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Introduction
Recent • Anterior cruciate ligament
injuries common
advances in • ~200,000+ injuries annually;
ACL Griffin et al 2000
• 130,000 surgeries annually
Rehabilitation • Mall 2014
• Often non-contact,
Lenny Macrina MSPT, CSCS deceleration & twisting
Champion PT and Performance
injuries
Boston, MA • ACL rehab
• Scientifically based
• Well designed per each patient
• Many variables

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Not an isolated Injury Not an Isolated Injury

• Meniscus injury • Bone bruises present 71-100%
• 55-65% incidence patients
• Potter et al: AJSM ’12
• Lohmander: AJSM ʼ07
• Spindler: AJSM ʼ93
• Noyes: JBJS ʼ83 • Rosen: Arthroscopy ʼ91
• Tandogan: Knee Surg ʼ04 • Graf: AJSM ʼ93
• Christino et al OJSM 2019 • Johnson: AJSM ʼ98
• For every one year increase in age at surgery, • 65% exhibited marrow changes
there was a 21% increase in the odds of having a & cartilage thinning 6 yrs after
MMT and a 13% increase in the odds of having a
LMT ACL injury
• 47-62% had a meniscus tear • Faber: AJSM ʻ99

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Potter et al Long term implications to a knee injury

AJSM Feb ‘12 Snoeker et al BJSM 2019
• 42 knees in 40 patients
• Isolated ACL’s • Longitudinal cohort study in
• 14 non-op Sweden with & without diagnoses
• 28 reconstructed of knee injuries
• MRI f/u for 11 years
• In general, knee injury was
• ALL HAD A BONE BRUISE!!!! associated with a 6x increased risk
• 1 year out risk doubled for of knee OA.
cartilage loss
• 3x for PF joint • Cruciate ligament injury, meniscal
• 5-7 years post-op tear and fracture of the tibia
• Chondral degeneration accelerates plateau/patella associated with the
• 7-11 years out highest OA risks.
• 50x cartilage loss LFC
• 30x PF
• 19x MFC

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The Female Athlete Female ACL Injuries

• Female to Male incidence • Females appear to be more
• Reported as high as 9:1 depending on susceptible than males
the sport • Chandy (HS sports) 4.6 : 1
• By sport (Arthroscopy 2007) • Arendt (coll. sports) 4 : 1
• Basketball 3.5:1 • Malone (basketball) 8 : 1
• Soccer 2.67:1 • Lindenfeld (soccer) 6 : 1
• Trends show significant increase female • Ferratti (volleyball) 4 : 1
ACL’s since 2004 (Mall 2014) • McFarland (USNA) 10: 1
• Numerous reasons why but beyond this • Viola (skiing) 1.4: 1
lecture

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t to choose?
raf
What g

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Graft Selection
Ultimate Load to Failure and Stiffness of Various Graft Selections Graft Selection
• Patella tendon
• Autograft- gold standard
Graft Selection Strength(N/m) StiffnessTo Failure (N) • Allograft
• Hamstring tendon
• ‘less pain’- LIES!!
Native ACL 2160 240
• Increased laxity Paterno et al AJSM 2012
• Quad tendon
Patellar tendon 2977 455 • Lund et al Arthroscopy 2014
• less kneeling pain, graft site pain,
and sensitivity loss than seen with
Quadrupled hamstring 4140 807 BPTB grafts; however, similar
anterior knee stability and
subjective outcomes
Quadriceps tendon 2353 326 • Slone Arthroscopy 2015
• Xerogeanes OJSM July 2017

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BEAR- Bridge • Murray et al OJSM Mar 2019

Enhanced ACL • first-in-human study!

Repair
• similar outcomes to ACLR with a hamstring autograft

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BEAR- Bridge Enhanced ACL Repair

• Barnett et al Tissue Eng Jul 2020
BEAR- Bridge • Sanborn et al OJSM Feb 2022
• 100 patients
• 65 patients (28 males & 37 females), age 14-35 with a complete ACL
tear
Enhanced ACL • 65 BEAR, 33 HS, 2 PTG
• Underwent BEAR procedure
Repair • BEAR procedure had higher ACL-RSI scores at 6 months
postoperatively • Female subjects
• lower pain levels, better muscle recovery, and less knee • hamstring and quadriceps strength indices at 6 months than males
laxity at 6 months.
• better hop test results at the 6 and 12-month time period.
• No difference in reinjury rates at 24 months

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Ligamentization
• Still evolving and not well understood despite the research
• Limited research
Graft • Graft viable throughout healing
• Patella and hamstring
Revascularization tendon
• Resembles native ACL
• Vascularization does
Claes et al AJSM • Ultrastructural collagen differences exist occur
2011 • No agreement on timeframe of healing • Claes et al AJSM 2011
• Sampling error • Faster in animals than
• Lack of good research humans
• Animal data to human comparison • 3 Distinct remodeling
phases
• Pauzenberger et al
Arthroscopy 2013

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• Graft type
• PTG, HS, QTG, Allo, BEAR
• Meniscus repair vs excision
• Articular cartilage status
ACL • Bone bruise, chondroplasty,
previous lesions
Rehabilitation • Other structures involved?
• MCL
• PCL
• PL corner
• LCL
• NV structures

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Loss of
• Shelbourne & Gray: AJSM ’09
Extension • ACL-PTG reconstruction
• How the loss of motion and development of OA
• Loss of arthrokinematics (Ahmad ’98) • Loss of extension – even a loss of 3-5 degrees
affected outcome
• Loss of quad force (Blazevich ’09,
• Especially with meniscectomy & art cart
Knight ‘79)
• Scar tissue (Cyclops lesion)
Get Extension! damage
• Paulos ’87 • Patients with loss of extension & flexion had
• Must work to restore hyperextension
worse results
• Must get full knee hyperextension equivalent to
contralateral side!

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Mobilize the Patellar

Must have good patella mobility in all directions
Infrapatella scarring
Fat pads

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Range of Extension Correlates with Posterior Capsule Length

after Knee Remobilization Motion, motion, motion
Zhou et al Med Sci Sports Exerc 2018
• Get the knee moving
• 259 male rats • Prevents scarring
• Immobilized at 45 degree angle • Pain modulation
• Knee's posterior capsule limits extension after immobilization (in • Swelling control?
rats!) 🐭 • Mentally helps
• Knees immobilized for 1 and 2 wks partially recovered posterior capsule
length (P > 0.05).
• Knees immobilized beyond 2 wks failed to recover posterior capsule length

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ACL Strain
Weight bearing during WB
activities
Escamilla et al
• Typically WBAT depending on what’s involved
JOSPT 2012
• MD preference
• Brace locked vs unlocked
• Crutch training
• Usually off crutches after ~ 2 weeks
• Use Quad control and swelling as your guide

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ACL Beynnon J Biomechanics ‘98

Peak Strain @ Knee Angles

Isometric Leg Extension seated? (30 • Dynamic Leg Extension seated without
Nm Torque) external resistance
• 4.4% @15° • 2.8% @ 10°

• Dynamic Leg Extension • One-Legged Sit-to-Stand (tested at 30,

seated??with 45 N (10 lb) 50, 70°)
resistance • 2.8% @ 30°
• 3.8% @ 10° • Step-up/down & Stair-climbing (tested
at 30, 50, 70°)
• 150 N (33 lbs) Lachman Test
• 2.5-2.7% @ 30°
• 3.7% @ 30°
• Leg Press with 40% bodyweight
• Squatting with or without 136 N resistance
(30 lb) resistance • 2.1% @ 20°
• 3.6-4.0% @ 10° • Forward Lunge (tested at 30, 50, 70°)
• 1.9% @ 30°
• Stationary Bicycling 1.7%

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What about BFR after ACL surgery?

• Wortman et al 2021 AJSM
• Systematic review of 10 studies
• BFR can lead to improvements in strength, muscle size, and markers
of sports performance in healthy athletes

• Bowman et al Sports Health 2019

• BFR training had similar strengthening effects on both proximal and distal
muscle groups.
• Gains in the contralateral extremity may corroborate a systemic or crossover
effect.

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Blood Flow Restricted Resistance Exercise as a Post-

Orthopedic Surgery Rehabilitation Modality: A Review
of Venous Thromboembolism Risk
JOSPT Bond et al 2018

• Close to 40 different precaumons or contraindicamons

including:
❇ Age >40 years
❇ Creamne Supplement Use
❇ Diabetes
❇ General/Local Infecmon
❇ Hypertension
❇ Immobility >48 hr in the Past Month
❇ Open or Unhealed Soq Tissue Injuries
❇ Amongst many others

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What about BFR after ACL surgery?
• Okoroha et al OJSM 2023
• 46 patients in 2 groups
• 80% Limb occlusion pressure (LOP)
• Strength tested with HHD into table
• BFR group had significantly greater strength at 6 weeks
• No difference later on
What about BFR after ACL surgery?
• Garcia-Rodrigues et al Sports Health 2023
• Systematic review of 6 studies
• low loads combined with BFR improves pain, strength, functionality,
and CSA
• knee pain reduction and functionality are greater with BFR compared
with the use of high loads or immobilization.
• Analgesic effect?

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6

Videos
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Can the ACL heal on its own?
Big question recently!
Filbay et al BJSM Dec. 2023
• Cross Bracing protocol
• ‘pragmatic study, whereby data were
collected in the course of clinical
practice’
• 90 degrees for 4 weeks then slowly
extend
• Prophylactic DVT meds
• 90% had ‘healed’ ACL ruptures
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Arthrogenic Muscle
InhibiOon
• Norte et al J Sport Rehabil Dec. 2021
• Muscle function/activation issues after
an injury, particularly an ACL tear
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When to start open chain quads?
• Sooner than we once thought!?
• found no differences in joint laxity between ACLr patients that start
‘early’ vs delaying at 3 or 6 months
• Forelli et al Phys Ther Sport 2024
• Perriman et al JOSPT 2018
• Culvenor BJSM Dec 2022
• Forelli OJSM June 2023
• Start full OKC at ~ 4 weeks
• As ROM and symptoms allow
• Don’t rush it but safe to initiate
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Can the ACL heal on its own?
• Encouraging but…
• No control group
• We know about 1/3 can have a stable knee
without surgery
• Filbay BJSM Jan. 2023
• Hewett J Orthop June 2022
• Wait 8-12 weeks?
• DVT risk
• Patients and docs not blinded
• Radiologists
• Lachman bias
• Does MRI truly tell us a ligament is healed?
• 2nd look arthroscopy
• Knee arthrometer like KT2000
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Arthrogenic muscle inhibition after #ACL reconstruction: a
scoping review of the efficacy of interventions
• Sonnery-Cottet et al BJSM Sept 2018
• 20 papers included in the review
• Moderate-quality evidence for the efficacy of cryotherapy in the treatment of
AMI.
• Moderate-quality evidence for the efficacy of exercise in the treatment of AMI.
• Hamstring fatigue to improve quadriceps strength and decrease muscle
coactivation?
• Lowe et al 2018
• Vibration therapy- moderate-to high-quality evidence to support that adding
WBV
• Sogut et al J Sport Rehabil Mar 2022
• 4 randomized controlled trials
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AMI

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• Recently thought to have important factors in ACL rehab

Arthrogenic Muscle Inhibition • ACL tear affects vision and somatosensation

• Ultrasound!?
• Norte et al ArchPhys Med Rehabil
• Sept 2015
• Sham vs non-thermal ultrasound to
anteromedial knee for 17 min
• Quadriceps motoneuron pool
excitability was facilitated 20 minutes
afer treatment
• Rely on vision and not somatosensation
• Grooms et al JOSPT May 2015
• “increased uti-lization of visual processing and motor planning
resources”
• Rehab focuses on external vs internal cueing
Neurocognitive • vestibular, visual, and somatosensory)
• Chaput et al J Orthop Res Jan 2022
ACL • “visual cognition as a compensatory mechanism to sustain knee
proprioception and dynamic stability”
Implications • Criss et al Nature May 2023
• strength asymmetry exhibit recruit higher levels of brain activity
within regions responsible for visual-spatial integration and motor
planning
• modifying patient visual attention, clinician instruction, and motor
learning principles as a means to modulate neural activity during
rehabilitation
• Q-LSI > 90% do not show any cortical activation differences to
controls.

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Neurocognitive ACL Implications

Combining Neurocognitive and
Functional Tests to Improve
Return-to-Sport Decisions
Following ACL Reconstruction

• Grooms et al JOSPT Aug

2023
• “recommend evaluating
athletes’ neurocognitive
reliance by augmenting
return-to-sport testing with
combined neurocognitive
and motor dual-task
challenges”
• dual-task return to sport
tests

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• Mostly compare to bilateral extremity 6-12 months

Baseline post-op
• Is this good enough?
Strength • 70 athletes with ACL tear tested pre-op
• Quads strength
Tes/ng at • 4 hop tests

Wrong Time? • 57% achieved 90% LSIs for quadriceps strength and
all single-leg hop tests.

Wellsandt et • 28.6% patients met 90% EPIC levels

al JOSPT • Is this realistic to test people 1-4 months pre

surgery? And make them wait 3-4 months until
2017 testing is complete?

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Strength Testing Quadriceps and Hamstring

testing
Drop Jump Vertical
testing- Kotsifaki et al
BJSM 2022 and 2023

Wei et al- jump height,

reactive strength and
propulsion force deficit
10 months s/p

Issues 2 years after

surgery too!

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ACL Rehab-
Discussion
• Obtain homeostasis
• Control pain/swelling
• Progressive ROM
• Respect tissues
• Healing constraints
• There’s no rush
• 1st to finish line doesn’t always win
• Progressive strength/power/endurance
• NM control drills

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ACL Rehab- Discussion

• Get full knee ROM early
Thank You!
• Calm the knee down through motion and modalities
• Understand why the quads struggler to come back and do all we can
to help restore strength
• Don’t go too fast- achieve knee homeostasis
@LenMacPT
• Test regularly!
• At least 9-12 months and seems like even more time needed

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