plus rotation • Ball against wall/floor, thrown
• Ball against wall/floor, • Ball against wall/floor, thrown by other by other
thrown by other • Other individually adjusted relevant sport-specific activities • Other individually
• Other individually adjusted adjusted relevant sport-
relevant sport-specific activities specific activities
• Ball against wall/floor, medial/lateral plus rotation • Ball against wall/floor, thrown
thrown by other • Ball against wall/floor, thrown by other by other
• Other individually adjusted • Other individually adjusted relevant sport-specific activities • Other individually
relevant sport-specific activities adjusted relevant sport-
specific activities
• Ball against wall/floor, medial/lateral plus rotation • Ball against wall/floor, thrown
thrown by other • Ball against wall/floor, thrown by other by other
• Other individually adjusted • Other individually adjusted relevant sport-specific activities • Other individually
relevant sport-specific activities adjusted relevant sport-
specific activities
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[ research report ]

Ingrid Eitzen, PT, PhD1 • Håvard Moksnes, PT, MSc2

A Progressive 5-Week Exercise Therapy

in Knee Function Early After Anterior

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40-11 Eitzen.indd 706 10/20/10 1:02 PM

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Assessed for eligibility (n = 211) between January 2007

Included (n = 100) Excluded (n = 111)

Baseline screening examination (n = 100): Reasons for exclusion:

• Minimum 2, maximum 4, sessions per wk • Quadriceps strength index 70% after 3 mo (n = 3)

Incomplete single-leg hops at posttest (n = 5):

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medical records. Each training session Age (y)* 26.1 (14-47)

on a stationary ergometer cycle, tread- Classification, potential copers/noncopers (%) 52/48

mill, or ellipse walker. Complications KT-1000 static laxity† 5.6  2.3

After completion of the progressive Team handball 22

5-week exercise therapy program, pa- Alpine skiing 22

tients went through posttesting and the Basketball 5

final decision for reconstructive surgery Martial arts 4

or further nonoperative management was Other 14

addressed. The majority of the patients in * Data presented as mean (range).

our cohort had a preference for surgery,

based on their desire to return to pivoting

LSI Pretest LSI Posttest Difference Pretest-Posttest

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Limb Symmetry Index

Limb Symmetry Index

Pretest Posttest Pretest Posttest Pretest Posttest

Potential copers Noncopers

values of the isokinetic muscle strength

evaluate whether percentage changes 96.00

Limb Symmetry Index

could be regarded as clinically relevant,

(6-meter timed hop test) from pretest to 92.00 91.00

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Hamstrings PT (Nm) 96.8  27.1 103.2  29.8 6.6% 0.37

distance at posttest. However, this sub- ‡

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Limb Symmetry Index

posttest. Four of the remaining 98 pa- 89.0 89.0

had to reduce exercise intensity to the Pretest Posttest Pretest Posttest

Limb Symmetry Index

pain during muscle strength exercises,

turbation sessions. Two of the 4 patients 90.0 90.0

he purpose of this study was

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90.0 90.0 85.0

70.0 70.0 60.0

Pretest Posttest Pretest Posttest Pretest Posttest

Potential copers Noncopers

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40-11 Eitzen.indd 714 10/20/10 1:02 PM

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ment injuries in adults. Cochrane Database

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Treadmill Continuous warm-up at your preferred speed 10 min

Elliptical trainer Continuous warm-up at your preferred resistance 10 min

Single-limb squat Maintain knee-over-toe position 3×8

Step-up Maintain knee-over-toe position 2 × 10

Single-limb leg press Start in 90° knee flexion 3 × 6 (+2)

©2010 Exercise Organizer®

• Minimum 2, maximum 4, sessions per wk • Quadriceps strength index 70% after 3 mo (n = 3)