• Hip & Knee Conditions
• Sports Medicine

• Orthopaedics
• Hip & Knee Conditions
• Sports Medicine

The Department of Physical Therapy at the University of Delaware has a specific rehabilitation and training program for athletes to prevent secondary injury following an initial anterior cruciate ligament (ACL) tear. Lynn Snyder-Mackler, ScD, PT, University of Delaware, Newark, Delaware, USA, discussed the program.

Dr. Snyder-Mackler reviewed the scientific data that served as the impetus for her department's rehabilitation program. In a 24-month follow-up study among athletes who played sports that required cutting or pivoting movements and who had ACL reconstruction, 29.5% with a history of ACL reconstruction and 8.5% of the controls suffered an ACL injury; 30.4% were injured in < 20 athlete-exposures and 52.2% in < 72 [Paterno MV et al. Am J Sports Med 2014]. Female athletes were more than twice as likely to suffer a contralateral ACL injury as an ipsilateral injury. Similar data were reported in an Australian study [Webster KE et al. Am J Sports Med 2014]. The odds for sustaining an ACL graft rupture or contralateral injury increased 6- and 3-fold, respectively, for patients aged < 20 years. Odds of sustaining a graft rupture increased by a factor of 3.9 and contralateral rupture by a factor of 5 among those returning to cutting or pivoting sports.

Dr. Snyder-Mackler recommends early treatment following an ACL injury, with cold, compression, elevation, and active motion to decrease effusion. To restore and preserve passive and active knee extension, stretching, patellar mobilization, and quadriceps strengthening are recommended. This is followed by progressive exercises and neuromuscular electrical stimulation (NMES) to increase muscle and quadriceps strength and maintain muscle mass. A number of sessions of neuromuscular training should be employed to restore normal movement patterns and gait.

Rehabilitation programs should entail early techniques (ie, first week following ACL reconstruction) that control inflammation, improve patellar mobility, strengthen quadriceps, and improve gait. NMES can be used for selective muscle retraining, control of edema, and pain. The 1996 guidelines from the University of Delaware, updated in 2012 [Adams D et al. J Orthop Sports Phys Ther 2012], emphasized an 8-level progressive running regimen over 3 to 12 months following injury, but only for those athletes with full range of motion, no effusion, and a quadriceps index > 80%. A score of ≥ 90% on the return-to-activity (RTA) criteria determines progression through the running levels. The tests includes quadriceps strength index, 4 single-legged hop tests, the Knee Outcome Survey—Activities of Daily Living Scale, and the Global Rating Score of Perceived Knee Function. Passing the RTA exam and running progression means a graded return to activity, not a return to sports.

In addition to the rehabilitation program, a preventive ACL reinjury program has been developed. Nordic hamstring curls, standing squat exercises, drop jumps, triple single-legged hops, and tuck jumps are performed as part of the ACL-SPORTS Training protocol. Agility drills, quadriceps strengthening, and perturbation training are also part of the program.

Dr. Snyder-Mackler noted that the median time to RTA is 10 months but that it is getting increasingly longer.

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