Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression

Abstract

The management of patients after anterior cruciate ligament reconstruction should be evidence based. Since our original published guidelines in 1996, successful outcomes have been consistently achieved with the rehabilitation principles of early weight bearing, using a combination of weight-bearing and non-weight-bearing exercise focused on quadriceps and lower extremity strength, and meeting specific objective requirements for return to activity. As rehabilitative evidence and surgical technology and procedures have progressed, the original guidelines should be revisited to ensure that the most up-to-date evidence is guiding rehabilitative care. Emerging evidence on rehabilitative interventions and advancements in concomitant surgeries, including those addressing chondral and meniscal injuries, continues to grow and greatly affect the rehabilitative care of patients with anterior cruciate ligament reconstruction. The aim of this article is to update previously published rehabilitation guidelines, using the most recent research to reflect the most current evidence for management of patients after anterior cruciate ligament reconstruction. The focus will be on current concepts in rehabilitation interventions and modifications needed for concomitant surgery and pathology.

Level of evidence: Therapy, level 5.

FIGURE 1

Prone hang. Begin without weight for 10 minutes and progress to increased weight around the ankle and longer duration as needed for the desired result. A belt above the hips, wrapped around the table, may also be used to help avoid compensations at the hip during the activity.

FIGURE 2

Neuromuscular electrical stimulation (NMES). NMES is applied with the patient in a seated position and the knee in 60° of flexion (varying angles are used based on pain and comorbidities). The patient relaxes while electrical stimulation is applied to achieve 50% of the maximal volitional isometric contraction against a fixed resistance.

FIGURE 3

Wall squats. The patient begins, back against the wall and legs shoulder-width apart, by lowering down into a squat position of up to 90° of knee flexion, as pain and strength allow. The exercise is progressed by adding a hold time in the squat position and progressing to 90° of knee flexion if not achieved initially.

FIGURE 4

Single-leg balance. Single-leg balance should be performed with the stance knee slightly flexed and avoiding excessive genu valgum. Increasing time and adding distractions, such as a ball toss, will progress the difficulty.

FIGURE 5

Single-leg cone pick-up. The single-leg cone pick-up is a single-leg squat, while touching cones in a semicircle using the same hand. Proper knee alignment should be maintained, especially as the trunk rotates to reach the cones. Decreasing the height of the cones and placing the stance leg on an unstable surface will progress the difficulty of the exercise.

FIGURE 6

Progression to sports-related activities (adapted from Fitzgerald et al).