Abnormal findings

• •
  

  Present if examined within a week of injury

  
  
  
  
  • •
    

    Large knee hemarthrosis

    
    
  • •
    

    Stiffness of the knee, lacking terminal flexion and extension

  
  
  
  
• •
  

  Present if a relaxed examination of the knee is possible

  
  
  
  
  • •
    

    Positive Lachman test ( Figure 32-2 )

    
    

    
    

    
    

    

    
    

    
    

    Positive Lachman test. ( A ) No forces are being applied. ( B ) The tibia is being pulled anteriorly. The black lines represent the relationship between the anterior aspect of the tibia and the anterior aspect of the patella (used as a consistent landmark between the two images). Note how the black lines show the tibia moves anteriorly in relation to the patella (and, therefore, the femur).

    
    
    
    
  • •
    

    Positive anterior drawer

    
    
  • •
    

    Positive pivot shift

  
  

Pertinent normal findings

• •
  

  Negative valgus and varus stress tests

  
  
• •
  

  Negative posterior drawer

  
  
• •
  

  Negative patellar apprehension

  
  
• •
  

  Painless arc of motion (normally from approximately 25° to 75° of flexion)

  
  
• •
  

  Ability to hold leg extended against gravity

  
  
• •
  

  No palpable defects or crepitus

Guidelines for Choosing among Nonoperative Treatments

• •
  

  All patients should be initially treated with nonsurgical options to decrease pain and swelling and increase range of motion

  
  
  
  
  • •
    

    Patients who undergo ACL reconstruction while their knee has an effusion and limited range of motion generally have more difficulty regaining motion postoperatively

  
  
  
  
• •
  

  Patients unwilling or unable to undergo ACL reconstruction should proceed with nonsurgical treatment

Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment

• •
  

  Age and activity level

  
  
  
  
  • •
    

    Younger, higher-demand athletes, and those who tear their ACL during sport participation usually require ACL reconstruction in order to return to high-level activities

    
    
  • •
    

    Older, lower-demand individuals usually do not require ACL reconstruction to return to low-demand activities. ACL is required for rotational stability of the knee and is not necessary for walking, stair-climbing, and low-demand in-line activities

  
  
  
  
• •
  

  Willingness to modify activities

  
  
  
  
  • •
    

    Individuals willing to modify their level of activity to moderate or lower levels may successfully be treated with nonoperative therapy

  
  
  
  
• •
  

  Degree of instability of the knee

  
  
  
  
  • •
    

    Recurrent instability with lower levels of activity, such as light dancing, may require ACL reconstruction in order to continue such activities

  
  
  
  
• •
  

  Concomitant injuries

  
  
  
  
  • •
    

    Large, unstable vertical meniscal tears

    
    
    
    
    • •
      

      Meniscal repairs performed in ACL-deficient knees have a high incidence of reinjury. Options include meniscal repair in association with ACL reconstruction or meniscectomy.

    
    
    
    
  • •
    

    Multiligament injured knee

    
    
    
    
    • •
      

      Knees with multiple injured ligaments are often more unstable and frequently require multiligament reconstruction

    
    

  
  

Aspects of Clinical Decision-Making When Surgery is Indicated

• •
  

  Graft use

  
  
  
  
  • •
    

    Autograft options: patellar tendon, hamstrings, quadriceps tendon

    
    
    
    
    • •
      

      Increased pain postoperatively from donor site

    
    
    
    
  • •
    

    Allograft options: patellar tendon, hamstrings, Achilles, anterior tibialis, posterior tibialis

    
    
    
    
    • •
      

      Risk of disease transmission

    
    

  
  
  
  
• 
  

  HIV: approximately 1 in 1.5 million

  
  
• 
  

  Hepatitis C: approximately 1 in 150,000

  
  
  
  
  • 
    
    
    
    
    
    • •
      

      Recent literature has shown higher re-rupture rates following allograft ACL reconstruction in patients under 25 years old

    
    

  
  
  
  
• •
  

  Tunnel placement

  
  
  
  
  • •
    

    Anatomic versus nonanatomic

    
    
    
    
    • •
      

      Current literature supports anatomic tunnel drilling to increase rotational stability of the knee and improve functional results

    
    

  
  
  
  
• •
  

  Single bundle versus double bundle reconstruction

  
  
• •
  

  Method of graft fixation

  
  
  
  
  • •
    

    Cortical: suspensory button; cross-pin; screw and washer; staple

    
    
  • •
    

    Aperture: interference screw

  
  

Manual Therapy Techniques

• •
  

  To assist with knee-joint effusion management, retrograde massage can be performed by providing effleurage massage techniques from distal to proximal to move to fluid out of the affected area. This should be performed in addition to effusion management techniques listed above.

  
  
• •
  

  For deficits with range of motion, manual techniques should be used.

  
  
• •
  

  Overpressure to the tibiofemoral joint at end ranges of motion in both flexion and extension can be performed to increase knee range of motion.

  
  
• •
  

  Mobility of the patella should also be evaluated to assist with a proper superior and inferior glides of the patella. Good mobility of the patella in the superior direction will allow for improved quadriceps contraction, while good patellar mobility in the inferior direction is essential for achieving full knee flexion range of motion.

Stretching and Flexibility Techniques for the Musculotendinous Unit

• •
  

  Often, limitations in range of motion are caused by soft tissue musculotendinous restrictions.

  
  
• •
  

  Flexibility of muscles that cross the knee joint should be evaluated and stretching should be completed where limitations exist.

  
  
• •
  

  Flexibility limitations often occur in to the hamstrings, quadriceps, and triceps surae muscles. Stretching of these muscles should be done daily to improve and maintain flexibility after injury. Stretches can be held for 30 seconds and repeated at least 3 times. Additional stretching may be needed for some patients, and patient’s tolerance should be considered.

Other Therapeutic Exercises

• •
  

  Stationary cycling

  
  
• •
  

  Classification screening

  
  
• •
  

  Within 6 months of initial injury, classification of the patients with ACL deficiency should be performed using objective measures.

  
  
• •
  

  A screening classification system has been developed to determine which active individuals with an ACL injury have a good probability of returning to high level of functioning without operative management for short periods of time, such as to complete a sports season.

  
  
• •
  

  Athletes classified as potential copers who received perturbation training are more likely to return to high-level activities in the short term than those who received standard training.

  
  
• •
  

  Noncopers have the potential to return to their previous activity level but only after undergoing lengthy rehabilitation.

  
  
• •
  

  The screening examination consists of 6-meter timed hop ; patient reported outcome measures with the knee outcome survey, activities of daily living scale (KOS-ADLS) and global rating scale of perceived function and the number of episodes of giving way.

  
  
• •
  

  For patients to be eligible to complete the screening exam, they must demonstrate less than 1+ knee-joint effusion, normalized knee range of motion, quadriceps strength measure 70% or greater compared to the contralateral limb with maximal voluntary isometric contraction with a central activation ratio of 95% or more with burst superimposition test and no complaints of pain with single-legged hopping. The burst superimposition test is completed with an electromechanical dynamometer with patients seated in an upright position and their hip and knee flexed to 90°. A supramaximal burst of electrical stimulation is given to the patient while they are actively contracting their quadriceps. If the patient is able to give a true maximal contraction, then no increase in force from the stimulation will be produced. This is reported as the central activation ratio and should be 95% or greater.

  
  
• •
  

  Potential copers are classified based on the following criteria: one or less episode of giving way, 80% or more on 6-meter timed hop test compared to the contralateral limb, 80% or more on KOS-ADLS, and 60% or more on global rating score ( Table 32-2 ). Failure to meet any of these criteria will classify the patient as a noncoper.

  
  
  
  

  Table 32-2

  
  

  Screening Classification

  
  

  
  
  
  
  
  
  
  
  
  
  
  

  	Potential Coper	Noncoper
  Episodes of giving way 6-m hop test KOS-ADLS score Global rating score	≤ 1 ≥ 80% timed ≥ 80% ≥ 60%	Failure to meet any of these criteria

   
  
  

Activation of Primary Muscles Involved

• •
  

  Quadriceps activation deficits are most prominent in Phase I of rehabilitation. Neuromuscular electrical stimulation may be used as an effective tool to improve quadriceps activation. High intensity setting (2500 Hz, alternating current at 75 burst per second, 10 to 15 seconds on with 50 second rest period) should be performed isometrically, with the knee flexed to 90° for 10 repetitions, 3 to 5 times per week.

  
  
• •
  

  This can also be used with active quadriceps contraction during a quadriceps setting exercise or straight leg raise.

  
  
• •
  

  Isotonic exercises, such as open chain knee extension exercises, may be used to increase quadriceps muscle activation.

  
  
• •
  

  Additionally, isokinetic strength training has been found to increase quadriceps strength.

Range of Motion Exercises

• •
  

  Range of motion limitations are addressed using several techniques. Along with manual techniques, additional exercises can be completed by the patient to improve range of motion deficits.

  
  
• •
  

  Knee extension:

  
  
  
  
  • •
    

    Prone passive hangs with weight around ankle

    
    
  • •
    

    Seated knee extension hangs with weight on knee joint

  
  
  
  
• •
  

  Knee flexion:

  
  
  
  
  • •
    

    Supine heel slides with heel on the table or the wall

    
    
  • •
    

    Prone knee flexion stretching

    
    
  • •
    

    Seated knee flexion stretching in closed chain

  
  

Open and Closed Kinetic Chain Exercises

• •
  

  Open Kinetic Chain (OKC)

  
  
  
  
  • •
    

    Quadriceps setting: Quadriceps setting should be initiated with the patient in long sitting. Verbal and tactile cueing can be given from the rehabilitation specialist to isolate the quadriceps muscle and limit cocontraction of the hamstrings, quadriceps, and gastrocnemius. Patients should be instructed to perform 50 repetitions of quadriceps sets up to 5 to 10 times a day. This exercise can be progressed to standing to provide an additional weight-bearing component.

    
    
  • •
    

    Straight leg raise (SLR): The SLR exercise can be completed with the quadriceps setting exercise. Patients should complete a quadriceps set first and then complete the SLR. A sign of quadriceps weakness is a quadriceps lag while the patient is completing the SLR exercise. Patients can complete 3 sets of 10 repetitions. This can be progressed with the addition of ankle weights as well as sets and repetitions.

    
    
  • •
    

    Seated knee extension (long arc quadriceps (LAQ)): Unilateral LAQs can be completed with the patient seated at 90° of hip and knee flexion. Patients should be encouraged to complete the exercise through the entire range of motion since at this phase of rehabilitation, no range of motion restrictions are present. Patients can complete 3 sets of 10 repetitions and progression of resistance and volume should be done to challenge the patient. If patients complain of anterior knee pain with this exercise, knee extension can be initiated at 60° of flexion or a pain-free range. This exercise should be discontinued if patients report a worsening of knee symptoms, and the rehabilitation specialist should reassess for additional impairments.

  
  
  
  
• •
  

  Closed Kinetic Chain (CKC)

  
  
  
  
  • •
    

    Sit-to-stand activities: Sit-to-stand activities should be performed in front of a mirror for visual feedback. If one is not available, verbal and tactile feedback can be given by the rehabilitation specialist. Patients should be able to complete this task with symmetrical weight through the lower extremities and minimal trunk shifting. Patients can begin with 1 set of 10 repetitions and progress to 3 sets of 10 to 15 repetitions. The height of the sit-to-stand surface can also be lowered to provide an additional challenge to the patient.

    
    
  • •
    

    Leg press: The leg press should be completed with the involved limb only if tolerated by the patient. Assist from the uninvolved limb may be needed if the patient is affected shortly after injury. Patients can complete this exercises with 3 sets of 10 to 15 repetitions. Resistance and volume can be increased to progress the exercise.

    
    
  • •
    

    Isometric wall sits: Wall slides should be completed with the patient’s back against the wall and feet shoulder-width apart. The patient should begin by sliding down the wall until their knees are flexed to 90°. This exercise can be held for 10 seconds for 5 repetitions and can progress to be held for 30 to 60 seconds for 10 repetitions.

  
  

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  After initial injury, quadriceps strength and activation deficits exist.

  
  
• •
  

  Open chain exercises, such as quadriceps setting, straight leg raises (SLR), and unweighted, seated knee extension long arc quadriceps (LAQ), can be performed to strengthen the quadriceps muscles.

  
  
• •
  

  Progression towards weight-bearing (closed kinetic chain) exercises should be initiated once the patient demonstrates improved quadriceps strength with open chain exercises, such as the absence of a quadriceps lag with a straight leg raise (SLR).

Functional Exercises

• •
  

  Altered movement patterns during gait are present in noncopers with ACL deficiency and differ based on gender.

  
  
• •
  

  After ACL injury, noncopers demonstrate increased cocontraction of quadriceps and hamstrings musculature throughout gait.

  
  
• •
  

  Limitations in knee-joint range of motion, quadriceps strength measures, and patient’s complaints of pain may contribute to gait deviations.

  
  
• •
  

  In addition to resolving these impairments, gait training should be performed in the clinic with verbal, tactile, and visual cuing. Emphasis should be placed on heel strike at initial contact with quadriceps muscle contraction as well as symmetrical stance time between limbs.

  
  
• •
  

  Interventions in the later phases of rehabilitation (perturbation training) have been suggested to abate these asymmetrical movement patterns in male and female noncopers.

Manual Therapy Techniques

• •
  

  Tibiofemoral mobilization with rotation are used to regain full passive knee flexion.

Stretching and Flexibility Techniques for the Musculotendinous Unit

Stretching should be done to improve and maintain flexibility. The following stretches below are recommended after ACL injury. Stretches should be held for 30 seconds and repeated at a minimum of 3 times. Additional repetitions may be needed for some patients.

• •
  

  Quadriceps stretch

  
  
• •
  

  Hamstring stretch

  
  
• •
  

  Iliotibial band (ITB) stretch

  
  
• •
  

  Gastrocnemius/soleus stretch

Other Therapeutic Exercises

The type of cardiovascular training should be related to the patient’s sport or occupational activity. A graded program should be initiated for 5 to 10 minutes using the soreness rules and effusion grades to determine progression. When patients can perform the activity for 15 to 20 minutes without pain or swelling, they can progress to road or track-related activities.

Stationary cycling: Should be used to improve endurance. Resistance and time can be increased as per patient’s response.

• •
  

  Elliptical machine: Reduces body weight to approximately 75%, so this should be initiated until patients can tolerate full weight bearing, pain-free. Progressive resistance should be added to improve endurance.

  
  
• •
  

  Stair climber can be used as an additional form of cardiovascular training. Only when full, pain-free weight bearing can be tolerated should patients complete this form of cardiovascular exercise.

Activation of Primary Muscles Involved

• •
  

  If quadriceps index is less than 80%, neuromuscular electrical stimulation to the quadriceps muscles is used to augment quadriceps strengthening exercises.

  
  
• •
  

  Neuromuscular stimulation may improve quadriceps strength if applied in a high-intensity setting.

Open and Closed Kinetic Chain Exercises

• •
  

  The implementation of nonweightbearing (open kinetic chain) and weightbearing (closed kinetic chain) quadriceps strengthening exercises has been demonstrated to improve muscle strength and functional outcomes in patients with ACL injury. Quadriceps muscles strength training involves the use of high-intensity, low-repetition, nonweightbearing and weightbearing quadriceps strengthening exercises to the involved limb (60% to 70% of 1-repetition maximum for 8 to 12 repetitions for 1 to 3 sets, with progression to 80% to 100% of 1-repetition maximum to maximize strength).

  
  
• •
  

  Nonweightbearing quadriceps strengthening exercises include knee extension exercises and isokinetic exercises on an electromechanical dynamometer.

  
  
• •
  

  Weightbearing exercises included resisted leg press and lateral and forward step-downs. Step-downs were performed initially on a 10.16 cm (4 inches) step and subjects were progressed in step height when they demonstrated adequate performance and proper technique.

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Open Kinetic Chain (OKC):

  
  
  
  
  • •
    

    Resisted knee-extension exercises: seated knee extension should be completed with progressive weights. Unilateral strengthening and eccentric strengthening will improve quadriceps strength deficits of the involved limb. Low repetitions with high intensity are recommended for making improvements in strength deficits. To determine initial resistance, a resistance of approximately 75% of the patients’ 1-repetition maximum should be used. It is recommended that 3 to 5 sets of 6 to 8 repetitions at this resistance is completed.

    
    
  • •
    

    Isokinetic exercises on electromechanical dynamometer at various speeds: This strengthening protocol includes concentric and eccentric resistance of the knee extensors during active knee flexion and extension. Isokinetic strengthening can be completed using an isokinetic dynamometer at speeds beginning at 60°/s and progress to 180°/s at 30°/s increments.

  
  
  
  
• •
  

  Closed Kinetic Chain (CKC):

  
  
  
  
  • •
    

    Resisted leg press: Both unilateral and eccentric leg press exercises are recommended to improve strength deficits. Similar to knee-extension exercises, low repetitions at 75% of the patient’s 1-repetition maximum are recommended; 3 to 5 sets of 6 to 8 repetitions are suggested.

    
    
  • •
    

    Lateral and forward step-downs: These exercises are recommended for functional benefits and must be completed with proper form. The rehabilitation specialist should monitor the patient’s mechanics, observing a level pelvis and that the patient keeps the knee alignment correctly over the foot. The height of the step should be chosen based on the highest height that the patient can properly maintain their form; 3 sets of 10 repetitions are recommended, and the height of the box is progressed as per patient’s tolerance.

  
  

Neuromuscular Dynamic Stability Exercises

• •
  

  Perturbation training is a specialized neuromuscular training technique designed to encourage compensatory muscle strategies in patients with ACL deficiency

  
  
• •
  

  The proposed mechanisms for increasing dynamic knee stability with perturbation training is based on increasing the heightened sensitivity of muscle spindles to facilitate antagonist muscle activation to respond to perturbations (length feedback) and reciprocal inhibition of agonist muscles mediated by Golgi tendon organs (force feedback).

  
  
• •
  

  Perturbation training involves the destabilization of the lower extremity in a systematic progressive manner with translatory and rotary perturbations on support surfaces to elicit selective muscle activation without gross muscle cocontraction.

  
  
• •
  

  Perturbation training consists of 3 specific techniques to facilitate joint stability ( Figure 32-7 ) (A) rocker board perturbations, (B) multiplanar roller board perturbations, and (C) multiplanar roller board perturbations with a stationary platform.

  
  

  
  

  
  

  

  
  

  
  

  A, Perturbation training on rocker board. B, Perturbation training on roller board. C, Perturbation training on roller board and platform.

  
  
  
  
• •
  

  For the rocker-board and roller-board techniques, initially all patients begin the first session in a double limb support stance. If the patient exhibits good balance reaction without loss of balance, they progress to single limb support stance for the remainder of the sessions.

  
  
• •
  

  For the roller board/stationary platform condition, the subject placed the involved limb on either the roller board or the stationary platform and after the completion of 3 sets, the limbs were alternated and the treatment was repeated.

  
  
• •
  

  The goal for this condition was to have the subject resist the speed and magnitude of the perturbation force applied by the therapist without anticipatory muscle contraction or rigid cocontraction. Subjects were given verbal commands: “Meet my force, don’t beat my force,” “Don’t overpower me,” “Soften your knees,” and “Relax between perturbations”.

  
  
• •
  

  The objective was to either resist the force or to reestablish a balanced posture after the perturbation was applied by the therapist.

  
  
• •
  

  For the first 2 to 5 sessions, the patient is informed with verbal cues of the direction and timing of perturbation movement. Verbal and tactile cues are used to inform the patient to avoid cocontractions at the knee.

  
  
• •
  

  Subsequent sessions progressed from expected to random directions and timing of the perturbation, increasing intensity and magnitude of the force, and decreasing verbal cues.

  
  
• •
  

  Progression of perturbations is individualized depending on the subject’s ability to apply appropriate directional and counter-resistive force, selective muscle activation patterns, and reduction in loss of balance.

  
  
• •
  

  During the last 5 sessions, a sports- or activity-specific task was introduced to distract the subject’s attention to increase difficulty of the task.

  
  
• •
  

  The progression of perturbation training is detailed in Table 32-3 .

  
  
  
  

  Table 32-3

  
  

  Perturbation Exercises and Progression Guidelines

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  	Early (Estimated Treatment 1–3)	Middle (Estimated Treatment 4–7)	Late (Estimated Treatment 8–10)
  Roller Board	Position: Patient on board (bilateral 1st treatment, progress to unilateral) Application: Slow application of force, low magnitude, Straight plane of movement (do all A/P reps before you begin M/L) Observe: Cue patient to avoid massive cocontraction at knee. Do not overstress beyond limit of stability (do not induce fall)	Position: Unilateral Application: Unexpected forces with rapid increasing magnitude force application with added rotatory and diagonal motions Distraction: Add distraction (ball toss, stick work) Observe: Observe difficulty with recovery but few to no falls	Position: Unilateral Application: Increased magnitude of force application with random direction movements Distraction: Increase speed and magnitude of distraction in sport specific positions Observe: Look for disassociation of hip, knee, and ankle
  Rocker Board	Position: Begin bilateral, progress to unilateral Application: Slow application of force, low magnitude with less force medial than lateral Observe: Cue patient to maintain equal weight bearing bilaterally and avoid massive cocontraction at the knee	Position: Unilateral Application: Unexpected forces with rapid increasing magnitude force application Distraction: Add distraction (ball toss, stick work) Observe: Look for a rapid return to a stable base after perturbation	Position: Unilateral with foot on a diagonal Application: Increased magnitude force application with random direction movements Distraction: Increase speed and magnitude of distraction in sport specific positions Observe: Look for minimal sway from stable stance at rest or following any perturbation
  Roller-board and Stationary Platform	Position: One foot on the roller board, one on the platform with equal weightbearing on both lower extremities Application: Slow application of force, low magnitude in all directions Observe: Cue patient to maintain equal weightbearing bilaterally (watch for unweighting of the involved limb as level of difficulty increases). Do not overpower the patient. Patient should match therapist’s forces without excessive movement of roller board	Position: One foot on the roller board, one on the platform with equal weight bearing on both lower extremities Application: Unexpected forces with rapid increasing magnitude force application with added combined movements Distraction: Add distraction (ball toss, stick work) Observe: Cue patient to maintain equal weightbearing bilaterally. Cue patient to react as you remove force (avoid rebound board movement)	Position: One foot on the roller board, one on the platform with equal weightbearing on both lower extremities Application: Increased magnitude force application with random direction movements Distraction: Increase speed and magnitude of distraction with added diagonal/sport specific stance (forward split, backward split) Observe: Cue patient to maintain equal weight bearing bilaterally. Cue patient to react as you remove force (avoid rebound board movement)
  Time: 3 sets of 1 minute of each with 30 to 60 seconds rest periods Phases: 10 treatments total

   
  

  Courtesy of Tara Jo Manal, University of Delaware Physical Therapy Clinic.
  
  

Functional Exercises

• •
  

  Agility training is designed to expose the lower extremities to rapid body movement and directional changes of the limbs.

  
  
• •
  

  Clinicians should observe the patient’s willingness to use and rely on the operated lower limb. We recommend the use of functional knee braces during agility training.

  
  
• •
  

  Side shuffles and carioca drills are used to expose the involved limb to quick changes of direction in the lateral direction.

  
  
• •
  

  Shuttle runs are used to promote rapid acceleration and deceleration.

  
  
• •
  

  Cutting and pivoting drills are incorporated to expose the patient to more sport-specific movements. The drills are initiated at half-speed and progress to full speed based on the knee’s response to the training by using the soreness and effusion criteria for progression.

  
  
• •
  

  Progression of the distance and the incorporation of unexpected direction changes and sports equipment into the drill is based on the patient’s apprehension, pain, and swelling.

Sport-Specific Exercises

• •
  

  Sport-specific skills and movements are gradually incorporated into the perturbation and agility training programs.

  
  
• •
  

  Patients must be able to perform the agility training without pain, swelling, or apprehension.

Stretching and Flexibility Techniques for the Musculotendinous Unit

Stretching should be maintained as part of a home exercises program in this phase of rehabilitation. If flexibility restrictions remain in this phase, manual stretching by the therapist may be required. The stretches below are recommended, holding for 30 seconds for 3 repetitions.

• •
  

  Quadriceps stretch

  
  
• •
  

  Hamstring stretch

  
  
• •
  

  Iliotibial band (ITB) stretch

  
  
• •
  

  Gastrocnemius/soleus stretch

Other Therapeutic Exercises

All exercises should be completed as per patient’s response to activity. An increase in knee-joint effusion or knee symptoms may occur, therefore, these exercises should not be progressed and symptoms should be treated and monitored.

• •
  

  Stationary cycling: Recommended at this phase to continue to improve endurance. Progressive resistance with interval training will increase endurance and strength, with progression to 20 to 30 minutes.

  
  
• •
  

  Elliptical machine: Progressive resistance and increased incline can be added at this phase to improve endurance and strength with progression to 20 to 30 minutes. This can be completed both forward and backward as well as in a squat position to increase strengthening.

  
  
• •
  

  Stair climber: Should be increased in resistance to improve endurance and increase strength with progression to 20 to 30 minutes.

Activation of Primary Muscles Involved

• •
  

  The burst superimposition test should be used to determine muscle activation. Patients should demonstrate less than 5% quadriceps inhibition. This is measured as the force exerted by the patient volitionally divided by the force exerted with the burst super imposition multiplied by 100. This should be performed bilaterally.

Open and Closed Kinetic Chain Exercises

Muscle strength training involves the use of high-intensity, low-repetition, nonweightbearing and weightbearing muscle-strengthening exercises to the involved limb as recommended by the American College of Sports Medicine position on progression models in resistance training for healthy adults (60% to 70% of 1-repetition maximum, for 8 to 12 repetitions, for 1 to 3 sets; with progression to 80% to 100% of 1-repetition maximum to maximize strength).

• •
  

  Open Kinetic Chain (OKC):

  
  
  
  
  • •
    

    Resisted knee-extension exercises: Similar to exercises in Phase II, these exercises can be competed with increased resistance. Unilateral and eccentric exercises can be used to increase strength of the involved limb knee extensors.

    
    
  • •
    

    Resisted knee flexion exercises: Hamstring weakness relative to quadriceps strength is linked to a higher rate of injury. A hamstring to quadriceps ratio of at least 55% is recommended.

    
    
  • •
    

    Isokinetic exercises on electromechanical dynamometer at various speeds: Concentric and eccentric resistance of the knee extensors can be completed with an isokinetic dynamometer. Similar to recommendations in Phase II, increased resistance can be added to challenge the patient.

  
  
  
  
• •
  

  Closed Kinetic Chain (CKC):

  
  
  
  
  • •
    

    Resisted leg press: Unilateral and eccentric exercises will improve quadriceps strength. Progressive resistance should be increased from the recommendations in Phase II.

    
    
  • •
    

    Lateral and forward step-downs: Repetitions and height of the box should be progressed from Phase II without resulting in poor mechanics. Proper mechanics should be maintained with this exercise.

    
    
  • •
    

    Squats: Can be completed both bilaterally and unilaterally with proper mechanics. Similar to step-downs, patients should maintain a level pelvis and correct knee alignment over the foot. This can be progressed to unstable surfaces, such as foam or a BOSU ball.

    
    
  • •
    

    Lunges: Should be completed as long as patients are free of pain. Lunges can be repeated or alternating to improve quadriceps and hip extensor muscle strength. This can be progressed to holding weights or lunging on unstable surfaces, such as foam.

    
    
  • •
    

    Heel raises: Can be completed bilateral or unilateral and can be progressed with the addition of weights.

  
  

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  See OKC and CKC exercises

Functional Exercises

• •
  

  Walk/jog running progression for the benefit of unilateral lower limb strengthening and increased force generation and attenuation during a dynamic running task ( Table 32-4 ).

  
  

Sport-Specific Exercises

• •
  

  The demands and performance characteristics of the athlete’s sport will dictate the necessary performance enhancement techniques.

Anesthetic

• •
  

  Femoral nerve block usually provides excellent pain relief for the first 8 to 24 hours postoperatively. After wearing off, however, other methods will likely need to be employed including nonsteroidal antiinflammatories and cryotherapy.

  
  
• •
  

  Patients using cryotherapy postoperatively have been demonstrated to require less narcotic analgesics for pain control.

Surgical

• •
  

  Surgical

  
  
  
  
  • •
    

    Concomitant knee pathology:

    
    
    
    
    • •
      

      Preoperatively or during diagnostic arthroscopy, concomitant pathology (tendinous injuries, cartilage lesions, meniscal, and ligamentous tears) are often identified. These may dictate alteration to the rehabilitative protocol, and thus make it important to identify, before rehabilitation, which other lesions are present or procedures were performed.

    
    
    
    
  • •
    

    Bone-patellar tendon-bone (B-PT-B) autograft versus allograft:

    
    
    
    
    • •
      

      Patellar tendon grafts can be obtained either from the patient’s own knee (autograft) or from a cadaver source (allograft). A goal of rehabilitation is to gain quadriceps strength, because this has been demonstrated to decrease following ACL injury. Current literature suggests that this extensor weakness is caused by the ACL injury itself rather than surgery or graft choice; thus, progressive gains in quad strength should be a goal of rehabilitation regardless of graft choice.

      
      
    • •
      

      Patients with autograft experience graft site morbidity which may need to be addressed including patellar tendonitis and patellofemoral syndrome.

      
      
    • •
      

      As patients with allograft tend to experience less postoperative pain, they may be prone to putting early excess stress on their grafts. In addition, allografts have been demonstrated to take longer to incorporate caused by their foreign origin. Thus, some authorities suggest using less aggressive rehabilitative programs for those with allografts, although this is not a consensus opinion.

      
      
    • •
      

      Because allografts are foreign tissue, there is an increased (albeit rare) incidence of prolonged sterile inflammation.

    
    
    
    
  • •
    

    Graft type and graft fixation

    
    
    
    
    • •
      

      Bone-patellar tendon-bone autograft is considered the gold standard of ACL reconstruction caused by its demonstrated track record of strength; however, occasional anterior knee pain is considered its major drawback.

      
      
    • •
      

      Bone to bone healing takes approximately 8 weeks to complete in the majority of cases, whereas soft tissue to bone healing takes approximately 12 weeks.

    
    

  
  

Other Therapeutic Exercises

• •
  

  Heel slides (see Before Surgery section)

  
  
• •
  

  Quadriceps/hamstring sets

  
  
  
  
  • •
    

    Quad sets: Sitting on the floor with affected leg in front of body, tighten quadriceps by pressing the posterior knee flat to the floor. Hold for 10 seconds, and repeat. Neuromuscular electrical stimulation can be used to facilitate the quad contraction.

    
    
  • •
    

    Hamstring sets: Laying on back with knees partially flexed and heels resting against the ground, press heels against the ground and isometrically contract hamstrings (no sliding). Hold for 10 seconds, and repeat

  
  
  
  
• •
  

  Gastrocnemius/soleus stretching in a nonweightbearing position

  
  
  
  
  • •
    

    Sitting with affected leg out in front of body, wrap a towel around ball of foot and pull back and hold until moderate tension is achieved in calf.

  
  
  
  
• •
  

  Straight leg raise in flexion, extension, abduction, and adduction with brace in full extension until quad strength prevents extension lag ( Figure 32-8 )

  
  

  
  

  
  

  

  
  

  
  

  Straight leg raise (flexion, extension, abduction, and adduction).

  
  
  
  
• •
  

  Prone hangs: Lie prone with legs hanging with the edge of the table at the thighs

  
  
• •
  

  Gait training emphasizing full extension and quad activation

  
  
• •
  

  Stationary bike, half to full revolutions without resistance to facilitate flexion

Activation of Primary Muscles Involved in Injury Area or Surgical Structures

• •
  

  Quad and hamstring sets

  
  
• •
  

  Straight leg raise with brace in full extension until quad strength prevents extension lag (hip flexion, abduction, adduction, extension)

Other Therapeutic Exercises

• •
  

  Continue heel slides, quad and hamstring sets, and straight leg raises as in Phase I

  
  
• •
  

  Progress to weightbearing gastrocnemius/soleus stretch (with towel)

  
  
• •
  

  Begin standing heel raises (knees in extension)

  
  
• •
  

  Begin closed chain extension exercises (see below)

  
  
• •
  

  Begin balance and proprioception exercises (see below)

  
  
• •
  

  Hamstring curls (begin with standing and no resistance)

  
  
• •
  

  Stationary bike

Activation of Primary Muscles Involved in Injury Area or Surgical Structures

• •
  

  Isometric quadriceps and hamstring sets

  
  
• •
  

  Straight leg raises

  
  
• •
  

  Leg press and squats (partial range of motion)

  
  
• •
  

  Hamstring curls (standing)

  
  
• •
  

  Calf raises (in extension and with knees at 90°)

Sensorimotor Exercises

• •
  

  Begin balance training with bilateral stance on a tilt board and medicine ball throws

  
  
• •
  

  Single-leg balance with emphasis on full extension

Open and Closed Kinetic Chain Exercises

• •
  

  Partial squats

  
  
• •
  

  Leg press ( Figure 32-9 )

  
  

  
  

  
  

  

  
  

  
  

  A, B, Leg press.

  
  
  
  
• •
  

  Weight shifts

  
  
• •
  

  Front and side lunges

  
  
• •
  

  Lateral step-ups

  
  
• •
  

  Front step-ups

  
  
• •
  

  Standing terminal knee extensions with resistance

Techniques to Increase Muscle Strength, Power, and Endurance

Stationary bicycle for endurance

Neuromuscular Dynamic Stability Exercises

• •
  

  Begin perturbation training

  
  
  
  
  • •
    

    Roller-board translations

    
    
  • •
    

    Tilt board perturbation

    
    
  • •
    

    Roller board and stationary platform perturbation

  
  

Goals

• •
  

  Continue to increase strength, proprioception, balance, and neuromuscular control

  
  
• •
  

  Gain full pain-free range of motion equal to nonsurgical knee

  
  
• •
  

  Achieve normal gait without assistance device

  
  
• •
  

  Improve endurance

  
  
• •
  

  Improve limb confidence

Protection

• •
  

  The graft is at its weakest point during the postoperative period from weeks 4 to 8

  
  
• •
  

  Early in Phase III, avoid activities that place high stress on the graft (see Clinical Pearls above)

  
  
• •
  

  Conditioning activities which avoid shifting and pivoting

  
  
  
  
  • •
    

    Stair stepper/NordicTrack, and straight ahead running may be started at week 12

  
  

Other Therapeutic Exercises

• •
  

  Continue and progress on flexibility and isometric strength work

  
  
• •
  

  Continue stationary bicycle

  
  
• •
  

  Stair stepper/NordicTrack starting at week 12

  
  
• •
  

  Straight ahead running starting at week 12

  
  
• •
  

  Advance closed chain exercises (see below)

  
  
• •
  

  Advance hamstring curls (add band resistance)

  
  
• •
  

  Advance balance/proprioceptive training (see below)

Activation of Primary Muscles Involved in Injury Area or Surgical Structures

• •
  

  Advancement of isometric strength program (quad sets, hamstring sets, straight leg raises, etc.)

  
  
• •
  

  Advance hamstring exercises

  
  
  
  
  • •
    

    Hamstring curls with band resistance

    
    
  • •
    

    Swiss ball hamstring curls ( Figure 32-10 )

    
    

    
    

    
    

    

    
    

    
    

    Chair walk. Sitting in a rolling desk chair with the unaffected foot off the ground, reach the foot of the injured forward and flex at knee to move the chair forward.

    
    

  
  
  
  
• •
  

  Advance close chain strengthening (see below)

Sensorimotor Exercises

• •
  

  Balance training on a tilt board (bilateral to unilateral, eyes open/closed)

  
  
• •
  

  Balance training with medicine ball throws

Open and Closed Kinetic Chain Exercises

• •
  

  Lateral lunge step-overs

  
  
• •
  

  Front and side lunges

  
  
• •
  

  Lateral step-downs

  
  
• •
  

  Front step-downs

  
  
• •
  

  Wall squats

  
  
• •
  

  Vertical squats

  
  
• •
  

  Calf raises

  
  
• •
  

  Stair stepper machine

  
  
• •
  

  Lateral side stepping

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Stair stepper/NordicTrack

  
  
• •
  

  Stationary bicycle

  
  
• •
  

  Walking program

  
  
• •
  

  Straight ahead running

Neuromuscular Dynamic Stability Exercises

• •
  

  Biodex Stability system

  
  
• •
  

  Perturbation training

  
  
  
  
  • •
    

    Roller-board translations

    
    
  • •
    

    Tilt-board perturbation

    
    
  • •
    

    Roller board and stationary platform perturbation

  
  

Other Therapeutic Exercises

• •
  

  Continue to progress on flexibility and isometric strength work

  
  
• •
  

  Stair stepper, NordicTrack, straight ahead running, or stationary bicycle to continue increasing endurance

  
  
• •
  

  Advance closed chain exercises (see below)

  
  
• •
  

  Advance hamstring exercises

  
  
• •
  

  Advance balance/proprioceptive training (see below)

Activation of Primary Muscles Involved in Injury Area or Surgical Structures

• •
  

  Progress isometric strengthening program (quad and hamstring sets, straight leg raises, etc.)

  
  
• •
  

  Hamstring curls and advanced hamstring exercises

  
  
• •
  

  Continued progression of closed chain extension exercises (bilateral to unilateral, increasing resistance, increasing range of motion, etc.)

Sensorimotor Exercises

• •
  

  Continue balance training on a tilt board and with medicine ball throws ( Figure 32-11 )

  
  

  
  

  
  

  

  
  

  
  

  Single-leg balance training with medicine ball throws. This medicine ball exercise is performed while balancing on a tilt board with one leg.

  
  
  
  
• •
  

  Another advanced balance exercise is to have patient do a single-leg stance while reaching to cones on the floor or pulling a band laterally

  
  
• •
  

  Progress unilateral perturbation training ( Figure 32-12 )

  
  

  
  

  
  

  

  
  

  
  

  A – C, Single-leg perturbation training using a tilt board.

  
  

Open and Closed Kinetic Chain Exercises

• •
  

  Lateral lunge step-overs

  
  
• •
  

  Front and side lunges

  
  
• •
  

  Lateral step-downs

  
  
• •
  

  Front step-downs

  
  
• •
  

  Wall squats

  
  
• •
  

  Vertical squats

  
  
• •
  

  Toe calf raises

  
  
• •
  

  Stair stepper machine

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Stair stepper/NordicTrack (Logan, UT)

  
  
• •
  

  Bicycle

  
  
• •
  

  Walking program

  
  
• •
  

  Straight-line running

Neuromuscular Dynamic Stability Exercises

• •
  

  Biodex stability system (Shirley, NY)

  
  
• •
  

  Balance training on a tilt board and medicine ball throws (see Sensorimotor Exercises )

  
  
• •
  

  Perturbation training

Plyometrics

• •
  

  Initiate plyometric leg press and plyometric jumping exercises ( Figure 32-13 )

  
  

  
  

  
  

  

  
  

  
  

  Plyometric jumping exercises.

  
  
  
  
• •
  

  Correct form as needed

Functional Exercises

• •
  

  Lunges with sport cord ( Figure 32-14 )

  
  

  
  

  
  

  

  
  

  
  

  Lunges with sport cord.

  
  
  
  
• •
  

  Forward and backward running

  
  
• •
  

  Jogging in place with sport cord

  
  
  
  
  • •
    

    Can advance by pulling from various directions

  
  
  
  
• •
  

  Pool running (backwards and forwards)

Sport-Specific Exercises

• •
  

  Cone drills

  
  
• •
  

  Side shuffles

  
  
• •
  

  Grapevine drill

  
  
• •
  

  Cariocas

  
  
• •
  

  Sudden start/stops

  
  
• •
  

  45° cutting maneuvers

  
  
• •
  

  90° cutting maneuvers

  
  
• •
  

  Combinations of agility drills

  
  
• •
  

  Progress to sport-specific plyometric training drills

  
  
  
  
  • •
    

    Hop variations, skipping and bounding variations, return to throwing program in overhead throwers, etc.

  
  

Other Therapeutic Exercises

• •
  

  Continue to progress on flexibility and isometric strength work

  
  
• •
  

  Stair stepper, NordicTrack, straight ahead running, or stationary bicycle to continue increasing endurance

  
  
• •
  

  Progression on closed chain exercises (see below)

  
  
• •
  

  Progression on hamstring exercises

  
  
• •
  

  Continue balance/proprioceptive training (see below)

Activation of Primary Muscles Involved in Injury Area or Surgical Structures

• •
  

  Hamstring curls and advanced hamstring exercises

  
  
• •
  

  Leg press and squats

  
  
• •
  

  Progress isometric strengthening program

Sensorimotor Exercises

• •
  

  Continue balance training on a tilt board

  
  
• •
  

  Continue balance training with medicine ball throws

  
  
• •
  

  Continue perturbation training on single leg

Open and Closed Kinetic Chain Exercises

• •
  

  Lateral lunge step-overs

  
  
• •
  

  Front and side lunges

  
  
• •
  

  Lateral step-downs

  
  
• •
  

  Front step-downs

  
  
• •
  

  Wall squats

  
  
• •
  

  Vertical squats

  
  
• •
  

  Toe calf raises

  
  
• •
  

  Stair stepper machine

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Stair stepper/NordicTrack

  
  
• •
  

  Bicycle

  
  
• •
  

  Walking program

  
  
• •
  

  Straight-line running

  
  
• •
  

  Advanced sport-specific endurance exercises (e.g., interval training)

Neuromuscular Dynamic Stability Exercises

• •
  

  Biodex stability system

  
  
• •
  

  Balance training on a tilt board

  
  
• •
  

  Balance training with medicine ball throws

  
  
• •
  

  Perturbation training

Plyometrics

• •
  

  Can progress plyometric leg presses

  
  
• •
  

  Continue other plyometric training drills

Functional Exercises

• •
  

  Lunges with sport cord

  
  
• •
  

  Forward and backward running

  
  
• •
  

  Jogging in place with sport cord

  
  
  
  
  • •
    

    Can advance by pulling from various directions

  
  
  
  
• •
  

  Pool running (backward and forward)

Sport-Specific Exercises

• •
  

  Cone drills

  
  
• •
  

  Side shuffles

  
  
• •
  

  Cariocas

  
  
• •
  

  Sudden start/stop

  
  
• •
  

  45° cutting maneuvers

  
  
• •
  

  90° cutting maneuvers

  
  
• •
  

  Combinations of agility drills

  
  
• •
  

  Continue other plyometric training drills

  
  
• •
  

  Sport- and position-specific skill training (e.g., coming out of a 3-point stance for football lineman, changing direction from backpedal to sprint, lateral mobility drills for linebackers, etc.).

Continuing Fitness or Rehabilitation Exercises

• •
  

  Athletes are encouraged to continue strength and agility exercises on their own to preserve strength, functional, and proprioceptive gains

  
  
• •
  

  Female athletes may benefit from using an ACL prevention program for warmup before practice/games versus a traditional warmup. Compared to a traditional warm-up, these 15-minute programs emphasize posterior chain strength and proper plyometric landing mechanics.

Exercises and Other Techniques for Prevention of Recurrent Injury

• •
  

  Lateral box jumps

  
  
• •
  

  Single leg hurdles

  
  
• •
  

  Single leg lunges and squats