Postoperative Rehabilitation of the Multiple-Ligament Injured Knee

  • Craig J. EdsonEmail author
  • Gregory C. Fanelli


During the past several years, advancement in the surgical techniques and rehabilitation for the multiple-ligament injured knee has allowed patients to return to a higher level of function than previously considered following these devastating knee injuries. This chapter will provide guidelines for developing a rehabilitation program based on current scientific theories and experience gained over the past 25 years treating this challenging patient population. It is not intended as the final word but as the blueprint for implementing rehabilitation programs that can be modified depending on each individual patient’s need. Communication between the surgeon and the rehabilitation specialist is essential to assure that patients are able to progress steadily without compromising the surgically treated structures.


Postoperative rehabilitation Proprioceptive skills Strength Conditioning Rehabilitation program 


  1. 1.
    Edson CJ, Fanelli GC, Beck JD. Rehabilitation after multiple ligament reconstruction of the knee. Sports Med Arthrosc Rev. 2011;19(2):162–6.CrossRefGoogle Scholar
  2. 2.
    Edson CJ, Fanelli GC, Beck JD. Postoperative rehabilitation of the posterior cruciate ligament. Sports Med Arthrosc Rev. 2010;18(4):275–9.CrossRefGoogle Scholar
  3. 3.
    Fanelli GC. Posterior cruciate ligament rehabilitation: how slow should we go. Arthroscopy. 2008;24(2):234–5.CrossRefGoogle Scholar
  4. 4.
    Van Dommelon BA, Fowler PJ. Anatomy of the posterior cruciate ligament. A review. Am J Sports Med. 1989;17:24–9.CrossRefGoogle Scholar
  5. 5.
    Jackson WFM, Van der Tempel WM, Salmon LJ, Williams HA, Pinczewski LA. Endoscopically-assisted single-bundle posterior cruciate ligament reconstruction: results at minimum ten-year follow-up. J Bone Joint Surg Br. 2008;90B:1328–33.CrossRefGoogle Scholar
  6. 6.
    Escamilla RF, Zheng N, Imamura R, Macleod TD, Edwards WB, Hreljac A, Fleisig GS, Wilk KE, Moorman CT, Andrews JR. Cruciate ligament force during the wall squat and the one-leg squat. Med Sci Sports Exerc. 2009;41:408–17.CrossRefGoogle Scholar
  7. 7.
    Li G, Papannagari R, Li MS, Bingham J, Nha KW, Allred D, Gill T. Effect of posterior cruciate ligament deficiency on in vivo translation and rotation of the knee during weightbearing flexion. Am J Sports Med. 2008;36:474–9.CrossRefGoogle Scholar
  8. 8.
    Defrate LE, Gill TJ, Li G. In vivo function of the posterior cruciate ligament during weightbearing knee flexion. Am J Sports Med. 2004;32:1923–8.CrossRefGoogle Scholar
  9. 9.
    Pappannagari R, Defrate LE, Nha KW. Function of posterior cruciate ligament bundles during in vivo knee flexion. Am J Sports Med. 2007;35:1507–12.CrossRefGoogle Scholar
  10. 10.
    Shelbourne KD, Klootwyck TE, Wickens JH. Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in an accelerated rehabilitation program. Am J Sports Med. 1995;23:574–9.Google Scholar
  11. 11.
    Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med. 2008;27:405–24.CrossRefGoogle Scholar
  12. 12.
    Fanelli GF, Gianotti BF, Edson CJ. Arthroscopically assisted combined posterior cruciate ligament/posterior lateral reconstruction. Arthroscopy. 1996;12:521–30.CrossRefGoogle Scholar
  13. 13.
    Katonis P, Papoutsidakis A, Aligizakis A, Tzanakakis G, Kontakis GM, Papagelopoulous PJ. Mechanoreceptors of the posterior cruciate ligament. J Int Med Res. 2008;36:387–93.CrossRefGoogle Scholar
  14. 14.
    Lutz GE, Palmatier RA, An KN. Comparison of tibiofemoral joint forces during open-kinetic-chain and closed-kinetic-chain exercises. J Bone Joint Surg Am. 1993;75:732–9.CrossRefGoogle Scholar
  15. 15.
    Wilk KE. Rehabilitation of isolated and combined posterior cruciate ligament injuries. Clin Sports Med. 1994;13:649–77.PubMedGoogle Scholar
  16. 16.
    Gerber JP, Marcus RL, Dibble LE. Safety feasibility and efficacy of negative work exercise via eccentric muscle activity following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2007;37:10–8.CrossRefGoogle Scholar
  17. 17.
    Clarc N. Functional performance testing following knee ligament injury (review article). Phys Ther Sports. 2001;2:91–105.CrossRefGoogle Scholar
  18. 18.
    Griffin LY, Agel J, Albohm MJ, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000;8:141–50.CrossRefGoogle Scholar
  19. 19.
    Hewett TE, Paterno MV, Myer GD. Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Orthop Relat Res. 2002;302:76–94.CrossRefGoogle Scholar
  20. 20.
    Myers GD, Paterno MV, Ford KR, Hewett TR. Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament reconstruction. J Strength Cond Res. 2008;22:987–1014.CrossRefGoogle Scholar
  21. 21.
    Bjorklund K, Andersson L, Dalen N. Validity and responsiveness of the test of athletes with knee injuries: the new criterion based functional performance test instrument. Knee Surg Sports Traumatol Arthrosc. 2009;17:435–45.CrossRefGoogle Scholar
  22. 22.
    Zwolski C, Schmitt LC, Quatman-Yates C, Thomas S, Hewett TE, Paterno MV. The influence of quadriceps strength asymmetry on patient-reported function at time of return to sport after anterior cruicate ligament reconstruction. Am J Sports Med. 2015;43(9):2242–9.CrossRefGoogle Scholar
  23. 23.
    Lepley LK, Palmierei-Smith RM. Quadriceps strength, muscle activation failure, and patient-reported function at the time of return to active in patients following anterior cruciate ligament reconstruction: a cross-sectional study. J Orthop Sports Phys Ther. 2015;45(12):1017–25.CrossRefGoogle Scholar
  24. 24.
    Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction. Arthroscopy. 1996;12:5–14.CrossRefGoogle Scholar
  25. 25.
    Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction: 2–10 year follow-up. Arthroscopy. 2002;18:703–14.CrossRefGoogle Scholar
  26. 26.
    Fanelli GC, Edson CJ. Combined posterior cruciate ligament-posterolateral reconstruction with Achilles tendon allograft and biceps femoris tenodesis: 2–10 year follow-up. Arthroscopy. 2004;20:339–45.CrossRefGoogle Scholar
  27. 27.
    Fanelli GC, Orcutt DR, Edson CJ. Current concepts: the multiple ligament injured knee. Arthroscopy. 2005;21:471–86.CrossRefGoogle Scholar
  28. 28.
    Fanelli GC, Edson CJ, Orcutt DR, Harris JS, Zijerdi D. Treatment of combined ACL PCL medial lateral side injuries of the knee. J Knee Surg. 2005;28:240–8.Google Scholar
  29. 29.
    Fanelli GC, Edson CJ, Reinheimer KN, Garofalo R. Posterior cruciate ligament and posterolateral corner reconstruction. Sports Med Arthrosc Rev. 2007;15:168–75.CrossRefGoogle Scholar
  30. 30.
    Fanelli GC, Edson CJ, Reinheimer KN, Beck JD. Arthroscopic single bundle v double bundle posterior cruciate ligament reconstruction. Arthroscopy. 2008;24:e26 (Supplement).Google Scholar
  31. 31.
    Fanelli GC, Beck JD, Edson CJ. Double bundle posterior cruciate ligament reconstruction: surgical technique and results. Sports Med Arthrosc Rev. 2010;18(4):242–8.CrossRefGoogle Scholar
  32. 32.
    Fanelli GC, Beck JD, Edson CJ. Combined PCL ACL lateral and medial side injuries: treatment and results. Sports Med Arthrosc Rev. 2011;19(2):120130.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Physical Therapy Department, Sports MedicineGeisinger/HealthSouth Rehabilitation HospitalDanvilleUSA
  2. 2.Department of Orthopedic SurgeryGeisinger Medical Center/Health SystemDanvilleUSA

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