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Recent Advances in The Rehabilitation of Anterior Cruciate Ligament Injuries
Recent Advances in The Rehabilitation of Anterior Cruciate Ligament Injuries
KEVIN E. WILK, PT, DPT1 • LEONARD C. MACRINA, MSPT, SCS, CSCS2 • E. LYLE CAIN, MD3
JEFFREY R. DUGAS, MD4 • JAMES R. ANDREWS, MD5
I
njury to the anterior cruciate ligament (ACL) is potentially isolated ACL reconstruction. We have an
functionally debilitating and often requires surgical intervention accelerated program and a regular pro-
gram for patellar tendon reconstruction
followed by an extensive course of rehabilitation. Approximately
and a separate protocol for hamstring re-
200 000 ACL injuries occur annually in the United States, leading construction. The accelerated approach
to nearly 100 000 ACL reconstruction surgeries, one of the most is utilized for the young and/or athletic
common orthopaedic surgeries, which has expectations of excellent patient. The main differences between
outcomes.26,73,85,105,112,150,171,175 The surgical procedure is one aspect the 2 programs are the rate of progres-
sion through the various phases of reha-
of a successful outcome after ACL re- Current programs emphasize full passive bilitation and the recovery time necessary
construction; however, a scientifically knee extension,101,151,155,173,179 immediate prior to running and a full return to ath-
based and well-designed rehabilitation motion,35,52,101,122,147,173,174,179 immediate par- letic activities.
program also plays a vital role. Although tial weight bearing (WB),145,173,176,179 and In 1990, Shelbourne and Nitz151 re-
we expect all our patients to return to un- functional exercises.29,94,95,173 This trend is ported improved clinical outcomes in
restricted activities and preinjury levels due in part to the documented improved patients who followed an accelerated
after surgery,5,6,162 some authors have re- outcomes with more aggressive reha- approach rather than a conservative
ported some concerning results in which bilitation.151 Howe et al77 also reported rehabilitation approach. These patients
professional football players’ careers have improved outcomes—greater motion, im- exhibited better strength and range of
been altered and even shortened by ap- proved muscular strength, and enhanced motion (ROM) with fewer complica-
proximately 2 years and their overall per- earlier function—with formal, supervised tions, such as arthrofibrosis, laxity, and
formance has decreased by 20%.22,26,148 rehabilitation compared to no supervised graft failures. Furthermore, the accel-
Current rehabilitation programs fol- rehabilitation. erated group had fewer patellofemo-
lowing ACL reconstruction are more ag- Presently, we utilize 3 different reha- ral complaints and an earlier return to
gressive than those utilized in the 1980s. bilitation programs for patients with an sport. The senior author (K.E.W.),172,176,179
since 1994, and others37,88,103,183 have uti-
TTSYNOPSIS: Rehabilitation following anterior the patient to his or her sport or activity as safely
lized components of the accelerated ACL
cruciate ligament surgery continues to change, as possible. Unique rehabilitation techniques and rehabilitation program with excellent
with the current emphasis being on immediate special considerations for the female athlete will results.
weight bearing and range of motion, and progres- also be discussed. The purpose of this article is In this paper, we will provide a sci-
sive muscular strengthening, proprioception, to provide the reader with a thorough scientific entific basis for the rationale behind our
dynamic stability, and neuromuscular control basis for anterior cruciate ligament rehabilitation ACL rehabilitation program following
drills. The rehabilitation program should be based based on graft selection, patient population, and
a reconstruction, discuss variations in
on scientific and clinical research and focus on concomitant injuries. J Orthop Sports Phys Ther
2012;42(3):153-171. doi:10.2519/jospt.2012.3741 rehabilitation based on graft type and
specific drills and exercises designed to return the
TTKEY WORDS: ACL, knee, neuromuscular
concomitant injuries, as well as discuss
patient to the desired functional goals. The goal
is to return the patient’s knee to homeostasis and training, proprioception special considerations for the female
athlete.
Associate Clinical Director, Champion Sports Medicine-Physiotherapy Associates, Birmingham, AL; Director of Rehabilitative Research, American Sports Medicine Institute,
1
Birmingham, AL; 2Physical Therapist, Champion Sports Medicine, Birmingham, AL; Orthopaedic Sports Medicine Fellow, American Sports Medicine Institute, Birmingham,
AL. 3Orthopaedic Surgeon, Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL; Fellowship Director, American Sports Medicine Institute, Birmingham,
AL. 4Orthopaedic Surgeon, Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL; Orthopaedic Sports Medicine Fellow, American Sports Medicine Institute,
Birmingham, AL. 5Orthopaedic Surgeon, Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL; Orthopaedic Sports Medicine Fellowship Director, American Sports
Medicine Institute, Birmingham, AL. Address all correspondence to Dr Kevin Wilk, 805 St Vincent’s Dr, Suite G100, Birmingham, AL 35205. E-mail: kwilkpt@hotmail.com
journal of orthopaedic & sports physical therapy | volume 42 | number 3 | march 2012 | 153
O
ur accelerated rehabilitation weeks and progressed as tolerated. Neu- as needed (FIGURE 1A). The patient is in-
program following ACL reconstruc- romuscular control drills are gradually structed to lie supine while the low-load,
tion with an ipsilateral patellar ten- advanced to include dynamic stabiliza- long-duration stretch is applied for 12 to
don autograft is provided in the APPENDIX. tion and controlled perturbation training 15 minutes 4 times per day, with the total
We begin rehabilitation before surgery 2 or 3 weeks after surgery. Once satisfac- low-load, long-duration stretch time per
when possible. It is imperative to reduce tory strength and neuromuscular control day equaling at least 60 minutes.108 We
swelling, inflammation, and pain, restore have been demonstrated to the reha- utilize this technique immediately fol-
normal ROM, normalize gait, and pre- bilitation specialist, functional activities lowing surgery to maintain and improve
vent muscle atrophy prior to surgery. The such as running and cutting may begin knee extension and prevent a flexion
goal is to return the knee to its preinjury, 10 to 12 weeks and 16 to 18 weeks after contracture.
normalized state and to obtain tissue ho- surgery, respectively. A gradual return The amount of hyperextension we
meostasis. Full motion is restored before to athletic competition for running and attempt to restore is dependent on the
surgery to reduce the risk of postopera- cutting sports, such as baseball, football, uninjured knee. During the first week fol-
tive arthrofibrosis.155 Patient education, a tennis, and soccer, occurs approximately lowing surgery, for patients who exhibit
critical aspect of preoperative rehabilita- 6 months after surgery, once the patient 10° or more of hyperextension on the
tion, informs and prepares the patient for demonstrates at least 85% of contralat- uninjured knee, we will restore approxi-
the surgical procedure and postoperative eral strength in the quadriceps and ham- mately 7° of hyperextension on the sur-
rehabilitation. strings.180 Return to jumping sports such gical side. We will gradually restore the
The preoperative phase, which we be- as basketball and volleyball, however, remaining hyperextension once joint in-
lieve is critical to a successful outcome, may be delayed until 6 to 9 months after flammation is reduced and muscular con-
may require several weeks; however, 21 surgery. trol is restored over the following several
days are typically adequate.110,155 We have Our postoperative programs were de- weeks. We often utilize extension devices
found that patients undergoing a preop- signed according to several key principles to create overpressure into extension, as
erative rehabilitation program progress of ACL rehabilitation to ensure satisfac- seen in FIGURE 1B. The authors feel that re-
more easily through the postoperative tory outcomes and to return the athlete storing hyperextension is imperative to a
rehabilitation program, especially the to sport as quickly and safely as possible. successful outcome and an asymptomatic
earlier phases, and regain their ROM We will discuss each of these principles in knee.150
with diminished symptoms. detail in the following sections.
Postoperative rehabilitation begins Restore Patellar Mobility
with passive range of motion (PROM) Full Passive Knee Extension The loss of patellar mobility following
and WB activities immediately follow- The most common complication and ACL reconstruction may have various
ing surgery. Full passive knee extension cause of poorer outcomes following ACL causes, including excessive scar tissue
is emphasized while gradually restoring reconstruction is motion loss, particularly adhesions along the medial and lat-
flexion motion. Immediately following loss of full knee extension.8,60,80,143,155 The eral retinacula, fat pad restrictions,3,7
surgery, WB as tolerated in a locked knee inability to fully extend the knee results in and harvesting the patellar tendon for
brace in full extension is allowed, and the abnormal joint arthrokinematics,17,21,89,130 the ACL graft. The loss of patellar mo-
patient is progressed to full WB without scar tissue formation in the anterior bility, referred to as infrapatella con-
crutches after 10 to 14 days. Despite con- aspect of the knee, and subsequent in- tracture syndrome, results in ROM
flicts in the literature, we recommend a creases in patellofemoral/tibiofemoral complications and difficulty activating
drop-lock knee brace during ambulation joint contact pressure.3 Therefore, two of the quadriceps.129 Patellar mobilizations
to emphasize full knee extension and our goals are to achieve some degree of are performed by the rehabilitation spe-
assist the patient during the gait cycle hyperextension during the first few days cialist in the clinic and independently
while the quadriceps is inhibited.144,150,154 after surgery and eventually to work to by patients during their home exercise
The locked brace is used while ambulat- restore symmetrical motion. program. Mobilizations are performed
ing and sleeping during the first 2 weeks Specific exercises include PROM ex- in the medial/lateral and superior/infe-
after surgery. Studies have also shown ercises performed by the rehabilitation rior directions, especially for those with
that patients achieve improved function- specialist, supine hamstring stretches a patellar tendon autograft, to restore the
al knee scores and proprioception when with a wedge under the heel, and gas- patella’s ability to tilt, especially in the
using a brace after surgery.20,138 trocnemius stretches with a towel. Pas- superior direction.
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state and reached the level of homeo- for the female athlete to learn to control
stasis described by Dye and Chew.40 If this valgus moment.64,69,137 In addition
the patient’s knee is still sore or exhibits to education on optimal knee alignment
swelling after running, stiffness, or local- (keeping the knee over the second toe),
ized pain, the activities are reduced to a exercises designed to control this moment
level that does not produce these effects. at the knee include front step-downs
(FIGURE 9), lateral step-downs with resis-
REHABILITATION OF THE tance (FIGURE 10), and squats with resis-
FEMALE ATHLETE tance around the distal femur (FIGURE 11).
Rehabilitation should train the patient to
A
n increasing number of females stabilize the knee through coactivation of
are participating in athletics, and the quadriceps and hamstrings using vari-
this group warrants special con- ous exercises, including tilt board balance
sideration.64,65,67,70,79,137,158 Malone et al100 exercises while performing a throw and
reported that female college basketball catch. Because females tend to land with
players were 8 times more likely to injure increased knee extension and decreased
their ACL than their male counterparts. hip flexion after jumping, dynamic stabi-
Lindenfeld et al98 reported that female lization drills should be performed, with FIGURE 9. Front step-down movement: during the
soccer players were 6 times more likely the knee flexed approximately 30° to pro- eccentric or lowering phase, the patient is instructed
to sustain an ACL injury than male soc- mote better alignment and activation of to maintain proper alignment of the lower extremity to
prevent the knee from moving into a valgus moment.
cer players. There are similar data for the quadriceps and hamstrings.66,69 A key
other sports, such as volleyball and gym- rehabilitation aspect for the female ath-
nastics.28,48 It is also noteworthy that in lete is to train the hip extensors, external We believe that after ACL surgery it is
female athletes, the vast majority of ACL rotators, abductors, and core stabilizers, important that female athletes undergo
injuries occur without contact.176 while emphasizing a flexed knee posture a specific rehabilitation program that
Females have some unique charac- during running, cutting, and jumping. addresses the predisposing factors that
teristics that may predispose them to We instruct the female athlete to control potentially led to the injury.
injury, including increased genu valgum the knees via the hip/pelvis68,86,132 and foot
alignment, a poor hamstring-quadriceps position.86 Furthermore, we emphasize VARIATIONS IN
strength ratio, running and landing on strength training of the hip abductors, REHABILITATION BASED
a more extended knee, quadriceps-dom- extensors, and external rotators. We take ON GRAFT TYPE
inant knee posture, and hip/core weak- special consideration to eccentrically train
G
ness. It has also been postulated that these muscle groups to help control exces- raft selection has some impact
hormonal changes associated with the fe- sive adduction and internal rotation of the on the rehabilitation program used
male menstrual cycle may play a role.64,79 femur during WB activities. Moreover, following ACL reconstruction. To-
Because a common mechanism of core stabilization exercises are utilized to day, the most commonly utilized sources
noncontact ACL injury is a valgus stress aid in controlling lateral trunk displace- of graft tissue are the autogenous patellar
with rotation at the knee, it is important ment during sport movements.66,68,117,186,187 bone-tendon-bone33,149 and autogenous
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stronger than the native ACL and 39% of using hamstring tendon grafts versus
stronger than the patellar tendon. The bone-tendon-bone grafts in a consecutive
FIGURE 10. Lateral step-down with resistance bands. patellar tendon graft is approximately series of 60 patients. The results indicat-
A resistance band is applied around the inner knee to 37% stronger than the native ACL. Al- ed no significant difference in outcomes
provide resistance and to control the valgus moment
though all potential grafts listed in between the 2 types of grafts. In the pa-
at the knee by recruiting hip abductors and rotators.
TABLE 3 are stronger than the native ACL, tellar tendon graft group, compared to
graft fixation strength and graft size must the semitendinosus group, there was a
be factored into the equation when devel- trend toward better objective stability;
oping a rehabilitation program. The heal- however, there was more knee extension
ing of bone to bone in the osseous tunnel motion loss and more patellofemoral
(patellar tendon autograft), which occurs complaints. These results are similar to
in approximately 8 weeks in most in- the findings of Marder et al.102
stances, is faster than the healing of ten- Our rehabilitation program for al-
don to bone (hamstring autograft), which lograft reconstruction is slower than
takes approximately 12 weeks.140,165 The the regular program for autogenous
theoretical advantage of a larger, stron- grafts. When using allograft tissue, the
ger allograft that allows more aggressive limiting factor to consider is fixation of
rehabilitation remains unproven.111 the soft tissue as it is healing within the
The potential disadvantage of using bone tunnels. It is believed that this can
hamstring autograft or patellar tendon take longer than 4 to 6 months76,81,82 and
allograft tissue is increased graft laxity or therefore may limit the patient’s progres-
graft failure due to delayed or inappro- sion to higher-level functional activities.
priate healing.96 Conversely, the potential Several authors have described the re-
disadvantage of using a bone-patellar habilitation program following alloge-
tendon–bone autograft is the higher rate nous patellar tendon bone-tendon-bone
of arthrofibrosis and anterior knee pain.96 grafts.51,78,81,82,122 Although the initial pro-
Both issues can be minimized or avoided gression is similar, the rehabilitation pro-
FIGURE 11. Lateral stepping with resistance bands by using the appropriate supervised reha- gram for allograft tissue should be slower
around the distal femur to further recruit hip bilitation program. to progress to aggressive activities such as
musculature.
Our clinical approach to developing running, jumping, and cutting.
and designing a rehabilitation program
hamstring tendons.1,99,184 Some physi- based on the type of ACL graft is to be VARIATIONS BASED ON
cians use allografts4,51,157 and others use initially less aggressive with soft tissue CONCOMITANT PROCEDURES
the quadriceps tendon.53,61 Postoperative grafts such as the quadrupled hamstring/
rehabilitation needs to be adapted based semitendinosus graft. Therefore, the re- Medial Collateral Ligament Injury
H
on differences in graft tissue strength, turn to running, plyometrics, and sports irshman et al72 reported a 13%
stiffness, and fixation strength. is slightly slower with a semitendinosus incidence of combined ACL and
The ultimate load to failure of vari- graft. Additionally, we do not allow isolat- medial collateral ligament (MCL)
ous tissues has been reported by several ed hamstring strengthening for approxi- injuries in acute knee ligament inju-
investigators (TABLE 3).59,134,164,182 Hamner mately 8 weeks, to allow appropriate ries. Isolated MCL injuries are often
et al59 reported that the quadrupled ham- graft site healing to occur. treated nonoperatively; however, when
string tendon graft is approximately 91% Aglietti et al2 compared the outcomes combined with ACL disruption, grade
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T
between the surgical team and the re- Although there is very limited research, he rehabilitation process be-
habilitation team to ensure the highest we allow immediate WB on meniscus gins immediately following ACL
quality of care for each individual can- repairs with the knee brace locked in injury, with emphasis on reducing
not be overemphasized, especially when full extension. WB with the knee locked swelling and inflammation, regaining
a concomitant articular cartilage pro- in full extension produces a hoop stress quadriceps control, allowing immediate
cedure, such as a microfracture, is per- on the meniscus, which may aid heal- WB, restoring full passive knee extension,
formed. Knowledge of the healing and ing capacity. Repair of complex tears is and gradually restoring flexion. The goal
maturation processes following these progressed much slower than repair of of preoperative rehabilitation is to men-
procedures will ensure that the repair peripheral tears of the meniscus. More- tally and physically prepare the patient
tissue is gradually loaded and that ex- over, isotonic hamstring strengthening for surgery. Once the ACL surgery is per-
cessive forces are not introduced too is limited for 8 to 10 weeks to allow ad- formed, it is important to alter the reha-
early in the healing process. Long-term equate healing of the repaired meniscus, bilitation program based on the type of
studies are needed to better understand due to the close anatomical relationship graft used, any concomitant procedures
whether these articular cartilage lesions of the joint capsule to the meniscus and performed, and the presence of an ar-
can lead to degenerative osteoarthritis hamstrings. The patient is not allowed ticular cartilage lesion. This aids in the
and functional disability, although some to squat past 60° for 8 to 12 weeks and prevention of several postoperative com-
studies reported that 40% to 90% of needs to avoid squats with twisting mo- plications, such as loss of motion, patello-
ACL patients will exhibit radiographic tions for at least 16 weeks. femoral pain, graft failure, and muscular
knee osteoarthritis 7 to 12 years follow- Specific ROM guidelines differ based weakness. Current rehabilitation pro-
ing surgery.97,119,131 on the extent and location of meniscal grams focus not only on strengthening
damage, although immediate motion with exercises but also on proprioceptive and
Meniscal Pathology emphasis on full passive knee extension neuromuscular control drills to provide a
Meniscal injuries occur in approximately is universal. Patients with repair of a tear neurological stimulus so that the athlete
64% to 77% of ACL injuries.27,111 Shel- isolated at the periphery of the meniscus can regain the dynamic stability that is
bourne et al153 stated that meniscal tears should exhibit approximately 90° to 100° needed in athletic competition. We be-
in the ACL-injured knee typically occur of flexion by week 2, 105° to 115° by week lieve that it is also important to address
traumatically and are nondegenerative 3, and 120° to 135° by week 4. Patients any pre-existing factors, especially for
in nature compared to meniscal tears in with repair of complex meniscal tears fol- the female athlete, that may predispose
ACL-intact knees. If meniscal pathology low a slightly slower approach, with 90° the individual to future injury. Our goal
is present, a partial meniscectomy or me- to 100° of knee flexion by week 2, 105° to in the rehabilitation program follow-
niscus repair may be necessary to allevi- 110° by week 3, and 115° to 120° by week ing ACL surgery is to restore full, unre-
ate symptoms. An arthroscopic partial 4. Patients with complex meniscus repairs stricted function and to assist the patient
meniscectomy does not significantly al- may also need to use crutches and partial to return to 100% of the preinjury level
ter the rehabilitation protocol. However, WB for an additional 1 to 2 weeks. while achieving excellent long-term out-
additional time may be required before Barber and Click9 evaluated the effi- comes. t
initiating a running or jumping program, cacy of an accelerated ACL rehabilitation
depending on the amount of meniscal in- program for patients with concomitant
jury. If surgical repair of the meniscus is meniscus repair. At follow-up (24-72
required, alteration to the rehabilitation months after surgery), 92% of repairs
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@ MORE INFORMATION
cruciate ligament reconstruction rehabilita- clinical application. J Orthop Sports Phys Ther.
tion—the results of aggressive rehabilitation: a 1993;17:225-239.
12-week follow-up in 212 cases. Isokin Exerc Sci. 182. Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S. WWW.JOSPT.ORG
APPENDIX
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• 20-lb and 30-lb and manual maximum tests 3. Isokinetic test that fulfills the criteria listed below (180°/s)
Isokinetic test: 4. Quadriceps bilateral comparison (80% or greater)
• Concentric knee extension/flexion at 180°/s and 300°/s 5. Hamstring bilateral comparison (110% or greater)
Exercises: 6. Quadriceps torque-body weight ratio (55% or greater)
• Continue all exercises listed in week 6, 8, and 10 7. Hamstrings-quadriceps ratio (70% or greater)
• Plyometric training drills 8. Proprioception test: Biodex Stability System test127 (100%
• Continue stretching drills of contralateral leg)
9. Functional hop test (85% or greater of contralateral side)
Advanced Activity Phase (Week 10-16) 10. Satisfactory clinical exam
Criteria to Enter Phase 4 11. Subjective knee score (Cincinnati Knee Rating System)
1. AROM of 0° to 125° or greater of 90 points or higher
2. Quadriceps strength greater than 79% of contralateral side; knee Goals
flexor-extensor ratio of 70% to 75% • Gradual return to full, unrestricted sports
3. No change in KT values (comparable with contralateral side, • Achieve maximal strength and endurance
within 2 mm) • Normalize neuromuscular control
4. No pain or effusion • Progress skill training
5. Satisfactory clinical exam Tests:
6. Satisfactory isokinetic test (values at 180°/s) • KT 2000, isokinetic, and functional tests before return
a. Quadriceps bilateral comparison: 75% Exercises:
b. Hamstrings equal bilateral • Continue strengthening exercises
c. Quadriceps peak torque/body weight: males 55% to 60%; • Continue neuromuscular control drills
females 45% to 50% • Continue plyometric drills
d. Hamstrings-quadriceps ratio of 66% to 75% • Progress running and agility program
7. Hop test (80% of contralateral leg) • Progress sport-specific training
8. Subjective knee score (ie, Cincinnati Knee Rating System)
of 80 points or higher
Goals 6-Month Follow-up
• Normalize lower extremity strength • Isokinetic test
• Enhance muscular power and endurance • KT 2000 test
• Improve neuromuscular control • Functional test
• Perform selected sport-specific drills
Exercises:
12-Month Follow-up
• Continue all exercises
• Isokinetic test
• KT 2000 test
Return to Activity Phase (Week 16-22) • Functional test
Criteria to Enter Phase 5
1. Full ROM Abbreviations: AROM, active range of motion; PROM, passive range
2. Unchanged KT 2000 test (within 2.5 mm of opposite side) of motion; PTG, patellar tendon graft; ROM, range of motion.
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