Annotated Bibliography

Rehabilitation Protocol for Injuries Related to the Unhappy Triad

Kemi Adeleke
5/2/2018

1. Anoka N, Nyland J, McGinnis M, Lee D, Doral M, Caborn D. Consideration of growth

factors and bio-scaffolds for treatment of combined grade II MCL and ACL
injury. Knee Surg Sports Traumatol, Arthrosc. May 2012;20(5):878-888.

When a grade II MCL injury occurs in combination with an ACL injury, its

dysfunction can lead to ACL graft slippage, elongation, and possible lift-off of the medial

femoral condyle with valgus knee force. The authors discuss how to improve the healing

of the above mentioned concomitant injuries. The role of growth factors and bio-

scaffolds will be dissected to determine their contribution to the situation at hand.

Researchers and surgeons should listen closely: if bio-scaffolds are proving to be

effective in the healing of MCLs by increasing tensile strength and presence of type I

collagen, what’s the next step on the path to getting bio-scaffolds safely approved as an

option for humans with an MCL tear? For a combined grade II MCL-ACL injury, a

strong MCL is vital when the ACL graft is vulnerable to compromise.

Surgeons must evaluate the patient holistically prior to determining the type of ACL-

graft used as well as its position to give the patient the best odds possible. I hope that

surgeons are advocating for further research on methods of bettering the treatment of

MCL lesions. My suggestions are made firmly with the understanding that most extrinsic

factors cannot be avoided.

2. Antonio F, Raffaello F, Erika G, Costanza F, Patrizia P, Stefano M. The meniscus tear.
State of the art of rehabilitation protocols related to surgical procedures. Muscles
Ligaments Tendons J. October 2012;2(4):295-301.

Varying from previous annotations, this article primarily focuses on the education of

the meniscal tear, conservative and surgical treatment, and specifically, rehabilitation

protocol. Several factors are to be considered when determining type of surgery as well

as rehabilitation protocol: type and location of tear, patient’s functional needs, recovery

time, and patient compliance, just to name a few. Partial meniscectomy is preferred over

total meniscectomy if the goal is preinjury sports activity level. Return to full activity

differs pert type of meniscal repair: 6-8 weeks after partial meniscectomy; 20 weeks after

peripheral suture; and at least 20 weeks after a complex meniscal suture. Generally,

meniscal rehabilitation begins with the reduction of pain and swelling followed by joint

mobility, strength and gait. Once good strength has been accomplished, proprioception

and balance can begin. Straight running and cutting is followed by return to physical

activity. 90% strength of uninvolved limb is recommended by this study before return.

Authors discredit the efficacy of rehabilitation protocols due to limited research and

scientific evidence. I found this article to be incredibly useful and detailed in the

discussion of every component of meniscal tears. Surgeons, physical therapists, athletic

trainers, and patients can all gain from this information.

3. Boguszewski D, Tomaszewska I, Adamczyk J, Białoszewski D. Evaluation of

effectiveness of kinesiotaping in supporting of rehabilitation of patients after
meniscus injury. Preliminary report. Asian J Med Sci. July 2015;6(4):61-66.
 The effect of kinesiotaping on patients with a damaged meniscus is being observed in

this study. Authors are looking to see if kinesiotaping can be of additional benefit to the

rehabilitation process. 23 participants, both male and female between the ages of 20 and

41, were split into an experimental and control group. They both had the same

rehabilitation protocol, with the exception of the experimental group receiving

kinesiotaping application. The outcomes measured were pain, edema, and ROM.

By four weeks of rehabilitation, all participants were close to reaching the ROM of

the uninjured limb. Those in the experimental group had improved flexibility sooner than

the control group. In addition, reduction of edema was seen more quickly in the group

with kinesiotaping application. Although all participants had a similar reduction in pain,

the control group frequented the use of analgesics more than the experimental group.

This study was completed in just 28 days and does not view long term benefits of

kinesiotaping. I’ve seen kinesiotaping used as a placebo effect; sometimes that’s all it

takes for an athlete to return to play. This study should be replicated with a longer time

period for this evidence to be applicable.

4. Bulgheroni E, Grassi A, Marcheggiani Muccioli G, et al. Long-term outcomes of medial

CMI 4. implant versus partial medial meniscectomy in patients with concomitant
ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. November
2015;23(11):3221-3227.

CMI is being compared to partial medial meniscectomy to determine long-term,

which is better in clinically and objectively treating patients with an ACL lesion and

partial medial meniscus. Previous studies are repeatedly referred to in this study to either

support or deny the present study’s results. At first glance, one might suggest this study
 to physicians or surgeons alone, but really this study could benefit both physical

therapists and athletic trainers recommending next steps for patients.

From the authors’ discussion, a few things are evident. In comparison to medial

meniscectomy, CMI improved knee laxity in the treatment of acute meniscal lesions only

and a decrease in reoperation rate in chronic patients was noted (in a previous study). The

latter had an effect on the participants’ choice of CMI over partial medial meniscectomy.

Less pain and higher activity levels were reported at the 10-year follow-up in patients

with chronic meniscal lesions.

CMI shows promise in individuals with chronic and acute meniscal lesions but it

should be noted that partial medial meniscectomies also had good long-term results.

Results should be taken lightly due to the small number of patients in both treatment

groups.

5. Christensen J, Goldfine L, Barker T, Collingridge D. What can the first 2 months tell us
about outcomes after anterior cruciate ligament reconstruction?. J Athl Train
(Allen Press). May 2015;50(5):508-515.

It is assumed that how you start can determine how you finish. This must be the basis

of which the cited journal stems from. Plenty of research has been done on the long-term

outcomes of an ACLR, so this study decided to hone in on the early phase of recovery

and its effect on long-term outcomes: both self-reported and subjective. Data was

collected at 1 and 2 months and compared to ≥12 months. This journal could benefit

several professions but I believe it to be especially important for athletic trainers and

physical therapists so that this information can be explained to athletes and patients alike.
 Results both agreed and disagreed with my opening statement. Subjective outcomes

were collected by the International Knee Documentation Committee (IKDC). Patients

scores during the first two months mainly showed positive correlation with their long-

term IKDC scores. In comparison, participants that had ACLR with meniscal or articular

cartilage damage had significant improvements at 1 month but their pain and limited

mobility was probably worse due to concomitant injuries.

Areas of improvement include data collection format, pre- and post-operative

assessments of all variables, less an assortment of participants plus an increase in sample

size.

6. Damian C, Damian M. Futsal Player Rehabilitation after anterior cruciate ligament

(ACL) reconstruction. Rom J Multidim Edu. March 2018;10(1):62-70.

Not only does this research aim to scientifically prove the steps of rehabilitation

protocol for an ACL injury, but it also aims to provide a futsal-specific return to sport

protocol in the span of 6 months. In the case of a male, 18-year-old, futsal player: he was

motivated to return to competition quickly and was psychologically prepared for a highly

intense rehabilitation protocol.

In 144 days, he was able to play in his first futsal game post-surgery. Studies show

that 4-9 months is the range for return; albeit the 6-month goal for return, the athlete’s

high intensity rehabilitation worked in his favor. This work is purposeful in providing

both physical therapists and athletic trainers a way to return an athlete quickly and

successfully. It should be noted that no two individuals with an ACL tear are the same,

therefore this protocol may not benefit all athletes. It took a psychologically-stable
 athlete, two-a-day sessions, and the Lower Extremity Functional Scale (LEFS) for this

athlete to return quickly.

With this case study having only recently been published, I do hope the authors plan

on following the athlete to see if re-injury or another injury occurs to further support or

oppose the case.

7. Defroda S, Hiller K, Cruz Jr. A. Pediatric anterior cruciate ligament rehabilitation: A

review. R I Med J. November 2017;100(11):26-30.

This review understands and prefers for return to play decisions to be made based on

functional testing as opposed to predetermined timelines that are subject to change. With

the focus on pediatric ACL rehabilitation, this information can be sought out by family,

AT, surgeon, coaches, and physical therapist because communication between this team

is necessary to ensure success of the athlete’s rehabilitation.

The purpose of this work is to address how best to rehabilitate an ACL injury in the

pediatrics population that is often eager to return to play. For this population, avoiding

surgery is considered since it preserves the growth plate. But research has shown that

nonsurgical treatment can increase risk of injury caused by instability. Pre-rehabilitation,

post-operative weight bearing, range of motion, and strengthening were all discussed

followed by functional training as the goal of post-operative ACLR.

After considering both the Children’s Healthcare of Philadelphia (CHOP) and the

Hospital for Special Surgery (HSS) protocols, the HSS protocol of allowing return to

sport after 7 months and at least 85% function compared with the uninvolved leg seems
 to better suit the pediatric population. I’d love to see the two protocols compared in a

longitudinal study for evidence-based advice.

8. Garrison J, Bothwell J, Cohen K, Conway J. Effects of hip strengthening on early

outcomes following anterior cruciate ligament reconstruction. Int J Sports Phys
Ther. April 2014;9(2):157-167.

The main focus of this study was to determine if the addition of hip strengthening

exercises to traditional rehabilitation might benefit the early stages of rehabilitation.

ROM, pain, and self-reported function were assessed at weeks 1, 4, 8, and 12; dynamic

balance was assessed with the Y Balance Test at 8 and 12 weeks. Results showed there

were no differences in YBT-LQ (lower quarter) reach differences at 8 weeks, only at 12

weeks in the ANT direction (could be caused by the increase in volume of hip exercises).

Pre- and post-hip strength were not tested at the beginning or at the 12-week mark. It

couldn’t be tested immediately post-surgery; a baseline for each individual would have

been necessary.

Previous research has identified weak gluteal muscles a cause of patellofemoral pain,

causing altered kinematics at the knee. Patients with patellofemoral pain often exemplify

great knee adduction and hip internal rotation, both mechanisms of ACL injuries. Lack of

neuromuscular control at the hip in conjunction with frontal plane loading in knee valgus

can predict ACL injury in female athletes, explaining the benefit of adding hip

strengthening exercises after ACL reconstruction (ACLR) could be beneficial.

9. Goyal A, Tanwar M, Joshi D, Chaudhary D. Practice guidelines for the management of

multiligamentous injuries of the knee. Indian J Orthop. September
2017;51(5):537-544.
 Authors sought to gather literature on trends associated with the management of

multiligamentous injuries of the knee. Data was compiled on the following: incidence,

surgical vs nonsurgical treatment, timing of surgery and repair vs reconstruction. This

study is aimed at researchers and physicians as a suggestion for further research on the

topic at hand.

It should be noted that none of the following is definitive due to the low incidence of

multiligamentous knee injury. Overall, subjectively surgical repair is preferred.

Objectively, conservative treatment has been effective in concomitant ACL and MCL

injuries (in terms of laxity) as well as grade 2 injuries to collaterals. A definite answer to

the question of acute vs delayed repair has not been reached but one thing is pretty

certain: an early, staged/single technique shows favorable outcomes. Reconstruction and

repair mainly depend on the type of, as well as the concomitant injuries. Still,

reconstruction seemed to outweigh repair in satisfactory outcomes.

Just like any rehabilitation protocol, it must be individualized case by case.

Regardless, an overarching standard protocol needs to be implemented. With the low

incidence of multiligamentous injuries, each case should be reported and dissected for

future practice to truly be evidence based.

10. Harston A, Nyland J, Brand E, McGinnis M, Caborn D. Collagen meniscus implantation:

A systematic review including rehabilitation and return to sports activity. Knee
Surg Sports Traumatol Arthrosc. January 2012;20(1):135-146.

Authors sought to determine how efficient the use of collagen meniscus implants

(CMI) would be. The question of whether or not CMI could be a viable option for serving

similarly to the meniscus, is still unknown. Although specifically aimed at physicians and
 surgeons alike, I am sure physical therapists and athletic trainers should be aware of if

CMI can be an option for clinical patients or athletes.

Generally, knee function and activity level among the patents post-CMI use showed

improvement. With the goal being growth of meniscus-like fibrocartilaginous tissue, it

was observed among the participants. What caused some confusion was the decrease in

size of the CMI-regenerated tissue in comparison to the original CMI.

Moving forward, authors suggest a number of improvements. Improvements include

determination of the following: how best to prevent knee osteoarthritis; safe and legal

amount of material to be used; the effect of rehabilitation guidelines on return to activity;

and the level at which return to sport activity can safely post-operation. I agree with the

authors’ additional suggestion of further research, specifically longitudinal studies to

properly answer questions about the future status of the knee.

11. Hirzinger C, Tauber M, Tempfer H, et al. ACL injuries and stem cell therapy. Arch
Orthop Trauma Surg. November 2014;134(11):1573-1578.

A non-operative approach to an ACL injury is not a foreign concept. These authors

hope to introduce a method of healing from the inside out. The usage of mesenchymal

stem cells (MSCs) for the treatment of an injured ACL is the basis of this study. Stem cell

therapy is the goal for less invasive strategies for ACL repair to be noted by physicians

primarily.

It is to my understanding that stem cell research has reached new heights since this

journal was published in 2014. But just four years ago, the authors reached a few

conclusions that weren’t as promising as they’d hoped. Having tested stem cells for ACL
 regeneration in only animal models, conclusions could not be made for humans. It was

unclear the source of regeneration: either trophic factors from the stem cells or the stem

cells alone. In addition, a timeline must be evidence based for proper implantation of the

stem cells.

Further research is without a doubt required. Luckily, with the knowledge of its

current use today, I know the authors’ need for future investigation was satisfied. Its use

specific to ACL regeneration is where I fall short. I have no doubt it is still attainable.

12. Joreitz R, Lynch A, Rabuck S, Lynch B, Davin S, Irrgang J. Patient-specific and surgery-
specific factors that affect return to sport after ACL reconstruction. Int J Sports
Phys Ther. April 2016;11(2):264-278.

This article aims to present what the literature says about outcomes of return to sport

after ACLR and to explain the biologic and patient-specific factors to be considered

throughout rehabilitation progression. Currently, two-thirds of individuals return to pre-

injury level of sport participation while only less than half returned to competition. This

study investigates who’s to blame.

Biologically, improper healing of the graft may be the primary cause of re- or

subsequent injury. The anatomic ACLR approach hopes to elongate the timespan of the

ACL. The use of non-invasive MRI has shown promise in detecting the biomechanical

qualities of a graft. There must be more research done to assess the endurance and

maturation of the graft. There are several risk factors to be considered for re-injury: time

after ACLR, functional capacity, hasty RTP and age. Female athletes are at a higher risk

of re-injury post-ACLR than males, because of greater dynamic valgus.

 The process of an ACLR is multi-factorial. The progression of rehabilitation can

depend on the mechanism of injury, graft, technique, physician and sport. All must be

considered when deciding on how best to get an individual back. This study is beneficial

to athletes, physicians, physical therapists, and athletic trainers.

13. Kraus T, Heidari N, Švehlík M, Schneider F, Sperl M, Linhart W. Outcome of repaired

unstable meniscal tears in children and adolescents. Acta Orthop. June
2012;83(3):261-266.

This study decided to focus on children and adolescents to note any differences seen

in younger populations. All 25 patients between the ages of 4 and 17 received an

intraarticular meniscal repair, some occurred simultaneously with an ACLR. Type and

location of the tear were considered in the collection of data. I believe pediatric

physicians can best benefit from this information because of its specificity and

comparisons to adult populations.

The success of adults with meniscal repairs heavily depends on the size and location

of the tear while in children and adolescents, their meniscal tears are successful

regardless of their location and vascular zone. The meniscus is entirely vascular at birth

so the patient, the better their chance of successful repair. In addition, half of the patients

also had an ACL tear. An ACLR in conjunction with a meniscal repair resulted in a more

favorable outcome, benefitting the healing process.

My suggestions coincide with the authors’ limitations: their short follow-up time

doesn’t touch on the possible deterioration that could come as the patients age. A

subjective collection of symptoms doesn’t reveal whether or not the meniscus has healed.

Future research must provide MRI evaluations to track progress.

14. Lejkowski P, Pajaczkowski J. Utilization of vascular restriction training in post-surgical
knee rehabilitation: a case report and introduction to an under-reported training
technique. J Can Chiropr Assoc. December 2011;55(4):280-287.

Vascular Restriction Training (VRT) is when an instrument, usually a blood pressure

cuff, is placed around the distal aspect of an extremity (in this case, the base of the thigh)

and pumped to a desired level (100 mmHg) to restrict blood flow either at rest or while

exercise is being conducted. This athlete had sustained the unhappy triad of a right ACL

tear, a grade 3 MCL sprain and a significant bucket-handle tear of the medial meniscus.

Measures were taken prior to and following the surgery, at which an accelerated post-

surgical ACL rehabilitation program began. With the follow-up only conducted 3

months’ post-surgery, the audience must consider that the rehabilitation process is not

quite complete. Regardless of limitations, the results suggested that atrophy was

prevented and there was some improvement in the following subjective functional

impairments: pain, symptoms, ADLs, sports & recreation function, and knee-related

quality of life. One must remember that as a case study, results cannot be generalized. It

is not certain that the results weren’t due to the traditional post-surgical rehabilitation

program. There is still future research to be done. As long as the individual doesn’t

complain of side effects, implementation of VRT may be beneficial.

15. Mikiko N, Tittle M, Piccininni J. Iliotibial band rupture and multiligamentous knee injury
in a football player. Int J Athl Ther Train. September 2014;19(5):20.

This case study stood out to me primarily because of the multiligamentous knee

injury. It follows the traumatic injury of a football player, surgical treatment, and
 rehabilitation. It serves to take the audience, specifically athletic trainers and physical

therapists, through a complex case of great detail.

The athlete went up to catch a ball, and upon landing, his foot was caught in the

turf while tackled above the waist, sending his upper body in the opposite direction of his

knee. Imaging ruled out a tibia fracture. An MRI revealed the following structures were

compromised: ACL, LCL, lateral meniscus, contusion of medial femoral condyle, IT

band, and calf and biceps femoris strain. Surgery was scheduled 14 days’ post injury.

The first surgery repaired the lateral structures, followed by three weeks

immobilized in extension. The surgeon required 90 degrees of flexion as a goal prior to

second surgery. At five weeks’ post-operation, ACLR and standard ACL protocol were

conducted. Specific to the injuries endured by our athlete, lateral exercises were added to

target the vastus lateralis. The athlete exemplified exception RTP. All I would request is a

detailed medical history to compare cases in the future.

16. Obada Bashir A, Alqarni S, Abdullghany Mohammed D, et al. A systematic review of

ACL reconstruction rehabilitation. Egypt J of Hosp Med. July 15, 2017;68(1):853-
864.

This systematic review of ACL rehabilitation used five studies to observe the

following rehabilitation components: bracing; continuous passive motion (CPM);

neuromuscular electrical stimulation (NMES); open kinetic chain (OKC) vs closed

kinetic chain (CKC) exercise; progressive eccentric exercise; home vs supervised

rehabilitation, accelerated rehabilitation and water based rehabilitation. The primary

focus is assessment of the above mentioned components to provide evidence based

advice for physicians, physical therapists, athletic trainers, and patients.

 Many components found no additional benefit over standard treatment, specifically

bracing and CPM. Bracing was thought to help promote full extension but opposing

views believe the brace to increase joint stiffness and muscle weakness. Neither can be

supported. CPM has been argued as a tool for promoting knee ROM in patients with

significant time between injury and surgery but the RCTs failed to report time. CKC vs

OKC found no significant difference. Home vs supervised rehabilitation were equally

effective. In the selection of RCTs, a limitation was placed on both CKC vs OKC

exercises and home vs supervised rehabilitation

These components each play a role in rehabilitation. Higher evidence is required for

confidence to accompany presentation of results. Aside from low evidence reviews, the

focus and purpose were clearly stated.

17. Oravitan M, Avram C. The Effectiveness of electromyographic biofeedback as part of a

meniscal repair rehabilitation programme. J Sports Sci Med. September
2013;12(3):526-532.

This study aims to determine if electromyographic biofeedback (EMG-BFB) can

be an effective tool for restoring muscle strength and neuromuscular coordination in

patients who have undergone meniscal repair. 64 patients were split into a study group

(SG) and a control group (CG). All participants partook in the same eight-week

rehabilitation protocol. Both groups had similar strength of hamstrings and vastii

muscles, therefore EMB-BFB wasn’t influential in regards to muscle strength. In other

news, EMG-BFB was beneficial in increasing the speed of muscle response to acoustic

stimulation, helping participants in the SG present better neuromuscular control.

Although EMG-BFB did no influence the activities of daily living, it did increase the
 participants’ perception of performing sport-specific activities following the eight-week

rehabilitation.

This study used hand-held dynamometry which had reliable measurements all

conducted by the same researcher, but an isokinetic machine would produce more

consistent and trustworthy results. In addition, continued check-ups would be useful in

reporting successes and/or setbacks, like re-injury. EMG-BFB can be an additional tool

utilized post-operative meniscal rehabilitation, but as usual, further studies are required.

18. Saha S, Adhya B, Dhillon M, Saini A. A study on the role of proprioceptive training in
non operative ACL injury rehabilitation. Indian J Physiother Occup Ther. July
2015;9(3):226-231.

The purpose of the following study is the define the role of proprioceptive training in

non-operative ACL rehabilitation. Physicians could find this useful in suggesting

rehabilitation protocol; athletic trainers and physical therapists could also add or increase

proprioceptive training in their rehabilitation plans.

Proprioceptive training proved to be beneficial. Specifically outlined in the study,

wobble board exercises were effective in the recovery of non-operative ACL injury.

Balance deficits can negatively affect knee function if not corrected. Strength is of

obvious importance to the ACL-deficient knee but it alone cannot guarantee overall

stability of proper functioning of the knee alone.

Upon individual examination per participant, significant improvement was

identified. In comparison, no significance was found. This study reaffirms a previously

mentioned statement: each case is to be treated person by person because no two

individuals are the same. For more concise results, an increase in sample size is required.
 Another interesting approach could be comparison of how beneficial proprioceptive

training is in the non-operative ACL injury vs surgically repaired ACL injury. Today,

standard rehabilitation protocol would lack without proprioceptive training so it’s

interesting to see past studies referenced for their results on proprioceptive training’s

usefulness.

19. Schein A, Matcuk G, White E, et al. Structure and function, injury, pathology, and
treatment of the medial collateral ligament of the knee. Emerg Radiol. December
2012;19(6):489-498.

This article serves as an informational discussion of the medial collateral ligament

(MCL), primarily of use for individuals unfamiliar with the MCL. The MCL is divided

into the superior MCL (sMCL) and the deep MCL (dMCL), which in between lies the

MCL bursa. The posterior oblique ligament (POL) also plays a significant part in

supporting the knee medially. Most sMCL injuries are low grade and can utilize

conservative nonoperative treatment. dMCL injuries seem to be the underlying cause of a

few pathologies including meniscal tears. It’s common to see ACL and PCL tears as well

as medial meniscus tears accompanying MCL injury. In the case of multiple injuries,

surgery is more than likely required.

Most authors agree that isolated grade 1 and 2 tears don’t need surgery. They can be

managed in-house by a physical therapist or an athletic trainer. Some might even argue

that a grade 3 could manage without surgery, as long as the ACL was still intact. If

surgery is required, the method of repair is determined by the surgeon. For both sMCL

and dMCL, return to high level of activity is possible.

20. Setuain I, Izquierdo M, Alfaro-Adrián J, et al. Differential effects of 2 rehabilitation
programs following anterior cruciate ligament reconstruction. J Sport Rehabil.
November 2017;26(6):544-555.

The authors pose one loaded question: is an Objective Criteria-Based Rehabilitation

(OCBR) algorithm more effective than the usual care (UCR) for ACLR one year

following the operation when primarily considering strength and cross-sectional area

(CSA)? Evidence based practice depends on recent research so that the most accurate

information can be used practically, which is why this article is comparing to methods of

rehabilitation: to find which is best. Now this is mainly addressed to the physician and the

physical therapist or the athletic trainer, whichever is conducting rehabilitation for the

individual.

Although neither the OCBR nor UCR protocols were effective in reducing atrophy of

the semitendinosus and gracilis, the OCBR protocol did result in greater muscle strength

gains. The authors would also recommend OCBR after ACLR to combat knee flexor

strength deficits and ensure symmetries of laxity levels at the knee. Further research

should be conducted and include different graft types to see if OCBR could still be

beneficial to individuals with a patellar tendon graft or an allograft. It could also be

interesting to find out how strength gains were significant with atrophy present.
Rehabilitation Protocol for Unhappy Triad of ACL, MCL, and Meniscus Tears

Phase I (first 6 to 8 weeks post-op)

Rehabilitation Goals - Control pain and inflammation

- Eliminate edema
- Initiate ROM (knee flexion and extension)
- Light strengthening
Precautions - NWB for 3-6 weeks
- Use of crutches with 25-50% WB
- Avoid OKC exercises
- Avoid excessive hamstring stretching till close of phase
- Must wear brace at all times (removed for showering)
- Graft is weakest around 6-8 weeks, avoid
strengthening during this time
- Core strengthening allowed
ROM - No limits on flexion
- 90 degrees of flexion by halfway mark of phase I
- Prone hangs (3 x 30 sec)
- SAQ sets (3 x 10)
- Heel slides/Wall slides (3 x 10)
- Ankle pumps 4-way (3 x 10)
- Gastroc-soleus stretching (3 x 30 sec)
- Hip ROM 4-way
- Stationary bike (seat adjusted to allow tolerable knee
flexion) (5-10 min)
Therapeutic Modalities/Exercise - Cryocuff, or ice (10-15 min)
- NMES (quad control)
30 - 35Hz @ 400 µs
usually 10 sec ON / OFF
- Self-mobilization of patella
- SLR 4 way (3 x 10)
Once flexion has reached 90°:
- CKC mini squats (3 x 10)
- Lateral step ups, bilateral (3 x 10)
- In-line lunges, bilateral (3 x 10)
- Leg press, progress to weighted (3 x 10)
- TKE (3 x 10)
- Seated BAPS board 4-way, (3 x 10)
Cardiovascular Exercise - Upper body ergometer (UBE) 5-10 min
- Swimming at close of phase
Progression Criteria - 75% to full WB as tolerated
- Greater than 110° of flexion
- Little to no edema
- Little to no pain
Additional notes:
- Use of treadmill (no incline) can begin around week 3 or 4 if tolerated
 - Exercise prescription to be modified as needed. Let pain be your guide

Phase II (8 to 16 weeks post-op)

Rehabilitation Goals - Increase strength (emphasis on hamstrings)

- Full flexion
- Return to normal gait
- Treadmill (progress fast walk to jog toward close of
phase)
Precautions - ACL graft is weakest at start of phase
- No hyperextension
- Continuation of core strengthening
- Ice as needed
ROM - Continue ROM exercises
- Progress hip ROM to hip strengthening (t-band, 3 x 10)
Therapeutic Exercises - Continue exercises following 90° goal
- Progress leg press to single leg
- Add lateral lunges towards close of phase (3 x 10)
- Standing wall squat (3 x 15 sec)
- Functional PNF patterns D1/D2
- Toe raises weighted (3 x 10)
- Weighted SLR 4-way (3 x 10
- Progress BAPS board to standing (balance, 3 x 30 sec)
Cardiovascular Exercise - Continue from phase I
- Add stationary bike (light resistance towards close of
phase)
Progression Criteria - Normalized gait
- Full ROM
- Light jog to run with normal gait
- Single leg stance
Additional notes:
- Initiate plyometric drills at close of phase

Phase III (16 to 24 weeks post-op)

Rehabilitation Goals - OKC exercises

- Implement agility drills
- Progress plyometrics
- Initiate sport-specific activity at close of phase
Precautions - Isokinetic testing
- Continuation of core strengthening
ROM - See additional notes
Therapeutic Exercises - Continue phase II exercises
- Ladder drills (down and back, twice)
Cardiovascular Exercise - Continue from phase II
- Increase resistance of stationary bike PRN
 - Stairmaster
- Elliptical
Progression Criteria - Ability to run with normal gait
- No pain with plyometrics
- Good performance with multi-planar functional
movements
Additional notes:

- Full ROM has been completed, ROM should be continued resistively

- Ex. of ladder drills: carioca, figure 8, backward running
- Ensure soreness does not surpass 3 to 5 days (note what elicits pain or soreness)

Phase IV (24 weeks+ post-op)

Rehabilitation Goals - Complete sport-specific activity

- Advanced functional training
Precautions - Continuation of core strengthening
ROM - Continue resistive ROM
Therapeutic Exercises - One foot multiplanar activities
- Sport-specific plyometrics/agility drills
Cardiovascular Exercise - Continue from phase III
Progression Criteria - Ability to run with normal gait and no pain
- Quad and Ham strength at least 80% of uninvolved
side (see additional notes)
- No swelling
- No restrictions of ROM
- Sport-specific qualifications
- Functional testing
Additional notes:

- As a result of severity of injury, greater than 80% strength bilaterally is suggested before RTP
- Treat individuals case by case
Additional resources

NMES: Muscle Stimulation, Tim Watson (2013).

http://www.electrotherapy.org/assets/Downloads/NMES%20Muscle%20Stimulation%20march%202013
.pdf

Roger Clemens Institute for Sports Medicine & Human Performance, Dr. Mark Adickes.
http://www.aclreconstructionhouston.com/pdf/acl-standard-protocol.pdf

Sports Medicine North/Orthopedic Specialty Center, Ira K. Evans, M.D.

https://www.sportsmednorth.com/sites/sportsmednorth.com/files/ACL-Reconstruction-Protocol.pdf

Rehabilitation of Knee Injuries

https://pdfs.semanticscholar.org/presentation/0074/e0a5dbb739e4875c34deb0277f148c334176.pdf

University of Wisconsin Sports Medicine. Rehabilitation Guidelines for Knee Multi-Ligament

Repair/Reconstruction (February 2018)
https://www.uwhealth.org/files/uwhealth/docs/pdf5/MultiLigament.pdf