Issue: June 2017
June 14, 2017
21 min read
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Orthopedists, physical therapists discuss rehabilitation as it relates to ACL surgery

Issue: June 2017
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Injuries to the ACL are among the most common and functionally disabling conditions in orthopedics and sports medicine. The incidence in the United States has increased dramatically in the past 20 years. About 200,000 people sustain an ACL injury annually. In 1994, an estimated 86,687 surgeries for these injuries were performed. By 2013, the yearly number of procedures to treat ACL injuries increased by 58% to 148,714. By far, the female high school athlete is the patient demographic that is undergoing the greatest increase in ACL surgeries annually.

A proper clinical diagnosis and careful and precise ACL reconstruction surgery followed by proper, well-designed and progressive rehabilitation ensures a successful outcome and reduces the risk of postoperative complications. We have assembled an expert panel to answer frequently asked questions about the treatment of patients with an ACL injury. We hope the information conveyed helps Orthopedics Today readers learn some key points about ACL treatment that they can readily implement.

Kevin E. Wilk, DPT, FAPTA
Moderator

Roundtable Participants

  • Kevin E. Wilk, DPT, FAPTA
  • Moderator

  • Kevin E. Wilk, DPT, FAPTA
  • Birmingham, Ala.
  • Brian J. Cole, MD, MBA
  • Brian J. Cole, MD, MBA
  • Chicago
  • Darren L. Johnson, MD
  • Darren L. Johnson, MD
  • Lexington, Ky.
  • Robert E. Mangine, MEd, PT, ATC
  • Robert E. Mangine, MEd, PT, ATC
  • Cincinnati
  • Frank R. Noyes, MD
  • Frank R. Noyes, MD
  • Cincinnati
  • Russ M. Paine, PT
  • Russ M. Paine, PT
  • Houston

Kevin E. Wilk, DPT, FAPTA: How important is preoperative rehabilitation before ACL surgery?

Frank R. Noyes, MD: All our patients are treated with preoperative rehabilitation for about 6 weeks or until pain and swelling subside and joint motion, normal gait mechanics, and muscle function are restored. In our experience, this delay markedly reduces the incidence of postoperative knee motion complications and persistent muscle weakness. The program includes electrical muscle stimulation, gait retraining, open and closed kinetic chain exercises (with range of motion limits for knee extension to 90° to 30° and leg press to 70° to 10°). Aerobic conditioning begins when pain and swelling permit and includes stationary bicycling, swimming, elliptical machines and ski machines.

Brian J. Cole, MD, MBA: I believe having a “quiet” knee with minimal swelling and pain is a requisite for surgery. More importantly, restoration of motion, especially extension is also necessary to optimize the postoperative outcome. Notably, some patients might have a mechanical block (ACL stump, displaced meniscus tear) that prevents them from achieving full extension, but much of the time hamstring over-activity is responsible and this can be rectified presurgically with prehabilitation. I tell my patients that absent of engaging in “ACL-dependent” activities presurgically, I want their knee to feel as normal as possible. This includes re-engaging upstream (core) and downstream muscle function.

Darren L. Johnson, MD: Preoperative rehabilitation is important for acute ACL tears, but less so for chronic tears in patients who have full motion and the major muscle groups are all working normally. Also important for preoperative rehabilitation is to educate patients and tell them these are the exact things they need to be doing daily after their surgery on the days they do not attend formal physical therapy. In today’s world, that is often 4 days to 5 days of a 7-day week. There can be no off days once surgery is done, until the motion is normal.

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Robert E. Mangine, MEd, PT, ATC: Presurgical rehabilitation is just as critical as the post-surgical phase, as it sets the tone for the entire process. In addition to the typical treatment of regaining range of motion, assuring extensor mechanism, control and reducing the post-injury effusion, other elements need to be evaluated. In today’s sports medicine climate, athletes are more tuned into the injury management based on information readily available on various websites leading most patients to have preconceived ideas of what they will be going through. Our goal in this stage is to define the process, be goal oriented and manage not only the physical, but also the psychological element. This phase also allows the clinician to evaluate all the factors that will control the outcome.

Russ M. Paine, PT: Preoperative rehabilitation offers the injured athlete a distinct advantage over those patients who are unable to receive treatment prior to reconstruction of the ACL. There is a definite overflow of the preoperative rehabilitation achievements to the postoperative rehabilitation regime. I believe that regaining a strong quadriceps contraction is often overlooked prior to surgery and one of the main factors that has positive transitional effects to successful early ACL postop recovery. If the patient can maintain a strong quadricep electromyogram (EMG) signal and force the knee into extension during the isometric quad contraction, then many of the early postoperative complications can be avoided.

Wilk: We firmly agree that preoperative rehabilitation is critical to postoperative success. The patient’s goals are to physically and mentally prepare for the surgery and postoperative rehabilitation program. Reducing swelling, pain, normalizing motion, activating quadriceps and restoring neuromuscular are all critical goals prior to surgery. We also need to protect the knee from further injury during this phase. We use a drop locked brace in full extension to prevent giving way episodes of the knee. Failla and colleagues reported a preoperative rehabilitation program improved ACL reconstruction outcomes at 2-year follow-up.

Wilk: Do you have any specific criteria you like to meet prior to performing ACL surgery?

Noyes: Resolution of pain and swelling and restoration of muscle function and normal range of motion are paramount. The only exception is knees that have a concomitant displaced bucket-handle meniscus tear; these undergo surgery within 7 days to 10 days to reduce the meniscus to a normal location and repair the tear. Indications for ACL reconstruction include a complete ligament rupture (greater than 5-mm increased anteroposterior translation on KT-2000 and positive pivot shift test) and a patient who desires the best knee possible.

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Cole: Optimally, it is full range of motion, no swelling, pain or limp. Essentially, I would like them to feel that their knee feels “almost normal.” Obviously, there are injury patterns that require earlier intervention, such as a bucket-handle meniscus tear or a posterolateral corner injury that may not allow the patient to achieve these preoperative goals.

Johnson: Criteria before surgery include full extension with isometric quad firing without lag. “Walk without a limp,” is one guideline patients understand. The exception is acute or chronic ACL injury with a bucket-handle meniscus tear, that gets braced, toe-touch weight-bearing and surgery urgently. I am not as worried about full flexion as I am about full extension and normal patellar excursion.

Paine: Specific criteria that we like to see prior to surgery include: ability to ambulate without a limp; 5° or less of extension (may be unable to achieve full extension due to meniscus tear/ACL stump impingement); and flexion to 125° (cold).

Wilk: We strive for full passive knee extension, flexion to at least 125°, minimal swelling/pain, quad activation, normal gait and a patient who is mentally ready for surgery.

Wilk: What are the most important limitations to normalize before ACL surgery?

Johnson: They are full extension and isometric quadriceps fire with normal patellar excursion proximally.

Cole: An acute ACL injury is a traumatic event to the ligament and the joint as a whole. Therefore, allowing the acute inflammatory response (swelling, pain, etc.) to be minimized over time is good, and modalities and prehabilitation can best prevent postoperative deficits that are otherwise avoidable.

Noyes: Pain, swelling, muscle weakness, limitations in knee motion, and gait abnormalities are important to normalize before ACL surgery.

Mangine: Prior to surgery, the main concern continues to assuring range of motion is in an acceptable range, as well as evaluation of the injury on muscular strength dampening. Efforts to restore motor tone are important, as well as adequate control of ambulation to obtain as normal as a gait pattern as possible.

Wilk: What is the best graft for a young, athletic patient undergoing ACL reconstruction?

Noyes: We prefer bone-patellar tendon-bone (BPTB) autografts for athletes. Semitendinosus and gracilis (STG) autografts should be avoided in female athletes as these muscle function to limit anterior tibia translation and valgus alignment in sports. A second choice is a quadriceps-patella bone graft. In recreational athletes and more sedentary patients, a four-strand or six-strand STG autograft is recommended. In addition, STG autografts are used in patients who have pre-existing patellofemoral problems, such as articular cartilage damage, anterior knee pain or a history of patellar subluxation or dislocation. We strictly avoid allografts in these patients.

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Johnson: Patellar tendon autograft sized to the patient is my preferred graft. A normal size patient is 9 mm to 10 mm or a large patient who plays level 1 sports is 11 mm to 12 mm.

Cole: I prefer BPTB autograft.

Wilk: BPTB grafts in athletes are best. Hamstring grafts are in recreational active adult patients.

Mangine: Since the first reported ACL surgery by Heygroves in 1917, this has been a perplexing problem and it comes down, basically, to surgeon selection comfort zone. That said, histological data in animal models demonstrate the ipsilateral autograft patellar tendon remains a gold standard. Over the years, multiple tissues have been tried, and studies that follow patients long enough show most tissues struggle to meet the demand of recreational or competitive athletic activity.

Paine: The patellar tendon graft is our primary graft choice as long as the physes are closed or nearly closed. There is a trend toward using the quadriceps tendon soft tissue graft vs. hamstring grafts for younger individuals with open physes. During rehabilitation of high-performance athletes who are required to sprint, preservation of the hamstring muscle makes my job easier.

Wilk: Does your rehabilitation change if a meniscus repair was performed concomitantly with the ACL reconstruction? If so, how?

Cole: In general, I let the ACL rehabilitation drive the postoperative course, even in the presence of a meniscal repair. Depending on the nature of the tissue and repair, I might restrict loading, prolong the use of the brace to avoid early twisting loads and ask the patient to limit weight-bearing with greater than 90° flexion in the first 6 weeks to 8 weeks.

Noyes: In patients in whom a complex meniscus repair is performed (for tears that extended into the central-third region), delays are incorporated into the postoperative program for the following reasons: return of full knee motion (7 weeks to 8 weeks vs. 5 weeks to 6 weeks without a repair) and full weight-bearing (5 weeks to 6 weeks vs. 3 weeks to 4 weeks); initiation of gait retraining (3 weeks to 4 weeks vs. 1 week to 2 weeks); knee extension and multi-hip machines (3 weeks to 4 weeks vs. 1 week to 2 weeks); and hamstring curls and leg press machines (5 weeks to 6 weeks vs. 1 week to 2 weeks). Running and agility drills are delayed for 6 months and return to sports is delayed for at least 7 months.

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Johnson: Ninety percent of meniscal repairs are relatively stable after suture repair, so after full weight-bearing with the brace locked in extension for 1 month, the brace comes off every waking moment when in a neutral weight-bearing position without restrictions on motion. The only patients in whom I delay weight-bearing are patients with a large, lateral radial tear or unstable bucket-handle tear. Usually, I delay weight-bearing from about 1 month in a patient with chronic ACL with medial meniscus in the notch that does not like to be reduced.

Mangine: In our protocol, we consider meniscus pathology in the post-surgical process, especially with the lateral meniscus, our approach is more conservative approach than for medial pathology. Furthermore, the meniscal repair zone may also change the pathway. The positive side is historically, in our population of patients with ACL and meniscal repair, the success of the ACL surgery appears enhanced. That said, range of motion and weight-bearing are both delayed by perhaps 1 week or 2 weeks depending on which meniscus is injured and in what zone.

Paine: Rehabilitation of the meniscus tear takes precedence over ACL rehabilitation (during the early stages of rehabilitation). Small meniscus repairs performed with arthroscopic techniques do not delay the traditional ACL rehabilitation protocol. Open suturing of the meniscus and root repairs of the meniscus, however, cause delays in return to motion and weight-bearing. We will begin motion after week 1 and advance 30° per week until full motion is achieved. Weight-bearing is also delayed with this group, but full weight-bearing without crutches should be achieved by 6 weeks.

Wilk: What do you work on in rehabilitation during the first session following ACL surgery?

Mangine: The multifactorial effort post-surgically revolves around regaining functional motion, while aggressively pushing joint effusion reduction as both factor control muscle contractile potential. Loss of muscle control is primarily a result of neurological shutdown by post-surgical pain and joint effusion. Post-surgical joint effusion is also a casual factor in motion loss. Therefore, we traditionally answer that increasing range of motion is our first goal, until joint effusion is controlled. Then, the complex cycle of loss of motor control and joint pressure restrict motion. Multiple new modalities have appeared on the market in the last 15 years to attack the joint effusion, and aid in the result of regaining both motion and motor control.

Paine: Rehabilitation begins the day following ACL surgery. Our number one goal is to “turn on” the quadriceps and gain extension as soon as possible. We also begin side-to-side standing weight shifting within the first few days to begin facilitating the proprioceptors of the knee. Assuming a normal gait pattern is of vital importance, we will not allow patients to dismiss the use of crutches until they are able to ambulate without a limp and have no giving-way sensations.

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Johnson: The first week is critical to get full extension, quadriceps firing to move the patella and manual patellar mobility. Prone hangs, a pillow under the foot, not the knee, and having gravity help with extension whenever the patient is sitting down is a reliable approach. The patient should be shown on his or her good knee how the knee cap moves north, south, east and west, and tilts side to side, because they need to do that manually to themselves daily on the operated knee.

Noyes: Active and passive range of motion, patellar mobilization, quadriceps strengthening, gait retraining and control of pain and swelling is what I work on. It is important for the patient to follow a home-based rehabilitation program three to four times a day, including maintaining knee extension, performing active knee extension exercises, closed chain exercises, hip clam and toe raise exercises. Icing the knee and elevating it to decrease swelling are also important.

Cole: Reduction of pain, swelling and early activation of upstream and downstream muscle function is the focus of my initial session with patients. Maintenance of extension is the primary goal in the first 7 days to 10 days.

Wilk: Do you use a postoperative brace following ACL surgery?

Paine: Yes, we use a postoperative rehabilitation brace for the first 4 weeks and then transfer to the functional brace for protection during activities that implement pivoting and cutting during the rehabilitation process.

Mangine: Yes, we continue to use a post-surgical brace. There are no reliable data to date that show a negative impact from this, and it serves a reminder to athletes that they are in the post-surgical phase.

Cole: Bracing is done only to maintain extension in the first 2 weeks at night and to reduce discomfort during ambulation. It may also protect against a patella fracture should the patient inadvertently fall during the early postoperative period due to quadriceps shut down. I try to get them off the brace and crutches by 3 weeks to 4 weeks as long as they lose their limp and have full extension.

Johnson: I use a postoperative brace locked in extension only when the patient is upright and walking around. As soon as they sit down, at any time, which includes sleeping, I have them remove the brace and move their knee. All patients are out of the brace by 8 weeks, at the latest.

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Wilk: Yes, we use a postoperative hinged brace locked at full extension for 4 weeks to protect the knee and prevent pivoting and twisting of the knee. The patient is only locked for walking and sleeping. The brace is unlocked all other times.

Wilk: What is the most common complication following ACL surgery? How do you prevent and/or treat?

Cole: Complications are rare, but we are most aware of extension loss and anterior knee pain, which are likely intrinsically related and largely preventable.

Noyes: Clinical studies have reported ACL reinjury rates ranging from 3% to 22%. We use the Sportsmetrics Knee Ligament Prevention Program as end-stage rehabilitation after ACL reconstruction in athletes who wish to resume high-risk sports that involve cutting, pivoting and jumping. This advanced neuromuscular training program teaches athletes to control the upper body, trunk and lower body positions; lower the center of gravity by increasing hip and knee flexion during activities; and to develop muscular strength and techniques to land with decreased ground reaction forces. Athletes are instructed to preposition the body and lower extremity before initial ground contact to obtain the position of greatest knee joint stability and stiffness. In 2014, the American Academy of Pediatrics issued a policy statement that said, “Neuromuscular training appears to reduce the risk of injury in adolescent female athletes by 72%. Prevention training that incorporates plyometric and strengthening exercises, combined with feedback to athletes on proper technique, appears to be most effective.... Pediatricians and orthopedic surgeons who work with schools and sports organizations are encouraged to educate athletes, parents, coaches and sports administrators about the benefits of neuromuscular training in reducing ACL injuries and direct them to appropriate resources.”

Paine: The most common complication following ACL surgery is a lack of focus on quadriceps firing and associated weakness. Far too often we see the institution of “functional exercise” before the quadriceps of the patient has been properly rehabilitated and is firing with EMG activity that is approaching the normal side. This can lead to swelling, patellar tendinopathy, altered gait patterns and poor performance. I have seen this in professional athletes, as well as recreational athletes, as late as 1 year postop. Athletes may be able to “hide” the quadriceps weakness during functional testing, but when they are required to decelerate or sprint at top speed, the deficit will be evident. You must learn to fire the quadriceps muscle before moving through the protocol of ACL rehabilitation. We use biofeedback on every patient during our early stage rehabilitation process to avoid this common problem. Biofeedback while performing quad setting is used until the EMG activity equals the opposite normal side.

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Johnson: Lack of full extension and decreased patellar mobility are common. A steroid dose pack can help, as can increased physical therapy visits weekly. I cannot overemphasize the importance of education. Orthopedists should call the physical therapist themselves, which often helps because the therapist may suddenly become more engaged with the patient because the doctor called and was not happy. A threat of more surgery often helps, too.

Wilk: The most common complication following ACL surgery in the literature is a second ACL injury to either the contralateral side or the ipsilateral knee. To prevent this, I believe in an extended rehabilitation program which includes neuromuscular training, jump training and a criteria-based testing format to determine if the patient is ready to return to sports reduces ACL injuries. To this point, Grindem and colleagues in British Journal of Sports Medicine in 2016 reported when patients passed a specific return-to-play criteria, reinjury rates were reduced. The second most common complication is loss of motion.

Wilk: Do you have any specific criteria to initiate running?

Johnson: Impact loading should occur at about 4 months, not before. There is a need to build up proximal muscle mass, ie, as a shock absorber that supports the “tire” I just fixed that needs to heal. Impact loading is restricted until motion normal, including that of the knee cap, occurs and no effusion is present. If effusion develops, this process must be discontinued to eliminate the effusion and then resumed from the beginning. None of steps in therapy can be skipped.

Noyes: Patients are allowed to begin the running program when they demonstrate less than 30% deficit on isokinetic testing for peak quadriceps and hamstrings torque; have a normal Lachman examination (less than 3-mm increased anteroposterior tibial displacement) and negative pivot shift; and have no pain, swelling or instability with all other rehabilitation activities. Although some patients may reach these milestones as early as 12 weeks to 16 weeks after surgery, most are 20 weeks to 24 weeks postoperative. Closely monitor for any joint effusion or swelling, which indicates the athlete is progressing too quickly.

Mangine: In reviewing the literature, the primary attention is often given to strength return and range of motion. During the years, we have attempted to look at both factors simultaneously by evaluating the patients overhead squat position as this is a culmination of lower extremity mobility, as well as a strength summary. As we continue to look at the classic isokinetic strength factors and range of motion, we continue to utilize joint arthrometry as a progression criteria, as well. In vivo measurement of strain on the ACL has been done in limited functional positions, other studies are mathematical in nature, so the true strain on the ACL with running has not been measured. Therefore, clinical judgment is a prerequisite in the equation.

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Paine: We normally begin running at 8 weeks to 10 weeks (or at 12 weeks with concomitant open meniscus repair). The patient should be able to perform single-leg raises using a 10-pound weight for 5 minutes at this juncture. They should also be able to perform a single-leg squat with near 70% normal symmetry (measured in cm of reach). Isometric Biodex (Biodex Medical Systems) scores should be near 70% of normal.

Wilk: Do you use a specific return to sport criteria?

Noyes: The knee examination must show a normal range of motion, normal/nearly normal Lachman and pivot shift tests, KT-2000 less than 3-mm side-to-side difference, no patellar pain and no joint effusion. Quadriceps and hamstrings muscle strength and endurance tests must show less than 10% deficit compared with contralateral side. Single-leg hop tests should demonstrate less than 15% deficit lower limb symmetry on any two tests. The video drop-jump test must reveal greater than 60% normalized knee separation distance. The single-leg squat test must show no knee valgus, medial-lateral movement or pelvic tilt. The video plant and cut drill should subjectively demonstrate high hip and knee flexion, upright posture and no valgus collapse. It is important to note many clinics do not have the ability to monitor isokinetic muscle parameters, which is required for objective data for return to sports.

Wilk: We prefer to use a series of tests to determine the patient’s readiness to return to sport. These include physical exam by the patient’s surgeon, KT-1000 or KT-2000 testing, isokinetic testing, hop testing (when appropriate) Y balance, functional movement screen tests, and running and cutting drills.

Paine: We have our re-check day on Tuesday morning each week from 7:00 a.m. to 11:00 a.m. We have approximately eight to 10 clinicians who are involved in functional, strength and movement testing for patients who are 8 weeks and beyond. We see an average of 20 ACL patients during this morning re-check. This involves activities such as single-leg hop, figure of 8-yard to 40-yard run, deceleration 45° pivot test, 5-10-5, functional reach assessment and IKDC scores. These tests are videotaped and the clinician reviews these data and the performance with our surgeon, Walter Lowe, MD, fellow and staff to determine the patient’s strength and functional level. The data are summarized in a two-page report that helps us make a determination of whether the athlete is ready to return to sport. The full release to competitive sport occurs, on average, at about the 8-month mark for ACL-reconstructed patients.

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Johnson: Functional evaluation of athletes includes assessment of hopping ability, leg extension strength and core/hip strength. First, a series of five hops are performed, including a vertical hop on a jump mat, single-leg broad jump, single-leg hop for time over a 6-meter distance, triple hop and a crossover triple hop with the best results recorded. The average of the five hops provides a limb symmetry index value with a goal of less than a 10% difference between limbs, with a good quality of movement indicated for return-to-play competition.

Athletes are also asked to perform a 1-minute front, step-down test from a 6-inch to 8-inch height (depending on the athlete’s height) to measure endurance, strength and quality of movement. Again, there should be less than a 10% difference between limbs and there should be good quality of movement (no remarkable trunk lean, hip drop or dynamic valgus). Maximum time for front and side planks are recorded, as well as the maximum number of one-legged bridges that can be performed, to help calculate core strength performance and to assist with return-to-play recommendations.

Mangine: Return to sports is an integration of subjective feedback and objective testing, since our early work on functional hop testing in the literature is diverse in recommendations. From an objective standpoint, the classics such as isokinetic testing within 15%, joint arthrometer, in our experience stabilizes around +/-2 mm displacement prior to return to activity. Our functional testing is still critical for the various positions and needs to be within 85% bilateral comparison with limited to no valgus, or the trunk breaking the straight planes. In the last 10 years, we shifted our emphasis looking at the mobility and core control associated with the overhead squat position with the addition of mechanical foot position objective testing. The position assesses the overall lower extremity and not the isolated limb. Lastly, the athlete runs through a series of cutting, acceleration, deceleration and sport-specific positions. At the college level, we are extremely cautious with jump landing drills due to the potential effect on the articular surfaces.

Cole: We allow sport-specific activities at 4 months, and no competitive play for at least 5 months or 6 months. Definitively, we use a functional sports assessment (FSA) tool at 5 months to define side-to-side differences that are dampened during the final 4 weeks to 6 weeks by coordinated work with the therapist who is apprised of the findings of the FSA.

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Wilk: Do you routinely prescribe functional braces for return-to-sport or strenuous work?

Johnson: I avoid functional braces except for offensive, defensive lineman and female basketball players with DNA that says, “I want to tear my ACL again (ie, with hyperextension, high BMI and valgus knee).”

Cole: I do not prescribe them.

Paine: We use functional braces, primarily during the rehabilitation process. They are applied at the 6-week mark, on average. The athlete will typically use the brace for 2 months to 3 months during the return to play period, but may discard the brace when he or she feels psychologically and physically ready to do so.

Noyes: No, we do not use them.

Wilk: That is determined during the physician, patient and physical therapy interaction. Athletes going back to running, cutting and jumping sports will probably receive an ACL functional brace and use it for a period of time and then potentially reduce the wear time.

Mangine: Functional bracing is, again, a clinical preference rather than a hard data-controlled recommendation. Although in most of our athletes we use bracing, the length of use is decreased except in contact sports, which may be for one season.

Wilk: What are the most important aspects of either ACL surgery or rehabilitation of which readers should be aware?

Johnson: Surgery is the easy part, but there is a 1-year commitment to rehabilitation, particularly in terms of what is done independently by the patient and the core work that must be done to prevent another ACL tear. The knee will not start to feel “normal” during level 1 sports until about 1 year. The first year back playing sports will not be the patient’s best year, but it will improve. This requires patients to continually do core work. Everyone underestimates the importance of the work patients must do to help themselves get well, avoid repeat injury and have a safe return to sports.

Noyes: For an ACL rehabilitation program to be successful in regaining normal knee function, many factors must be considered that may influence the eventual outcome. These include obtaining a full range of knee motion; normal gait mechanics; adequate lower extremity, upper extremity and core muscle strength required for the desired activity level; and normal bilateral proprioception and neuromuscular function using exercises and modalities that are not deleterious to the healing graft. The exercise program should not produce harmful forces on the patellofemoral or tibiofemoral compartments, result in chronic joint effusions or cause tendinitis. Complete ACL ruptures may result in abnormal gait patterns, muscle strength and activation patterns, neuromuscular function, and proprioception which may last many months or even years after the injury or surgery. ACL reconstruction followed by traditional strength training may not correct these abnormalities. Therefore, neuromuscular retraining is recognized as an essential component of ACL rehabilitation programs.

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Cole: Patient education is paramount to manage expectations and avoid surprises by the patient that can otherwise derail a smooth postoperative course. In addition, failing to consider the psychological impact of this injury, addressing the patient’s fears and concerns and understanding how important a return to normal function is in the eyes of the patient can short-change the patient from having an excellent outcome. The treatment is a multidisciplinary approach that engages the entire family when relevant, the therapists and the system that surrounds the athlete. Remaining sensitive to all the stakeholders will assure the best possible outcome that minimizes the chances of complications and maximizes the performance when the athlete returns to sport.

Wilk: I support a team approach to treatment. The physician and rehabilitation team must be together on what is happening and when it is happening for the patient to have a successful outcome. The patient must understand where they are at and what they need to do to achieve a successful outcome. Communication is key, as well as proper and skilled treatment.

Mangine: In the 1990s, we developed a model called the evaluation-based model, which was based on histological data that suggested return to play was a parabolic curve based on the patient’s healing potential and tissue type. Most clinicians today use a timeframe basis for initiating the next phase of a protocol. However, the range for return is wide, as my personal experience has shown, in which one of our athletes played full-contact sports after 11 weeks and 6 days, but another athlete’s return-to-play was 20 months.

Clinicians need to be better oriented to the various evaluation measures and the incorporation of histological data to determine advancement of the patient. Some studies have shown the graft is weakest in the early phase of rehabilitation, and we are looking for the 10% of patients who may stretch out in this phase. Whatever the surgeon places in the notch is a checkrein, not a native ACL with which the patient was born. Also, with or without ACL reconstruction, the data are clear that return to sports has a high risk of arthritic changes developing within the joint surfaces and this process is unpredictable.

Paine: I believe most patients underestimate the time and effort required to complete the rehabilitation process. Of course, if you are a professional athlete and your livelihood depends on your recovery, you have a distinct advantage in time, cost and motivation. We should continue to stress the importance of dedication in the postoperative and preoperative period after an ACL tear. I have been lucky in my career to care for some of the most gifted athletes in the world, but those who have achieved greatness following an ACL reconstruction are always the most dedicated and focused and have intensity while exercising.

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The most successful orthopedic surgeons with whom I have been involved understand many of the aspects of rehabilitation. I believe orthopedic fellows can greatly benefit from spending a couple of days with a talented sports medicine rehabilitation specialist. Those patients who have detailed aftercare will ultimately have fewer complications and more successful outcomes. Thus, I believe appropriate follow-up after ACL reconstruction is one of the most important aspects of successful surgery and rehabilitation.

Disclosures: Cole, Johnson, Mangine, Noyes and Wilk report no relevant financial disclosures. Paine reports he is owner of mTrigger biofeedback.