Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 18, Issue 8, pp 1128–1144

Evidence-based rehabilitation following anterior cruciate ligament reconstruction

  • S. van Grinsven
  • R. E. H. van Cingel
  • C. J. M. Holla
  • C. J. M. van Loon
Knee

Abstract

Following a bone-patellar tendon-bone autograft (BPTB) or four-stranded semitendinosus/gracilis tendons autograft (ST/G) anterior cruciate ligament (ACL) reconstruction, the speed and safety with which an athlete returns to sports (or regains the pre-injury level of function) depends on the rehabilitation protocol. Considering the large differences in clinical and outpatient protocols, there is no consensus regarding the content of such a rehabilitation program. Therefore, we conducted a systematic review to develop an optimal evidence-based rehabilitation protocol to enable unambiguous, practical and useful treatment after ACL reconstruction. The systematic literature search identified 1,096 citations published between January 1995 and December 2006. Thirty-two soundly based rehabilitation programs, randomized clinical trials (RCT’s) and reviews were included in which common physical therapy modalities (instruction, bracing, cryotherapy, joint mobility training, muscle-strength training, gait re-education, training of neuromuscular function/balance and proprioception) or rehabilitation programs were evaluated following ACL reconstruction with a BPTB or ST/G graft. Two reviews were excluded because of poor quality. Finally, the extracted data were combined with information from background literature to develop an optimal evidence-based rehabilitation protocol. The results clearly indicated that an accelerated protocol without postoperative bracing, in which reduction of pain, swelling and inflammation, regaining range of motion, strength and neuromuscular control are the most important aims, has important advantages and does not lead to stability problems. Preclinical sessions, clear starting times and control of the rehabilitation aims with objective and subjective tests facilitate an uncomplicated rehabilitation course. Consensus about this evidence-based accelerated protocol will not only enhance the speed and safety with which an athlete returns to sports, but a standardized method of outcome measurement and reporting will also increase the evidential value of future articles.

Keywords

Bone-patellar tendon-bone graft Tendon transfer Physiotherapy Accelerated protocol IKDC questionnaire Systematic review 

Supplementary material

167_2009_1027_MOESM1_ESM.pdf (359 kb)
Supplementary material 1 (PDF 359 kb)

References

  1. 1.
    Allum R (2003) Aspects of current management, complications of arthroscopic reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 85-B:12–16CrossRefGoogle Scholar
  2. 2.
    Beynnon B, Benjamin S, Johnson R, Abate J, Nichols C, Fleming B et al (2005) Rehabilitation after anterior cruciate ligament reconstruction, a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med 33:347–359CrossRefPubMedGoogle Scholar
  3. 3.
    Beynnon B, Johnson R, Abate J, Fleming B, Nichols C (2005) Treatment of anterior cruciate ligament injuries, Part I. Am J Sports Med 33:1579–1602CrossRefPubMedGoogle Scholar
  4. 4.
    Beynnon B, Johnson R, Abate J, Fleming B, Nichols C (2005) Treatment of anterior cruciate ligament injuries, Part 2. Am J Sports Med 33:1751–1767CrossRefPubMedGoogle Scholar
  5. 5.
    Beynnon B, Johnson R, Fleming B (2002) The science of anterior cruciate ligament rehabilitation. Clin Orthop 402:9–20CrossRefPubMedGoogle Scholar
  6. 6.
    Cascio B, Culp L, Cosgarea A (2004) Return to play after anterior cruciate ligament reconstruction. Clin Sports Med 23:395–408CrossRefPubMedGoogle Scholar
  7. 7.
    Cooper R, Taylor N, Feller J (2005) A randomised controlled trial of proprioceptive and balance training after surgical reconstruction of the anterior cruciate ligament. Res Sports Med 13:217–230PubMedGoogle Scholar
  8. 8.
    DeHaven K, Cosgarea A, Sebastianelli W (2003) Arthrofibrosis of the knee following ligament surgery. Instr Course Lect 52:369–381PubMedGoogle Scholar
  9. 9.
    Fleming B, Oksendahl H, Beynnon B (2005) Open- or closed kinetic chain exercises after anterior cruciate ligament reconstruction. Exerc Sport Sci Rev 33:134–140CrossRefPubMedGoogle Scholar
  10. 10.
    Frosch KH, Habermann F, Fuchs M, Michel A, Schmidtmann U, Stürmer K (2001) Ist die erweiterte ambulante physiotherapie (EAP) nach vorderer kruezbandersatzplastik indiziert. Unfallchirurg 104:513–518CrossRefPubMedGoogle Scholar
  11. 11.
    Gale T, Richmond J (2006) Bone patellar tendon bone anterior cruciate ligament reconstruction. Tech Knee Surg 5:72–79CrossRefGoogle Scholar
  12. 12.
    Goldblatt J, Fitzsimmons S, Balk E, Richmond J (2005) Reconstruction of the anterior cruciate ligament, meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 21:791–803CrossRefPubMedGoogle Scholar
  13. 13.
    Harilainen A, Sandelin J (2006) Post-operative use of knee brace in bone-tendon-bone patellar tendon anterior cruciate ligament reconstruction, 5-year follow-up results of a randomized prospective study. Scand J Med Sci Sports 16:14–18CrossRefPubMedGoogle Scholar
  14. 14.
    Haverkamp D, Sierevelt I, Breugem S, Lohuis K, Blankevoort L, Dijk CN (2006) Translation and validation of the Dutch version of the international knee documentation committee subjective knee form. Am J Sports Med 34:1680–1684CrossRefPubMedGoogle Scholar
  15. 15.
    Heijne A, Werner S (2007) Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts, a prospective randomized outcome study. Knee Surg Sports Traumatol Arthosc 15:402–421CrossRefGoogle Scholar
  16. 16.
    Henriksson M, Rockborn P, Good L (2002) Range of motion training in brace versus plaster immobilization after anterior cruciate ligament reconstruction, a prospective randomized comparison with a 2-year follow up. Scand J Med Sci Sports 12:73–80CrossRefPubMedGoogle Scholar
  17. 17.
    Hooper D, Morrissey M, Drechsler W, Morrissey D, King J (2001) Open and closed kinetic chain exercises in the early period after anterior cruciate ligament reconstruction. Am J Sports Med 29:167–174PubMedGoogle Scholar
  18. 18.
    Insall JN, Scott WN (2001) Surgery of the knee. 3rh edn. Volume 1. Churchill Livingstone, New YorkGoogle Scholar
  19. 19.
    Keating J, Matyas T (1996) The influence of subject and test design on dynamometric measurements of extremity muscles. Phys Ther 76:866–889PubMedGoogle Scholar
  20. 20.
    Lahav A, Burks R (2005) Evaluation of the failed ACL reconstruction. Sports Med Arthrosc Rev 13:8–16CrossRefGoogle Scholar
  21. 21.
    Liu-Ambrose T, Taunton J, MacIntyre D, McConkey P, Khan K (2003) The effects of proprioceptive or strength training on the neuromuscular function of the ACL reconstructed knee, a randomized clinical trial. Scand J Med Sci Sports 13:115–123CrossRefPubMedGoogle Scholar
  22. 22.
    Maddison R, Prapavessis H, Clatworthy M (2006) Modelling and rehabilitation following anterior cruciate ligament reconstruction. Ann Behav Med 31:89–98CrossRefPubMedGoogle Scholar
  23. 23.
    Majima T, Yasuda K, Tago H, Tanabe Y, Minami A (2002) Rehabilitation after hamstring anterior cruciate ligament reconstruction. Clin Orthop 397:370–380CrossRefPubMedGoogle Scholar
  24. 24.
    Mc Carty L, Bach B (2005) Rehabilitation after patellar tendon autograft anterior cruciate ligament reconstruction. Tech Orthop 20:439–451CrossRefGoogle Scholar
  25. 25.
    Meyers M, Sterling J, Marley R (2002) Efficacy of stairclimber versus cycle ergometry in postoperative anterior cruciate ligament rehabilitation. Clin J Sport Med 12:85–94CrossRefPubMedGoogle Scholar
  26. 26.
    Mikkelsen C, Cerulli G, Lorenzini M, Bergstrand G, Werner S (2003) Can a post-operative brace in slight hyperextension prevent extension deficit after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthosc 11:318–321CrossRefGoogle Scholar
  27. 27.
    Mikkelsen C, Werner S, Eriksson E (2000) Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sport, a prospective matched follow-up study. Knee Surg Sports Traumatol Arhrosc 8:337–342CrossRefGoogle Scholar
  28. 28.
    Möller E, Forssblad M, Hansson L, Wange P, Weidenhielm L (2001) Bracing versus nonbracing in rehabilitation after anterior cruciate ligament reconstruction, a randomized prospective study with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 9:102–108CrossRefPubMedGoogle Scholar
  29. 29.
    Morrissey M, Drechsler W, Morrissey D, Knight P, Armstrong P, McAuliffe T (2002) Effects of distally fixated versus nondistally fixated leg extensor resistance training on knee pain in the early period after anterior cruciate ligament reconstruction. Phys Ther 82:35–43PubMedGoogle Scholar
  30. 30.
    Morrissey M, Hudson Z, Drechsler W, Coutts F, Knight P, King J (2000) Effects of open versus closed kinetic chain training on knee laxity in the early period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 8:343–348CrossRefPubMedGoogle Scholar
  31. 31.
    O’Connor D, Laughlin M, Woods G (2005) Factors related to additional knee injuries after anterior cruciate ligament injury. Arthroscopy 21:431–438CrossRefPubMedGoogle Scholar
  32. 32.
    Perry M, Morrissey M, King J, Morrissey D, Earnshaw P (2005) Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 13:357–369CrossRefPubMedGoogle Scholar
  33. 33.
    Pförringer W, Kremer C (2005) Die nachbehandlung operativ versorgter frischer vordere kreuzbandrupturen, eine randomisierte prospective studie. Sportverletz Sportschaden 19:134–139CrossRefPubMedGoogle Scholar
  34. 34.
    Pinczewski L, Lyman J, Salmon L, Russell V, Roe J, Linklater J (2007) A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft, a controlled, prospective trial. Am J Sports Med 35:564–574CrossRefPubMedGoogle Scholar
  35. 35.
    Plas C, Dingjan R, Hamel A et al. (1998) Nederlands Huisartsen Genootschap standaard traumatische knieproblemen M66. Available via DIALOG. http://nhg.artsennet.nl/upload/104/standaarden/M66/std.htm. Accessed June 1998
  36. 36.
    Potter N (2006) Complications and treatment during rehabilitation after anterior cruciate ligament reconstruction. Oper Tech Sports Med 14:50–58CrossRefGoogle Scholar
  37. 37.
    Raynor M, Pietrobon R, Guller U, Higgins L (2005) Cryotherapy after ACL reconstruction. J Knee Surg 18:123–129PubMedGoogle Scholar
  38. 38.
    Rebel M (2000) Koordinatives training nach VKB-operationen. Sportverletz Sportschaden 14:12–19CrossRefPubMedGoogle Scholar
  39. 39.
    Risberg M, Holm I, Steen H, Eriksson J, Ekeland A (1999) The effect of knee bracing after anterior cruciate ligament reconstruction, a prospective, randomized study with two years follow up. Am J Sports Med 27:76–83PubMedGoogle Scholar
  40. 40.
    Risberg M, Lewek M, Snyder-Mackler L (2004) A systematic review of evidence for anterior cruciate ligament rehabilitation, how much and what type. Phys Ther Sport 5:125–145CrossRefGoogle Scholar
  41. 41.
    Risberg M, Mork M, Jenssen H, Holm I (2001) Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 31:620–631PubMedGoogle Scholar
  42. 42.
    Ross M, Denegar C, Winzenried J (2001) Implementation of open and closed kinetic chain quadriceps strengthening exercises after anterior cruciate ligament reconstruction. J Strength Cond Res 15:466–473CrossRefPubMedGoogle Scholar
  43. 43.
    Shaw T (2002) Accelerated rehabilitation following anterior cruciate ligament reconstruction. Phys Ther Sport 3:19–26CrossRefGoogle Scholar
  44. 44.
    Shaw T, Chipchase L, Williams M (2004) A users guide to outcome measurement following reconstruction. Phys Ther Sport 5:57–67Google Scholar
  45. 45.
    Shaw T, Williams M, Chipchase L (2005) Early quadriceps exercises affect the outcome of ACL reconstruction, a randomised controlled trial. Aust J Physiother 51:9–17PubMedGoogle Scholar
  46. 46.
    Shelbourne K, Patel D (1999) Treatment of limited motion after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthosc 7:85–92CrossRefGoogle Scholar
  47. 47.
    Strehl A, Eggli S (2007) The value of conservative treatment in ruptures of the anterior cruciate ligament (ACL). J Trauma 62:1159–1162CrossRefPubMedGoogle Scholar
  48. 48.
    Tandogan R, Taser O, Kayaalp A et al (2004) Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears, relationship with age, time from injury, and level of sport. Knee Surg Sports Traumatol Arthrosc 12:262–270CrossRefPubMedGoogle Scholar
  49. 49.
    Trees A, Howe T, Dixon J, White L (2005) Exercise for treating isolated anterior cruciate ligament injuries in adults (review). Cochrane Database Syst Rev 4:1–41Google Scholar
  50. 50.
    Tsaklis P, Abatzides G (2002) ACL rehabilitation program using a combined isokinetic and isotonic strengthening protocol. Isokinet Exerc Sci 10:211–219Google Scholar
  51. 51.
    Wilk K, Reinold M, Hooks T (2003) Recent advances in the rehabilitation of isolated and combined anterior cruciate ligament injuries. Orthop Clin North Am 34:107–137CrossRefPubMedGoogle Scholar
  52. 52.
    Wu G, Ng G, Mak A (2001) Effects of knee bracing on the sensorimotor function of subjects with anterior cruciate ligament reconstruction. Am J Sports Med 29:641–645PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • S. van Grinsven
    • 1
  • R. E. H. van Cingel
    • 2
  • C. J. M. Holla
    • 3
  • C. J. M. van Loon
    • 4
  1. 1.Department of Physical TherapyRijnstate HospitalArnhemThe Netherlands
  2. 2.Sports Medicine Center PapendalArnhemThe Netherlands
  3. 3.Department of Physical TherapyRijnstate HospitalArnhemThe Netherlands
  4. 4.Department of Orthopaedic SurgeryRijnstate HospitalArnhemThe Netherlands

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