Rehabilitation of 
Knee Injuries
Robert C. Manske and Mark V. Paterno
27.1 Introduction
Tennis is a sport when placed at high levels places
players at risk for multiple musculoskeletal inju-
ries. Tennis is a physically demanding sport that
can be played on multiple surfaces. Due to the
repetitive jarring compressive forces during match
play which can last for hours, knee injuries are
commonplace. Tennis players move in all direc-
tions oftentimes pivoting and rotating on surfaces
that are non-yielding. Lateral movements fol-
lowed by quick anterior or posterior transitions
are common and place tremendous stress on the
musculoskeletal system. Acute injuries to mus-
cles, tendons, menisci, ligaments, and articular
cartilage can occur with fast cutting-type move-
ments inherent in match play. Through the years,
reported incidence and prevalence of injury in
tennis have varied widely due to differences in the
definition of injury study populations, methods of
R. C. Manske (*)
Department of PT, Wichita State University,
Wichita, KS, USA
e-mail: Robert.Manske@wichita.edu
M. V. Paterno
Division of Occupational Therapy and Physical
Therapy, Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH, USA
Division of Sports Medicine, Cincinnati Children’s
Hospital Medical Center, Cincinnati, OH, USA
e-mail: Mark.Paterno@cchmc.org
© Springer International Publishing AG, part of Springer Nature 2018
G. Di Giacomo et al. (eds.), Tennis Medicine, https://doi.org/10.1007/978-3-319-71498-1_27
27
data collection, and duration and or frequency of
follow-up between investigations. Overuse ten-
don injuries also abound as competitive tennis
players, like other competitive athletes, continue
workouts and play for in some instances weeks at
a time without a break. Chard and Lachmann [1]
report that knee injuries are very common in all
racquet sports. Collateral ligament, cruciate liga-
ment, and meniscal injury occurred in about 24%
of their population, while patellofemoral pain and
patellar dislocation occurred in about 60% of ten-
nis players. One large epidemiologic study docu-
mented 17,397 athletes of all skill levels and ages
with 19,530 sports injuries over a 10-year period.
There were nearly 300 knee injuries related to
tennis, and of these, 11% incurred injury to the
anterior cruciate ligament (ACL). This same study
also reported injuries to the lateral collateral liga-
ment, and medial meniscus pathology was fre-
quent in tennis players [2]. Still others have
reported findings that 10–13% of tennis players
with knee injuries incur intra-articular anterior
cruciate ligament injury [3, 4]. Hjelm and col-
leagues [5, 6] report that knee injuries are more
common in female tennis players. These injuries
tend to be 72% of the injuries reported in their
case series of 39 players. Injuries to the knee
included patellar tendinopathy, iliotibial band
friction syndrome, quadriceps tendinopathy,
Osgood-Schlatter’s disease, patellofemoral pain
syndrome, and an unspecified knee pain due to
overuse. Others also describe patellofemoral pain
and patellar tendonitis to be very common [7, 8].
415
416
Although as tennis players age the risk of osteoar-
thritis increases, an association with tennis has not
[9] been highly correlated, at least in Swedish
male tennis players. The purpose of this chapter is
to describe knee injuries in competitive and recre-
ational tennis. The chapter will start with a review
of anatomy and biomechanics of the knee. This
will be followed by a discussion of the various
injuries and how they will be managed by sports
medicine professionals. Finally a return to sports
program for a player with a tennis injury will be
described.
27.2 Anatomy and Biomechanics
of the Knee
The anatomy and biomechanics section of the
knee is presented as a foundation to better under-
stand clinical decision-making regarding knee
injuries. The knee joint proper consists of several
joints and articulations including the tibiofemoral
joint and the patellofemoral joint. The bones that
are inherent to these joints include the femur,
tibia, and patella. At first glance this seemingly
simple synovial structure looks relatively nonde-
script; however upon a closer look, one will see
that the knee is one of the more complex diarthro-
dial joints in the human body. As the knee sits at
the confluence of the two longest bones in the
human body, tremendous forces are placed upon
this articulation. The knee is also expected to
operate in both an open kinetic chain (OKC) and
closed kinetic chain (CKC) functions.
27.3 Tibiofemoral Joint
The tibiofemoral joint is comprised of the distal
femur and the proximal tibia. Each of these bones
has unique characteristics. The distal femur
includes the femoral condyles and the intercon-
dylar notch. This portion of the femur is covered
with hyaline articular cartilage which, when
healthy, can tolerate large shear and compressive
forces that are placed upon the knee. Two con-
dyles, one lateral and one medial, are rounded
protuberances that are centrally divided the inter-
R. C. Manske and M. V. Paterno
condylar notch or fossa, which is the attachment
site for the cruciate ligaments. Each of the
­condyles is cam shaped with a smaller curvature
posterior that of the anterior. The lateral femoral
condyle is wider both anterior-posterior and
medial-lateral when compared to the medial fem-
oral condyle. The medial condyle extends further
anterior than the lateral; however because the
shaft of the femur angles in a medial direction,
the two condyles sit relatively even in the hori-
zontal plane. The proximal tibia articulates with
the distal femur. The proximal tibia is formed by
the medial and lateral tibial plateau which expand
its proximal end over the smaller shaft. The
medial tibial plateau is slightly concave to accept
the convex medial femoral condyle. However, the
lateral tibial plateau is either flat or slightly con-
vex [10, 11], which may create a problem with a
convex distal lateral femoral condyle. An impor-
tant ridge runs down the center of the tibia. This
ridge, the intercondylar eminence, is the attach-
ment of the anterior cruciate and posterior cruci-
ate ligaments. Several other important landmarks
on the tibia are the tibial tubercle and the Gerdy’s
tubercle. The tibial tubercle is situated on the
anterior surface of the tibia and is the attachment
site of the patellar tendon. Gerdy’s tubercle is on
the anterior lateral tibial flare and is the attach-
ment site of the iliotibial band.
27.4 Patellofemoral Joint
The patellofemoral joint consists of the posterior
patella and the anterior femoral trochlea. The
patella is the largest sesamoid bone in the body.
The patella is engulfed within the extensor mech-
anism which includes the quadriceps tendon and
the patellar tendon. The patella has both a base
(proximal) and an apex (distal). The anterior sur-
face of the patella is very palpable due to its
superficial location on the anterior knee. The
patella is convex anteriorly in both superior-infe-
rior and medial-lateral direction. The thickest
cartilage in the body (up to 6 mm) is found on the
posterior patella and is thought to distribute very
large compressive and shear forces that occur at
the patellofemoral joint during dynamic a­ ctivities.
27  Rehabilitation of Knee Injuries
A vertical ridge runs down the center of the
patella dividing it into almost equal medial and
lateral halves. However, there is a second smaller
vertical ridge that runs along the medial facet that
separates the medial facet from the odd facet.
Most of the posterior patella, except the distal
inferior pole, is articular. The patellofemoral
joint is a relatively unstable joint as the sulcus is
shallow and patella does not fit deeply into the
sulcus. As the intercondylar notch continues
anteriorly, it becomes the trochlear grove also
known as the femoral sulcus. This sulcus is bor-
dered both medially and laterally by the patellar
facets of the distal femur.
27.5 Ligaments and Knee Capsule
Because the knee has little inherent osseous sta-
bility, it relies on strong ligamentous restraint and
dynamic muscular stability. The four major liga-
ments contributing support to the knee include
the anterior cruciate (ACL), posterior cruciate
(PCL), medial collateral (MCL), and lateral col-
lateral (LCL) ligaments. Together these liga-
ments each individually and collectively provide
both primary and secondary restraints to single-
plane instability and multidirectional instability,
respectively.
The ACL emerges from a position anterior and
medial to the tibial eminence of the tibial plateau.
It runs superiorly, laterally, and posteriorly to
insert on the posterior margin of the medial wall
of the lateral femoral condyle. The ACL is one
ligament; however it is composed of two separate
bundles, an anteromedial bundle and a postero-
lateral bundle. The anteromedial bundle is taut in
60° or more of knee flexion, while the postero-
medial bundle is taut in extension and rotations.
The PCL arises from the posterior tibia just below
the tibial plateau. The PCL runs superiorly, ante-
riorly, and medially from the tibia to the femur.
Very similar to the ACL, the PCL has two bands:
the anterolateral band and the posteromedial
band. The anterolateral band is taut in knee flex-
ion, while the posteromedial band is taut in
extension. The LCL is more chord-like or pencil
shaped and runs from the lateral epicondyle of
417
the femur to the fibular head. Between the LCL
and the bony structures runs the popliteus tendon.
This ligament restrains a varus stress placed on
the knee. The MCL is a large, broad, flatter liga-
ment that runs from the medial epicondyle of the
femur to the tibia below the joint line. The MCL
is divided into a deep and superficial portion. The
deep portion attaches to medial meniscus and
includes a meniscofemoral and meniscotibial
portion. The superficial band inserts at the femo-
ral epicondyle and the tibial plateau. (Fig. 27.1).
27.6 Meniscus
Due to the significant amount of movement
around the tennis court, twisting, pivoting, and
change of direction both medial-lateral and ante-
rior-posterior are commonplace. It is exactly
these movements, in which torsional rotation
with the knee loaded in various degrees of flex-
ion, which are a recipe for knee meniscal injuries.
Meniscal injuries are so commonplace in athlet-
ics that arthroscopic treatment of meniscal tears
has become the most common knee surgical pro-
cedure in the United States.
The medial meniscus is shaped similar to a C
with the open end toward midline. Each meniscus
has horns which are the attachments of the menis-
cus to the tibial eminence. The medial meniscus
has a posterior horn which is larger (anteroposte-
rior dimensions) than the anterior horns. A large
portion of the medial meniscus is attached to the
knee capsule and to the deep fibers of the medial
collateral ligament. The meniscus is seen in the
image in Fig. 27.2.
The lateral meniscus is almost a complete cir-
cle. Its anterior and posterior horns are much
similar in size and much closer in proximity to
each other than the medial meniscus. The lateral
meniscus covers a larger % of total surface area
than that of the medial meniscus. In about 3–5%
of cases, known as lateral discoid meniscus, the
structure covers the entire surface of the tibial
plateau [12]. The lateral meniscus has two ves-
tiges that run to the PCL.  The ligament of
Wrisberg comes from the PCL and is also known
as the posterior meniscofemoral ligament. The
418 R. C. Manske and M. V. Paterno

Anterior
cruciate
ligament

Posterior
cruciate
Lateral ligament
Posterior
collateral
cruciate
ligament
ligament

Medial
collateral
ligament

Fig. 27.1  Lateral and medial collateral ligaments. (Image taken from Loudon, Manske and Reiman. Clinical Mechanics
and Kinesiology. Human Kinetics, 2013. Page 286, Figure 14.7)

Fig. 27.2  Lateral and

medial meniscus. (Image Transverse ligament
Anterior cruciate
taken from Loudon, ligament
Lateral meniscus
Manske and Reiman.
Clinical Mechanics and
Kinesiology. Human
Kinetics, 2013. Page
288, Figure 14.8)

Medial meniscus
Posterior cruciate ligament

ligament of Humphrey is known as the anterior
meniscofemoral ligament and runs from the PCL
to the lateral meniscus.
Both menisci in the cross section are pie
shaped or wedged. The outer periphery is thicker,
while the inner portion is thinner. The vascular
supply to the meniscus is from the superior and
inferior branches of the medial and lateral genic-
ular arteries. This blood supply reaches approxi-
mately 25% and 10–30% of the thicker periphery
of the lateral and medial meniscus, respectively
[13]. This is problematic for adequate healing if
an injury to the meniscus occurs in the inner thin-
ner portion of the meniscus. Due to the
­arrangement of the blood supply to the menisci,
an injury to the periphery has a chance to heal,
27  Rehabilitation of Knee Injuries
while injury to the inner 1/3 to 2/3 has minimal
chance to heal intrinsically if at all.
27.7 Articular Cartilage
Hyaline articular cartilage is the material that
covers the ends of long bones in synovial joints.
Articular cartilage is primarily composed of
water contributing up to 80% of its weight. It is
water that gives the cartilage its ability to absorb
stress and compressive forces that occur during
normal activities of daily living such as walking,
running, and jumping. The remaining compo-
nents of cartilage include proteoglycans and non-
collagenous proteins and collagen. Because
cartilage covers the ends of long bones, it is espe-
cially important in knee function. This is espe-
cially true since the area of cartilage that is
injured in the knee makes contact with the patella
or femur around 30–70° of knee flexion [14].
This is even further problematic that following
injury to articular cartilage, healing is often com-
promised due to cell apoptosis and the presence
of catabolic enzymes. Due to these issues, articu-
lar cartilage cannot form a fibrin scaffold or
mobilize cells to repair the defect.
27.8 Ligament Injuries
Ligament injuries may occur as the result of a
non-contact mechanism during tennis. Frequent
pivoting and cutting place the knee ligamentous
structure at risk. Epidemiologic data suggests the
knee ligaments at greatest risk while playing ten-
nis are the anterior cruciate ligament, represent-
ing 11–13% of all knee injuries in tennis [2–4],
the medial collateral ligament, and lateral collat-
eral ligament [2].
27.9 A
 nterior Cruciate Ligament
Injury
The ACL provides stability to the knee during
pivoting, cutting, and rotational activities. Injury
may occur when landing from a jump or planting/
419
cutting activity. Classically, ACL injury was
described as a hyperextension injury [15], but
more recent evidence suggests that if the knee is
positioned with excessive valgus and femoral/
tibial rotation, it becomes vulnerable to injury as
well [16]. Athletes who present with ligament
dominance (reliance on ligamentous structures
rather than neuromuscular contributions to con-
trol dynamic knee movement), quadriceps domi-
nance (high quadriceps-to-hamstring strength
ratio), limb dominance (tendency to favor one
limb with dynamic activity) [17], and trunk dom-
inance (excessive trunk movement) [16] often
demonstrate high-risk movements during athletic
activity and are, subsequently, at increased risk
for ACL injury. Injury to the ACL results in
mechanical instability of the knee as there is an
increase in anterior tibial translation of the knee
as well as excessive tibial rotations. If the ACL
injury is coupled with other ligamentous injuries,
this mechanical instability may be even greater.
In addition to mechanical instability, the athlete
may present with functional instability or a sen-
sation that the knee is “giving way” after ACL
injury. This sensation of giving way may be
reported only with higher-level pivoting and cut-
ting activities, such as tennis, or it may be
reported with lower-level activities of daily living
[18]. The level of activity, at which time the
patient reports functional instability, often factors
into the decision to undergo surgical manage-
ment of the ACL injury.
Injury to the ACL can be medically treated both
non-operatively and operatively. Non-operative
treatment following ACL injury requires an imme-
diate focus on the management of acute impair-
ments as well as a systematic assessment of ability
to safely participate in pivoting and cutting activi-
ties without the athlete reporting a sensation of
“giving way.” Repeated giving way at the knee
results in high vulnerability to sustaining further
meniscal and articular cartilage injury and neces-
sitates surgical management to restore knee stabil-
ity. Once the acute impairments of knee joint
effusion and loss of motion and strength are man-
aged, the athlete can be assessed to determine if
they are a candidate to pursue non-operative man-
agement of ACL injury. In a body of work by
420
Fitzgerald, Snyder-Mackler, and colleagues from
the University of Delaware [19, 20], a screening
tool was developed to determine if a patient is a
“coper” indicating potential to function in the
absence of an ACL or a “non-coper” indicating an
individual who likely would not function well with
ACL deficiency. The screening tool includes
assessment on four single-leg hop tests, reported
number of giving way episodes, the Knee Outcome
Survey, and a global rating of knee function [20].
Patients who are classified as “non-copers” are
often recommended for surgical intervention. If
the patient is determined to be a “coper,” they par-
ticipate in rehabilitation designed to enhance
strength and mobility as well as a specialized “per-
turbation” rehabilitation program which focuses
on balance and reactive neuromuscular control
designed to maximally challenge and train the pro-
prioceptive system as a means to enhance dynamic
functional stability of the knee. Once rehabilita-
tion is complete, the patient is able to successfully
pass all return to sports assessments, and a func-
tional progression back to tennis is complete; these
athletes may attempt a return to sport. Although
some athletes are successful with non-operative
management of ACL injury, a 10-year outcome
study of patients with ACL injury suggests a rela-
tively low percentage of athletes are able to resume
prior levels of function in the presence of ACL
deficiency [21]. Further, a case report specific to
tennis players with ACL deficiency noted that in a
cohort that was able to return to recreational ten-
nis, they continued to report lower level of tennis
function as well as difficulty with higher-level
movements [22]. Collectively, these data suggest
return to high-level tennis with an ACL-deficient
knee may be a challenge for many athletes, and a
systematic evaluation of potential ability to suc-
ceed with this treatment course is required prior to
attempting a non-operative course.
27.10 ACL Reconstruction
Rehabilitation
If the athlete’s goal is to return to high-level ten-
nis, which requires fast-paced pivoting and cut-
ting, surgical reconstruction may be necessary.
The goal of the ACL reconstruction would be to
R. C. Manske and M. V. Paterno
provide mechanical and functional stability in the
knee and allow for an attempt to return to pre-
injury level of activity. Variation in surgical
reconstruction technique as well as graft-type
selection may result in necessary modification to
the rehabilitation process. Despite these vari-
ables, rehabilitation after surgical reconstruction
is guided by a criteria-based progression from
immediate postoperative management to func-
tional transition back to sport. Table  27.1 will
outline this rehabilitation.
27.10.1  Phase I: Preoperative Phase
The preoperative phase is seen in Table 27.1 and
is followed prior to surgery. Goals of this phase
are to restore motility, increase quadriceps activa-
tion and decrease pain and effusion. Ambulation
at this time is weight bearing as tolerated with
crutches and a brace locked in full extension.
Gentle range of motion (ROM) as tolerated
and a progression of exercises as patient is able
to tolerate is utilized in this early preoperative
period. Exercise progression should not
increase symptoms, pain, or effusion.
27.10.2  Phase II: Immediate PO Phase
Acute phase rehabilitation after ACL reconstruc-
tion is focused on managing acute, postoperative
swelling, range of motion (ROM), and initiation
of quadriceps activation. Postoperative effusion
is prevalent after ACL reconstruction and inhibits
quadriceps activation [23] and mobility. Acute
phase rehabilitation includes use of modalities
such as cryotherapy and compression dressings
to assist in swelling reduction. In addition, the
patient is advised in frequent elevation and home
use of compression and cryotherapy to assist in
reduction of effusion. Early resolution of postop-
erative effusion assists in restoring the patient’s
ability to actively contract the quadriceps and
slows postoperative disuse atrophy.
Weight bearing after ACL reconstruction is
typically progressed over 3–6  weeks. Patients
may initiate touch-down weight bearing immedi-
ately after ACL reconstruction and progress as
27  Rehabilitation of Knee Injuries 421

Table 27.1  ACLR table

Days–
Phase weeks Goals Restrictions Treatment Clinical milestones
Phase I: Pre- Restore ROM WBAT with bilateral RICE Surgical
Preoperative operative both active and axillary crutches Electrical stimulation reconstruction
passive Brace locked at 0° Extension ROM Full knee
Quadriceps Passive flexion ROM extension
activation Glute/Quad/Ham sets Restoration of
Decreased Hip abduction/ strength
effusion adduction Minimal effusion
Pain reduction Leg presses No increased pain
Minisquats
Step-downs
Phase II: Post- WBAT bilateral Full WBAT brace Patellar mobilization Previous
Immediate operative axillary crutches locked in full Scar tissue milestones
PO Phase Wks 0–2 locked in extension × 1 week mobilization Clean incisions
extension After week 1 PROM PROM flexion and Good quadriceps
Full knee flexion can be started extension recruitment
extension Brace still locked in PROM flexion SLR with minimal
Quadriceps extension for weight progressed to 110° lag
control bearing until SLR with week 1 Normalized
Pain reduction no extensor lag 130° week 2 patellar mobility
Normal patellar Quadriceps sets Weight bearing
mobility Straight leg raise × 4 progressed without
Ankle pumps symptoms
CPM Minimal pain and
Weight shifts effusion
Cryotherapy
Phase III: Post- Normalized Braced unlocked for Progression of Previous
Intermediate quadriceps
operative weight bearing as previous isometric milestones
PO Phase Wks 2–4 recruitment tolerated quad sets at 0°, 60°, Satisfactory
Normal patellar Crutches discontinued and 90° clinical exam
mobility at approximately 2 Squats and leg press ROM 0–130°
No pain or weeks 0–60° Improved stability
effusion Stationary bike with unilateral
Restoration of Step-downs stance
motion Calf raises No pain
Maintain full Minisquats Normal gait
weight bearing Balance drills
Improve balance Band exercises
Phase IV: Post- Full bilateral None Previous Previous
Strengthening operative ROM strengthening milestones
Phase Wks 4–12 Increase strength Progress bilateral Full motion:
and endurance loading to single limb 0–130°
No pain loading exercises Single leg
No swelling Lunges 0–60° stance × 30 s
Preparation for Advanced balance Squat 60° with
activities activities equal weight
Hip extension bearing
progressing to No pain or
isolated hamstring effusion
exercises in 12 weeks
(continued)
422
Table 27.1 (continued)
Days–
Phase weeks Goals Restrictions
Phase V: Post- Restoration of full None
Return to operative motion
Activity Wks 12+ No swelling
Phase No pain
Return of full
activities
CKC closed kinetic chain, CPM continuous passive motion, PO postoperative, RICE rest, ice, compression, elevation,
ROM range of motion, SLR straight leg raise, WBAT weight bearing as tolerated, Wks weeks
Rehabilitation following anterior cruciate ligament reconstruction. (Taken from: From Manske RC, Lehecka BJ, DeCarlo
M, McDivitt R.  Rehabilitation of the Knee. In: Hoogenboom BJ, Voight ML, Prentice WE, (eds). Musculoskeletal
Interventions: Techniques for Therapeutic Exercise, 3rd ed. Table 24-1 page 751: McGraw Hill Education, New York, 2014
effusion resolves and motion and quadriceps acti-
vation improve. The use of a postoperative brace
such as an immobilizer or a postoperative ROM
brace can provide additional support in the acute
phase and may allow a more rapid progression of
weight bearing but will require gait retraining to
insure a normal gait pattern once the brace is dis-
continued. Patients are permitted to discontinue
crutch use once they have resolution of postopera-
tive effusion, full extension, and sufficient knee
flexion to demonstrate a normal gait pattern and
adequate quadriceps control to demonstrate a sin-
gle-leg squat to 30° of knee flexion. Once these
criteria are met, they can progress off of crutches.
Early exercise in the acute phase of ACL
reconstruction rehabilitation is focused on mus-
cle activation and ROM. Prior to progression to
the subacute phase of rehabilitation, the patients
must demonstrate full knee extension, flexion to
120–135°, sufficient quad activation to execute a
straight leg raise without an extensor lag, and
normal patellar mobility. Once these criteria are
met, the patient is prepared to progress to the sub-
acute phase of rehabilitation.
27.10.3  Phase III: Intermediate
PO Phase
The intermediate PO phase of rehabilitation is
focused and initiated when the initial acute
R. C. Manske and M. V. Paterno
Treatment Clinical milestones
Previous Previous
strengthening milestones
Unilateral calf raises Full motion
Progress CKC Full confidence in
exercises knee
Advance hamstring Function testing
exercises >90% of
Agility drills uninvolved
Advanced balance Isokinetic testing
drills >90% of
Sports specific drills uninvolved
impairments are resolved and focus turns to the
advancement of foundational strength and neuro-
muscular control. While the return of quadriceps
strength remains the primary focus after ACL
reconstruction, progressive resistive exercises to
address hamstring strength deficits, as well as hip
and core strength, are critical.
Quadriceps strength training requires a
dynamic incorporation of both open kinetic chain
strengthening to address isolated quadriceps
weakness often seen after ACL surgery and
closed kinetic chain strengthening to encourage
dynamic incorporation of quad activity while
executing functional tasks. Open kinetic chain
knee extension should be executed in protected
ranges initially, avoiding full extension, to limit
anterior translation stress on the healing graft.
Hamstring contraction provides dynamic
resistance to anterior tibial translation. Return of
hamstring strength after ACL reconstruction
helps protect the healing graft as it reduces the
underlying risk factor of quad dominance.
Initiation of hamstring strengthening early after
ACL reconstruction with a hamstring graft is
contraindicated; however as the patient pro-
gresses to the neuromuscular reeducation phase
of rehabilitation, hamstring strengthening can be
progressed.
Proximal hip and core strengthening is critical
after ACL reconstruction. Evidence has demon-
strated the importance in hip strength and muscle
27  Rehabilitation of Knee Injuries
activation [24], in reducing the risk of future
injury as well as normalizing movement patterns
postoperatively. Further, the ability to control
trunk movement and maintain trunk position over
the base of support during dynamic movement
can help to reduce stress on the knee joint. Trunk
strengthening as well as dynamic proprioception
activities are critical during this phase of rehabili-
tation to prepare the athlete to participate in the
final phase of rehabilitation.
27.10.4  Phase IV: Strengthening Phase
The final phase before release to return to tennis
is the Strengthening and Return to sport phase.
This phase is focused on introducing and reinte-
grating the athlete back into dynamic activity
which will be experienced on the court. Prior to
entering this phase of rehabilitation, the patient
must demonstrate sufficient lower extremity
strength and functional performance. The athlete
who is ready to initiate the Return to Activity
phase must demonstrate a solid foundation of
strength as well as a baseline proficiency with the
initiation of dynamic movement. Isokinetic quad-
riceps and hamstring strength deficits of less than
15% of the contralateral limb are necessary to
enter this phase of rehabilitation. Similarly, func-
tional hop test performance should be less than a
15% deficit, and patient-reported function on the
IKDC should be a minimum of 85 prior to entry
to this phase [25]. The focus of this phase should
be on integration back to tennis-specific activity,
beginning with activities at sub-max speed,
­followed by a progression to higher-level activity
at max effort and full speed. Prior to full release
to tennis activity, the patient should pass a return
to sports assessment as outlined at the end of this
chapter.
27.11 M
 edial Collateral Ligament
Injury
Medial collateral ligament (MCL) injury occurs
less frequently in tennis; however the pivoting and
cutting stress of the sport do place the MCL at
risk. Valgus stress to the knee, either through con-
423
tact or non-contact mechanisms, can result in
MCL injury. Injury to the MCL is diagnosed
along a continuum with Grade I injuries repre-
senting the least structural damage to the ligament
while Grade III injuries representing complete
disruption of the MCL. Injuries can occur either at
the attachment site or in the mid-substance of the
ligament. As the MCL is an extra-articular liga-
ment structure, there is potential for healing, and,
as a result, the majority of these injuries are suc-
cessfully managed nonoperatively.
Initial management of an acute MCL injury will
be dependent on the extent of tissue injury and the
expected time needed to allow tissue healing to
occur. The focus of acute rehabilitation of MCL
injury is pain and effusion management coupled
with progression of ROM and strength. Grade I
injuries may be permitted to initiate weight bearing
and ROM activity without restriction in the early
phases of rehabilitation if stability is good and pain
is minimal. Grade III injuries may require a period
of restricted ROM with a brace, which can protect
against valgus stress, while limiting full extension
as the MCL is at greatest tension in full extension.
With respect to strengthening exercises, activity to
focus on core, hip, and lower extremity strength
can be initiated as tolerated by the patient as long as
all valgus stress to the knee is avoided. Due to the
wide continuum in the extent of MCL injuries, the
length of time spent in the acute phase of rehabili-
tation after MCL injury is highly variable.
Once sufficient healing has occurred and the
patient has regained full ROM, focus turns to
advancing strength and neuromuscular control.
Strengthening continues to be advanced with a
continued focus on core, hip, quadriceps, and ham-
string strengthening. Prior limitations with lateral
movements and valgus stress may start to be slowly
initiated at sub-max speeds and intensities and
slowly progressed over time as tolerated. In addi-
tion to strengthening, balance and proprioception
exercises should be progressed at this time.
Advancement from double-leg to single-leg tasks
and progression for sagittal plane to more tri-planer
movement is indicated at this time. Once sufficient
strength and neuromuscular control are gained, the
patient must successfully progress through a transi-
tion to function phase, similar to the end of ACL
reconstruction rehabilitation prior to progression
424
back to sport. If residual laxity is a concern, the use
of a brace may be considered prior to return to
sport, but this is not typical in tennis.
27.12 Patellofemoral Pain
Patellofemoral pain syndrome (PFPS) is the most
prevalent disorder involving the knee [26] and is
the second most common musculoskeletal symp-
tom presenting to physical therapists [26].
Despite this high prevalence, the potential etiol-
ogy of and risk factors for developing PFPS are
widespread and remain unclear [27], and a vari-
ety of theories about its etiology and appropriate
rehabilitation exist. The presence of impaired
anatomic morphology and/or altered dynamic
neuromuscular function can result in an increased
potential to experience anterior knee pain with
overuse. Frequent participation in tennis has the
potential to place repetitive stress on the anterior
knee resulting in pain.
Once an accurate diagnosis highlights the
underlying mechanism contributing to the over-
use syndrome, appropriate rehabilitation can be
initiated to target the underlying mechanisms.
Rehabilitative and etiologic investigations have
focused on three areas of dynamic neuromuscu-
lar function and their associated effect on PFPS:
the proximal area at the trunk and pelvis, the dis-
tal area at the foot and ankle, and the local area at
the quadriceps and the patellofemoral joint (PFJ)
itself.
Proximal interventions for PFPS focus on
enhancing proximal stability to serve as a stable
base for distal extremity movements. Excessive
trunk and pelvis movements as a result of core and
hip weakness can translate into inefficient move-
ment patterns and potentially placement of the
lower extremity in at risk positions. Proximal inter-
ventions should be initiated when these deficits are
identified in the presence of anterior knee pain.
Distal interventions at the foot and ankle in
patients with patellofemoral pain are initiated
when the patient presents with abnormal foot and
ankle alignment which may alter stress on the
knee joint. Typically, a more pronated or supi-
nated foot may result in dynamic changes at the
R. C. Manske and M. V. Paterno
extensor mechanism, increasing susceptibility to
anterior knee pain in the presence of overuse.
Interventions may focus on orthotic stabilization
to improve lower extremity alignment and reduce
stress on the extensor mechanism.
Local interventions at the knee joint in patients
with PFPS are utilized when the patient presents
with knee-specific impairments contributing to
anterior knee pain. This may include strength def-
icits, altered proprioception, or patellofemoral
instability to name a few. Attempts have been
made to classify types of anterior knee pain, in the
hopes of guiding interventions [28]. In the tennis
player, the most typical forms of local impair-
ments contributing to anterior knee pain result
from repetitive microtrauma and/or malalignment
at the knee joint. These types of patellofemoral
pain mechanisms are best managed with flexibil-
ity intervention in the presence of tightness and
strengthening interventions in the presence of iso-
lated weakness or weakness through the kinetic
chain. The key in successful management of ante-
rior knee pain in this population is proper identifi-
cation of the underlying mechanism and an
appropriate intervention plan to target these inter-
ventions. This should then be followed by a pro-
gressive return to tennis activity.
27.13 Meniscus
In any sports that requires running, twisting, and
pivoting, meniscus and articular cartilage injuries
are common. Meniscal and cartilage injuries can
be treated both conservatively and surgically. The
goal of treatment that is followed will depend on
the athlete’s ability to play without pain or symp-
toms. It is not uncommon to first attempt conser-
vative treatment before jumping into surgical
considerations.
27.14 Meniscus Tears
Meniscal tear types are numerous and include
oblique, vertical longitudinal, radial (or trans-
verse), horizontal cleavage, or complex
(Fig.  27.3). The majority of meniscal tears are
27  Rehabilitation of Knee Injuries
Oblique Transverse tear
(Parrot-beak) tear
Peripheral tear Vertical longitudinal
(Bucket-handle) tear
Fig. 27.3  Various types of meniscus tears. (Image taken from Magee D, Zachazewski JE, Quillen WS, Manske
RC. Pathology and Intervention in Musculoskeletal Rehabilitation. Elsevier, 2016. Figure 21-6; page 779)
oblique or vertical longitudinal; however as one
ages the risk of complex degenerative tears
increases [29]. Vertical longitudinal tears are also
known as the “bucket-handle” tear which occur
more often in younger individuals and are associ-
ated with concomitant ACL injuries. If the bucket
handle tear is large enough, it can be unstable and
dislocate into the intercondylar area causing a
mechanical “locking” of the knee. The complex
or degenerative tear is one that occurs in multiple
planes and is usually associated with an older
athlete. These are more commonly in the medial
side of the joint and may also be associated with
degenerative arthritis. A radial tear is very prob-
lematic as it creates a total disruption of the
meniscal tissue from the inner surface to the
periphery. Lastly the horizontal cleavage tear
begins near the inner margin and extends out-
ward horizontally. This injury pattern creates a
complete separation of the horizontally oriented
collagen fibers of the meniscus.
425
Vertical tear Flap tear
Discoid meniscus; Complex tear
degeneration and tear
Treatment of meniscal tears is predicated on
the type and classification of the tear. Some tears
are able to be treated conservatively, while others
require surgical intervention. Many tears are not
even symptomatic. Prevalence of asymptomatic
tears is found in 5–36% of knees [30, 31]. Small
stable asymptomatic tears certainly do not need
acute treatment surgically. However if healing
does not occur and these are left alone, they can
progress eventually to degradation of hyaline
cartilage.
Many forms of treatment exist for those tears
that need surgery. Treatment includes total men-
iscectomy, partial meniscectomy, meniscal
repair, and more recently meniscal allograft
replacement. Total meniscectomy rarely results
in positive long-term outcomes due to the
increased joint stress that occurs when the menis-
cus is removed. Even small amounts of resection
of meniscal tissue result in substantial increase in
joint contact pressure and loads [32–34].
426
Therefore, total meniscectomy should be a last
resort, while meniscal repair or partial meniscec-
tomy with preservation of as much tissue as pos-
sible should be the treatment goal. Meniscus
repair is an option if the tear is in the peripheral
area where the meniscus still has an adequate
blood supply. This blood supply is imperative for
biologic healing of the torn meniscus. Surgical
repairs historically have been repaired via an
open procedure; however presently these repairs
are done through a small incision or totally
arthroscopically.
27.15 Meniscectomy
Rehabilitation
Rehabilitation following meniscectomy is based
on symptoms. Because there is nothing repaired
or sutured together that requires soft tissue heal-
ing constraints, progression is fairly smooth. Most
patients following meniscectomy respond well
without problems. Evidence exists that demon-
strate in some instances a home exercise program
or medication following meniscectomy is equal to
supervised therapy [35–37]. These studies are in
contrast with those that have shown supervised
therapy demonstrates increased strength deficit in
the training group [38], significant extensor
strength deficits for up to 6 months in those fol-
lowing meniscectomy [39], and both knee flexor
and extensor strength deficits that would indicate
a need for supervised therapy [40].
Table 27.2 from Manske RC, Lehecka BJ,
DeCarlo M, McDivitt R.  Rehabilitation of the
Knee. In: Hoogenboom BJ, Voight ML, Prentice
WE, (eds). Musculoskeletal Interventions:
Techniques for Therapeutic Exercise, 3rd ed. out-
lines rehabilitation following a partial meniscec-
tomy. Goals of phase I are to control swelling and
edema, increase range of motion, normalize gait,
and improve quadriceps control.
Phase I: (Days 1–7) Cryotherapy will be per-
formed early either constantly or 6–8 times per
day to control pain and swelling. Use of com-
pressive garments is also beneficial to decrease
edema control in the lower leg. Usually with a
meniscectomy, a postoperative knee brace is not
R. C. Manske and M. V. Paterno
necessary. The leg should be elevated as much as
possible to allow gravity to help decrease swell-
ing in the first few days following surgery. The
patient should restrict the amount of time stand-
ing with the lower leg in a dependent position
which will also help decreased edema.
The ability to regain full knee extension is criti-
cal for almost all knee surgeries. Immediate exten-
sion should be the priority with flexion as tolerated.
Towel extensions, prone hangs, and heel props all
help to gain passive extension, while wall slides
help with knee flexion range of motion. Extension
can also be facilitated by weight shifting and lock-
ing out the knee in weight bearing.
Weight bearing following meniscectomy is as
full as tolerated. Ambulation should be with
bilateral axillary crutches, and these should be
discontinued once the athlete is able to ambulate
with normal gait. By 2 weeks the athlete should
be independently weight bearing with no antalgia
or limp.
Quadriceps, hamstring, and total leg strength-
ening exercises can begin and progress as toler-
ated. Straight leg raises (Fig.  27.4), quadriceps
and hamstring sets, and calf raises can begin as
tolerated.
Phase II: (Weeks 1–3) Goals of this phase are
a complete return to full ROM equal to the unin-
volved side, normalization of gait and improve-
ment of strength and control, and return to
controlled agility and sports-specific activities.
Cryotherapy can be continued as needed, espe-
cially following exercises and activities. If ROM
is not yet symmetrical to the uninvolved side,
exercises to facilitate it should continue. This may
include manual therapy and joint mobilization
techniques to continue progression until full.
Weight-bearing exercises such as squats, lunges,
and step-downs can all begin as long as pain and
swelling do not return, sure signs of too fast of
progression. Cardiovascular exercises such as sta-
tionary bike and elliptical or stair climber can
begin at easy levels of 10–15 min progressing to
moderate to high for 30 min or more.
Balance and proprioceptive exercises can
begin to improve neuromuscular limb control.
These forms of exercise should be performed
bilaterally initially with simple weight shifting
27  Rehabilitation of Knee Injuries 427

Table 27.2  Rehab after partial meniscectomy

Days–
Phase weeks Goals Restrictions Treatment Clinical milestones
Phase I: PO Independent WBAT with bilateral RICE Full extension
Immediate PO Week 1 ambulation axillary crutches as Glute sets No limp
Phase Quadriceps needed Quad sets No increased
activation AAROM flexion to effusion
Decreased effusion 60° No increased pain
Wound healing
Pain reduction
Phase II: PO Wks Quadriceps control Full WBAT Exercises as Previous
Intermediate PO 1–3 Pain reduction Discontinue crutches previous milestones
Phase Normal patellar as tolerated Patellar Full ROM
mobility mobilization Good quadriceps
Increased ROM Scar tissue recruitment
Begin proximal mobilization Normalized
strengthening Minisquats patellar mobility
Step-ups Full passive knee
Flexibility extension
exercises Full weight bearing
Balance and without symptoms
proprioception
Phase III: PO Wks Normalized None at this time Progression of Previous
Advanced 3–6 quadriceps previous milestones
Strengthening recruitment Advanced balance Satisfactory
Phase Normal patellar training clinical exam
mobility Leg presses Improved stability
Full active ROM Endurance with unilateral
No pain exercises stance
No effusion No pain
Equal hip strength
bilaterally
Phase IV: PO Wks Return to sports None at this time Previous Previous
Return to Activity 6–8+ and ADLs strengthening milestones
Phase Endurance drills Functional testing
Agility drills >90% of
Plyometrics uninvolved
Initiation of Isokinetic testing
running >90% of
progression uninvolved
Sport-specific drills
ADLs activities of daily living, AAROM active assisted range of motion, PO postoperative, RICE rest, ice, compression,
elevation, ROM range of motion, WBAT weight bearing as tolerated
Rehabilitation following meniscectomy. (Taken from: From Manske RC, Lehecka BJ, DeCarlo M, McDivitt
R. Rehabilitation of the Knee. In: Hoogenboom BJ, Voight ML, Prentice WE, (eds). Musculoskeletal Interventions:
Techniques for Therapeutic Exercise, 3rd ed. Table 24-4 page 764: McGraw Hill Education, New York, 2014)

progressing to unilateral as tolerated. All exer-
cises should start out simple progressing to more
complex as the athlete has demonstrated mastery
of the easier exercise.
As strength and control start to return in these
weeks, more traditional exercises can be included
to try to incorporate the principle of muscle
­overload to allow gaining quadriceps and ham-
string strength. Squats, leg presses, and ham-
string curls can begin bilaterally and progress too
unilaterally.
Phase II: (Weeks 3–6+) The focus of the final
phase is on functional return. More detail on a func-
tional return to sports will be presented near the end
of this chapter. Suffice it to say that the athlete should
have full ROM and strength at minimum. A gradual
implementation of sports-specific activities includes
running, agility, hopping, and jumping activities.
428
Fig. 27.4  Straight leg raise
27.16 Meniscus Repair
Rehabilitation
Following a meniscus repair (Table  27.3), reha-
bilitation is more guarded than during meniscec-
tomy. Weight-bearing status will depend on the
type of tear that is repaired. With a peripheral tear,
weight bearing in extension is protective [41].
Due to the shape of the meniscus, the compressive
loads while weight bearing in full extension actu-
ally approximate the tear margins. However, with
a radial tear or complex tear repairs, axial loading
may actually disrupt the repair by creating separa-
tion at the tear margins. In this case weight bear-
ing will be progressed more slowly and may even
begin without weight bearing [42].
Phase I: (Weeks 0–4) Goals for phase 1 of the
meniscus repair protocol include maintenance
of meniscus repair, decreasing pain and swell-
ing, increasing quadriceps activation, and start
work on proximal and distal strengthening exer-
cises for the lower limb. Weight bearing will be
R. C. Manske and M. V. Paterno
dependent on type of repair performed. If weight
bearing is limited, bilateral axillary crutches
should be utilized. ROM is limited to 0–60° of
flexion for the first several weeks. Full symmet-
rical knee extension is achieved as soon as
possible.
General exercises are tolerated at this time
and include quadriceps sets, gluteal sets, and
active assistive ROM from 0° to 60° flexion,
ankle pumps, and straight leg raise. Modalities
such as electrical stimulation can be used to
decrease pain and decrease swelling. After
about 2 weeks, soft tissue techniques can begin
on or along portal incision sites to decrease risk
of scar tissue formation creating pain and
symptoms.
Phase II: (Weeks 4–6) Goals for this phase
should be more geared toward continuing to
increase quadriceps recruitment and normalizing
ROM and gait. Additionally patellofemoral
mobility should be normal by the end of this
phase. After the 4 week time frame, the brace can
be opened to 90° of flexion. If the athlete is able
to walk without a limp and has good quadriceps
activation, the postoperative brace can be
discontinued.
Closed kinetic chain exercises can be pro-
gressed to include squats, step-ups, and lunges. If
proximal strength is an issue, the leg press can be
used with weight that is equal to less than the
body weight. Leg press should begin bilaterally
and progress unilaterally. Once weight bearing is
full, the athlete can begin balance and proprio-
ception exercises. Balance should begin bilater-
ally and progressing to unilateral. Tilt boards,
foam pads, and BAPS boards can be used to facil-
itate return of neuromuscular control.
Phase III: (Weeks 6–10) Goals for phase III
include more aggressive work on strength and
power and endurance. This phase prepares the
athlete for preparation to advanced sports
activities.
After 6 weeks, as long as strength is adequate
and swelling is resolving, the athletes brace is
opened to 130° of flexion. ROM should be pro-
gressed to 130 either active or active assisted.
PROM however should not be forced if it is
27  Rehabilitation of Knee Injuries 429

Table 27.3  Rehab after meniscus repair

Days–
Phase weeks Goals Restrictions Treatment Clinical milestones
Phase I: PO Wks Quadriceps WBAT with RICE Full knee
Immediate PO 0–4 activation bilateral axillary Electrical extension
Phase Decreased effusion crutches stimulation ROM 0–60° knee
Wound healing Brace locked at 0° Glute sets flexion
Pain reduction ROM 0–60° Quad sets AAROM Minimal effusion
Begin proximal flexion × 4 weeks flexion to 60° No increased pain
strengthening Hip abduction/ Single limb stance
adduction
Phase II: PO Wks WBAT bilateral Full WBAT brace Exercises as Previous
Intermediate PO 4–6 axillary crutches opened to 0–90° previous milestones
Phase Quadriceps control Discontinue Patellar Good quadriceps
Pain reduction crutches as tolerated mobilization recruitment
Normal patellar Scar tissue Normalized
mobility mobilization patellar mobility
Progress to CKC AROM progressed Full weight
exercises to 90° bearing without
Heel raises symptoms
Minisquats Normal gait
Step-ups
Flexibility
exercises
Balance and
proprioception
Phase III: PO Wks Increase strength, Knee flexion Progression of Previous
Advanced 6–10 power and motion not greater previous milestones
Strengthening endurance than 130° Advanced balance Satisfactory
Phase Normalized No pivoting training clinical exam
quadriceps Leg presses Full ROM
recruitment Endurance Improved stability
Normal patellar exercises with unilateral
mobility Swimming and stance
No pain or effusion cycling No pain
Preparation for Equal hip strength
advanced activities and bilaterally
Phase IV: PO Wks Increase power and Avoidance of Previous Previous
11–16+ endurance loaded full strengthening milestones
Return to sports and hyperflexion Endurance drills Full confidence in
ADLs Agility drills knee
Return to Plyometrics Functional testing
unrestricted Initiation of >90% of
activities running uninvolved
progression Isokinetic testing
Sports specific >90% of
drills uninvolved
ADLs activities of daily living, AAROM active assistive range of motion, CKC closed kinetic chain, PO postoperative,
RICE rest, ice, compression, elevation, ROM range of motion, WBAT weight bearing as tolerated, Wks weeks
Rehabilitation following meniscus repair. (Taken from: From Manske RC, Lehecka BJ, DeCarlo M, McDivitt
R. Rehabilitation of the Knee. In: Hoogenboom BJ, Voight ML, Prentice WE, (eds). Musculoskeletal Interventions:
Techniques for Therapeutic Exercise, 3rd ed. Table 24-3 page 761: McGraw Hill Education, New York, 2014)

p­ ainful at end range into full hyperflexion. Also 90°, cycling is added to the exercise routine. No
even though ROM is increased, cutting and pivot- loading exercises should be performed in ranges
ing are still restricted. Because ROM is now past past 60–80° before 12 weeks postoperatively [42].
430
At this time advanced balance and propriocep-
tion drills can begin. These include single-leg
balance and perturbation-type exercises. If the
athlete’s balance is improved enough, they can
perform balance drills also with eyes closed.
Weight bearing and loaded exercises can con-
tinue to progress by adding weight or resistance.
Phase IV: (Weeks 11–16+) Goals for phase IV
are increased strength, power, and endurance and
sports-specific drills to return the athlete back to
full activity. Restrictions of agility and pivoting
are lifted at this time but should begin in a safe
and controlled manner.
Exercises in this phase include advanced
strengthening drills and initiation of sports-spe-
cific exercises that mimic or simulate sports
activity. Agility drills are very important for ten-
nis-specific training. Plyometric exercises can
begin at this time starting bilaterally progressing
to unilateral. Usually jogging can commence at
12–16 weeks if strength deficits of the quadriceps
are less than 20%.
27.17 Articular Cartilage
27.17.1  Articular Cartilage
Rehabilitation
In general there are two broad methods of sur-
gery of articular cartilage defects: bone marrow
stimulating procedures and replacement tech-
niques. Bone marrow stimulation procedures
include abrasion arthroplasty, drilling, and micro-
fracture. These techniques utilize the athletes
own pluripotent marrow stem cells to create
reparative tissue consisting of fibrocartilage, pri-
marily type I which has different wear character-
istics of normal type II cartilage [43]. Replacement
techniques include osteochondral autologous or
allograft transplant surgery (OATS) and autolo-
gous chondrocyte implantation (ACI). Each of
these procedures has their own specific rehabili-
tation guidelines with most including some
degree of limited weight bearing and restricted
controlled early ROM (Table 27.4).
Rehabilitation following articular cartilage
surgery continues to evolve. As we begin to
R. C. Manske and M. V. Paterno
understand the biomechanics of cartilage and its
response to injury and surgery to allow healing
comes better understanding of how to handle
these injuries postoperatively. Like many other
knee procedures, early motion and a gradual pro-
gression to full weight bearing are important.
However, exact time frames for when these
should occur vary on pending surgeons and their
particular preference or philosophies of cartilage
healing. Until more specific guidelines can be
agreed upon, communication between therapist
and surgeon is paramount to achieving a success-
ful rehabilitation. It is important to have a full
understanding of the extent of damage, durability
of the surgical procedure, size and location of the
defect, and specific restrictions placed upon the
athlete [44]. When possible a diagram of the
lesion site is also helpful as it will enable the
treating therapist to know where ROM limita-
tions are and to ensure that the lesion is not
engaged during exercises.
For general purposes of this chapter we will
describe postoperative rehabilitation for both
microfracture and ACI procedures that can be
seen in Table 27.5.
27.17.2  Phase I: Weeks 1–6
The early postoperative phase is also known as
the proliferation phase. Goals for this phase
include independent ambulation, quadriceps
activation, limiting effusion, wound healing,
and pain reduction. During this phase there is a
significant amount of constraint placed upon
the athlete in an effort to protect the repair [45,
46]. In most instances weight bearing at this
point is non-weight bearing or a controlled par-
tial weight bearing. Communication is impor-
tant at this time to ensure appropriate
weight-bearing status. If you are unsure, it is
better to error on the conservative side and
begin non-weight bearing until status is
confirmed.
Passive range of motion (PROM) of the tibio-
femoral joint is performed by the therapist and
the patient themselves (Fig. 27.5) or with assis-
tance of a continuous passive motion (CPM)
27  Rehabilitation of Knee Injuries 431

Table 27.4  Rehab after microfracture and ACI

Clinical
Phase Weeks Goals Restrictions Treatment milestones
Phase I: PO Independent NWB or TTWB with RICE Full extension
Early PO 0–6 ambulation bilateral axillary crutches Glute sets Independent use
Phase Quadriceps Quad sets in ROM that of ambulatory
activation does not engage lesion device
Decreased PROM and AAROM in No increased
effusion range restriction that effusion
Wound healing does not engage lesion No increased pain
Pain reduction site per surgeon orders
Full extension × 1 week
Full flexion × 6 weeks
OKC exercises light
resistance in ROM that
does not engage
lesion × 4 weeks
Patellar mobilization
No CKC exercises
Phase II: PO Quadriceps DC crutches gradually as Exercises as previous Previous
Intermediate 6–12 control tolerated at 8 weeks Begin CKC exercises milestones
PO Phase Pain reduction May use pool or Restrict range that does Full ROM
Normal patellar unweighting devices to not engage lesion extension and
mobility transition to full weight Minisquats flexion
Increased ROM bearing Step-ups Good quadriceps
Begin CKC Flexibility exercises recruitment
exercises Balance and Normalized
Begin proximal proprioception patellar mobility
strengthening Full passive knee
Increased extension
balance Full weight
bearing without
symptoms
Phase III: PO Normalized Continue to increase Progression of previous Previous
Return to 12+ quadriceps tolerance to OKC, CKC Advanced balance milestones
Activity recruitment exercises as tolerated training Satisfactory
Phase Normal patellar limiting to ranges that do Leg presses clinical exam
mobility not engage lesion or cause Endurance exercises Improved stability
Full active symptoms Agility and sports with unilateral
ROM specific exercises should stance
No pain begin at 50% effort No pain
No effusion progressing to full as Equal hip strength
tolerated bilaterally
Running delayed until 6 Quadriceps and
months hamstring
strength to within
90% bilaterally
ADLs activities of daily living, AAROM active assisted range of motion, CKC closed kinetic chain, NWB non-weight
bearing, OKC open kinetic chain, PO postoperative, PROM passive range of motion, RICE rest, ice, compression, eleva-
tion, ROM range of motion, TTWB touch-toe weight bearing

device. PROM is done to create movement or dif-
fusion of synovial fluid to stimulate reparative
cell production [47, 48]. Gentle movement of the
knee is started immediately following surgery to
help nourish articular cartilage. It also provides
the additional benefit of preventing deleterious
intra-articular scar tissue formation. Movement
should not only occur at the tibiofemoral joint but
also at the patellofemoral joint. Patellar mobiliza-
tion and passive movement in all planes should
occur, as limitations of patellar mobility can be
disastrous for knee function.
432 R. C. Manske and M. V. Paterno

Table 27.5  Post-operative rehabilitation for articular cartilage surgery (microfracture and autologous chondral
implantation)
Weeks/
Phase months Goals Restrictions Treatment Clinical milestones
Phase I: Early PO 0–6 Independent NWB or RICE Full extension × 1
PO phase weeks ambulation with TTWB with Gluteal sets week
assistive devices SLR × 4
assistive device Full flexion × 6
Quadriceps activation Quad sets in range weeks
Decreased effusion that does not engage Independent use of
Wound healing lesion ambulatory device
Pain reduction PROM and AAROM No increased pain
Patellar mobilization No increased
Scar tissue effusion
mobilization
No CKC exercises
Phase II: PO 6–12 Quadriceps control DC assistive Exercises as previous Previous milestones
Intermediate/ weeks Normal patellar device as Begin CKC exercise Full ROM extension
transition mobility tolerated by 8 Restrict ROM that and flexion
phase Increase ROM weeks does not engage lesion Good quadriceps
Begin CKC activities My use pool or Mini-squats control
Proximal strengthening unweighting Step-ups Normal patellar
Begin balance and device to Flexibility exercises mobility
proprioception transition to Balance and FWB without
Pain reduction FWB proprioception symptoms
Phase III: PO 3–6 Normalize quadriceps No cutting Exercise as previous Previous milestones
Remodeling months recruitment No deep Progressive balance Good balance and
phase Normal patellar squatting exercise challenging proprioception
mobility No running or proprioceptive system Ability to jump and
Full AROM/PROM jogging Leg press land bilaterally
No pain Lunges without symptoms
No effusion Agility drills at 50%
effort progressing to
full after 6 months
Phase IV: PO 6–9 Same as previous No restrictions Agility exercise Previous milestones
Maturation months Return to full activity Strength and power Full confidence in
and Return to exercises knee
activity phase Jumping progressing Excellent clinical
Hopping progression exam
Running progression Pass functional
testing measures
CKC closed kinetic chain, FWB full weight bearing, NWB non weight bearing, PO post-operative, RICE rest, ice, com-
pression, elevation, ROM range of motion, SLR straight leg raises
Rehabilitation following microfracture and autologous chondral implantation. (Taken from: Manske RC, Lehecka BJ,
DeCarlo M, McDivitt R. Rehabilitation of the Knee. In: Hoogenboom BJ, Voight ML, Prentice WE, (eds). Musculoskeletal
Interventions: Techniques for Therapeutic Exercise, 3rd ed. Table 24-5 page 767: McGraw Hill Education, New York,
2014)

Due to weight-bearing limitations, exercises 27.17.3  Phase II: Weeks 6–12

for the knee initially will be non-weight bearing.
Quadriceps neuromuscular control will be used
rather than pure strengthening. Exercises include
quadriceps setting and straight leg raises
(Fig. 27.4). If there is a lack of motor control with
a volitional quadriceps contraction, the quadri-
ceps can be supplemented with electrical
stimulation.
Goals for this phase include improving quadri-
ceps control, pain reduction, increasing range of
motion, beginning closed kinetic chain exercises,
beginning proximal strengthening, and increas-
ing balance.
This phase is known as the transitional phase.
At this time frame postoperatively, the lesion has
27  Rehabilitation of Knee Injuries
Fig. 27.5  Active assistive knee flexion range of motion
begun to fill with immature cartilage cells and is
now able to tolerate some degree of progressive
weight bearing. Controversy exists as too aggres-
sive of weight bearing may risk cartilage delami-
nation, while too conservative of approach may
not provide adequate cartilage tissue stimulation
[49, 50]. Weight bearing is usually progressed
from non-weight bearing to partial and then to
full. Increased knee pain, increased swelling, or
decreased quadriceps volitional recruitment and
motor control are indications that the weight-
bearing progression is too fast. These signs and
symptoms should be watched for closely during
weight-bearing progressions and if seen may
require alteration of normal progression to one
more slowly in nature.
Exercise stresses can be gradually increased
through increased loads and reps. Stresses should
always begin bilaterally and in cardinal planes
and progressing unilaterally and in multiple
planes. Squats, lunges, and step-ups should begin
in the cardinal planes moving anterior to poste-
rior and medial and lateral (Fig. 27.6) directions
before addition multiple plane rotational type
433
Fig. 27.6  Lateral stepping with bands
movements or perturbation devices, which place
greater stress to the articular surface due to
increased shear forces (Fig. 27.7). Balance exer-
cises are initiated bilaterally on level ground then
progressing to single leg and on labile surfaces as
the athlete improves (Fig.  27.8). Using this
approach will ensure a gradual progression of
applied loads and increased demands that will
decrease the risk of damaging the healing articu-
lar cartilage.
27.17.4  Phase III: Months 3–6
Goals of the remodeling phase are to continue to
work on quadriceps control, maintain ROM,
progress weight-bearing ability, and increase bal-
ance. These goals are achieved through increas-
ing difficulty of exercise in the progression.
Due to the ongoing remodeling during phase
III, exercises are able to be applied with gradual
increased load and intensity without harming
the cartilage tissue that is becoming increas-
ingly tolerant. Light functional activities can
434
Fig. 27.7  Squats on a balance board for enhancing
­proprioception
Fig. 27.8  Single-leg balance on a foam pad
R. C. Manske and M. V. Paterno
begin including more sports-specific motions
like ladder drills, carioca, etc. As in the previous
phase, too fast of progression will be noted by
symptoms listed above. Low to moderate impact
functional and recreational activities can com-
mence as long as symptoms remain resolved.
These activities can include walking, cycling,
and golfing. This is an excellent time with phy-
sician approval to begin adapted higher-level
activities via unloading devices. Jogging in a
pool or with an Alter G Antigravity Treadmill
(Fremont, CA) or unweighting device may be
permitted.
27.17.5  Phase IV: Months 6–18
Goals of the last phase, the maturation phase,
include return to pain-free activities of daily liv-
ing (ADL), full strength of the leg, full balance
and proprioception, and tolerance for return to
sport. Return to sports information will be dis-
cussed in more detail near the end of this chapter.
Many factors are determined when articular
cartilage is fully matured and when it is safe to
return to full activity. Factors include patient
overall health and condition, patient age and
expectations, location and size of the articular
cartilage defect that was repaired, and the surgi-
cal procedure that was performed and its histori-
cal outcomes. Exercise load and intensity can
continue to be progressed in an objective and sys-
tematic manner. Advanced strengthening and
endurance exercise can continue to be progressed.
Continued standard strengthening can be supple-
mented with more sports-specific drills including
jumping, hopping, and directional changes.
27.18 Return to Sports: Tennis
The return to sports plan after any lower extrem-
ity injury should not be initiated until the
patients have demonstrated a foundation of
strength, balance, proprioception, and func-
tional movements. Schmitt et  al. [25] outlined
these key foundational milestones which should
be achieved prior to initiating a return to sports
27  Rehabilitation of Knee Injuries
program. Specifically, the athlete should dem-
onstrate a minimum of 85% limb symmetry
with quadriceps and hamstring strength as well
as performance on functional hop testing.
Further, the athlete should present with a
patient-reported outcome score on the IKDC of
85/100. Once these criteria are met, the patient
is ready to initiate a return to sports program.
The goal of this program is to integrate the ath-
lete back to the prior intensity and magnitude of
participation in tennis.
Initiation of a tennis-specific return to sports
program begins with an understanding of the nec-
essary movements to successfully resume activ-
ity. Tennis requires quick pivoting and cutting,
reactionary activities, jumping and landing on a
single limb, and rapid acceleration and decelera-
tion. A successful return to sports program will
include a dynamic progression to a point of profi-
ciency at full speed for all these activities. The
return to sports phase of rehabilitation should
include a focus on advancement of residual
strength and power deficits, transition to high-
speed pivoting and cutting activities, and integra-
tion into sports-specific activities.
Maintenance of foundational strength and
power or resolution of mild residual deficits in
this area is a key component of the end phase of
rehabilitation. Necessary strength criteria to enter
this final phase of rehabilitation are sufficient to
participate in these activities, but not sufficient to
return to sport. Strengthening interventions at
this phase are focused on a progression of closed
kinetic chain and functional strengthening activi-
ties. Often, activities such as double-limb and
single-limb squatting exercises initially on a sta-
ble surface but then progressing to unstable sur-
faces are examples of opportunities to advance
functional strength. During all of these exercises,
attention should be on maintaining good trunk
and lower extremity alignment to insure normal
movement patterns are engrained in the patients
as they return to sport [16, 51].
Beyond the resolution of residual strength
deficits, the return to sports phase must initiate
and progress dynamic, sports-specific move-
ments. The initiation of this process often begins
in the end stages of traditional rehabilitation and
435
translates into the return to sports phase.
Plyometric activities are ideal interventions at
this phase as they provide an opportunity to
enhance functional strength and power while
introducing sports-specific movements. Sub-
maximum effort and plyometrics in a single plane
of movement represent an ideal starting point.
Plyometrics such as wall jumps and broad jumps
helps to introduce the movement patterns while
providing an opportunity to evaluate technique.
Once technique is mastered, progression of plyo-
metric activity can continue to more explosive
movements, single-leg activities, and triplanar
movement. Activities such as 180° jumps, single-
limb maximum effort jumps, and single-limb
lateral jumping are appropriate progressions.
­
Tennis athletes should follow a continual pro-
gression of plyometric activities that align with
sports-specific movements. Participation in ten-
nis activities requires single-leg pivoting and cut-
ting in all planes, single-limb jumping, and quick
reactions. End-stage plyometrics for tennis play-
ers should mimic these movement patterns.
The final aspect of the return to sports phase
is a reintegration to sports-specific movements.
Agility drills, on the tennis court, which repli-
cate tennis activities such as approaching the net,
lateral movement, and diagonal cutting may
begin at sub-maximal speed, in a planned pattern
of movement, and progress toward full-speed,
unanticipated movements. These activities may
begin without a tennis racquet and the progress
toward replicating these movements with ball
and request involvement. Once the patient has
demonstrated ability to successfully execute all
necessary activities to participate in tennis, a
return to play progression should begin. Based
on the injury, the length of time in this phase
may vary but should begin with an abbreviated
time and intensity of participation and sequen-
tially progress as indicated. At the culmination
of the return to sports phase of rehabilitation, the
athlete should present with a strength and func-
tional performance deficit of less than 10% on
the involved limb, as well as a successful com-
pletion of a progressive return to high-level piv-
oting and cutting as well as integration back to
sport.
436
Conclusions
Tennis, when played at a high level, is a physi-
cally demanding sport. The quick pivoting and
cutting maneuvers as well as repetitive accel-
eration and deceleration movements place the
knee at risk for both acute, traumatic injuries
and overuse injuries. The presentation of these
injuries may vary greatly. Successful manage-
ment from the acute phase through the return
to sports integration requires an in-depth
knowledge of knee anatomy and pathology,
knee biomechanics, and appropriate rehabili-
tation progression after injury and surgery.
Finally, understanding an appropriate progres-
sion through the return to sports phase which
introduces stressors experienced on the tennis
court and ultimately a transition back to tennis
play will help facilitate an optimal outcome.
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