Current Concepts for Anterior Cruciate Ligament Reconstruction:
A Criterion-Based Rehabilitation Progression
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Douglas Adams1, David Logerstedt2, Airelle Hunter-Giordano3, Michael J. Axe4, Lynn SnyderMackler5
1
Physical Therapist, Premier Physical Therapy and Sports Performance, Middletown, DE
2
Post-doctoral Research Fellow, Department of Physical Therapy, University of Delaware,
Newark, DE
3
Associate Director of Sports, University of Delaware Physical Therapy Clinic, Newark, DE
4
Orthpaedic Surgeon, First State Orthopaedics, Newark, DE
5
Alumni Distinguished Professor, Department of Physical Therapy, University of Delaware,
Newark, DE
18 1 Current Concepts for Anterior Cruciate Ligament Reconstruction:
A Criterion-Based Rehabilitation Progression
1 2 3 Synopsis:
4 The management of patients after anterior cruciate ligament (ACL) reconstruction should be
5 evidence based. Since our original published guidelines in 1996, successful outcomes have been
6 consistently achieved with the rehabilitation principles of early weight bearing, using a
7 combination of weight bearing and non-weight bearing exercise focused on quadriceps and lower
8 extremity strength, and meeting specific objective requirements for return to activity. As
9 rehabilitative evidence and surgical technology and procedures have progressed, the original
10 guidelines should be revisited to ensure the most up to date evidence is guiding rehabilitative
11 care. Emerging evidence on rehabilitative interventions and advancements in concomitant
12 surgeries, including those addressing chondral and meniscal injuries, is continuing to grow and
13 greatly affects the rehabilitative care of patients with ACL reconstruction. The aim of this article
14 is to update our previously published rehabilitation guidelines using the most recent research to
15 reflect the most current evidence for management of patients after ACL reconstruction. The
16 focus will be on current concepts in rehabilitation interventions and modifications needed for
17 concomitant surgery and pathology.
18 Key Words: ACL, graft, surgery
19 2 1 More than 200,000 anterior cruciate ligament (ACL) injuries occur each year in the
2 United States, and approximately 65% of these injuries are treated with reconstructive surgery.8
3 A consistent approach to rehabilitation after ACL reconstruction can yield predictably good
4 outcomes, such as returning to previous levels of activity and normal knee function. The
5 University of Delaware published criterion-based rehabilitation guidelines in 1996.59 In these
6 guidelines, a progression was established with specific clinical milestones with respect to tissue
7 healing time frames. The goal of any criterion based guideline is to maximize the patient’s
8 response to exercise at the current level of function while minimizing the risk of injury to the
9 healing tissue. Based on sound principles and current evidence, the original guidelines have
10 continued to guide rehabilitative care to successful outcomes.
11 Advancements in surgical procedures directly impact post-operative rehabilitation. Since
12 the original guidelines were published in 1996, considerable advancements have occurred in
13 ACL reconstruction surgical procedures and common secondary surgical interventions to address
14 injuries often associated with ACL tears. Rehabilitation after ACL reconstruction has continued
15 to move from surgery modified rehabilitation, where the surgery actually constrained the
16 rehabilitation progression, to rehabilitation modified surgery, where the reconstruction
17 techniques are robust enough to withstand early mobilization and strengthening.33, 38
18 Modifications of the surgery over the past 16 years, (e.g. soft-tissue fixation) warrant a
19 reexamination of the rehabilitative management of patients after ACL reconstruction. Further
20 literature and understanding of secondary surgeries and their impact on ACL reconstruction call
21 for further clarification on their impact on post-surgical treatment and outcomes. The purpose of
22 this paper is to revisit the rehabilitation guidelines to reflect the most current evidence on
23 management of patients following ACL reconstruction.
3 1 ISOLATED ACL RECONSTRUCTION:
2 The original guidelines (Table 1) were developed around evidence based medicine along
3 with consideration for biological healing time frames. As a result, the treatment of an isolated
4 ACL reconstruction has required only minor adjustments to reflect recent advances in the
5 rehabilitation literature and surgical techniques (Appendix A). Time frames have been included
6 as a guide for the therapist, but it is required that the patient meet all of the clinical milestones
7 prior to advancing to the next stage no matter the time frame. Clarification and adjustments of
8 clinical milestones and additions of interventions are aimed at improving functional outcomes
9 and providing a safe return to sport.
10 11 Pre-surgical Rehabilitation
12 Knee function prior to surgery is important in expected and final outcomes after ACL
13 reconstruction.17, 22, 23, 48, 50, 51, 82, 84 Preoperative milestones have been included in the updated
14 guidelines to reflect the importance that these factors have on postoperative outcomes. Patients
15 with full knee extension range of motion (ROM), absent or minimal effusion, and without knee
16 extension lag during a straight leg raise (SLR) preoperatively have better outcomes, such as
17 returning to previous levels of activity and demonstration of normal knee function, after
18 surgery.89
Quadriceps strength deficit is significant after ACL injury, ranging from 15 to 40%.14, 17,
19 20 23, 35, 41, 46, 66
21 ACL reconstruction.17, 22, 48, 53, 83 Because of the large impact that quadriceps strength has on
22 knee function, the identification and treatment of quadriceps weakness prior to ACL
23 reconstruction is paramount in maximizing patient outcomes. Objective measures of quadriceps
Preoperative quadriceps strength is a significant predictor of knee function after
4 1 strength with isometric or isokinetic dynamometry allow the rehabilitation specialist to track the
2 progress of this critical impairment throughout the recovery period. Preoperative rehabilitation
3 that includes perturbation training and aggressive quadriceps strengthening should be used to
4 reduce limb-to-limb differences and the objective should be to improve the quadriceps index (a
5 ratio of the involved quadriceps strength to the uninvolved quadriceps strength) to greater than
6 90% prior to surgery.21, 55
7 8 Immediate post-operative phase
9 The milestones for the immediate postoperative phase (week 1) are to achieve
10 active/passive ROM equal to 0-90 degrees and perform an active quadriceps contraction with
11 superior patellar glide. Knee extension ROM loss is unfortunately a common issue, with one
12 study showing 25.3% of patients having more than a 5 degree side-to-side difference in passive
13 knee extension ROM 4 weeks after ACL reconstruction.61 Even small losses (3 to 5 degrees) in
14 knee extension adversely affect subjective and objective results following ACL reconstruction
15 with loss of normal extension and flexion being associated with weaker quadriceps.87 Early
16 achievement of full knee extension also decreases the risk of postoperative complications such as
17 arthrofibrosis.30, 44 If full extension is not achieved by week 2, low-load long-duration stretching
18 techniques such as prone hangs (FIGURE 1) or bag hangs are needed to effectively restore full
19 knee extension.56, 62
20 Deficits in quadriceps strength after ACL reconstruction have been reported to be present
21 months to years after surgery and at various isokinetic testing speeds. 43 The largest extent of
22 quadriceps weakness occurs in the first months after reconstruction.17, 43, 47 Neuromuscular
23 Electrical Stimulation (NMES) (FIGURE 2) is utilized to augment quadriceps strengthening
5 1 activities and has been shown to improve outcomes.49, 91, 92 The quadriceps muscles are often
2 affected by arthrogenic muscle inhibition after ACL reconstruction, which limits volitional
3 contraction. A benefit of NMES is that it directly recruits the motor neurons to produce better
4 quadriceps strength gains than voluntary exercise alone.75 Functional outcomes are improved
5 with increased strength gains of the quadriceps.75
6 7 Early post-operative phase
8 9 The milestones of the early post-operative phase (week 2 post surgery) are knee flexion
greater than 110 degrees, walking without crutches, the use of a cycle/stair climber without
10 difficulty, walking with full knee extension, reciprocal stair climbing, SLR without an extension
11 lag, and a Knee Outcome Survey – Activities of Daily Living Subscale (KOS-ADLS) score
12 greater than 65%. When recently reviewed, the average KOS-ADLS score for our patients at the
13 end of week 2 was 60.2% with a median of 64% (unpublished data, 2009). The median score
14 more accurately reflected the data with the presence of large outliers, therefore 65% was chosen
15 as our suggested criteria. Crutches and an immobilizer may be used early after an ACL
16 reconstruction. Crutches may be discontinued once a patient is able to ambulate without pain and
17 use of the immobilizer can be discontinued once the patient has demonstrated a SLR without an
18 extension lag. If a functional brace was ordered pre-operatively, patients may use the brace once
19 the immobilizer has been discontinued.
20 In this phase, treatments incorporate weight bearing (closed chain) activities (FIGURE
21 3) such as wall slides and step ups in pain free ranges (typically 0-60 degrees). Weight bearing
22 activities are safe and effective and may place less stress on the healing graft as well as cause
23 less patellofemoral pain.11
6 Mikkelsen et al64 found higher quadriceps strength and rates of return to sports but no
1 2 difference in laxity when comparing the use of a combination of non-weight bearing and weight
3 bearing exercises versus weight bearing exercises alone. Based on this systematic review, it
4 appears that non-weight bearing exercises can be safely incorporated with weight bearing
5 exercises into the rehabilitation process without deleterious effects on the healing ACL graft as
6 long as undue strain on the healing graft is avoided (i.e. limiting knee ROM from 90 to 45
7 degrees for the non-weight bearing exercises, progressing to knee ROM from 90 to 10 by week
8 12).
9 10 Immediate postoperative phase
11 The milestones for the intermediate post-operative phase are knee flexion within 10
12 degrees of the uninvolved side and quadriceps index greater than 60%. Balance and
13 neuromuscular re-education exercises begin in this time frame (FIGURES 4 and 5).
14 Neuromuscular alterations (i.e. muscle inhibition, impaired sensorimotor function) around the
15 ACL-reconstructed knee may contribute to clinical impairments, such as strength loss, atrophy,
16 and altered function.43 The use of balance and neuromuscular re-education activities has shown
17 no effects of increased joint laxity or decreased strength when compared to standard
18 rehabilitation methods.16 Self-reported knee function after ACL reconstruction improves with a
19 neuromuscular rehabilitation program.81
20 21 Late postoperative phase
22 23 The frequency of treatment during the late postoperative time frame is based on the
remaining impairments. The milestones are quadriceps index greater than 80%, a normal gait
7 1 pattern, full knee ROM, and knee joint effusion equal to a grade of trace or less. The quadriceps
2 index of 80% represents a minimal deficit in strength72, 100, and has been previously used to
3 distinguish between poor and good quadriceps strength. 53, 73, 88 The quadriceps index of 80% has
4 also been used as a cut off for the use of NMES to augment quadriceps strengthening.92 Effusion
5 can be assessed using the modified stroke test (TABLE 2) as a reliable method of rating knee
6 effusion in the outpatient setting.96
7 8 Transitional Phase
9 Once a patient is 8 weeks post-surgery and meets the criteria of 80% quadriceps index,
10 effusion of trace or less, and demonstrates an understanding of the soreness rules24 (TABLE 3),
11 a running progression may commence (TABLE 4). All active patients after ACL reconstruction,
12 including non-runners, are encouraged to perform the running progression for the benefits of
13 unilateral strengthening during the running gait and increased force generation from the dynamic
14 nature of running. The running progression begins as a two mile activity with alternating jogging
15 and walking. The ratio of jogging to walk distance is gradually increased and beginning at level
16 6 distances and pace are increased.
17 During this transitional phase patients should progress their strengthening program at a
18 fitness facility if no longer treated in a clinical setting. Patients who have not met the 80%
19 quadriceps index milestone should continue quadriceps strengthening and NMES, while those
20 patients with at least an 80% quadriceps index can continue with a gym strengthening program if
21 no other impairments persist. Exercise prescription should continue to focus on unilateral lower
22 extremity strengthening and neuromuscular control. Patients may have a desire to begin
8 1 exercising the uninvolved side and an individual plan should be designed to foster strength gains
2 aiming for bilateral limb symmetry.
3 Hop tests are a functional assessment of dynamic stability of the knee26, 71,7, 79 and
4 patients can undergo hop testing as early as 12 weeks after ACL reconstruction if all criteria are
5 met. Quadriceps strength, assessed with dynamometry, should be at least 80% quadriceps index
6 Additional criteria to meet for hop tests are trace or less effusion, full knee ROM, and no pain
7 with single leg hopping. Low to moderate correlations were found between hop test
8 performance and lower extremity muscular strength, and between hop test performance and self-
9 report outcome measures.26 Because no single test has been established that captures all of the
10 essential components necessary for return to sport, the use of several measurements of limb
11 impairments may capture different constructs of physical function and are necessary to gauge a
12 patient’s function at a given time point.26 Four single limb hop tests commonly used in patients
13 after ACL reconstruction are the single hop for distance, the crossover hop for distance, the triple
14 hop for distance, and the 6-meter timed hop (Instructions and milestones are detailed in
15 Appendix A).
16 Quadriceps weakness can exceed 20% at 6 months after ACL reconstruction and 10-15%
17 at 1 year.75 Recent research from our clinic indicate that limb-to-limb asymmetries are reduced
18 and limb symmetry indexes are restored to greater than 90% and return to preoperative levels by
19 6 months after ACL reconstruction when following these clinical guidelines.55 Previous research
20 utilizing these clinical guidelines have found a quadriceps index of 90% or greater in patients at
21 3, 6, and 12 month follow up in 55%, 65%, and 73% of subjects respectively.36 The mean
22 quadriceps index at the 3, 6, and 12 month follow up looking at groups who received either
23 perturbation or strength training prior to surgery were 88.7% and 92.7%, 95.7% and 93.0%, and
9 1 98.7% and 98.1% respectively.36 These quadriceps index values reflect good restoration of
2 quadriceps and limb symmetries utilizing these clinical guidelines as an essential component of
3 safe return to activity. We recommend that all patients should continue to strengthen the
4 involved lower extremity until 90% quadriceps index is obtained.
5 Agility, plyometric, and sport specific activities can be added to the patient’s home
6 exercise program10, provided that they have shown no adverse effects (i.e. increased effusion or
7 pain) to the running progression and that they can demonstrate pain-free performance of loading
8 activities. Patients should be instructed by the therapist and should be able to demonstrate proper
9 technique under supervision prior to adding these higher level activities to a home program.
10 Agility drills during a rehabilitation program can assist patients by allowing them to adjust to
11 sport specific activities, such as changing directions, accelerating, and decelerating.80
12 Plyometrics can improve neuromuscular control in athletes, which can become a learned skill
13 that will transfer to return to competitive play.68 Additionally, neuromuscular control of dynamic
14 lower extremity valgus is enhanced with plyometric training,67 which may be critical for the
15 prevention of ACL re-injury.40, 67 Athletes participating in jumping activities may benefit from
16 education on proper jumping and landing technique. High school female athletes in basketball,
17 volleyball, and soccer in a pre-season jumping program with instruction on proper landing
18 technique showed a significantly lower incidence of knee injury rates compared to untrained
19 females.39 The effects of plyometrics, however, have not been investigated in the functional
20 return of patients after ACL reconstruction.
21 Patients return for functional testing between 3 and 6 months as needed based on their
22 ability to meet the milestones (TABLE 5) and their time frame or desire to return to sport. If any
23 of the criteria are not met the patient is not cleared to begin return to sport activity. While
10 1 returning to preinjury levels or back to sport may be a short-term goal after reconstruction,19
2 intent to return to sports is not predictive of actual return to play.4 Patients may reduce their
3 activity levels for a variety of reasons, including: social reasons, knee problems, or fear of re-
4 injury.70, 99 Additionally, not all athletes choose or have the opportunity to return to previous
5 activity levels or sports.
6 For those who do desire to return to their previous level of sports, strict return to sports
7 criteria has been developed to ensure normal limb symmetry and knee function. Limb symmetry
8 indexes of 90% have previously been suggested as the milestone for determining normal limb
9 symmetry in quadriceps strength72, 92, 100 and functional testing. 26, 36, 71, 79 69 Additionally, the
10 cut-off of 90% is used for 2 self-reported outcome measures in this population. Athletes must
11 pass all the criteria in order to begin returning back to sports. Following these rehabilitation
12 guidelines and using the return to sport criteria (performance-based and self-report outcomes),
13 40% of athletes classified as noncopers preoperatively passed return to sport criteria at 6 months
14 after ACL reconstruction and 73% by 12 months.37 When examining the 3, 6, and 12 month
15 follow up for the self-report outcomes, the percentage of patients with 90% or greater was 70%,
16 92.5% and 92.5% for the KOS-ADLS, and 37.5%, 72.5% and 87.5% for Global Rating Score of
17 Knee Function (GRS).36 Using the age- and sex-matched norms on International Knee
18 Documentation Committee 2000 subjective knee form,1, 31 75% of patients had knee function
19 within normal ranges at 6 months after surgery and 87% by 1 year.55 While we have not
20 examined return to previous level of activity using these guidelines as of yet, the current data
21 suggests that it improves self-report and performance-based knee function. Athletes not meeting
22 the criteria continue rehabilitation focused on the areas in which they did not achieve the desired
23 return to sport score.
11 1 Once cleared, patients do not directly return to competition. Athletes begin with lower
2 level sports participation in practice and gradually build up to competition while monitoring
3 pain, effusion, and ROM.25 A systematic approach for return to sport participation is
4 recommended that accounts for pain and apprehension (FIGURE 6).25 If post-operative bracing
5 is used, our evidence shows they may discontinue use of the brace at 1 year.29 The patient’s
6 activity level should be monitored utilizing the soreness guidelines to minimize the potential of
7 impairments recurring.
8 9 GRAFT TYPES
10 Graft selection is an important consideration to the rehabilitation specialist. Certain
11 factors should be considered when rehabilitating patients with different graft types. With a bone-
12 patellar tendon-bone autograft, donor site morbidity can occur and the rehabilitation specialist
13 should be aware of patellar tendon pain during quadriceps strengthening.45 Although no
14 difference in anterior knee pain has been consistently shown between patients having a bone-
15 patellar tendon-bone compared to a hamstring autografts85, an increased incidence of pain with
16 kneeling has been found in those with the bone-patellar tendon-bone procedure.94 Patellar taping
17 and pain modalities may be effective in decreasing patellar tendon pain that patients may
18 experience.
19 If a hamstring autograft is used, resisted hamstring activities are not performed for 12
20 weeks after surgery. After hamstring graft harvest, the hamstring muscles retract, although most
21 tendons eventually regenerate and muscle force improves by 6 to 12 months after ACL
22 reconstruction.58, 101, 102 Resisted hamstring strengthening is delayed to allow for appropriate soft
23 tissue healing and to limit irritation to the hamstring donor site. After 12 weeks the patient can
12 1 begin a resisted hamstring strengthening progression and activities according to the soreness
2 rules. The use of hamstring autografts does not appear to limit the recovery of hamstring
3 strength.13, 102 Additionally, bone-patellar tendon-bone and hamstring autograft procedures do
4 not differ in clinical and functional outcomes in terms of laxity, clinical outcome, time to return
5 to sports, patellofemoral crepitations, one-legged hop test, ROM, thigh muscle circumference, or
6 anterior knee sensory deficit.86
7 clinical or functional outcomes and demonstrate good strength recovery,3, 86 the 12 week
8 restriction is used to allow for necessary hamstring recovery after harvesting.
9 Because the use of hamstrings autograft do not influence
Recent advances in surgical technique include use of a double bundle graft to attempt to
10 replicate the anatomical nature of the ACL. Double bundle grafts have shown some advantage in
11 decreasing anterior and rotational laxity after surgery,90 but no modifications to the rehabilitation
12 guidelines are warranted when compared with single bundle grafts.
13 Clinical and functional outcomes after ACL reconstruction using allograft tissue
14 compared to autograft tissue appear to be similar.12, 97 An allograft selection has the advantage
15 of no graft donor-site morbidity and donor-site precautions are not necessary during the
16 rehabilitation process.32 Despite that non-irradiated allografts are equal in strength to autografts,
17 allograft healing is delayed regarding graft incorporation and remodelling.32 An increased risk
18 for graft failure has been proposed as a potential limitation to allograft utilization. Individuals
19 with an allograft were 5 times more likely to have an ACL graft failure than those with an
20 autograft.9, 52 In patients participating at a high activity level after reconstruction, the odds of
21 allograft failure was 14.1 times more likely than autograft failure.9 Patients following allograft
22 ACL reconstruction have faster immediate postoperative recovery and less operative pain,
23 suggesting that they may be more likely to attempt return to high-level sports prematurely.9, 15
13 1 Combined with delayed healing of the allograft, premature return to sports may place these
2 athletes at greater risk for graft failure. Recent evidence indicates that it may be more beneficial
3 in younger patients to use an autograft93, but there is no evidence that delaying return to sport
4 will decrease the likelihood of re-rupture if an allograft is used. Therefore, all individuals,
5 despite graft selection, should be required to meet the criteria at each phase before being able to
6 progress to the next phase. Rehabilitation specialists should maintain the latest knowledge of the
7 effect of graft selection as evidence continues to emerge to determine the effect on return to
8 sport.
9 10 MENISCAL INURY
11 The meniscus plays a large role in the integrity of the knee with contributions to shock
12 absorption, load transmission, joint nutrition, and stability.5 Typically, when a partial
13 arthroscopic meniscectomy is performed concurrently with an ACL reconstruction, no
14 modifications to rehabilitation are necessary unless specified by the surgeon.
15 Meniscal repairs have become increasingly more common with the introduction of
16 arthroscopic fixation techniques.98 Meniscal repairs performed at the time of the ACL
17 reconstruction have superior healing rates and better outcomes in comparison to isolated
18 meniscal repairs.77 Toman et al98 showed a greater than 90% clinical success rate in patients
19 who had meniscus repaired in conjunction with ACL reconstruction. In the study by Toman et al
20 surgeons were allowed to select the post-operative rehabilitation program, but other studies that
21 included more aggressive rehabilitation as typically used following ACL reconstruction
22 rehabilitation have shown similar success rates.6, 60 The clinical practice guidelines for Knee pain
23 and mobility impairments: meniscal and articular cartilage lesions published by the Orthopaedic
14 1 Section, APTA suggests that clinicians can consider early weight bearing and mobilization.57 If a
2 meniscal repair is performed concurrently with ACL reconstruction, modifications include no
3 weight bearing activities at knee angles greater than 45 degrees of flexion for 4 weeks with no
4 restrictions on weight bearing in full extension. After the initial 4 weeks, weight bearing knee
5 flexion, as in a deep squat, is limited to less than 90 degrees. Because meniscal repairs are
6 commonly performed on the posterior horn of the meniscus,95 increased knee flexion greater than
7 90 degrees can irritate and potentially damage the healing meniscal repair site. After 8 weeks the
8 rehabilitation specialist should resume normal ACL guidelines. Therefore, there are no additional
9 restrictions on running progressions for an ACL reconstruction with meniscal repair.
10 Meniscus transplantation is also now being performed more often. It is still considered a
11 joint preserving surgery without return to sports as a goal. Meniscus transplant is complex; each
12 procedure is different. Often, meniscus transplantation is performed with a concomitant tibial or
13 femoral osteotomy. Meniscus transplantation and ACL reconstruction are often staged. The
14 rehabilitation guidelines for meniscal transplantation are therefore beyond the scope of this paper
15 and these guidelines should not be used for patients with staged or concomitant ACL
16 reconstruction and meniscus transplantation.
17 18 CHONDRAL DEFECTS
19 Addressing chondral defects of the knee has been an area of significant advancement in
20 recent years. With the increased understanding of articular cartilage lesions and the development
21 of chondral repair interventions (e.g. autologous chondrocyte transplantation), these situations
22 present unique tissue healing dilemmas. Similar to meniscus transplant, articular cartilage repair
15 1 is often performed with a concomitant tibial or femoral osteotomy and articular cartilage repair
2 and ACL reconstruction are often staged.54 3 A patient who undergoes a chondral debridement may be weight bearing as tolerated
4 with crutches for 3 to 5 days after surgery and have no other modifications made to the post ACL
5 reconstruction rehabilitation guidelines.78 Microfracture procedures are performed
6 arthroscopically, usually in conjunction with ACL reconstruction and the cartilage surgical site
7 requires additional protection. Patients are non-weight bearing with crutches from 2 to 8 weeks
8 depending on knee pain, effusion, the surgeon’s preference, and the location and size of the
9 lesion. Lesions that are larger in size and in weight bearing zones will require additional
10 precautions.78
11 Procedures aimed at repairing the damaged articular cartilage are becoming more
12 popular. The influence of articular cartilage in the prevention of degenerative changes and
13 generation of pain is more widely appreciated,2 and the preservation of the cartilage is
14 encouraged when possible. Procedures, such as osteochondral autograft transplantation (OATS)
15 and autologous chondrocyte implantation (ACI), challenge the rehabilitation specialist to further
16 enhance rehabilitation techniques. Recent literature has aimed at identifying the most beneficial
17 intervention and the individuals most likely to benefit from cartilage repair. Few of the studies
18 are higher level evidence and they are often without control groups. ACI and OATS have been
19 shown to lead to better outcomes than microfracture surgery. Microfracture, OATS, and ACI
20 procedures have all shown the ability to return athletes to sport with rates of return of 59 to 66%,
21 91 to 93%, and 67 to 78% respectively.34, 65 The patients who were younger, had shorter
22 preoperative duration of symptoms, had no prior surgical intervention, and higher pre-injury and
23 postsurgical levels of sports had better outcomes and higher rates of return to sport.34
16 1 Rehabilitation after isolated chondral repair surgery is highly individualized based on factors
2 such as the size and location of the lesions and rehabilitation guidelines can be found for the
3 different isolated chondral repair surgeries.78 Due to the complexity of the surgeries and specific
4 needs of post-operative management, the most conservative guidelines following chondral repair
5 procedures should be followed with concomitant ACL reconstruction.78
6 Return to sports after chondral injuries is controversial and studies to assess the
7 effectiveness of chondral surgeries are becoming more readily available. The authors of a
8 systematic review on articular cartilage repair in the athletes’ knee examined 20 studies on
9 clinical outcomes and return to competition.65 With an average of 42 month follow-up, 79% of
10 patients reported good to excellent results using self-report outcome measures. Seventy-three
11 percent returned to sports participation 7 to 18 months post-surgery, depending on the surgical
12 technique. A decline in continued sports participation at the same preinjury level was observed at
13 2 to 5 years after surgery.65 For microfracture and OATS procedures, we use the same criteria-
14 based guidelines for progression of exercise and determination of readiness for return to sports.
15 Our guidelines for ACI procedures are typically surgeon-specific due to the nature of the
16 technique, larger lesion size, and length of healing time and rehabilitation.65 However, soreness
17 and effusion guidelines are still used to direct the rehabilitation process and readiness to return to
18 sport testing.
19 20 LIGAMENTOUS
21 When there is a tear of the medial collateral ligament (MCL) combined with an ACL
22 rupture, the MCL is typically treated non-surgically. The severity of the MCL injury may
23 contribute to the outcome of a combined ACL-MCL injury when the MCL is treated non-
17 1 operatively.20, 42 Much of the current histologic and mechanical healing literature on non-
2 operative management of the MCL has been done on animals and this should be considered
3 when interpreting the literature. ACL reconstruction is usually delayed to allow for the MCL to
4 heal and to correct any additional impairments the patient may exhibit. Petersen and Laprell76
5 evaluated the effects of early (within 3 weeks of the original injury) versus delayed (minimum of
6 10 weeks after injury) ACL reconstruction in patients with combined ACL-MCL injuries. They
7 found that patients that had late ACL reconstruction had significantly lower rates of ROM
8 complications in both flexion and extension and lower rates of re-arthroscopies to address
9 extension ROM losses, as well as significantly better outcomes in Lysholm scores.
10 When combined ACL-MCL injuries occur, during the pre-operative stage, modifications
11 to the rehabilitation process are warranted. Treatment should be restricted to the
12 exercises/movements performed in the sagittal plane for 4 to 6 weeks to allow for MCL healing.
13 Tibial internal rotation, to minimize valgus stresses on the healing MCL, should also be
14 maintained during resisted strengthening exercises (TABLE 6).
15 For individuals with chronic MCL insufficiency and failed conservative management, it
16 may be indicated to perform an MCL repair with ACL reconstruction. With this scenario,
17 patients use crutches for 5 weeks, wear an immobilizer with the knee in full extension (0
18 degrees) for 6 weeks, and weight bearing as tolerated immediately post-operative day 1.74 Except
19 for these modifications, these patients will continue with the ACL reconstruction guidelines for
20 the isolated ACL reconstruction (Appendix A).
21 Multi-ligament instability (i.e. knee dislocation) occurs when the ACL, posterior cruciate
22 ligament (PCL) and either the medial structures or the lateral and posterolateral structures of the
23 knee are ruptured. This injury typically occurs with high energy forces such as a motor vehicle
18 1 accident or in a catastrophic sports injury. Typically a 6 to 8 week period of non-weight bearing
2 is recommended after multi-ligament stabilization surgery.20 Individuals who had a PCL
3 reconstruction concomitantly with ACL reconstruction should follow the more conservative PCL
4 post-surgical rehabilitation guidelines. With posterolateral corner repair/reconstruction the
5 rehabilitation specialist should minimize tibial external rotation and varus stresses. These
6 patients should also avoid hyper-extension and resisted knee flexion for 12 weeks 63.
7 Limited studies have been published on the effective management of an ACL revision.
8 The current literature has shown worse outcomes after ACL revisions in comparison to primary
9 ACL reconstruction.28 In a study by Fox27, an identical rehabilitation program was used for
10 revision and primary ACL reconstruction. Although the rehabilitation program itself could not be
11 directly associated with a higher failure rate in those with revision surgeries, future studies
12 should try to determine the best rehabilitation program for ACL revisions. Following a revision
13 ACL reconstruction, modifying the rehabilitation guidelines to account for possible fixation
14 concerns and complications from previous procedures may be needed by slowing the
15 progression.18 Patients should use crutches and an immobilizer for an additional 2 weeks after
16 surgery. The initiation of a running progression and functional testing is delayed to 12 and 16
17 weeks, respectively, after surgery.
18 19 SUMMARY
20 The goal of the original guidelines was to create a criterion based progression to protect
21 healing structures and ensure appropriate progression of activities for maximizing patient
22 outcomes. Upon revisiting the original guidelines with a look at the current evidence, we have
23 shown continued support for the foundation of the guidelines. The principles of early weight-
19 1 bearing, incorporation of weight bearing and non-weight bearing exercises at the appropriate
2 time frames, and the use of objective measures for determining progression and return to
3 activities continue to have growing support. The role of concomitant injury and subsequent
4 intervention necessitate rehabilitation modification to protect the integrity of the knee. Chondral
5 surgical techniques and continued understanding of the role of the menisci are areas of
6 expanding knowledge that a rehabilitation specialist should familiarize themselves with in order
7 to provide the most up to date evidence based practice. With ACL reconstruction rehabilitation
8 guidelines reaffirmed by the latest evidence and continued understanding of concomitant injuries
9 the rehabilitation specialist can ensure the best postsurgical outcomes.
10 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 References
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27 1 Table 1. Original ACL rehabilitation practice guidelines
ACL rehabilitation practice guidelines
Time
frame
Days 1-3
Week 2
Week 4
Week 6-8
Week 12
Clinical Milestones
Passive ROM/active ROM 0-90o
Quadriceps contraction
Walking without crutches
Full knee extension*
Flexion > 110o
Use of cycle/stairclimber without
difficulty
Walking with full extension
Use of stairs foot-over-foot
KOS-ADL > 85%
Flexion within 10o*
Quad strength >50%*
Normal gait pattern
Full ROM*
Quad strength >80%*
Activities
Wall slides
Patellar mobilizations
Active superior glide
Neuromuscular electrical
stimulation
Gait training
Cycle/stairclimber
Step exercises
Kinetron intervals
Portal/incision mobilization
Prone hangs if necessary
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 exercises
Maintaining or gaining
quadriceps 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.
2 3 4 Table 2. Stroke Test Effusion Grading.96 Reproduced with permission of JOSPT.
Stroke Test Effusion Grading
Grade Response
No wave of fluid produced with downstroke
Zero
Trace Small wave of fluid on medial side with downstroke
Larger wave of fluid on medial side with downstroke (fills the sulcus)
1+
Effusion spontaneously returns to medial side after upstroke
2+
So much fluid that it cannot be moved out of the medial aspect of the knee
3+
5 28 1 2 3 4 5 6 7 8 9 10 Table 3. Soreness Rules. Fees M, Decker T, Snyder-Mackler L, Axe MJ. Am J Sports Med
26(5), p. 735, copyright ©1998 by SAGE Publications. Reprinted by permission of SAGE
Publications.
Soreness Rules
Action
Criterion
2 days off, drop down 1 level
Soreness during warm-up that
continues
Stay at level that led to soreness
Soreness during warm-up that goes
away
2 days off, drop down 1 level
Soreness during warm-up that goes
away but redevelops during session
1 day off, do not advance program
Soreness the day after lifting (Not
to the next level
muscle soreness)
Advance 1 level per week or as
No soreness
instructed by healthcare
professional
Table 4. Running progression. Reprinted by permission of Tara Manal, University of Delaware
Physical Therapy Clinic. (Progress to next level when patient is able to perform activity for 2 miles
without increased effusion or pain. Perform no more than 4 times in one week and no more frequently
than every other day. Do not progress more than 2 levels in a 7 day period.) *Conversion: 1 mile = 1.6
km.
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
Level 8
11 12 Running Progression
Treadmill
Track
0.1 mile* walk/0.1 mile Jog repeat 10
Jog straights/Walk Curves (2 miles)
times
Alternate 0.1 mile walk/0.2mile jog (2
Jog straights/Jog 1 curve every other
miles)
lap (2 miles)
Alternate 0.1 mile walk/0.3 mile jog (2
Jog straights/Jog 1 curve every lap (2
miles)
miles)
Alternate 0.1 mile walk/0.4 mile jog (2
Jog 1¾ lap/Walk curve (2 miles)
miles)
Jog full 2 miles
Jog all laps (2 miles)
Increase workout to 2 ½ miles
Increase workout to 2½ miles
Increase workout to 3 miles
Increase workout to 3 miles
Alternate between running/jogging every Increase speed on straights/jog curves
0.25 miles
29 1 2 Table 5. Return to Sport Criteria. All criteria must be met prior to beginning a return to sport
progression. Knee Outcome Survey – Activities of Daily Living (KOS-ADLS)
Return to Sport Criteria
minimum 12 weeks post-operative
90% or greater on Quadriceps Index
90% or greater on all Hop Tests
90% or greater on KOS-ADLS
90% or greater on Global Rating Score of Knee Function
3 4 5 6 Table 6. Medial collateral ligament range of motion restriction guidelines for non-operative
management of MCL injuries
MCL Injury ROM Restrictions
Week 1
Week 2
Week 3
Grade
No restrictions
I
0-90˚
0-110˚
No restrictions
II
0-30˚
0-90˚
0-110˚
III
7 30 1 2 3 4 5 6 7 8 9 10 11 Figure 1: Prone Hang. (Begin without weight for 10 minutes and progress to increased weight
around the ankle and longer duration as needed for the desired result. Belting the patient above
the hips to the table may also avoid compensations at the hip during the activity.)
Figure 2: Neuromuscular Electrical Stimulation (NMES). (NMES is applied with the patient in a
seated position and the knee in 60 degrees of flexion (varying angles are used based on pain and
co-morbidities). The patient relaxes while electrical stimulation is applied to achieve 50% of
their maximal volitional isometric contraction against a fixed resistance.)
31 1 2 3 4 5 6 Figure 3: Wall squats. (The patient begins with their back against the wall with their legs
shoulder width apart and goes down into a squat position up to 90 degrees of knee flexion as pain
and strength allow. The exercise is progressed by adding a hold time in the squat position and
progressing to 90 degrees knee flexion if not achieved initially.)
7 8 9 10 11 Figure 4: Single leg balance. (Single leg balance should be performed with the stance knee
slightly flexed and avoiding excessive genu valgum. Increasing time and adding distractions,
such as a ball toss, will progress the difficulty.)
32 1 2 3 4 5 6 Figure 5: Single leg cone pick up. (Single cone pick up is a single leg squat while touching cones
in a semi-circle using the same hand. Proper knee alignment should be maintained, especially as
the trunk rotates to reach the cones. Decreasing the height of the cones and placing the stance leg
on an unstable surface will progress the difficulty of the exercise.)
33 Full-speed agility training
without pain or apprehension
No
Continue agility training
No
Continue unopposed
practice
No
Continue one-on-one
opposed practice
Yes
Unopposed practice of
sports-specific skills without
pain or apprehension
Yes
One-on-one opposed practice
of sports specific skills
Yes
Full practice activity with
team
1 2 3 Figure 6. Progression to sports-related activities (adapted from Fitzgerald et al25) .
34 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Appendix A:
Rehabilitation Practice Guidelines for Anterior Cruciate Ligament (ACL) Reconstruction
Primary surgery: ACL reconstruction
Assumptions: 1. Isolated ACL injury
2. Autograft (See specific graft types for precautions)
Expected # of visits: 25-38
Secondary surgery (possible): See precautions section for modifications related to
Neuromuscular Electrical Stimulation (NMES) Guideline:
1. Electrodes placed over proximal lateral quadriceps and distal medial quadriceps. (Modify
distal electrode placement as needed to avoid covering superior medial arthroscopy portal
until the stitches have been removed and skin is healed)
2. Stimulation parameters: 2500Hz, 75 bursts, 2 sec. ramp, 12 sec. on,50 sec. rest, intensity to
maximum tolerable [at least 50% Maximal Volitional Isometric Contraction (MVIC)(see
note at end)], 10 contractions per session. Three sessions per week until quadriceps strength
MVIC is 80% of uninvolved side.
3. Stimulation performed isometrically at 60° (dependent on graft site)
Pre-operative Goals: Full Knee Extension range of motion (ROM), absent or minimal effusion, and no
knee extension lag with straight leg raise (SLR)
Immediate Post-operative phase: (week 1) Total visits: 1-3
Milestones
24 1. Knee active/passive ROM = 0-90°
25 2. Active quadriceps contraction with superior patellar glide
26 Treatment
27  Wall slides, patellar mobilization, gait training, NMES (see guidelines) Bike for ROM
28  Home Exercise Program: supine wall slides, self patellar mobs 30 to 50times per day,
29 Quadriceps set, Long Arc Quads (90-45o), and SLR 3x10 (3 times per day)
30 31 Early Post-operative phase: (week 2) Total visits: 4-6
32 Milestones
33 1. Knee flexion >110°
38 5. Reciprocal stair climbing
34 2. Walking without crutches
39 6. SLR without a knee extension lag
35 3. Use of cycle/stair climber without
40 7. Knee Outcome Survey Activities of
36 difficulty
41 daily living (KOS ADL) > 65%
37 4. Walking with full knee extension
42 Treatment
43  Step ups in pain free range
47  Progress to functional brace as
48 swelling permits
44  Portal/incision mobilization as needed
49  Prone hangs if lacking full extension
45 (if skin is healed)
50  Patellar mobilization in flexion(if
46  Stairmaster, Wall squats/sits
51 flexion limited)
52 53 Intermediate Postoperative phase: (weeks 3-5) Total visits: 7-15
54 Milestones
55 1. Knee flexion ROM to within 10 degrees of uninvolved side
56 2. Quadriceps strength >60% of uninvolved side
57 35 1 2 3 4 5 6 7 8 9 10 14 15 16 17 18 19 20 21 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 42 43 44 45 46 47 48 49 50 Treatment
 Tibiofemoral mobilizations with rotation for ROM if joint mobility is limited
 Progress bike and Stair master duration (10 minute minimum)
 Begin balance and proprioceptive activities
Late Post-operative phase: (weeks 6-8) Total visits: 16-25
Milestones
1. Quadriceps strength >80% of
uninvolved side
2. Normal gait pattern
11 12 13 3. Full knee ROM (compared to
uninvolved side)
4. Knee Effusion of trace or less
22 23 *(If all milestones are met)
**(see running progression below)
Treatment



Progress exercises in intensity and
duration
Begin running progression**: on
treadmill or track with functional
brace (may vary with physician)*
Transfer to fitness facility*
Transitional Phase: (weeks 9-12) Total visits: 25-38
Milestones
1. Maintaining or gaining quadriceps strength (>80% of uninvolved side)
2. Hop tests >85% of uninvolved side (see attached) @ 12 wks
3. KOS Sports questionnaire >70%
Treatment



Sports specific activities
Agility exercises
Functional testing (see description below)
Follow up Functional Testing: 4 month, 5 month, 6 month, 1 year post-op.
Milestones
1. Maintaining gains in strength (> or
40 3. KOS Sports (> or = 90%)
= 90% to 100%)
41 4. return to sport criteria see below
2. Hop Test (> or = 90%)
Recommending changes in rehab as needed. Progression may include one-legged emphasis
in gym, explosive types of activities (cutting, jumping, plyometrics, landing training)
MVIC: Maximum Volitional Isometric Contraction
Patient is asked to volitionally extend the involved leg as hard as possible while knee is
maintained isometrically at 60° knee flexion. Side to side comparison: (involved/uninvolved
X 100 = % MVC)
36 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 Precautions:
 Patellar tendon autograft technique
Be aware of patellofemoral forces and possible irritation during progressive resistive
exercises.
Treat patellofemoral pain if it arises with modalities, possible patellar taping.
Consider alteration of knee flexion angle to most comfortable between 45°-60° for MVIC and
NMES treatments.
 Hamstring tendon autograft technique
No resisted hamstring strengthening until week 12.
 Partial meniscectomy
No modifications required; progress per patient tolerance and protocol.
 Meniscal repair
No weight-bearing flexion beyond 45° for 4 weeks.
Weight bearing in full extension is allowed.
Seated Kinetron and multi angle quadriceps isometric can substitute for weight-bearing
exercises.
 Concomitant Abrasion Chondroplasty
Weight bearing as tolerated (WBAT) with Axillary crutches 3-5 days
No modifications required, progress per patient tolerance and protocol
 Concomitant Microfracture
Non-weight bearing- 2-4 weeks with Axillary crutches
No weightbearing activities in treatment for 4 weeks
*Consider location and size of lesion for exercise specific alterations*
 Chondral Repair (OATS, ACI, MACI)
Follow procedure specific protocol if done concomitantly
 Meniscal Transplantation
Follow procedure specific protocol if done concomitantly
 Medial Collateral Ligament (MCL) injury
Restrict motion to sagittal plane until week 4-6 to allow healing of MCL.
Perform PRE’s with tibia in internal rotation during early post-op period to decrease MCL
stress.
Consider brace for exercise and periods of activity if severe sprain and/or patient has pain.
Non Repaired ROM restrictions: Grade 1 no ROM restrictions; Grade 2 0-900 week 1, 0-110o
week 2; Grade 3: 0-30o week1, 0-90o week 2, 0-110o week 3
 Posterior Cruciate Ligament (PCL) injury
Follow PCL rehabilitation guidelines. (Not ACL protocol)
 Posterolateral corner Repair
Minimize external rotation torques and varus stress 6-8 weeks
Avoid hyper-extension
No resisted Knee flexion 12 weeks
 ACL Revision
Delay progression of running, hop testing, agility drills, and return to sport by 4 weeks.
Crutches and immobilizer are used for 2 weeks following surgery. Otherwise follow same
milestones
37 1 2 3 Running Progression: (requires: trace or less effusion, 80% or > strength, understand soreness
rules)
Running Progression
Treadmill
Track
0.1 mile walk/0.1 mile Jog repeat 10
Jog straights/Walk Curves (2 miles)
times
Jog straights/Jog 1 curve every other
Level 2 Alternate 0.1 mile walk/0.2mile jog (2
miles)
lap (2 miles)
Jog straights/Jog 1 curve every lap (2
Level 3 Alternate 0.1 mile walk/0.3 mile jog (2
miles)
miles)
Jog 1¾ lap/Walk curve (2 miles)
Level 4 Alternate 0.1 mile walk/0.4 mile jog (2
miles)
Jog all laps (2 miles)
Level 5 Jog full 2 miles
Increase workout to 2½ miles
Level 6 Increase workout to 2 ½ miles
Increase workout to 3 miles
Level 7 Increase workout to 3 miles
Level 8 Alternate between running/jogging every Increase speed on straights/jog curves
0.25 miles
Progress to next level when patient is able to perform activity for 2 miles without increased
effusion or pain. Perform no more than 4 times in one week and no more frequently than
every other day. Do not progress more than 2 levels in a 7 day period.
Level 1
4 5 6 7 8 Functional Testing (Week12)
Single
Hop
X-Hop
Triple
Hop
9 Timed
10 Hop
11 25 26 27 28 29 30 31 32 33 12 13 14 15 16 17 18 19 20 21 22 23 24 Testing: Patient performs two practices on each leg for each hop sequence. Patient performs 2 timed
or measured trials on each leg for each hop sequence. Measured trials are averaged and compared
involved to uninvolved for single, triple, crossover hop. Compare uninvolved to involved for timed
hop.
Passing Criteria for Return to Sport: Greater than or equal to 90% on: quadriceps MVIC, hop
testing, KOS-ADLS score, and Global Rating of knee function score.
Reprinted by Permission from Tara Manal, University of Delaware Physical Therapy Clinic.
38