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Non-operative Care of the Patient with an ACL-Deficient Knee

  • ACL Rehab (T Sgroi and J Molony, section editors)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this review is to provide an update to the most objective, evidence-based path through a non-operative course of rehabilitation after anterior cruciate ligament injury for those hoping to return to pivoting and cutting sports.

Recent Findings

Anterior cruciate ligament (ACL) injuries are prevalent in pivoting and cutting athletes with many of these patients electing to pursue surgical reconstruction in hopes of returning to prior levels of function. Despite many athletes pursing ACL reconstruction, some may elect to pursue a non-operative course of care. Success with this treatment plan should be defined as the ability to return to sport without subsequent giving way episodes.

Summary

Identification of those most likely to successfully return to sport with a non-operative course begins with completion of an evidence-based screening tool. If the patient has no concomitant injury and successfully passes the screening, they may proceed to a systematic, evidence-based progression through rehabilitation. Finally, the patient must complete a return to sport program and meet appropriate objective criteria, prior to return to sport.

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References

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

  1. Gottlob CA, Baker CL Jr. Anterior cruciate ligament reconstruction: socioeconomic issues and cost effectiveness. Am J Orthop (Belle Mead NJ). 2000;29:472–6.

    CAS  Google Scholar 

  2. Wright RW, Magnussen RA, Dunn WR, Spindler KP. Ipsilateral graft and contralateral ACL rupture at five years or more following ACL reconstruction: a systematic review. J Bone Joint Surg Am. 2011;93:1159–65.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Paterno MV, Rauh 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;42:1567–73.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596–606.

    Article  PubMed  Google Scholar 

  5. Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. 2004;50:3145–52.

    Article  CAS  PubMed  Google Scholar 

  6. •• Smith TO, Postle K, Penny F, McNamara I, Mann CJ. Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. Knee. 2014;21:462–70. Systematic review and meta analysis comparing operative and non-operative management of ACL injury.

  7. Noyes FR, Butler DL, Paulos LE, Grood ES. Intra-articular cruciate reconstruction. I: Perspectives on graft strength, vascularization, and immediate motion after replacement. Clin Orthop Relat Res. 1983;71–7.

  8. Fitzgerald GK, Axe MJ, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc. 2000;8:76–82.

    Article  CAS  PubMed  Google Scholar 

  9. •• Hurd W, Axe M, Snyder-Mackler L. Management of the athlete with acute anterior cruciate ligament deficiency. Sports health. 2009;1:39–46. This is a review article highlighting evidence based management of the athlete with ACL deficiency.

  10. Barber SD, Noyes FR, Mangine RE, McCloskey JW, Hartman W. Quantitative assessment of functional limitations in normal and anterior cruciate ligament-deficient knees. Clin Orthop. 1990;204–14.

  11. Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80:1132–45.

    Article  CAS  PubMed  Google Scholar 

  12. •• Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 1, outcomes. Am J Sports Med. 2008;36:40–7. This is a 10 year outcome study of patients who have pursued non-operative management of ACL injury.

  13. •• Bogunovic L, Matava MJ. Operative and nonoperative treatment options for ACL tears in the adult patient: a conceptual review. Phys Sportsmed. 2013;41:33–40. This is a clinical update of both operative and non-operative management of ACl injury in the athletic population.

  14. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med. 1994;22:632–44.

    Article  CAS  PubMed  Google Scholar 

  15. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. 1982;10:329–35.

    Article  CAS  PubMed  Google Scholar 

  16. Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am. 1995;77:1166–73.

    Article  CAS  PubMed  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;73:1025–36.

    Article  CAS  PubMed  Google Scholar 

  18. Tagesson S, Oberg B, Good L, Kvist J. A comprehensive rehabilitation program with quadriceps strengthening in closed versus open kinetic chain exercise in patients with anterior cruciate ligament deficiency: a randomized clinical trial evaluating dynamic tibial translation and muscle function. Am J Sports Med. 2008;36:298–307.

    Article  PubMed  Google Scholar 

  19. Beynnon BD, Fleming BC, Johnson RJ, Nichols CE, Renstrom PA, Pope MH. Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med. 1995;23:24–34.

    Article  CAS  PubMed  Google Scholar 

  20. Hewett TE, Paterno MV, Myer GD. Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Orthop Relat Res. 2002:76–94.

  21. Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism. Br J Sports Med. 2009;43:417–22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Chmielewski TL, Hurd WJ, Rudolph KS, Axe MJ, Snyder-Mackler L. Perturbation training improves knee kinematics and reduces muscle co-contraction after complete unilateral anterior cruciate ligament rupture. Phys Ther. 2005;85:740–9. discussion 50-4

    PubMed  Google Scholar 

  23. Chmielewski TL, Rudolph KS, Snyder-Mackler L. Development of dynamic knee stability after acute ACL injury. J Electromyogr Kinesiol. 2002;12:267–74.

    Article  PubMed  Google Scholar 

  24. Di Stasi SL, Hartigan EH, Snyder-Mackler L. Unilateral stance strategies of athletes with ACL deficiency. J Appl Biomech. 2012;28:374–86.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Di Stasi SL, Snyder-Mackler L. The effects of neuromuscular training on the gait patterns of ACL-deficient men and women. Clin Biomech (Bristol, Avon). 2012;27:360–5.

    Article  Google Scholar 

  26. Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Phys Ther. 2000;80:128–40.

    CAS  PubMed  Google Scholar 

  27. Beynnon BD, Fleming BC, Churchill DL, Brown D. The effect of anterior cruciate ligament deficiency and functional bracing on translation of the tibia relative to the femur during nonweightbearing and weightbearing. Am J Sports Med. 2003;31:99–105.

    Article  PubMed  Google Scholar 

  28. Fitzgerald GK, Axe MJ, Snyder-Mackler L. Proposed practice guidelines for nonoperative anterior cruciate ligament rehabilitation of physically active individuals. J Orthop Sports Phys Ther. 2000;30:194–203.

    Article  CAS  PubMed  Google Scholar 

  29. Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player’s risk of subsequent injury. Br J Sports Med. 2016;50:471–5.

    Article  PubMed  Google Scholar 

  30. Schmitt LC, Paterno MV, Ford KR, Myer GD, Hewett TE. Strength asymmetry and landing mechanics at return to sport after anterior cruciate ligament reconstruction. Med Sci Sports Exerc. 2015;47:1426–34.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Myer GD, Ford KR, Hewett TE. Tuck jump assessment for reducing anterior cruciate ligament injury risk. Athl Ther Today. 2008;13:39–44.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Physical therapy in sport: official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2008;9:9–15.

    Article  Google Scholar 

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Authors and Affiliations

  1. Division of Occupational Therapy and Physical Therapy, Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave MLC 10001, Cincinnati, OH, 45229, USA

    Mark V. Paterno

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  1. Mark V. Paterno
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Correspondence to Mark V. Paterno.

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The author declares that he has 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.

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This article is part of the Topical Collection on ACL Rehab

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Paterno, M.V. Non-operative Care of the Patient with an ACL-Deficient Knee. Curr Rev Musculoskelet Med 10, 322–327 (2017). https://doi.org/10.1007/s12178-017-9431-6

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  • DOI: https://doi.org/10.1007/s12178-017-9431-6

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