Anterior cruciate ligament reconstruction, rehabilitation, and return to play: 2015 update

Abstract

Anatomical discoveries and a growing appreciation of the knee as a complex organ are driving innovations in patient care decision-making following anterior cruciate ligament (ACL) injury. Surgeons are increasing their efforts to restore combined mechanical-neurosensory ACL function and placing more consideration on when to reconstruct versus repair native anatomical structures. Surgical options now include primary repair with or without reinforcing the injured ACL with suture-based internal bracing, and growing evidence supports biological augmentation using platelet-rich plasma and mesenchymal stem cells to enhance tissue healing. Physical therapists and athletic trainers are increasing their efforts to facilitate greater athlete cognitive engagement during therapeutic exercise performance to better restore nonimpaired neuromuscular control activation amplitude and timing. Knee brace design and use needs to evolve to better match these innovations and their influence on the rehabilitation plan timetable. There is a growing appreciation for the multifaceted characteristics of the rehabilitation process and how they influence neuromuscular, educational, and psychobehavioral treatment goal achievement. Multiple sources may influence the athlete during the return to sports process and clinical outcome measures need to be refined to better evaluate these influences. This update summarizes contemporary ACL surgical, medical, and rehabilitation interventions and future trends.

Keywords: arthroscopy; decision-making; function; knee; outcomes.

Figure 1

(A) Primary ACL repair using suture-based internal bracing system. (B) Single-socket, double-bundle ACL reconstruction using soft tissue quadriceps tendon autograft with aperture and extra-cortical fixation. Abbreviation: ACL, anterior cruciate ligament.

Figure 2

Primary medial collateral ligament repair using suture-based internal bracing system. Note: This image provided courtesy of Arthrex, Inc.

Figure 3

Off-road motorcycle racer performing intensive primarily frontal plane agility challenge with functional knee brace support.

Figure 4

American football athlete performing forward lunge-rotation (A); lateral slides with integrated shoulder elevation focusing on integrated upper-lower extremity and core neuromuscular activation and postural control using the Theraband CLX system (B); and full-speed pole cutting agility challenge with functional knee brace support (C).

Figure 5

Soccer athlete performing single-leg crossover hopping task with proper body mechanics instruction without knee brace support.

Figure 6

Soccer, Taekwondo, and basketball athletes performing single-leg neuromuscular control tasks on Bosu ball without knee brace support.

Figure 7

Soccer athlete performing single-leg lateral step-up with medicine ball held overhead (A) and progressive height two-legged hopping (B) to train self-efficacy and balanced lower extremity power without knee brace support.

Figure 8

Quadriceps femoris and hip flexor stretching (including rectus femoris). Start position (A) and end position (B). Crossed knee to chest gluteal region stretch (C). Notes: Both stretches are maintained for 30 seconds for two repetitions at each lower extremity.