In order to reduce reinjury rates, postoperative progression should consider not only the individual’s strength but also differences in graft selection and fixation strength. If an athlete is advanced to activities involving excessive loading of the knee, such as plyometrics and running, prior to adequate healing time or without an appropriate strength base to meet the demands of the activity, delayed healing and elongation of the graft may lead to chronic instability.
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The most commonly used graft tissues in young athletes are autogenous patellar bone-tendon-bone
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13 and autogenous hamstring tendons.
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16 Bone-to-bone healing in the osseous tunnel for patellar tendon grafts occur in approximately 8 weeks. Healing of tendon to bone for hamstring autografts takes approximately 12 weeks.
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18 Therefore, our rehabilitation progression for hamstring or semitendinosus grafts tends to be less aggressive, and return to running, plyometrics, and sports is slightly slower.
19 In addition, it is important to note that the graft’s strength may reach its weakest point at approximately 6 to 8 weeks postoperatively secondary to graft remodeling.
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22 Although controlled loading in the early phases is important to enhance ligament and tendon healing, excessive loading can damage the healing graft and lead to graft elongation.
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25 Unfortunately, there is limited data in humans that makes determining timing and optimal loading on healing ACL reconstructions difficult to determine.
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Multiple techniques for surgical stabilization of the ACL-deficient knee in young athletes have been described. The guidelines to be discussed are a criterion-based progression and take into account general graft healing and incorporate strategies to address physiologic changes incurred by growth and maturation. Surgeon preference for range of motion (ROM) and weight bearing should be respected in the initial acute phase.