Skip to main content
SpringerLink
Log in

ACL Rehabilitation Progression: Where Are We Now?

Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Cite this article

Abstract

Purpose of Review

With the increase of publications available to the rehabilitation specialist, there is a need to identify a progression to safely progress the patient through their post-operative ACL reconstruction rehabilitation program. Rehabilitation after ACL reconstruction should follow an evidence-based functional progression with graded increase in difficulty in activities.

Recent Findings

Clinicians should be discouraged not to use strict time frames and protocols when treating patients following ACL reconstruction. Rather, guidelines should be followed that allow the rehabilitation specialists to progress the patient as improvements in strength, edema, proprioception, pain, and range of motion are demonstrated. Prior to returning to sport, specific objective quantitative and qualitative criteria should be met. The time from surgery should not be the only consideration.

Summary

The rehabilitation specialist needs to take into account tissue healing, any concomitant procedures, patellofemoral joint forces, and the goals of the patient in crafting a structured rehabilitation program. Achieving symmetrical full knee extension, decreasing knee joint effusion, and quadriceps activation early in the rehabilitation process set the stage for a safe progression. Weight bearing is begun immediately following surgery to promote knee extension and hinder quadriceps inhibition. As the patient progresses through their rehabilitative course, the rehabilitation specialist should continually challenge the patient as is appropriate based upon their goals, their levels of strength, amount of healing, and the performance of the given task.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Albrieght JC, Carpenter JE, Graf BK, Richmond JC, editors. Knee and leg: soft-tissue trauma. Rosemont: Orthopaedic Knowledge Update 6 American Academy of Orthopaedic Surgeons; 1999.

    Google Scholar 

  2. Centers for Disease Control & Prevention, National Center for Health Statistics. National hospital discharge survey: annual summary, 1996 [monograph on the Internet]. Atlanta: Centers for Disease Control and Prevention; 1996.

    Google Scholar 

  3. Kegerreis S. The construction and implementation of a functional progression as a component of athletic rehabilitation. J Orthop Sports Phys Ther. 1983;5(1):14–9.

    Article  CAS  PubMed  Google Scholar 

  4. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss of motion after anterior cruciate ligament reconstruction. Am J Sports Med. 1992;20(5):499–506.

    Article  CAS  PubMed  Google Scholar 

  5. • Shelbourne KD, Gray T. Minimum 10-year results after anterior cruciate ligament reconstruction: how the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery. Am J Sports Med. 2009;37(3):471–80. Study that demonstrates the long-term consequences of loss of knee extension range of motion following ACL surgery.

    Article  PubMed  Google Scholar 

  6. Benum P. Operative mobilization of stiff knees after surgical treatment of knee injuries and post traumatic conditions. Acta Orthop Scand. 1982;53(4):625–31.

    Article  CAS  PubMed  Google Scholar 

  7. McHugh MP, Tyler TF, Gleim GW, Nicholas SJ. Preoperative indicators of motion loss and weakness following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 1998;27:407–11.

    Article  CAS  PubMed  Google Scholar 

  8. Fulkerson JP, Hungerford D. Disorders of the patellofemoral joint. 2nd ed. Williams & Wilkens: Baltimore; 1990.

    Google Scholar 

  9. Schwartz RE, Asnis PD, Cavanaugh JT, Asnis SE, Simmons JE, Lasinski PJ. Short crank cycle ergometry. J Orthop Sports Phys Ther. 1991;13(2):95–100.

    Article  CAS  PubMed  Google Scholar 

  10. Fleming BC, Beynnon BD, Renstrom PA, et al. The strain behavior of the anterior cruciate ligament during bicycling. Am J Sports Med. 1998;26(1):109–18.

    Article  CAS  PubMed  Google Scholar 

  11. Bates A, Hanson N. The principles and properties of water. In: Aquatic exercise therapy. Philadelphia: WB Saunders, 1996:1–320.

  12. Harrison RA, Hilman M, Bulstrode S. Loading of the lower limb when walking partially immersed: implications for clinical practice. Physiotherapy. 1992;78:164.

    Article  Google Scholar 

  13. • Tyler TF, MP MH, Gleim GW, Nicholas SJ. The effect of immediate weightbearing after anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 1998;357:141–8. Study investigated the difference between beginning immediate weight bearing after surgery and delayed weight bearing after surgery.

    Article  Google Scholar 

  14. Spencer JD, Hayes KC, Alexander IJ. Knee joint effusion and quadriceps reflex inhibition in man. Arch Phys Med Rehabil. 1984;65(4):171–7.

    CAS  PubMed  Google Scholar 

  15. Delitto A, Rose SJ, McKowen JM, Lehman RC, Thomas JA, Shively RA. Electrical stimulation versus voluntary exercise in strengthening thigh musculature after anterior cruciate ligament reconstructive surgery. Phys Ther. 1988;68:660–3.

    Article  CAS  PubMed  Google Scholar 

  16. Lossing I, Gremby G, Johnson T, Morelli B, Peterson L, Renstrom P. Effects of electrical muscle stimulation combined with voluntary contractions after knee ligament surgery. Med Sci Sports Exerc. 1988;20(1):93–8.

    Article  Google Scholar 

  17. Snyder-Mackler L, Ladin Z, Schepsis AA, Young JC. Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament: effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles. J Bone Joint Surg Am. 1991;73(7):1025–36.

    Article  CAS  PubMed  Google Scholar 

  18. Henning CE, Lynch MA, Glick KR. An in vivo strain gauge study of elongation of the anterior cruciate ligament. Am J Sports Med. 1985;13(1):22–6.

    Article  CAS  PubMed  Google Scholar 

  19. Lutz GE, Palmitier RA, An KN, et al. Comparison of tibiofemoral joint forces during open kinetic chain and closed kinetic chain exercises. J Bone Joint Surg Am. 1993;75(5):732–9.

    Article  CAS  PubMed  Google Scholar 

  20. Yack HJ, Collins CE, Whieldon TJ. Comparison of closed and open kinetic chain exercise in the anterior cruciate ligament-deficient knee. Am J Sports Med. 1993;21(1):49–54.

    Article  CAS  PubMed  Google Scholar 

  21. Ohkoshi Y, Yasuda K, Kaneda K, et al. Biomechanical analysis of rehabilitation in the standing position. Am J Sports Med. 1991;19(6):605–11.

    Article  CAS  PubMed  Google Scholar 

  22. • Wilk KE, Escamilla RF, Fleisig GS, et al. A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med. 1996;24(4):518–27. Study compares the joint forces on the knee during two different open and closed kinetic chain activities commonly used during rehabilitation.

    Article  CAS  PubMed  Google Scholar 

  23. Bynum EB, Barrack RL, Alexander AH. Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study. Am J Sports Med. 1995 Jul-Aug;23(4):401–6.

    Article  CAS  PubMed  Google Scholar 

  24. Hooper D, Morrissey M, Drechsler W, Morrissey D, King J. Open and closed kinetic chain exercises in the early period after anterior cruciate ligament reconstruction. Am J Sports Med. 2001;297(2):167–74.

    Article  Google Scholar 

  25. Mikkelsen C, Werner S, Eriksson E. 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 Arthrosc. 2000;8:337–42.

    Article  CAS  PubMed  Google Scholar 

  26. Morrissey M, Drechsler W, Morrissey D, Knight P, Armstrong P, McAuliffe T. 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. 2002;82:35–43.

    Article  PubMed  Google Scholar 

  27. Corrigan JP, Cashman WF, Brady MP. Proprioception in the cruciate deficient knee. J Bone Joint Surg Br. 1992;74(2):247–50.

    CAS  PubMed  Google Scholar 

  28. Johansson H, Sjolander P, Soojka P. Activity in receptor afferents from the anterior cruciate ligament evokes reflex effects on fusimotor neurones. Neurosci Res. 1990;8(1):54–9.

    Article  CAS  PubMed  Google Scholar 

  29. Cavanaugh JT, Moy RJ. Balance and postoperative lower extremity joint reconstruction. Orthop Phys Ther Clin NA. 2002; 11(1):75–99.

  30. Flynn TW, Soutas-Little RW. Patellofemoral joint compressive forces in forward and backward running. J Orthop Sports Phys Ther. 1995;21(5):277–82.

    Article  CAS  PubMed  Google Scholar 

  31. Pinczewski LA, Lyman J, Salmaon LJ, Russell VJ, Roe J, Linklater J. A 10-year study comparison of anterior cruciate ligament reconstruction with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med. 2007;35:564–74.

    Article  PubMed  Google Scholar 

  32. • Paterno MV, Rauth MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014;42(7):1567–73. Study looks at the risk on further injury to both the ipsilateral and contralateral knees for up to 2 years following ACL reconstruction.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Decker MJ, Torry MR, Noonan TH, Sterett WI, Steadman JR. Gait retraining after anterior cruciate ligament reconstruction. Arch Phys Med Rehabil. 2004;85(5):848–56.

    Article  PubMed  Google Scholar 

  34. Ernst GP, Saliba E, Diduch DR, Hurwitz SR, Ball DW. Lower extremity compensations following anterior cruciate ligament reconstruction. Phys Ther. 2000;80(3):251–60.

    CAS  PubMed  Google Scholar 

  35. Mattacola CG, Perrin DH, Gansneder BM, Gieck JH, Saliba EN, McCue FC 3rd. Strength, functional outcome, and postural stability after anterior cruciate ligament reconstruction. J Athl Train. 2002;37(3):262–8.

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Sports Rehabilitation & Performance Center, Hospital For Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    John T. Cavanaugh & Matthew Powers

Authors
  1. John T. Cavanaugh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Matthew Powers
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to John T. Cavanaugh.

Ethics declarations

Conflict of Interest

Both authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

Additional information

This article is part of the Topical Collection on ACL Rehab

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cavanaugh, J.T., Powers, M. ACL Rehabilitation Progression: Where Are We Now?. Curr Rev Musculoskelet Med 10, 289–296 (2017). https://doi.org/10.1007/s12178-017-9426-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-017-9426-3

Keywords

search

Navigation