practice guidelines for anterior cruciate ligament rehabilitation

PRACTICE GUIDELINES FOR ANTERIOR
CRUCIATE LIGAMENT REHABILITATION:
A CRITERION-BASED REHABILITATION
PROGRESSION
TARA JO MANAL, MPT, and LYNN SNYDER-MACKLER, ScD, PT, SCS
Knowledge related to the anterior cruciate ligament (ACL) and its role in the stabilization of the knee has increased
exponentially since the 1980s. More precise and more anatomic surgical techniques have developed based on a
growing body of literature on the anatomy and biomechanics of the anterior cruciate ligament. The rehabilitation
arena has also risen to the challenge to provide state-of-the-art rehabilitation to complement advances in surgical
stabilization. The understanding and integration of the abundance of literature on surgical reconstruction, graft
biology, and behavior guides the design and progress of the rehabilitation program. Effective rehabilitation after
anterior cruciate ligament reconstruction must balance the loading of tissues necessary to stimulate the recovery of
the knee while at the same time avoiding stresses that compromise graft integrity. Historically, rehabilitation
programs have been temporally based. A performance-based decision-making approach may prove to be more
universally applicable and less confining. Achieving the critical clinical milestones, the basis for rehabilitation
progression, ensures that all patients are adequately challenged while at the same time assuring that none are
progressed too quickly. Combining contemporary surgical and rehabilitation techniques will maximize the patient's
potential and ensure optimal patient function and satisfaction.
KEY WORDS: anterior cruciate ligament, knee, rehabilitation, physical therapy
The anterior cruciate ligament (ACL) plays an important
role in the stabilization of the kneeJ ,2 Disruption of this
ligament can have devastating effects ranging from complaints of instability and buckling during high-level sports
participation to reports of giving w a y while walking down
the street or stepping off of a curb. Surgical techniques for
ACL reconstruction have evolved over the past 15 years,
and postoperative morbidity has diminished significantly.
The improvements in surgical technique are a result of
more detailed understanding of the anatomy and biomechanics of the ACL, the dynamic properties that the
ligament displays during knee motion, and advancements
in surgical approaches and technology. 3-6 The rehabilitation specialist must be cognizant of the evolution in
surgical techniques and their impact on the patient's
rehabilitation.
There is abundant literature describing the surgical
options for ACL reconstruction and the results of progressive rehabilitation programs. 7,8 Retrospective analysis of
results of accelerated rehabilitation programs have been
reported. 9-n These reports are confounded by the myriad
of definitions of successful outcome after ACL reconstruction. The surgeon's primary concern is the passive anterior
laxity of the tibiofemoral joint, which is a measure of the
From the Department of Physical Therapy, University of Delaware,
Newark, DE.
Address reprint requests to Tara Jo Manal, MPT, Department of Physical
Therapy, McKinley Laboratory, Room 309, University of Delaware, Newark, DE 19716.
Copyright © 1996 by W.B. Saunders Company
1048-6666/96/0603-0010505.00/0
190
success of the graft fixation, integrity, and location, n The
rehabilitation specialist is interested in postoperative functional morbidity: the impact of strength, gait, and balance
on return to activity. 13 Successful outcome may also be
related to pain, the ability to return to a preinjury activity,
or a willingness to accept some limitation in activity.
Functional recovery and patient satisfaction are results that
are the benchmarks of a successful outcome) 4
The patient's response to surgical intervention is dependent on individual and genetic intrinsic factors as well as
controllable and uncontrollable extrinsic factors. These
factors include the following: preoperative fitness level of
the patient, healing properties, status of the knee joint at
the time of injury, the time from injury to surgery, and the
presence of concomitant injury that occurred at the time of
the ACL disruption. 15-19The spectrum of patient presentations and responses is large. As a result of temporally
based rehabilitation progressions, the focus has shifted to
what we believe are more appropriate and more universal
criteria-based guidelines.
Achievement of clinical milestones is an indicator of
readiness for rehabilitation progression. This decisionmaking tactic allows the therapist to adapt a treatment
regimen to a young healthy athlete with an isolated ACL
tear as well as to a middle-aged patient with persistent
postoperative inflammation and range of motion (ROM)
complications. The progression depends on the time necessary to reach the defined milestones that permit progress to
the next rehabilitation stage. The criteria-based system
protects a patient from premature advancement in the
therapeutic setting simply because the time frame week 4
Operative Techniques in Orthopaedics, Vol 6, No 3 (July), 1996: pp 190-196
is approaching. This approach also allows the patient with
minimal postsurgical morbidity from being unjustifiably
underchallenged. 1I
Communication between the surgeon and the therapist
is a critical component of successful rehabilitation after
surgery. The exchange of information helps both professionals to maximize successful patient outcome. The rehabilitation specialist treating a patient after ACL reconstruction
has previous assumptions about graft selection and fixation, tunnel placement, and graft tensioning, and the
rehabilitation guidelines are predicated on these assumptions. The length and the type of graft influence the fixation
available to the surgeon, and variations in fixation hardware impact the graft's loading properties. 2° The therapist's knowledge of the strengths of graft material and
common fixation methods modify the decisions regarding
the rehabilitation program. 2°-z2 Correct tunnel placement
and graft tensioning allow restoration of full knee ROM
and ultimately affect the in situ integrity of the graft. If full
knee ROM is not achieved in the operating room, it is
unlikely to be attained in rehabilitation, and forcing full
k n e e ROM in this case may deliteriously affect the graft. 23-25
The surgeon's confidence in the achieved fixation and any
postoperative limitations in ROM should be communicated to the therapist to allow for appropriate modification
of the rehabilitation program.
The rehabilitation program described in this report is
predicated on several assumptions. We will address some
of the more frequent complications and comorbidities that
can affect rehabilitation. The focus however, will be on a
spedfic population of patients who have an isolated ACL
tear, no preoperative flexion contracture, meticulous reproducible surgical technique as outlined above, and have
been referred to physical therapy no more than 5 days after
surgery. Patients who do not meet these criteria can be
treated with this progression; however, achievement of
clinical milestones may be delayed.
TABLE 1. ACL Rehabilitation Practice Guidelines
Time
Frame
Clinical Milestones
Activities
Days 1-3
Passive ROM/active
ROM = 0°-90 °
Quadriceps contraction
Walking without crutches
Week 2
Full knee extension*
Flexion >110 °
Use of cycle/stairclimber
without difficulty
Walking with full extension
Use of stairs foot-over-foot
KOS ADL >85%
Flexion within 10° *
Quad strength >50%*
Wall slides
Patellar mobilization
Active superior glide
Neuromuscular electrical
stimulation
Gait training
Cycle/stairc]imber
Step exercises
Kinetron intervals
Portal/incision mobilization
Prone hangs if necessary
Week 4
Week 6-8
Normal gait pattern
Full ROM*
Quad strength >80%*
Week 12
Maintaining or gaining quadnceps strength
Hop tests >85%*
KOS sports questionnaire
>70%
NOTE. Discontinue treatments when goals are met. Recheck monthly
until 6 months after surgery.
*Compared with uninvolved,
insurance plans impose strict limitations on the use of
physical therapy or in cases in which proximity to a formal
therapy location is limited, the preoperative session can
also be used to inform patients of the clinical milestones
expected in the first postoperative week. Under these
circumstances, the therapist must be confident that the
patient is capable of understanding the instructions and
performing the initial postoperative plan independently.
IMMEDIATE
PREOPERATIVE
TREATMENT
One preoperative consultation is often all that is necessary
to ensure that the clinical milestones are met. The patient
should be able to volitionally activate the quadriceps.
Neuromuscular electrical stimulation, or biofeedback,
coupled with v01itional exercise can be used for a patient
w h o has difficulty activating the quadriceps. The patient
should have full knee extension equal to the contralateral
knee. These two clinical milestones are required before
surgery and are the only reason for more than one
preoperative treatment visit in this time frame. Preexisting
flexion contracture is associated with a much higher rate of
postoperative morbidity and must be resolved before
surgery.15i 16
Patients who are experiencing persistent and frequent
episodes of giving w a y may be fitted for a brace that has an
extension stop to protect the joint from further insult before
surgery. 26-29 If a functional brace will be used postoperatively, it may be ordered during this visit. The patient may
also be educated on the management of effusion. Ice,
elevation, and avoidance of stressful activities will usually
suffice, and patients rarely require supervised therapy to
manage preoperative effusion. In cases in which health
ACL REHAB GUIDELINES
Tibiofemoral mobilization
with rotation
Patellofemoral mobilization
in flexion
Progress exercise in intensity and duration
Begin running progression
Transfer to fitness facility
Agility exercises
Sports specific exercases
POSTOPERATIVE
PHASE
The immediate postoperative phase is the first week after
surgery and includes approximately two to three visits
(Table 1). Restoration of ROM, especially active knee
extension, is the most critical component of early rehabilitation after ACL reconstruction. 15,16,3°The physical therapist and the surgeon should communicate with the patients and reinforce the goal that achieving full active knee
extension is the highest priority milestone. Active assistive
ROM can begin in the recovery room. The wall sliding
exercise (Fig 1) and stationary cycling are among the first
exercises we introduce. The complications resulting from a
persistent flexion contracture can significantly hinder the
rehabilitation process and may require a second surgical
intervention. 31 In most cases, the second surgery is avoidable, and preventative measures should be aggressively
performed if extension is not achieved and maintained.
One helpful addition to the patient's home program is a
passive stretch with a weighted bag pushing the knee into
extension (Fig 2). Knee flexion range is also addressed in
the first postoperative week when the patient is expected
to achieve 90 ° of knee flexion and should be able to ride a
stationary bicycle at minimal resistance for 5 to 10 minutes.
The seat height is progressively lowered to emphasize
knee flexion ROM.
191
Fig 1. Wall sliding exercise. (A) The uninvolved leg is used to
help flex the involved knee, (B) The patient applies a force to
help extend the involved knee,
We encourage immediate weight bearing without
crutches. Many patients use postoperative orthoses, some
fixed in full extension and some hinged. The use of a brace
should not preclude the patient from fully activating the
quadriceps and achieving full active knee extension during
ambulation. 32~3Unbraced gait training, under the supervision of a therapist, should begin on the first rehabilitation
visit to ensure that the patient understands how to fully
bear weight and fully extend the knee during the end of the
stance phase of the gait.
ACL-deficient patients ambulate with a characteristic
flexed-knee gait pattern, which is a decreased knee flexion
excursion during the stance phase to stabilize the knee. 34
This gait pattern can persist after surgery and complicate
the restoration of proper tibiofemoral and patellofemoral
mechanics) 4 Patellar mobility can also be compromised if
abnormal knee kinematics continue after surgery.35 Patients who undergo reconstruction with a bone-patellar
tendon-bone autograft may be particularly at risk because
they may refrain from contracting the quadriceps to avoid
pulling on the harvest site.
Patellofemoral joint pain has been identified as one of
the primary causes of postoperative morbidity after ACL
reconstruction, especially in those who have had autologous bone-patellar tendon-bone procedures. 36-38Early intervention with active and passive patellar gliding and scar
mobilization after suture removal minimizes iatrogenic
effects associated with graft harvesting. Patellar restrictions contribute to graft site complaints, ~and aggressive
patellar mobilization should be initiated immediately.
Patients should be taught to pull through the tightness
with the use of their quadriceps to restore full gliding.
Harvest-site pain or inflammation should be treated directly with therapeutic techniques such as patellar strapping, electrical stimulation, and transverse friction massage. Patellar mobility is an important component of this
early postoperative phase for all patients after ACL reconstruction and should continue until normal active and
passive patellar mobility is achieved.
Persistent weakness of the quadriceps femoris muscle
has been associated with long-lasting morbidity after ACL
injury and reconstruction.32,33 Therefore, recovery of the
quadriceps strength is a pivotal component of rehabilitation after ACL reconstruction. Postoperative effusion may
result in some inhibition of the quadriceps very early in the
rehabilitation process, but it should not persist. We focus
on early active quadriceps exercise to minimize the effects
of disuse. Quadriceps setting and straight-leg raising
exercises are used early in the rehabilitation phase to
enhance quadriceps activation. Quadriceps action is also
encouraged during gait training; the patient is taught to
contract the muscle with each step (even when an immobilizer or brace is used) to increase the volitional control of
the muscle. Educating the patient on the importance of
recovery of quadriceps strength and its impact on functional recovery is essential.
EARLY POSTOPERATIVE PHASE
Fig 2. Passive knee extension stretch using a weighted
backpack.
192
The 2 to 4 weeks after surgery is considered the early
postoperative phase and usually involves six to eight
visits. The prone hang exercise is initiated if full extension
is not achieved by 2 weeks after surgery. The patient is
positioned prone and the pelvis is strapped to the table to
prevent compensatory hip flexion during the procedure.
Ten to 15 lbs of sandbag weights are attached to the
patient's ankle for 15 minutes (or less if full range is
achieved). The unsupported knee joint overhangs the
table, allowing gravity-assisted stretching into full knee
extension (Fig 3). This procedure is very uncomfortable,
MANAL AND SNYDER-MACKLER
Fig 3. Prone hanging exercise for knee extension.
not easily tolerated, and, in our opinion, as valuable as a
motivational tool (to encourage diligent adherence to a
passive home knee extension program) as it is therapeutic.
In our clinic, approximately 10% of the patients require the
use of prone hangs after uncomplicated ACL reconstruction, and rarely is it repeated more t h a n three times. A
greater percentage of problems with stiff knees can be
expected in patients who had a flexion contracture preoperatively or those who are operated on acutely.
Once full knee extension is restored, the treatment
emphasis shifts to continued gains in knee flexion ROM.
Initial supine wall slides or seated knee bends with the
assistance of the uninvolved lower extremity are stopped
to perform more aggressive full body weight-bearing knee
flexion stretches as indicated. Knee flexion of 110° or
greater is expected during the early postoperative phase.
The recovery of quadriceps femoris muscle strength is
the critical clinical milestone of the early and middle
post0perative phases of rehabilitation because the knee
ROM, patellar mobility, and inflammatory responses yield
to intervention. Weight-bearing exercises are encouraged
because of the stabilizing effect they provide to the tibiofemoral joinL These exercises are more commonly referred
to as Closed chain exercises in the current rehabilitation
literature. 39,4°,47 These include but are not limited to the
following: squats, leg press, step-ups, stair climber, toe
raises, and Kinetron (Cybex Division of Lumex, Ronkokorea, NY). The introduction and progression of these
exercises are dependent on rules of safety for both the
patient and the healing graft:
During the first 6 weeks, fixation strength is the biggest
concern. The knee should not be exposed to forces in excess
of the strength of the fixation. Common methods of soft
tissue and bone-to-bone fixation are sufficient to withstand
the progression described in this report for the early
postoperative period.2°,2~,41
Information about the biological status of the graft has
largely been extrapolated from animal models and studies
in which the knees were immobilized. 42-44 The model of
graft incorporatipn is therefore incomplete, Graft strength
has been reported to: d¢crease during the first 3 months and
t h e n to slowly increase in strength during the following
months. It is unclear whether true revascularization occurs
or whether a bldod: supply is reestablished via a synovial
envelope that surr0un~ts the graft. 4s In any case, it is clear
that fhe graft is the strongest on the day it is implanted and
probably n e v e r regains that strength. Allograft tissue
appeArst 0 have sI0wer rates of incorporation than autograA tissue, 46
Research into the strains produced in the ACL and graft
ACL REHAB GUIDELINES
during various exercises has given some insight into the
forces to which the graft is exposed. 3,s The underlying
thread in all these reports is the notion that the absence of
strain is the therapeutic goal. rn every other instance of
encouraging healing, tissues respond appropriate to loading. The critical issue related to exercise progression after
ACL reconstruction is not the removal of all strain from the
graft but the determination of the optimal loading of the
graft to encourage healing without stretching or rupturing
the graft. Taken to its logical conclusion, absence of strain
should result in stress shielding and graft failure. An
integrative approach advocates modulated activities that
present appropriate graft stresses and facilitate muscular
recovery.47 Our response to the contention that the graft is
the weakest at the 12-week time period is that only good
dynamic stability will protect the graft at this time. We
therefore use the 8 to 12-week period as a target for full
recovery of the stabilizing knee musculature.
In a randomized, controlled, clinical trial, we have
previously shown that closed chain kinetic exercises alone
are not sufficient to restore quadriceps strength after ACL
reconstruction.48 The quadriceps strength deficits were
clinically and functionally detectable in gait parameters. 34
High-intensity electrical stimulation has been shown to
ameliorate early and substantive quadriceps strength loss
and is a cornerstone of our postoperative rehabilitation
program. 49The stimulation protocol is begun as soon as the
superior arthroscopy portal sutures are removed. The
patient is positioned in a dynamometer with the knee
flexed between 45 ° and 600.3-5,5°,51 The patient performs a
maximum voluntary isometric contraction (MVIC), and
the results are recorded. The electrodes are placed proximally over the lateral quadriceps and distally over the
vastus medialis oblique. The quadr[ceps are stimulated
isometrically with a 2,500-Hz alternating current modulated at 75 bursts per second with a 2-second ramp time, 10
seconds on and 50 seconds off for 10 to 15 contractions. The
stimulation intensity is set to a minimum force level of 50%
of the MVIC. The contractions are isometric, and entirely
electrically elicited (not superimposed on a volitional
contraction).
The ACL rupture and resultant surgical intervention
affect the proprioceptive and kinesthetic sense in the
patient's knee. 14,52 Although surgical stabilization and return of muscle strength and knee joint ROM are essential to
recover3# they are not sufficient to restore proprioceptive
ability. Dynamic weight-bearing exercises provide stress to
this integrative system in a very controlled and limited
manner. 39 The introduction of more challenging balance
and control exercises is therefore essential. Activities involve the use of the balance board, the mini trampoline,
and rubber bands or tubing, and their use is limited only
by the creativity of the supervising therapist
MIDDLE
POSTOPERATIVE
PERIOD
The 5 to 8 weeks after surgery is considered the middle
postoperative period and usually involves four to eight
visits. During this phase of the rehabilitation, the focus is
on activity progression and the patient is transferred to a
local fitness facility. The exercises have been progressed to
continue to challenge the patient. Full knee extension has
193
been achieved, full patellar mobility has been restored, scar
management has been addressed, the patient has been
tested to determine if the clinical milestones have been
met, and the patient no longer requires supervised therapy
sessions.
The electrical stimulation is continued until the patient
can achieve an involved quadriceps MVIC, which is 80% or
greater than that of the uninvolved knee. This milestone is
generally achieved between the sixth and eighth postoperative week. Knee flexion ROM should be 90% or greater
than that of the uninvolved knee. If a functional brace is
requested by the referring surgeon, it is ordered at this
time. If there are no complications and these milestones are
met, the patient is transferred to an independent program
at a local fitness center. The patient begins treadmill
running and continues to progress the exercises previously
performed in the clinic. 53
LATE ACL POSTOPERATIVE PHASE
The 8 to 12 weeks after surgery is the late ACL postoperative phase. The emphasis during this phase of rehabilitation is the continued progression of activity level and
maintenance of quadriceps recovery. Continued emphasis
is placed on proprioception and cutting activities are
avoided. Sport-specific activities in straight planes are
introduced and progressed as the patient recovers. For the
patient who progresses without difficulty, biweekly or
monthly follow-ups are used to update or modify the
treatment plan.
The tensile strength of the graft is lowest (50%) at the
3-month postoperative period and must play a role in
treatment planning for this time period. If a patient's
quadriceps recovery is not sufficient, there are proprioceptive deficits, or they lack confidence in the function of the
knee, these issues need to be addressed to avoid injury. The
patient is reexamined at 8 weeks and again at 12 weeks.
The failure to maintain quadriceps strength may necessitate resumption of supervised therapy. The patient also
performs a series of hop tests 54 at the 12-week testing
session to ensure that both the ability and the willingness
to use the limb in an explosive manner are returning. 5~,56A
score of 85% or greater than that of the uninvolved is the
clinical milestone for this time period.
END OF ACL REHABILITATION PHASE
The 3 to 6 months after surgery is considered the end of the
ACL rehabilitation phase. The patient accelerates the sportspecific activities and continues an independent exercise
program during this phase. The patient continues the
running progression from the treadmill to the track, to flat
road/field running, and finally to hill running. Running
advancement is dependent on the return of balance, agility,
and the ability to run 2 miles at each level without pain or
swelling. 53,55,56 The full progression can take as long as 3
months. The MVIC and hop testing is repeated at the
6-month time period, and scores of 90% or greater are
expected on both scales. These criteria are often achieved at
the 3-month mark, but the patients are retested to insure
that no deficits have recurred.
Patients are most concerned about when they can return
194
to their sport. Even if the patient's muscle strength is
restored and balance and agility is recovering, the return to
sport involves uncontrolled factors. Our guidelines for
return to play are the culmination of progressive sportspecific return-to-independence skill drills, practice participation, and, finally, play. These guidelines are applied to
patients who uneventfully achieve all clinical milestones
and have no postoperative complications. We expect patients to return to full playing status for level 3 sports
(running) at 3 to 4 months, level 2 sports at 6 to 9 months
(depending on position played), and level 1 sports at 9 to
12 months. Patients usually begin practice activities 2 to 3
months before resuming full competitive activity.
CONCURRENT KNEE JOINT INJURIES
The effect of concurrent knee pathologies in the ACL
reconstructed knee is as varied as the potential pathology
list. The impact that concomitant injury and surgical
intervention have on the progression of the ACL rehabilitation is dependent on the involved structure and timing of
injury or surgery. The rehabilitation specialist's understanding of each coexisting pathology comprises the tools
needed for modification of the postoperative rehabilitation
plan. An accurate identification of the most limiting factor
in need of protection is the critical decision-making component for any multiple injury situation.
MENISCAL PATHOLOGY
Partial meniscectomy requires no modification in the
rehabilitation p r o c e s s J Concurrent meniscal repair however, may require modification of the rehabilitation progression. Weight-bearing flexion past 45 ° is avoided for the first
4 weeks. This does not preclude weight bearing in full knee
extension, which helps to prevent loss of knee extension
ROM and encourages quadriceps activation. Exercises that
do not stress the repair but do allow for quadriceps
recruitment should be substituted for closed chain exercises during the first 2 weeks. Non-weight-bearing exercises such as seated Kinetron and multiangle quadriceps
isometrics are excellent substitutes.
CHONDRAL DAMAGE
Treatment of an ACL-reconstructed knee with chondral
damage to a weight-bearing surface is similar to that used
after meniscal repair. We cannot restrict weight bearing
long enough to allow full healing of the articular cartilage
defect after drilling or microfracture without compromising the ACL rehabilitation. We do however, restrict weight
bearing for the first 3 to 4 weeks and refrain from
weight-bearing exercise. The use of a brace that unloads
the side of the chondral defect can be helpful in allowing
earlier protected functional activities. 57
MEDIAL COLLATERAL LIGAMENT INJURY
The medial collateral ligament (MCL) is rarely surgically
repaired. 18,58When an MCL injury occurs at the time of an
ACL rupture, the stabilization of the knee provided by the
ACL reconstruction usually provides an adequate environment for the healing of even a grade 3 MCL sprain. During
MANAL AND SNYDER-MACKLER
the rehabilitation process, m o t i o n should be restricted to
the sagittal plane to avoid any inadvertent stress on the
healing MCL. We also encourage the patient to position the
tibia in internal rotation while p e r f o r m i n g exercises d u r i n g
the early postoperative period. If the sprain is severe or the
patient has pain, a brace can be used d u r i n g exercise and
periods of activity w i t h no significant impact on the
treatment progression.
ACL AND POSTERIOR CRUCIATE
LIGAMENT RECONSTRUCTION
The rehabilitation of patients after concurrent ACL and
posterior cruciate ligament injury generally follow posterior cruciate ligament rehabilitation guidelines. 19,59,6°A full
review of rehabilitation for this p o p u l a t i o n is b e y o n d the
scope of this report; however, mitigation of the patient's
expectations and discharge activity level m a y assist greatly
in the patient's perceived outcome and ultimate knee
function satisfaction.
ACL RECONSTRUCTION AND
PATELLOFEMORAL JOINT PATHOLOGY
Anterior knee pain can be a persistent problem after the
harvest of the central third of the patellar t e n d o n for use as
an ACL graft. 36-38 Anterior knee pain can also occur as a
result of the perforation of the infrapatellar fat p a d b y the
arthroscope and partial resection of the fat p a d that is
necessary for visualization d u r i n g ACL reconstruction.
The quadriceps weakness, w h i c h occurs after ACL injury,
c o m p o u n d s this problem. Treatment of the patellofemoral
joint m a y be necessary to allow for effective strengthening
of the quadriceps. Treatment m a y include patellar strapping, modalities, or biofeedback to assist in quadriceps
muscle recruitment. Care should be taken to address
s y m p t o m s as they occur. The full activation of the quadriceps remains the focus for complete return of a n o r m a l gait
and function after ACL reconstruction. Patients m u s t be
e n c o u r a g e d to recruit the quadriceps early; adhere to
stringent harvest, incision, and portal site mobility; and
maximize patellar mobility to avoid any pain-inhibited
volitional quadriceps strength deficits.
ACCESS TO PHYSICAL THERAPY
An additional extrinsic factor that impacts the rehabilitation process is health insurance plans that severly restrict
access to physical therapy. Some health insurance plans
p u t time limits on care (eg, 60 days from the first visit), and
some restrict the n u m b e r of physical t h e r a p y visits. In the
first case, the challenge is to m a k e the timing fit the
rehabilitation. In the second case, the challenge is to
strategically allot visits to ensure the achievement of the
critical clinical milestones. The distribution of available
treatments will v a r y d e p e n d i n g on individual patient
n e e d s and insurance carrier restrictions. The intervention
w e have outlined i s based o n an 18 to 20-visit program.
This involves 2 to 3 visits per w e e k for the first 4 to 6 weeks
and allows for m o n t h l y follow-ups and 3- and 6-month
testing sessions.
Failure to attain clinical milestones m a y necessitate a
ACL REHAB GUIDELINES
variation from this typical disbursement pattern. For example, a failure to achieve full knee extension by week 2
will necessitate an increase in visits per week until full
extension is achieved and the overall distribution of the
treatments must be altered. In certain cases, persistent
range of motion or strength deficits m a y require more
intensive rehabilitation to achieve the clinical milestones.
Careful attention must be paid to the use of rehabilitation
resources. The full return to function is d e p e n d e n t not only
on early intervention b u t also appropriate advancements
even in the late postoperative phases. If the use of available
rehabilitation resources is m i s h a n d l e d early, the potential
effects m a y be a less functional and less satisfied patient.
SUMMARY
We have presented a criterion-based rehabilitation program for use after ACL reconstruction. The p r o g r a m is
designed for patients with isolated ACL ruptures, no
preoperative flexion contracture, and whose first postoperative visit occurs within 5 davs of surgery. Effects of
concommitant injury, postoperative complications, and
health insurance regulation on the rehabilitation progression have also b e e n discussed. Guidelines for running and
return to sports activity have been presented along with
critical clinical milestones for progression.
REFERENCES
1. Johansson H: Role of knee ligaments in proploception and regulation
of muscle stiffness.J Electromyogr Kinesiol 1:158-179.1991
2. Johansson H, Sjolander P, Sojka P: Receptors in the knee joint
ligaments and their role in the biomechm~ics of the joint. Crit Rev
Biomed Eng 18:341-368,1991
3. Flemming BC, Beynnon BD, Pope MH: Functional anatomy and
biomechanics of the anterior cruciate ligament. Oper TechSports Med
1:1-9, 1993
4. Arms SW, Pope MH, Johnson RJ, et al: The biomechanics of anterior
cruciate ligament rehabilitation and reconstruction. Am J Sports Med
12:8-18, 1984
5. Beynnon BD, Flemming BC, Johnson RJ, et al: Anterior cruciate strain
behavior during rehabilitation exercises in vivo. Am J Sports Med
23:24-34, 1995
6. YasudaK, SasakiT:Exerciseafter anterior cruciateligament reconstruc_
tion. Clin Orthop Rel Res 220:275-283,1987
7. Irrgang J: Modern trends in the anterior cruciate ligament rehabilitation: Nonoperative and postoperative management. Clin Sports Med
12:797-812,1993
8. Fu FH, Woo SL, Irrgang JL: Current concepts for rehabilitation
following anterior cruciate ligament reconstruction. J Orthop Sports
Phys Ther 15:270-278,t992
9. Shelbourne KD, Nitz P: Accelerated rehabilitation after anterior
cruciate ligament reconstruction. J Orthop Sports Phys Ther 15:256264, 1992
10. Shelbourne KD, Klootwyk TE, DeCar]o MS: Update on accelerated
rehabilitation after anterior cruciate ligament reconstruction. J Orthop
Sports Phys Ther 15:303-308,1992
11. Glasgow SG, Gabriel JP, Sapega AA, et al: The effect of early versus
late return to vigorous activities on the outcome of anterior cruciate
ligament reconstruction. Am J Sports Med 2:243-248,1993
12. Barber-WestinSD, Noyes FR: The effectof rehabilitation and return to
activity on anterior-posterior displacements after anterior cruciate
ligament reconstruction. Am J Sports Med 21:264-270,1993
13. Wilk KE, Romaniello WT, Soscia SM, et ah The relationship between
subjective knee scores, isokinetic testing, and functional testing in the
ACL-reconstructedknee. J Orthop Sports Phys Ther20:60-73,1994
14. Barrett DS: Propioception and function after anterior cruciate reconstruction. J BoneJoint Surg Br 73B:833-837,1991
195
15. Cosgarea AJ, Sebastianelli WJ, DeHaven KE: Prevention of arthrofibro-
37. Friis EA, Cooke FW, McQueen DA, et al: Effect of bone block removal
sis after anterior cruciate ligament reconstruction using the central
third patellar tendon autograft. Am J Sports Med 23:87-92,1995
16. Graf BK~ Ott JW, Lange RH, et ah Risk factors for restricted motion
after anterior cruciate reconstruction. Orthopedics Jul-Dec 909-912,
1994
17. FitzgibbonsRE, Shelbourne KD: "Aggressive" nontreatmentof lateral
meniscal tears seen during anterior cruciate ligament reconstruction.
Am J Sports Med 23:156-159, 1995
18. Noyes FR, Barber-Westin SD: The treatment of acute combined
ruptures of the anterior cruciate and medial ligaments of the knee.
Am J Sports Med 23:380-391, 1995
19. Wilk KE: Rehabilitation of isolated and combined posterior cruciate
ligament injuries. Clin Sports Med 13:649-677,1994
20. Steiner ME, Hecker AT, Brown CH, et al: Anterior cruciate ligament
graft fixation: Comparison of hamstring and patellar tendon grafts.
Am J Sports Med 22:240-247,1994
21. Barrett GR, Papendick L, Miller C: Endobutton endoscopic fixation
technique in anterior cruciate ligament reconstruction. Arthroscopy
11:340-343, 1995
22. Kurosaka N, Yoshiya S, Andrish JT: A biomechanical comparison of
different surgical techniques of graft fixation in anterior cruciate
ligament reconstruction. Am J Sports Med 15:225-229,1987
23. Howell SM, Taylor MA: Failure of reconstruction of the anterior
cruciate ligament due to impingement by the intercondylar roof. J
Bone Joint Surg Am 75A:1044-1055,1993
24. Howell SM: Arthroscopically assisted technique for preventing roof
impingement of an anterior cruciate ligament graft illustrated by the
use of an autogenous double-looped semitendinosus and gracilis
graft. Oper Tech Sports Med 1:58-65,1993
25. Hemming B, Beynnon BD, Johnson RJ, et al: Isometric versus tension
measurements: A comparison for the reconstruction of the anterior
cruciate ligament. Am J Sports Med 21:82-88, 1993
26. Cook FF, Tibone JE, Redfern FC: A dynamic analysis of a functional
brace for anterior cruciate ligament insufficiency. Am J Sports Med
17:519-524, 1989
27. Bagger J, Ravin J, Lavard P, et al: Effect of functional bracing,
quadriceps and hamstrings on anterior tibial translation in anterior
cruciate ligament insufficiency: A preliminary study. J Rehabil Res
Dev 29:9-12, 1992
28. Perlau R, Frank C, Fick G: The effect of elastic bandages on human
knee propioception in the uninjured population. Am J Sports Med
23:251-255, 1995
29. Gottlieb DJ, Westmoreland K, Elmqvist LG, et al: The effect of
functional knee bracing on the latency of reflex muscle contraction in
normal and ACL deficient limbs. Transactions of the 42nd Annual
Orthopaedic Research Society Meeting February p. 77-13, 1996
30. Rubinstein RA, Shelbourne KD, VanMeter CD, et al: Effect on knee
stability if full hyperextension is restored immediately after autogenous bone-patellar tendon-boneanterior cruciate ligament reconstruction. Am J Sports Med 23:365-368,1995
31. Dodds JA, Keene JS, Graf BK, et al: Results of knee manipulations
after anterior cruciate ligament reconstructions. Am J Sports Med
19:283-287,1991
32. LoPresti C, Kirkendall DT, Street GM, et al: Quadriceps insufficiency
following repair of the anterior cruciate ligament. J Orthop Sports
Phys Ther 9:245-249, 1988
33. Snyder-Mackler L, DeLuca PF, Williams PR, et ah Reflex inhibitionof
the quadriceps femoris muscle after injury or reconstruction of the
anterior cruciate ligament. J Bone Joint Surg Am 76A:555-560,1994
34. Snyder-Mackler L, Delitto A, Bailey SL, et al: Strength of the
quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am 77A:11661173, 1995
35. Andriacchi TP: Dynamics of pathological motion: Applied to the
anterior cruciate deficient knee. J Biomech 23:99-105, 1990
36. Nakagawa S, Shino K, Inone M, et al: Patello=femoral degeneration
following ACL reconstruction. Am J Sports Med 19:559-565, 1991
and patellar prosthesis on stresses in the human patella. Am J Sports
Med 22:6966-701, 1994
38. Kohn D, Sander-BeuermannAS: Donor-site morbidity after harvest of
a bone-tendon-bone patellar tendon autograft. Knee Surg, Sports
Traurnatol, Arthroscopy 2:219-223, 1994
39. Nyland J, Brosky T, Currier D, et al: Review of the afferent neural
system of the knee and its contribution to motor learning. J Orthop
Sports Phys Ther 19:2-11,1994
40. More RC, Karras BT, Neiman R, et al: Hamstrings--art anterior
cruciate ligament protagonist. An in vitro study. Am J Sports Med
21:231-237,1993
41. Matthews
42. Clancy WG, Narechania RG, Rosenberg TD, et al: Anterior and
posterior cruciate ligament reconstruction in rhesus monkeys. J Bone
Joint Surg Am 63A:1270-1284,1981
43. Noyes FR, Butler DL, Grood ES: Biornechanical analyses of human
ligament grafts used in knee-ligament reconstructions. J Bone Joint
Surg Am 66A:344-352,1984
44. Noyes FR, Grood ES: The strength of the anterior cruciate ligament in
humans and rhesus monkeys. J Bone Joint Surg Am 58A:1074-1082,
1976
45. Howell SM, Knox KE, Farley TE, et al: Revascularization of a human
anterior cruciate ligament graft during the first two years of implantation. Am J Sports Med 23:42-49, 1995
46. Gibbons MJ, Butler DL, Grood ES, et al: Effects of gamma irradiation
on the initialmechanical and material properties of goat bone-patellartendon-bone allografts. J Orthop Res 9:209-218, 1991
47. Palmitier RA, Kai-Nan A, Scott SG, et ah Kinetic chain exercise in knee
rehabilitation. Sports Med 11:402-413,1991
48. Snyder-Mackler L, Delitto A, Stralka SW: Use of electrical stimulation
to enhance recovery of quadriceps femoris muscle force production in
patients following anterior cruciate ligament reconstruction. Phys
Ther 74:901-907, 1994
49. Snyder-Mackler L, Ladin Z, Schepsis AA, et al: Electrical stimulation
of the thigh muscles after reconstruction of the anterior cruciate
ligament. J Bone Joint Surg Am 73A:1025-1036,1991
50. Wilk KE, Andrews JR: The effects of pad placement and angular
velocity on tibial displacement during isokinetic exercise. J Orthop
Sports Phys Ther 17:24-30,1993
51. Howell SM: Anterior tibial translation during a maximum quadriceps
contraction: Is it clinically significant? Am J Sports Med 18:573-578,
1990
52. Co FH, Skinner HB, Cannon WD: Effect of reconstruction of the
anterior cruciate ligament on propioception of the knee and the heel
strike transient. J Orthop Res 11:696-704,1993
53. Sailors ME, Keskula DR, Perrin DH: Effect of running on anterior
knee laxity in collegiate-level female athletes after anterior cruciate
ligament reconstruction. J Orthop Sports Phys Ther 21:233-239,1995
54. Noyes FR, Barber SD, Mangine RE: Abnormal lower limb symmetry
determined by functional hop tests after anterior cruciate ligament
rupture. Am J Sports Med 19:513-518,1991
55. Risberg MA, Ekeland A: Assessment of functional tests after anterior
cruciate ligament surgery. J Orthop Sports Phys Ther 19:212-217, 1994
56. Barber SD, Noyes FR, Mangine R, et al: Rehabilitation after ACL
reconstruction: Function testing. Orthopedics :969-974,1992
57. Lindenfeld TN, Hewett TE, Andriacchi TP: Decrease in knee joint
loading with unloader brace wear in patients with medial compartment gonarthrosis. Proc Annu Meet Am Acad Orthop Surg February
1996 p 243
58. Schierl M, Peterman J, Trus P, et al: Anterior cruciate and medial
collateral ligament injury. Knee Surg, Sports Traumatol, Arthroscopy
2:203-206, 1994
59. Harner CD, Xerogeanes JW, Livesay GA, et al: The human posterior
cruciate ligament complex: An interdisciplinary study. Am J Sports
Med 23:736-745,1995
60. Bergfield JA, Noyes FR, Warren RF, et al: The posterior cruciate
ligament injured knee: Principles of evaluationand treatment. Proceedings of ORS Annual Meeting Feb 1996, p 354
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