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Recent advances following anterior cruciate ligament reconstruction:

Rehabilitation perspectives - Critical reviews in rehabilitation medicine

Article  in  Current Reviews in Musculoskeletal Medicine · January 2012

DOI: 10.1007/s12178-011-9109-4 · Source: PubMed

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Recent advances following anterior cruciate
ligament reconstruction: rehabilitation
perspectives

Robert C. Manske, Daniel Prohaska &

Brennen Lucas

Current Reviews in Musculoskeletal

Medicine

ISSN 1935-973X

Curr Rev Musculoskelet Med

DOI 10.1007/s12178-011-9109-4

1 23
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 Author's personal copy
Curr Rev Musculoskelet Med
DOI 10.1007/s12178-011-9109-4

KNEE REHABILITATION (J CAVANAUGH, SECTION EDITOR)

Recent advances following anterior cruciate ligament

reconstruction: rehabilitation perspectives
Critical reviews in rehabilitation medicine

Robert C. Manske & Daniel Prohaska & Brennen Lucas

# Springer Science+Business Media, LLC 2011

Abstract Injuries to the anterior cruciate ligament are com- Introduction

mon. Surgical reconstruction is more prevalent than ever.
This review article discusses treatment of the patient follow- Reconstruction following injury to the anterior cruciate lig-
ing surgical reconstruction of the anterior cruciate ligament. ament (ACL) is a common surgical procedure with reports
Various phases of rehabilitation are discussed with emphasis ranging from 100 000 to upwards up 300 000 reconstruc-
on early return of passive motion, early weight bearing, tions performed each year [1, 2]. These injuries are very
bracing, kinetic chain exercises, neuromuscular electrical common as they occur among both professional and recre-
stimulation and accelerated rehabilitation. Although evi- ational athletes. Since the ACL is the primary stabilizer for
dence exists for the treatment of the surgically reconstructed anterior tibial displacement and the secondary stabilizer for
cruciate ligament, more is needed to better define specific tibial rotation, an ACL-deficient knee can often lead to
timeframes for advancement. Evidence exists that many of devastating consequences such as articular cartilage injuries,
these young individuals are not fully returning to unlimited meniscus tears, functional instability and the potential for
high level activities. This review article presents some of the early-onset osteoarthritis [3, 4]. The role of physical reha-
latest evidence regarding anterior cruciate ligament rehabil- bilitation of a patient following ACL rehabilitation is to
itation in an attempt to help the busy clinician understand return the athlete back to their premorbid functional level.
and relate basic and clinical research to rehabilitation of a This becomes especially important due to the fact that
patient following reconstruction. muscular deficits are seen following ACL reconstruction
for up to 2 years post- surgery [5•, 6]. Additionally, the
Keywords Anterior cruciate ligament . Rehabilitation . incidence of subsequent injury to either knee within 5 years
Physical therapy . Knee rehabilitation . Musculoskeletal following repair is 17% in those less than 18 years of age
medicine and 7% in those age 18–25 [7]. This is even further com-
plicated with the fact that rehabilitation progression now is
at an alarming rate due to advances in fixation methods.
Compared to past rehabilitation protocols an athlete may
now be released for sports activities as early as 8 weeks after
R. C. Manske (*)
Department of Physical Therapy, Wichita State University, surgery [8, 9]. Physical therapy post-operative protocols will
1845 North Fairmount, prescribe the speed and safety with which an athlete returns
Wichita, KS, USA to sports activity. Evidence for postoperative ACL rehabil-
e-mail: robert.manske@wichita.edu
itation will be discussed and includes modality use, return of
R. C. Manske motion, balance and proprioception, open and closed chain
Physiotherapy Associates Wichita, rehabilitation and return to sports criteria.
Wichita, KS 67260-0210, USA A plethora of literature has been written about rehabili-
D. Prohaska : B. Lucas
tation following ACL reconstruction. Because autograft tis-
Advanced Orthopaedic Associates, sues (bone patellar-tendon bone (BPTB) and hamstring) are
Wichita, KS, USA considered gold standards and most commonly used, this
 Author's personal copy
Curr Rev Musculoskelet Med

article will follow rehabilitation using autograft tissue. Re- Because pain and swelling impede quadriceps motor firing
cent evidence has shown only marginal clinical and func- patterns and gaining range of motion, cryotherapy and elec-
tional differences in outcomes between bone patellar tendon trical stimulation are encouraged early. Intraarticular swell-
bone and four-stranded semitendinosus/gracilis tendon auto- ing can have detrimental effects on the articular cartilage
grafts [3, 4, 10]. Certainly allograft tissue and synthetic and synovium when remaining in a joint for protracted time
grafts are sometimes used, but their use is less common in frames. A persistent hemarthrosis can occur in approximate-
comparison to autograft tissue. This manuscript will be ly 12% of post ACL patients [21]. Cryotherapy has potent
tailored for an isolated ACL reconstruction in a younger beneficial effects of releasing endogenous opiates and de-
active patient. A slower progression may be needed for an creasing nerve conduction velocity in those with painful
older more normal patient [11]. Additional pathology such as joints following ACL reconstruction [22]. Clear evidence
concomitant ligament repair, meniscus, or articular cartilage exists that cold therapy immediately following arthroscopic
injury will need to be taken into account and will more than surgery to the knee creates a decrease in intra-articular
likely create a delay in progression. temperatures resulting in a significant decrease in postoper-
Following ACL reconstruction the graft goes through a ative pain [23–29]. There is also evidence that cryotherapy
process called ligamentization. Ligamentization occurs in is beneficial in the dis-inhibition effect on the quadriceps
several different stages including a) necrosis, b) revascular- muscles [25, 30]. In addition to cold therapy the patient can
ization, c) cellular proliferation, and d) collagen formation be given treatment with interferential electrical stimulation
[12–15]. Very early following reconstruction the graft tissue to help relieve post -operative pain and edema [31]. Opti-
will go through a process of necrosis. The graft will require mally these treatments should be done with the lower ex-
a blood supply and early during the first several weeks will tremity elevated (higher than the heart) with intermittent
be nourished by bone blood and synovial fluid [15]. Fol- compression [21, 32, 33]. To decrease the risk of frostbite,
lowing early necrosis the process of revascularization these treatments should be done for up to 20–30 min with a
begins. This usually starts at approximately weeks 6–8 at light cloth between the superficial skin and the cold source.
which time animal studies have shown that the graft is at its If using a form of cryotherapy device, it is recommended to
weakest point in the post reconstruction process [16]. Some ensure using manufactured and physician recommended
studies indicate that the graft may only reach failure loads of temperature settings.
11 to 50% at 1 year post-operative [17]. This process con- Early randomized controlled trials on immobilization
tinues with cellular proliferation in which cells other than versus delayed range of motion demonstrated marked atro-
the native graft tissue may inhabit the graft. Usually by phy of the vastus lateralis and slow twitch muscle fibers
30 weeks the post transplanted graft will have tissue char- with no adverse effect on graft laxity [34–39]. Since joint
acteristics that appear ligamentous. Collagen formation will immobilization for extended time frames results in loss of
continue for greater than 1 year [18]. ground substance and dehydration and approximation of
fibers embedded in the extracellular matrix, range of motion
of the knee is started early [37, 40]. Normal range of motion
Phase I: post-operative week 1–4 of the knee extension has been shown to be hyperextension
of 5° in men and 6° in women [41]. Furthermore Shelboune
On the first physical therapy visit clear instructions related and colleagues have shown that even small losses of 3–5° of
to any information about the rehabilitation program will extension can significantly affect outcomes following cruci-
help increase self-efficacy and ease concerns. Education ate reconstruction [42•]. It is clear that extended immobili-
about postsurgical exercises, reasons for limited motion zation of the knee is detrimental to structures that surround
and crutch use and cryotherapy all will help stimulate early the knee including ligaments, cartilage, bone and muscles
functional recover of knee function and help the patient [37, 43–48]. If a patient has had additional procedures such
create a realistic image about the rehabilitation process in as a meniscus repair, knee flexion will be limited to 90° for
general [11, 19, 20]. Immediately following surgery the 4 weeks.
initial focus of post-surgical rehabilitation is to minimize Because one of the most common complications follow-
pain and swelling and to return knee extension symmetrical ing ACL reconstruction is post-operative motion loss, the
to the uninvolved side. Emphasis on early knee extension immediate goal is for full knee terminal extension to be
motion predominates, yet still achieving up to 90–120° of achieved as soon as possible. Immediate knee extension
knee flexion is wanted also. With correct isometric graft ensures that the intracondylar notch is not proliferated with
placement full range of motion should be able to be scar tissue, resulting in a Cyclops lesion. A loss of extension
achieved without damage to the newly placed graft. can be particularly deleterious as it results in abnormal joint
Following surgery swelling and pain are both a part of the arthrokinetmatics at both the tibiofemoral and the patellofe-
normal inflammatory response to begin the healing process. moral joints leading to abnormal cartilage contact pressures,
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Curr Rev Musculoskelet Med

and inability to contract the quadriceps muscle due to fa- deformation to the capsular structures on the posterior knee
tigue and pain [49, 50]. Preoperative knee extension motion that could be limiting full extension. Patellofemoral compli-
losses were studied in 102 patients within 2 weeks of having cations are common, especially following the patient with
an ACL reconstruction with a 6 month follow-up [51]. the BPTB reconstruction [53]. Scarring intra-articular in the
Patients with a loss of knee extension motion prior to areas of the medial or lateral gutter, along the harvest inci-
surgery (in comparison to the contralateral knee) were more sion site, or even around the smaller portal sites may create a
likely to have limited knee extension after surgery. In some loss of patellar mobility. These potential areas of limited
cases, a short stint in therapy prior to surgery to normalize mobility should be treated with immediate patellar mobili-
knee motion may be beneficial. Although the goal to zation in all directions. Emphasis should be placed on
achieve extension is immediate (regardless of timing of first superior-inferior directed patellar mobilization to increase
visit – day 2 versus week 2), range of motion into flexion is mobility for the extensor mechanism to function without
done as tolerated with an early goal of 90° flexion by the restrictions of mobility. Superior patellar glide mobilizations
end of week one, and up to 120° by the end of phase I at the will improve knee extension, while inferior patellar glides
4 week time frame. Following BPTB reconstruction active will assist with knee flexion. Patients can also be shown
heel slides are performed as needed. Due to wanting to how to perform these mobilizations on themselves as part of
allow healing medial structures, those with a hamstring their home exercise program.
tendon ACL reconstruction, active heel slides are held for Controversy exists on the restoration of full bilateral knee
up to 3–4 weeks. During this time a wall slide (Fig. 1) or symmetrical range of motion. Although some suggest that a
passive knee flexion by therapist or patient should be per- return of full symmetrical hyperextension does not affect
formed. Following the 4 week delay active heel slides ligament laxity, when significant genu recurvatum exists it
should be able to be initiated. Unlike knee extension limi- is our belief that up to approximately 5° should be sufficient
tations, knee flexion limitations usually are resolved without through manual mobilization or stretching techniques if the
complication. Intra-articular swelling and hemarthrosis may patient has normal to lax joints (>4/9 on Beighton Scale)
limit knee motion due to its space occupying effect or by [54, 55]. The remainder of hyperextension motion to be-
pain created due to this swelling. Pain and swelling can be come symmetrical will return through functional activities.
treated as described earlier in this manuscript with judicious If the patient is very hypomobile (0/9 on Beighton Scale)
use of cold therapy, compression, elevation and modalities. they may require additional stretching to bring them closer
If knee extension motion persists selected therapeutic to symmetrical.
exercises can be beneficial. Manual passive range of motion Due to the effects of asymmetrical limb loading early
into hyperextension, supine hangs with a towel roll under weight bearing is done with bilateral axillary crutches in a
the heel, prone hangs and knee thunks can all be used to weight bearing as tolerated fashion progressing to full
create passive knee extension force [20, 52]. Allowing the weight bearing over the first 1–2 weeks [56, 57]. Weight
knee to fall into extension for up to 20 min while the patient bearing may be delayed in those with concomitant articular
is in either prone or supine is a nice way to create low- load, cartilage repair or meniscus repair which may not tolerate
long-duration prolonged stretch to induce a more plastic the increased stress of full weight bearing. Tyler et al.
followed 49 patients following BPTB reconstructions by
placing subjects into an immediate weight bearing group
and one that had 2 weeks delayed weight bearing [58]. At
2 weeks follow up range of motion was not significantly
different between the two groups, however vastus medialis
oblique electromyographic (EMG) activity was significantly
increased in the weight bearing group. At the conclusion of
the study muscle EMG activity was similar, but there were
significantly different anterior knee pain levels with the
early weight bearing group demonstrating less pain. Although
early weight bearing has shown a decrease in pain with
immediate weight bearing with no increase in graft laxity,
immediate weight bearing’s effects on articular cartilage is
still unknown.
Motor control and function of the muscles around the
knee are needed for all functional activities. Early emphasis
Fig. 1 Patient performing wall slide exercise to increase passive knee day one should also include volitional contraction of the
flexion range of motion quadriceps muscle. With the BPTB reconstruction the
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Curr Rev Musculoskelet Med

extensor mechanism has undergone significant insult in the however at longer-term follow-up there does not appear to
harvesting process. Early motor control will help to mini- have a substantial effect on clinical outcomes such as range
mize surgical morbidity. An active quadriceps contraction of motion, laxity or function [70–72]. Although brace use is
pulls tension through the patellar tendon, minimizing the controversial, we utilize bracing more for relief of pain
potential for entrapping scar tissue. It additionally squeezes following surgery more than for pure stability purposes.
the soft tissue of the anterior knee helping to decrease Once the patient obtains good quadriceps control with abil-
swelling [58]. Emphasis is placed on ability to produce a ity to perform a straight leg raise without extensor lag they
full sustained contraction of the quadriceps muscle. Several will be allowed to discontinue the use of their postoperative
trials have demonstrated the benefits of high intensity elec- brace. If they continue to have an extensor lag >five degrees
trical stimulation to improve quadriceps strength and gait they will be asked to continue to use brace including sleeping
parameters [3, 4, 59–64]. It is not uncommon for patients to with the brace locked in extension.
have poor quadriceps tone during the first postoperative
visit. If after 2–3 visits the quadriceps muscles are not firing
effectively, use of neuromuscular electrical stimulation is
warranted. Evidence appears to conclude that the most ap- Phase II: postoperative weeks 4–6
propriate use of neuromuscular electrical simulation is with
a volitional contraction of the quadriceps and hamstrings. This is the shortest phase in the rehabilitation process.
Empirically, it seems that contractile activity is improved if During this time frame gait should be normalized. Any
this can be done during weight bearing. This can be done in remaining lost extension motion should be treated with
an upright position once the patient can tolerate placing the more aggressive means to decrease the risk of arthrofibrosis
limb in a dependent position with at minimum partial weight and the need for manipulation under anesthesia or arthro-
bearing. An additional benefit of the closed kinetic chain scopic debridement of scar tissue. Flexion range of motion
position is the decreased stress placed on the graft tissue as may not be completely full, but should be progressing
compressive forces at the tibiofemoral joint and con- toward full. If there is a persistent effusion still after 4 weeks,
contraction of muscles surrounding the knee help control judicious use of cryotherapy can be continued to decrease
excessive motion at all joints in the closed chain [65–68]. pain and swelling that may impair motion, decrease quadriceps
Additional positions for quadriceps exercises can include control, and cause an altered gait pattern.
seated during isometric contractions with the knee in a Sometimes gait may still be impaired due to compensa-
position of a quadriceps set, straight leg raise, or within safe tory strategies used when the knee was having more dis-
ranges of 90–45° of knee flexion. If the patient has difficulty comfort immediately following surgery. This altered gait at
performing supine terminal knee extension, they can perform this time may be more unconscious in nature. Using a mirror
this exercise in the prone position with hip extensors aiding to that the athlete can view themselves and their abnormal
achievement of full extension [69]. pattern during gait can be helpful. A useful drill for when
Total leg strengthening is defined as exercise to joints the athlete is still walking with a stiff knee that lacks flexion
proximal or distal to the joint in question are done to help following toe off is the high-stepping drill. The high-
decrease unwanted excessive frontal or transverse plane stepping drill can also be helpful to allow the patient to
rotations that can occur due to either proximal or distal see that greater degrees of hip and knee flexion can occur
weaknesses. Lack of proximal trunk control can contribute during the gait cycle without pain (Fig. 2). Have the athlete
to abnormal lower extremity alignment during functional perform a high stepping gait cycle where they pull the thigh
exercises. Exercises for the hip and foot/ankle can be done higher into flexion to about waist level with each step.
in either open kinetic chain (OKC) or closed kinetic chain Performance of this bilaterally for approximately 10–15
(CKC) positions. steps can assist the athlete to see that normal degrees of
Exercises in Phase I can include isometric exercises and a knee flexion will not cause problems.
mixture of both OKC and CKC exercises. As the replaced At this time frame graft necrosis should be ending and the
graft is going through a process of necrosis at this time, the process of revascularization should be beginning. Isometric
graft requires protection. Safe exercises at this time include exercises can be progressed to isotonic to slowly allow
isometric quadriceps sets, straight leg raises, CKC leg press, increased stress to the knee allowing greater graft strength
shuttle or squats (0–60°), and OKC extension (90–40°). In the during incorporation. Isotonic progressive resistive exer-
early phases OKC knee extension should be done without cises can be performed in the ranges listed above for both
additional weight distally. open and closed chain strengthening. Contrary to popular
Rehabilitation post- operative bracing during the early belief there is some limited evidence that ranges of CKC 0–90,
phases appears to result in fewer problems with swelling, and OKC 90–0° may be safe without risk of graft laxity or
and less pain compared to rehabilitation without a brace, elongation [73–77].
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Curr Rev Musculoskelet Med

be added to this exercise by having the therapist provide a

perturbation force by taping on the board in different loca-
tions. Fitzgerald et al. examined perturbation training in ACL
deficient patients and found that those undergoing this form of
training had more satisfactory outcomes and decreased fre-
quency of giving way episodes following their ACL injury
[81].
As proprioceptive control is increased the athlete should
be asked to perform advanced drills that work on prepara-
tory agonist-antagonist co-contraction. These would include
dynamic stabilization drills such as cone stepping, and
lunges in multiple directions including anterior/posterior,
medial/lateral and diagonal drills. Performance of lunges
should be done by landing on a slightly flexed knee and
holding this position briefly so that co-contraction can oc-
cur. Lunge progression should occur by performing lunges
in classical movement patterns such as anterior/posterior
and lateral prior to diagonal and multi-plane lunges last.
Higher level lunges can occur by lunging with a rotation,
onto a labile surface or with a perturbation. When these
lunges are tolerated, the patient concentration can be altered
by having them throw or catch a ball indicative of their
respective sport (basketball, soccer, football, etc.).

Fig. 2 High stepping over cones to increase normal heel toe gait cycle Phase III: postoperative 6 weeks–3 months

Quadriceps strengthening can begin with wall slides pro- The hallmark of this phase is moving the patient to basic
gressing to mini-squats or progressive resistive leg press functional activities to tolerance of those more advanced
exercises. Heel raises can begin now unilaterally while activities that allow them to progress to full recreational or
balance and proprioceptive exercises can include weight sporting activities at much higher levels. An overall concern
shifting bilaterally with progressions to unilateral if tolerat- during this phase is evidence that the autograft itself is
ed. If a hamstring autograft was utilized initiation of gentle reaching its weakest point structurally during the 6 to 8 week
sub maximal isometrics can begin, while hamstring curls time frame postoperatively [16]. Additional evidence states
can be started if BPTB was the graft source. Historically that the actual graft may only reach between 11 and 50%
hamstring activity was thought to be needed as these poste-
rior knee muscles are synergistic to the ACL. Strengthening
of the hamstring muscles may provide a primary dynamic
restraint to anterior tibial translation [78]. The ACL- mech-
anoreceptor reflex arc to the hamstrings may cause a loss of
proprioception, as a latency of the hamstrings is almost
twice that of the normal contralateral uninjured knee [79].
At this time enough soft tissue healing of the hamstrings
should allow tolerance to perform gentle hamstring and
gastrocnemius and soleus flexibility exercises.
Closed kinetic chain squats can be done beginning on a
stable surface with progressions to unstable or labile surface.
The athlete is asked to flex the knees to approximately 25–30°
and maintain that position as it will produce a co-contraction
of the hamstrings and quadriceps [80]. Squats on tilt board can
be done with a board tilting in either medial/lateral or anterior/
posterior directions (Fig. 3). A proprioceptive component can Fig. 3 Squats done on a tilt board to increase proprioceptive effect
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Curr Rev Musculoskelet Med

failure loads of the native ACL at the 1-year point [17]. It is

theorized that controlled loading will enhance ligament and
tendon healing, while excessive stress loading to an ACL
graft may cause graft elongation leading to excessive un-
wanted anterior-posterior laxity [44, 82, 83]. The patient
should have full range of motion of both knee extension
and flexion. There should be no pain or discomfort with
basic functional activities. By the end of 12 weeks they
should have enough strength and balance to allow progression
of controlled individual sports and recreational activities. This
does not mean that they will be independent with a full return
of sports, but that they can begin controlled individual
functional sports activities.
Exercises can progress to knee progressive resistive iso-
tonic knee extension exercises in the range of 90–45°. This
range can be done both concentrically and eccentrically at Fig. 4 Plank exercises to strengthen core
this time. Single leg squats and unilateral leg press in the
range of 0–45° can be done safely. At 12 weeks as long as a movement patterns such as flexion/extension, abduction/
satisfactory exam is performed the patient is progressed to adduction. Once this has been proven successful movements
higher functional activities. of the contralateral extremity through the transverse plane is
added. Single limb balance can be progressed by time or
numbers of repetitions of the contralateral extremity move-
Phase IV: postoperative 3 months–6 months ments. These balance exercises can be progressed by having
the athlete perform balance techniques in increasing degrees
It is during this phase that the patient readies themselves for of knee flexion which may also have a protective effect as
a gradual progression of return to full sports participation. If activities in knee flexion may limit exposure to excessive
the patient has a successful clinical examination with no anterior tibial shear loads that may overload graft tissue
swelling or pain with normal activities, if they have full while performance of dynamic tasks [88–90]. Increased
motion, and no instability they are allowed to begin straight progression of single limb balance can include balance with
in-line jogging. This is usually progressed on an every other eyes closed, progressing to the entire balance sequence
day basis to give a full day rest between jogging sessions. being done on a labile surface. Although these types of
Bilateral plyometric exercises requiring the stretch shortening exercises are thought to be beneficial for increasing balance
cycle can also begin progression to unilateral as tolerated. and proprioception, their use for objective assessment may
Exercises that stress single-limb postural control are given be difficult to assess by a clinician as they may not be
first on level ground and then progressed to an unstable labile sensitive enough to determine deficits following ACL
surface. reconstruction [91].
As most advanced activities require core stability to A more conservative approach is utilized with plyometric
maintain center of mass, balance and postural control, exer- activity beginning after 12 weeks. Plyometric exercises use
cises for the trunk and hips are desired. Core trunk training the muscles stretch shortening cycle to allow maximum
and stability are related to the body’s ability to actively production of concentric contraction following a rapid ec-
control the body’s center of mass in response to the forces centric loading of the muscles [92, 93]. Hewett has shown
generated from distal body parts during athletic competition that a 6-week plyometric training program was able to alter
[84]. Consensus is that by restoring core strength and sta- the strength and landing mechanics of female athletes as a
bility a reduction of injury risk my occur due to the more result of increased strength and function [94]. The authors
effective control of athletes center of mass during higher found a 22% decrease in peak ground reaction forces and
level activities [85–87]. Core training can consist of multi- 50% decrease in abduction/adduction moments at the knee
ple exercises for the core such as sit-ups, bridging exercises, during landing. These improvements in function are ex-
single leg bridges, straight leg deadlifts and planks (Fig. 4) tremely important for those following ACL reconstruction
just to name a few. All exercise progression for the lower as increased loading and valgus collapse are common mech-
extremities should begin bilaterally and progress to unilat- anism of cruciate ligament injury. As the patient progresses
eral loading. Improvement in single limb balance can begin through this phase they can begin to perform entry-level
by maintenance of single limb stance on a flat level surface double-limb plyometric jumps with a progression to low-
while moving the contralateral extremity through classic intensity single- limb plyometrics. These activities will
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Curr Rev Musculoskelet Med

allow a gradual progression of the addition of ground reac- preference for testing method rather than evidence-based sci-
tion force attenuation during more functional activities. In- ence. Most of these standard objective measures such as these
ability to attenuate ground reaction forces are considered are temporal based measures and therefore are quit variable
to put athletes at an increased risk for ACL injury [95]. and may have limitations if used in isolation to determine
Examples of bilateral entry level plyometrics would in- return to full activity. This is concerning since as many as
clude simple bilateral ankle jumps, bilateral jumping in one in four patients undergoing an ACL reconstruction will
place, and bilateral ricochets. Entry level single-leg plyo- suffer a second tear within 10 years of their first [101].
metrics would include low-level lateral bounding, step Furthermore recent biomechanical data has shown that altered
and stick, and jogging in place. As the patients strength neuromuscular control of the hip and knee during a dynamic
increases and they demonstrate tolerance to these exercises landing task as well as postural stability deficits after ACL
they can progress to higher level plyometric exercises reconstruction are predictors of a second ACL injury after an
described in Phase IV. athlete has returned to sports [102•]. This data would seem to
indicate that even after rehabilitation, there may be ongoing
neuromuscular deficits that continue. Indeed several studies
Phase IV: 6 months + have demonstrated decreased muscular strength, joint position
sense, postural stability, and various parameters of force at-
It is during this final stage of rehabilitation that the patient may tenuation for 6 months to 2 years following reconstruction [5•,
be released for full return to functional individual and team 56, 102•, 103–105, 106•].
recreational or sports activities. This could not occur at a more Rehabilitation exercises as this time frame should utilize
perfect time as the physical therapist is lifting activity restric- the concept of overload to develop strength and power in the
tions as the athlete is becoming more confident in their knee. It athlete yet at the same time are within a level of acceptance
must clearly be remembered that this is the same time frame to create minimal exposure to potential injury risk of re-
that athletes will start to expose their knee to forces and rupture of the still maturing graft. In this final phase of
motions that may load the reconstructed graft to near it limits rehabilitation activities that require unique aspects of their
[89, 96]. This phase is usually a little more vague in regards to respective sport can be used in treatments. Those that re-
appropriate exercise progressions with less detail in regard to quire power generation, cutting, and change of direction
clinical guidelines as to when it is safe to introduce more high- may be important. In addition to the previous exercises
risk or high-load activities [11, 97]. Presently there is little described these athletes can now perform in a controlled
agreement as to when it is safe to return to sports participation environment exercises such as higher level plyometric exer-
[98–100]. Determining return to play is often dictated by cises including bilateral box jumps (jumping to the box)
several forms of assessment. Isokinetic strength tests are often performed in both anterior and lateral directions, single-leg
used as criteria to return to full unrestricted sports activity. box jumps (hopping to the box) (Fig. 5) performed both
Others utilize functional testing methods such as jumping, anterior and lateral, higher level lateral bounding, power
hoping, and agility tests. As no single test (strength or func- skipping, and zigzag bounding, and scissor-jumps just to
tion) has been proven to be superior, return to sports partici- name a few. Myer et al. suggest ensuring adequate knee and
pation is oftentimes based on physician and therapist hip flexion angles and a decrease in knee abduction or

Fig. 5 Plyometric power strengthening via single leg hoping to surface (a 0 starting position, b 0 ending position)
Table 1 Postoperative anterior cruciate ligament reconstruction protocol

Phase/Criteria for advancement Goals Brace/WB status Therapeutic exercises

Phase I: PO Weeks 1–4 Protect graft fixation Brace Heel slides as tolerated BPTB
Criteria for Advancement II Minimize effects of immobilization Week 0–1 Wall slides 0–45° (hamstring repairs)
Good quad set Control inflammation Locked full extension Quadriceps sets(NMES if poor control)
Approximately 120° flexion Full extension ROM Week 1–2 Patellar mobilizations
Full knee extension Education Unlocked for ambulation when Non-weight bearing gastrocnemius and hamstring stretches
full extension with no lag (hold 3 weeks if hamstring repair)
Week 2–4 SLR in all planes – with brace if extensor lag
DC brace when full extension Multi-hip
with no lag
If lag in extension >5 sleep in brace Quadriceps isometrics at 60° and 90°
WB Status Toe raises bilaterally
WB as tolerated Terminal knee extension (T-band)
Bilateral axillary crutches Balance – bilateral weight shifts
Stationary bike (high seat, low tension)
Phase II: PO Weeks 4–6 Restore normal gait WB Status Exercise as previous
Criteria for Advancement III Maintain full extension No assistive device when gait Wall slides 0–90°
Excellent quadriceps set Progress flexion ROM with no antalgia Multi-hip
SLR without extensor lag Protect graft fixation Toe raises unilaterally
Full knee extension Leg press - bilaterally
No signs of inflammation Balance – bilateral weight shifts – unilateral
Hamstring isometrics (hamstring repairs) – curls (BPTB)
Hamstring and gastrocnemius & soleus stretch
Phase III: PO 6 Weeks–3 Months Full ROM Functional brace may be Flexibility as appropriate
Author's personal copy

Criteria for Advancement to IV Improve strength recommended by Stairmaster/Nordic Track (avoid knee hyperextension)
physician for use during sports
Full pain-free ROM Improve endurance Isolated knee extension 90°–45° progress to eccentrics
for first 1–2 years after surgery
85% quadriceps and hamstring strength Improve proprioception Advanced CKC – Single leg squats; leg press – unilaterally
(0°–45°)
Good static proprioception and balance Prepare for functional activities Step-ups (begin 2′′ progressing to 8′′)
Physician clearance for advanced activities Avoid overstressing graft
Protect PF joint
Phase IV: PO 3 months–6 months Progress strength Functional brace may be Begin in-line jogging
Criteria for Advancement to V Progress power recommended by physician for Initiate bilateral plyometric exercises
use during sports for first
Full pain-free ROM – flexion and extension Progress proprioception Progress proprioception - Slide board, ball toss, racquets
1–2 years after surgery
No patellofemoral irritation Prepare for return to controlled Walk/jog progressions
90% quadriceps and hamstring strength individual functional activities/sports
Sufficient proprioception
Physician clearance for advanced activities
Curr Rev Musculoskelet Med
 Author's personal copy
Curr Rev Musculoskelet Med

Forward/backward running progressing from ½, ¼, full speed

Revision surgery please delay protocol by 2 weeks. BPTB 0 bone patellar – tendon bone; DC 0 discontinue; NMES 0 neuromuscular electrical stimulation; PO 0 post-operative; PWB 0 partial
valgus collapse are performed during these higher level
activities to ensure safety and to decrease faulty motor
patterns that could have been part of the injury mechanism
to begin with [107, 108]. These higher level exercises re-
quire more careful scrutiny of biomechanics and require
Continue to progress flexibility and strength

Initiate sports specific drills as appropriate

verbal and visual feedback commonly to develop safe exercise

Maintenance of strength and endurance

progression.

Gradual return to sports participation

Cutting, cross-over drills, carioca
Progress plyometrics – unilateral

Home – versus supervised therapy

Therapeutic exercises

Walk/jog progression

Despite the fact that Howe et al. reported improved out-

comes with formal supervised rehabilitation as compared to
those who did not receive supervision, there appear to be
several recent studies that compare home-based rehabilita-
tion to that of supervised therapy by physical therapist
[109]. Most of these studies appear to support that home
by physician for use during sports for
Functional brace may be recommended

based therapy may produce similar outcomes as clinic-based

programs [110, 111, 112•, 113]. It must be stressed that
each of these studies included some form of formalized
first 1–2 years after surgery

physical therapy in a supervised fashion and none of

these protocols were completely unsupervised. These
reports would suggest that ACL rehabilitation may not
Brace/WB status

need continuous monitoring on a daily or weekly basis,

but attending physical therapy for the purpose of educa-
tion, assessment, monitoring function and progression of
treatment plan remain a critical aspect of a safe and
effective rehabilitation program [4]. Future randomized
weight bearing; ROM 0 range of motion; SLR 0 straight leg raise; WB 0 weight bearing;

controlled trials without any formal therapy will be need-

ed to determine if a simple home exercise program is
Education on possible limitations
Safe return to athletics including

truly comparative to formal therapy.

Prepare for full return to

individual/team sports
Progress proprioception

functional activities

Conclusions
Progress strength
Progress power

Immediate rehabilitation following ACL reconstruction

begins by reducing swelling and post-surgical inflammation,
Goals

improving range of motion (including full terminal knee

extension), and optimizing quadriceps motor control. The
ability to return an athlete to unrestricted return to competi-
tion requires a full return of neuromuscular control, strength
and endurance of the post-surgical extremity. A gradual
progression of increased stress is applied to the knee and
Phase/Criteria for advancement

lower extremity through a four phased program described

(Table 1). Rehabilitation following ACL reconstruction
Phase V: 6 months +

should be based on clinical science and the best available

Table 1 (continued)

evidence.

Disclosure R Manske: consultancy with Elsevier and Human Kinetics;

D Prohaska: none; B Lucas: none.
 Author's personal copy
Curr Rev Musculoskelet Med

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