Postoperative rehabilitation programs are believed to influence clinical outcome. The purpose of this paper was to outline the evolution of postoperative rehabilitation following anterior cruciate ligament reconstruction. Because of the controversy surrounding accelerated ACL rehabilitation and the concept of gaining terminal knee extension immediately following reconstruction, the authors felt justified in carrying out a retrospective comparison of traditional rehabilitation versus an accelerated approach. The objective variables under consideration included range of motion, isokinetic strength, and ligamentous stability. Results showed that active and passive range of motion, including hyperextension, returned more quickly and more fully in the accelerated group. Ligamentous stability was found to be equal to or better in the accelerated group despite a more aggressive rehabilitation approach. The results of this study indicated that an accelerated rehabilitation program following ACL reconstruction resulted in improved range of motion and strength gains without compromising stability.

J Orthop Sports Phys Ther 1992;15(6):309-316.

Key Words: anterior cruciate ligament, accelerated rehabilitation, terminal extension

J Orthop Sports Phys Ther 1992;15(6):303-308.

Key Words: anterior cruciate ligament reconstruction, rehabilitation, clinical outcome

Address reprint requests to: K. Donald Shelbourne, MD, Methodist Sports Medicine Center, 1815 North Capitol Avenue, Suite 530, Indianapolis, IN 46202.

To overcome many of the complications after ACL reconstruction (prolonged knee stiffness, limitation of complex extension, delay in strength recovery, anterior knee pain), yet still maintain knee stability, we developed a rehabilitation protocol that emphasizes full knee extension on the first postoperative day and immediate weightbearing according to the patient's tolerance. Of 800 patients who underwent intraarticuar ACL patellar tendon-bone graft reconstruction, performed by the same surgeon, the last 450 patients have followed the accelerated rehabilitation schedule as outlined in the protocol. A longer than 2 year followup is recorded for 73 of the patients in the accelerated rehabilitation group. On the 1st postoperative day, we encouraged these patients to walk with full weightbearing and full knee extension. By the 2nd postoperative week, the patients with a 100° range of motion participated in a guided exercise and strengthening program. By the 4th week, patients were permitted unlimited activities of daily living and were allowed to return to light sports activities as early as the 8th week if the Cybex strength scores of the involved extremity exceeded 70% of the scores of the noninvolved extremity and the patient had completed a sport-specific functional/agility program. The patient database was compiled from frequent clinical examinations, periodic knee questionnaires, and objective information, such as range of motion measurements, KT-1000 values, and Cybex strength scores. A series of graft biopsies obtained at various times have revealed no adverse histologic reaction. The evidence indicates that in this population, the accelerated rehabilitation program has been more effective than our initial program in reducing limitations of motion (particularly knee extension) and loss of strength while maintaining stability and preventing anterior knee pain.

J Orthop Sports Phys Ther 1992;15(6):256-264.

Key Words: retrospective study, clinical outcome, anterior cruciate ligament

Study Design: Case report. Background: To present the rehabilitative course, decision-making, and clinical milestones that allowed a top-level professional soccer player to return to full competitive activity 90 days after surgery. Case Description: The patient was a 35-year-old forward player who sustained an isolated complete tear of the left anterior cruciate ligament (ACL) in the midst of the competitive 2001-2002 season. He was in contention for a position on the Italian World Cup Team that was to be played 135 days after his injury, only if he demonstrated that he could return to play at the highest level before the team was selected. The patient underwent an arthroscopically assisted ACL reconstruction with a double-loop semitendinosus-gracilis autograft 4 days after the injury. Eight days after surgery he began rehabilitation at a rate of 2 sessions a day, 5 days a week, plus 1 session every Saturday morning. These sessions were performed in a pool for aquatic exercises, in a gymnasium for flexibility, coordination, and strength exercises, and on a soccer field for recovery of technical and tactical skills, with continuous monitoring of training intensity. Outcomes: The surgical technique and the progressive rehabilitation program allowed the patient to play for 20 minutes in an official First Division soccer game 77 days after surgery and to play a full game 90 days after surgery. Eighteen months postsurgery, the player had participated in 62 First Division matches, scoring 26 times, and had received no further treatment for his knee. Discussion: This case report suggests that early return to high-level competition after ACL reconstruction is possible in some instances. Some factors that may have favored the early return include optimal physical fitness before surgery, a strong psychological determination, an isolated ACL lesion, a properly placed and tensioned graft, a personalized progression of volume and intensity of exercise loads, and an appropriate density of rehabilitative training consisting of a mix of gymnasium, pool, and field exercises.

J Orthop Sport Phys Ther. 2005;35(2):52-66. doi: 10.2519/jospt.2005.1583

Key Words: ACL, knee, rehabilitation, semitendinosus

Study Design: Case study of a basketball player who underwent an alternative surgical procedure for anterior cruciate ligament (ACL) reconstruction and outline of the rehabilitation process designed for this procedure. Objectives: To describe the surgical procedure, detail the rehabilitation program, and report on this patient's clinical outcome. Background: Anterior cruciate ligament injury, its treatment, and rehabilitation continue to be an area of interest to both clinicians and researchers. Surgical procedures have been refined and rehabilitation programs are constantly being evaluated and updated to allow the safest and most predictable return to activity. Currently, the autogenous bone-patellar tendon-bone graft is the graft of choice for ACL reconstruction. Typically the graft is taken from the ipsilateral knee. An alternative procedure is to take the graft from the contralateral, noninvolved knee, allowing 2 separate rehabilitation programs to take place. Methods and Measures: The patient was followed from the time of injury to 2 years postoperatively. Data collected included range of motion, isokinetic strength scores, ligament stability scores, subjective evaluation, and functional measures. Results: At 3 weeks postoperative, the patient had nearly full range of motion in both knees, normal gait, and was beginning sport-specific drills. He was shooting the basketball and jumping by 5 weeks and returned to competitive sports 6 weeks after surgery. He was able to play in all 32 games of the season, starting in 23 of them. Conclusions: Using the contralateral patellar tendon graft may be appropriate for primary ACL reconstruction of patients, particularly those desiring an early, expedient return to athletic competition.

J Orthop Sports Phys Ther. 1999;29(3):144-159.

Key Words: functional clinical outcomes, contralateral patellar tendon graft, physical therapy