Algorithm Based ACL Algorithm Based ACL Rehabilitation - - PowerPoint PPT Presentation

Algorithm Based ACL Rehabilitation

Justin Shaginaw MPT, ATC

Revised 11/13/05

Algorithm Based ACL Rehabilitation

Justin Shaginaw MPT, ATC

Revised 11/13/05

Introduction Introduction

• Common contact and non-contact

injury in athletes

• 100,000 new cases annually (Bach,

Boonos)

• Previously meant season ending, if

not career ending injury

• Athletes are returning to pre injury

levels, at times within the same season

• Outcomes are accomplished through

a post operative program focusing

• n functional rehabilitation and

neuromuscular control activities

• Common contact and non-contact

injury in athletes

• 100,000 new cases annually (Bach,

Boonos)

• Previously meant season ending, if

not career ending injury

• Athletes are returning to pre injury

levels, at times within the same season

• Outcomes are accomplished through

a post operative program focusing

• n functional rehabilitation and

neuromuscular control activities

Anatomy & Biomechanics Anatomy & Biomechanics

ACL

• 2 bands: anteromedial &

posterolateral

• Functions
• Primary restraint to

anterior tibial translation

• Significant restraint to

hyperextension

• Limits tibial internal

rotation

• Secondary restraint to

varus/valgus stresses ACL

• 2 bands: anteromedial &

posterolateral

• Functions
• Primary restraint to

anterior tibial translation

• Significant restraint to

hyperextension

• Limits tibial internal

rotation

• Secondary restraint to

varus/valgus stresses

PCL

• 3 bundles:

Anteriolateral, Intermediate & Posteriomedial

• Functions
• Primary restraint to

posterior tibial translation

• Secondary restraint to

hyperextension & varus /valgus stress

PCL

• 3 bundles:

Anteriolateral, Intermediate & Posteriomedial

• Functions
• Primary restraint to

posterior tibial translation

• Secondary restraint to

hyperextension & varus /valgus stress

MCL

• 2 Layers: superficial and

deep

• Functions
• Primary restraint to

valgus stress

• 57 % at 0°
• 78% at 25°

LCL

• Functions
• Restraint to varus stress
• 55% at 0°
• 69% at 30°

MCL

• 2 Layers: superficial and

deep

• Functions
• Primary restraint to

valgus stress

• 57 % at 0°
• 78% at 25°

LCL

• Functions
• Restraint to varus stress
• 55% at 0°
• 69% at 30°

Anatomy & Biomechanics

Medial Meniscus

• Semi lunar or C shaped
• Extensive capsular

attachment

Lateral Meniscus

• Circular shape
• Minimal capsular

attachment

Meniscal functions

• Shock absorption
• Joint lubrication and

nutrition

• Joint stability

Medial Meniscus

• Semi lunar or C shaped
• Extensive capsular

attachment

Lateral Meniscus

• Circular shape
• Minimal capsular

attachment

Meniscal functions

• Shock absorption
• Joint lubrication and

nutrition

• Joint stability

Anatomy & Biomechanics

Surgical Considerations Surgical Considerations

Procedure

• “Mini-open” vs all

arthroscopic

Graft type

• Autograft vs allograft

Fixation

• Boney vs soft tissue

Graft properties

• Tensile strength
• Stiffnes

Graft “Ligamentization” Procedure

• “Mini-open” vs all

arthroscopic

Graft type

• Autograft vs allograft

Fixation

• Boney vs soft tissue

Graft properties

• Tensile strength
• Stiffnes

Graft “Ligamentization”

Graft Properties Graft Properties

302 3391 Posterior Tibialis Tendon 463 2352 Quadriceps Tendon 776 4108 Quadruple Hamstring 812 2376 Bone Patella Bone 242 2160 Intact ACL Stiffness (N/mm) Ultimate Strength (N)

From presentation by Arthur Bartolozzi MD From presentation by Arthur Bartolozzi MD

Fixation Properties

Ultimate Tensile Load (N)

Fixation Properties

Ultimate Tensile Load (N)

725-1600 Cross-pin Technique 768 Tandem Soft Tissue Washers 1126 Bone Mulch Screw 341 +/- 163 Bioabsorbable Screw (7mm) 242 +/- 90 Metal Interference Screw (7mm) 588 Staples 565 Bioabsorbable Screw (9mm) 330-418 Bioabsorbable Screw (7mm) 330-418 Metal Interference Screw (15mm) 328 Metal Interference Screw (13mm) 302 Metal Interference Screw (11mm) 276 +/- 436 Metal Interference Screw (9mm) 640 +/- 201 Metal Interference Screw (7mm)

Direct Soft Tissue Direct Soft Tissue Direct Bone Direct Bone

From presentation by Arthur Bartolozzi MD From presentation by Arthur Bartolozzi MD

Post Op Evaluation Post Op Evaluation

ROM Strength Girth Patella mobility Observation Swelling/joint effusion Lachman’s Gait Other special tests ROM Strength Girth Patella mobility Observation Swelling/joint effusion Lachman’s Gait Other special tests

Protocol vs Algorithm Based Rehab Protocol vs Algorithm Based Rehab

Protocols

• Rehab programs that are usually

time based

• Often times separated into

accelerated and non-accelerated programs

Algorithms

• Allow all patients to follow the

same rehabilitation guidelines progressing according to specific goals irrespective of time frames

• “Phases” of algorithm based

rehab

Protocols

• Rehab programs that are usually

time based

• Often times separated into

accelerated and non-accelerated programs

Algorithms

• Allow all patients to follow the

same rehabilitation guidelines progressing according to specific goals irrespective of time frames

• “Phases” of algorithm based

rehab

Protocol vs Algorithm Based Rehab Protocol vs Algorithm Based Rehab

Protocol

• Were developed according to

biological healing times

• Based on time frames

Algorithm

• Goal based rehab
• Based on objective and

functional goals

Algorithm allows for a more appropriate progression for each individual patient Protocol

• Were developed according to

biological healing times

• Based on time frames

Algorithm

• Goal based rehab
• Based on objective and

functional goals

Algorithm allows for a more appropriate progression for each individual patient

Initial Post Op Phase Initial Post Op Phase

Goals to be achieved

• PROM 0°-110°
• Full active extension
• Minimal joint effusion
• Normal gait
• Good quad control/tone
• Normal patella mobility

Goals to be achieved

• PROM 0°-110°
• Full active extension
• Minimal joint effusion
• Normal gait
• Good quad control/tone
• Normal patella mobility

Gait Gait

Focus on normal heel to toe pattern Start with bilateral crutches and brace

• pen to available

AROM Progress out of brace before off of crutches Focus on normal heel to toe pattern Start with bilateral crutches and brace

• pen to available

AROM Progress out of brace before off of crutches

Proprioception & Neuromuscular Control Proprioception & Neuromuscular Control

Three inputs: visual, tactile, vestibular

• Try to challenge all three

Unilateral standing activities: slight knee flexion to eliminate stability from boney congruence and screw home mechanism Look to progress to activity/sport specific balance exercises “Toys”: Dyandisc, wobble board, foam pad, physioball, BOSU, balance beam Three inputs: visual, tactile, vestibular

• Try to challenge all three

Unilateral standing activities: slight knee flexion to eliminate stability from boney congruence and screw home mechanism Look to progress to activity/sport specific balance exercises “Toys”: Dyandisc, wobble board, foam pad, physioball, BOSU, balance beam

Strengthening and Muscle Re-Education Strengthening and Muscle Re-Education

Quad tone/control

• Russian/neuromuscular electric

stimulation with quad set during supine extension stretch Strengthening

• Initiate exercises focusing on

single plane/single muscle group

• Progress to multiple

plane/multiple muscle group exercises

• Include proprioceptive/

neuromuscular control component

• Look to include activity/sport

specific exercises Quad tone/control

• Russian/neuromuscular electric

stimulation with quad set during supine extension stretch Strengthening

• Initiate exercises focusing on

single plane/single muscle group

• Progress to multiple

plane/multiple muscle group exercises

• Include proprioceptive/

neuromuscular control component

• Look to include activity/sport

specific exercises

Strengthening Progression Strengthening Progression

Mini Squats → Leg Press → Unilateral Leg Press → Leg Press on Disc/Foam Roll/Ball Leg Raises → Hip Machine → Walking/Stepping with Theraband Prone Hamstring Curls → Standing Curls → Resisted Curls → Bilateral Curls on Physioball → Unilateral Curls on Physioball Mini Squats → Leg Press → Unilateral Leg Press → Leg Press on Disc/Foam Roll/Ball Leg Raises → Hip Machine → Walking/Stepping with Theraband Prone Hamstring Curls → Standing Curls → Resisted Curls → Bilateral Curls on Physioball → Unilateral Curls on Physioball

Joint Effusion Joint Effusion

Some benefit with modalities initially Sign of healing within the joint Warmth sign of acute inflammation Monitor changes in joint effusion to assess tolerance with rehab program Some benefit with modalities initially Sign of healing within the joint Warmth sign of acute inflammation Monitor changes in joint effusion to assess tolerance with rehab program

Controlled Activity Phase Controlled Activity Phase

Goals to be achieved

Full strength with manual muscle testing No joint effusion PROM 0°-125° + Passing isokinetic test at 85% Passing functional hop test at 85% Running initiated in this phase

Goals to be achieved

Full strength with manual muscle testing No joint effusion PROM 0°-125° + Passing isokinetic test at 85% Passing functional hop test at 85% Running initiated in this phase

Proprioception & Neuromuscular Control Proprioception & Neuromuscular Control

Progress sport specific activities Initiate speed ladder for agility and foot work Initiate weight acceptance/attenuati

• n activities

Must develop limb confidence Progress sport specific activities Initiate speed ladder for agility and foot work Initiate weight acceptance/attenuati

• n activities

Must develop limb confidence

Neuromuscular Control Neuromuscular Control

Replicate demands place on lower extremity Include activity specific input Be creative and think activity/sport/position specific! Replicate demands place on lower extremity Include activity specific input Be creative and think activity/sport/position specific!

Strengthening Strengthening

Incorporate neuromuscular control component Work on both muscle power and endurance Isokinetic exercises Incorporate neuromuscular control component Work on both muscle power and endurance Isokinetic exercises

Criteria to Initiate Running Program Criteria to Initiate Running Program

Isokinetic test at least 75% of uninvolved No patellofemoral symptoms No joint effusion Start on treadmill; progress to outside due to running mechanics Isokinetic test at least 75% of uninvolved No patellofemoral symptoms No joint effusion Start on treadmill; progress to outside due to running mechanics

Return to Sport/Activity Phase Return to Sport/Activity Phase

Slow progression into practices

• Simple straight plane

drills

• Progress to

multidirectional drills

• Non-contact

progressing to contact drills

Follow up isokinetic testing as indicated Slow progression into practices

• Simple straight plane

drills

• Progress to

multidirectional drills

• Non-contact

progressing to contact drills

Follow up isokinetic testing as indicated

Advanced Training Advanced Training

Initiated during Return to Sport/Activity Phase

• f post operative rehabilitation

Remember training should include both rehabilitation and integration into practice Initiated during Return to Sport/Activity Phase

• f post operative rehabilitation

Remember training should include both rehabilitation and integration into practice

Advanced Training Advanced Training

Goals are to return the athlete to pre injury levels

• Neuromuscular

control

• Strength
• Endurance
• Power
• Limb confidence
• Sport specific skills

Goals are to return the athlete to pre injury levels

• Neuromuscular

control

• Strength
• Endurance
• Power
• Limb confidence
• Sport specific skills

Lower Extremity Strength and Conditioning Lower Extremity Strength and Conditioning

Must return to pre injury levels of strength, power, and endurance Must be sport specific as well as position specific Many athletes return to sport activities prior to reaching pre injury levels Should be based on principals of periodization Must return to pre injury levels of strength, power, and endurance Must be sport specific as well as position specific Many athletes return to sport activities prior to reaching pre injury levels Should be based on principals of periodization

Periodization Periodization

Strength and conditioning program based

• n cyclic program of work and

recovery/rest phases Is systematic, sequential, and progressive Must integrate individual’s rehabilitation program into team’s/coach’s seasonal program Strength and conditioning program based

• n cyclic program of work and

recovery/rest phases Is systematic, sequential, and progressive Must integrate individual’s rehabilitation program into team’s/coach’s seasonal program

Lower Extremity Strength Lower Extremity Strength

Strength: the ability to exert maximum force Can be assessed manually, isokinetically

• r in weight room

SAID principle Continuation of rehabilitation exercises Should incorporate dynamic exercises Strength: the ability to exert maximum force Can be assessed manually, isokinetically

• r in weight room

SAID principle Continuation of rehabilitation exercises Should incorporate dynamic exercises

Lower Extremity Endurance Lower Extremity Endurance

Endurance: ability to maintain optimal levels of strength, power and neuromuscular control Needs to be sport, position, and level of play specific Both aerobic and anaerobic Endurance: ability to maintain optimal levels of strength, power and neuromuscular control Needs to be sport, position, and level of play specific Both aerobic and anaerobic

Lower Extremity Endurance Lower Extremity Endurance

Can be measured isokinetically (?) Aerobic vs Anaerobic conditioning Must be sport, position, and level specific Needs to be performed within the context of the sport Can be measured isokinetically (?) Aerobic vs Anaerobic conditioning Must be sport, position, and level specific Needs to be performed within the context of the sport

Lower Extremity Power Lower Extremity Power

Power: the ability to exert maximal force in the shortest time Ability to convert strength to movement Functional/sport specific progression of strengthening exercises Includes plyometric training Power: the ability to exert maximal force in the shortest time Ability to convert strength to movement Functional/sport specific progression of strengthening exercises Includes plyometric training

Plyometric Training Plyometric Training

Training of stretch shortening cycle of muscle action Goals of Plyometrics

• Improve explosive power
• Tolerate greater stretch

loads

• Attenuate ground reaction

forces Isn’t a conditioning activity Training of stretch shortening cycle of muscle action Goals of Plyometrics

• Improve explosive power
• Tolerate greater stretch

loads

• Attenuate ground reaction

forces Isn’t a conditioning activity

Advanced Training Program Components Advanced Training Program Components

Flexibility program Dynamic Stabilization exercises Strength program Core Program Speed and Agility exercises Anaerobic Conditioning Aerobic Conditioning Flexibility program Dynamic Stabilization exercises Strength program Core Program Speed and Agility exercises Anaerobic Conditioning Aerobic Conditioning

Flexibility Program Flexibility Program

Should include both static and dynamic stretches Lower extremity should focus on

• Hamstrings
• Quads
• Gastroc/soleus
• Hip flexor
• Hip rotators
• Illiotibial band

Should include both static and dynamic stretches Lower extremity should focus on

• Hamstrings
• Quads
• Gastroc/soleus
• Hip flexor
• Hip rotators
• Illiotibial band

Dynamic Stabilization Exercises Dynamic Stabilization Exercises

Proprioceptive/ neuromuscular control exercises for the lower extremity Should include

• Balance exercises (balance

boards, disc, etc)

• Manual rhythmic

stabilization and PNF exercises

• Partner balance exercises

(ball toss, manual perturbations) Proprioceptive/ neuromuscular control exercises for the lower extremity Should include

• Balance exercises (balance

boards, disc, etc)

• Manual rhythmic

stabilization and PNF exercises

• Partner balance exercises

(ball toss, manual perturbations)

Strength Program Strength Program

Should include both bilateral and unilateral exercises Think sport and position specific Emphasize quad and hamstring exercises Should include both bilateral and unilateral exercises Think sport and position specific Emphasize quad and hamstring exercises

Core Training Core Training

Core: Lumbar-pelvic-hip complex All movement begins with the core Accelerates, decelerates and dynamically stabilizes the body Allows the body to work as an integrated unit Can improve performance and prevent injury Core: Lumbar-pelvic-hip complex All movement begins with the core Accelerates, decelerates and dynamically stabilizes the body Allows the body to work as an integrated unit Can improve performance and prevent injury

Core Program Core Program

Need to teach draw in maneuver Incorporate stabilization with all rehabilitation exercises Not just “ab” work Examples

• Bridging progression
• Plank exercises
• Reverse curl ups
• Leg raises
• Physioball exercises

Need to teach draw in maneuver Incorporate stabilization with all rehabilitation exercises Not just “ab” work Examples

• Bridging progression
• Plank exercises
• Reverse curl ups
• Leg raises
• Physioball exercises

Speed and Agility Exercises Speed and Agility Exercises

Straight Ahead Speed

• Includes acceleration, top

speed, speed endurance, deceleration

Lateral Speed and Agility

• Includes acceleration, change
• f direction, deceleration

Speed and agility exercises

• Speed ladder
• Resisted running
• Assisted running
• Change of direction drills

Straight Ahead Speed

• Includes acceleration, top

speed, speed endurance, deceleration

Lateral Speed and Agility

• Includes acceleration, change
• f direction, deceleration

Speed and agility exercises

• Speed ladder
• Resisted running
• Assisted running
• Change of direction drills

Anaerobic Conditioning Anaerobic Conditioning

Interval training Needs to be sport, position, and level

• f play specific
• Frequency
• Duration
• Intensity
• Distance

Interval training Needs to be sport, position, and level

• f play specific
• Frequency
• Duration
• Intensity
• Distance

Aerobic Conditioning Aerobic Conditioning

General Fitness Base Recovery activity Needs to be sport, position, and level of play specific General Fitness Base Recovery activity Needs to be sport, position, and level of play specific

Return to Practice Return to Practice

Initiated in advanced training phase Systematic return to full sport activates Non-contact drills Full contact drills Scrimmages Full practice Initiated in advanced training phase Systematic return to full sport activates Non-contact drills Full contact drills Scrimmages Full practice

Non-Contact Practice Non-Contact Practice

Start with straight line drills Add sport specific input Progress to change of direction drills Add sport specific input No symptoms and equal quality of movement and neuromuscular control side to side before progressing to non-contact scrimmages Start with straight line drills Add sport specific input Progress to change of direction drills Add sport specific input No symptoms and equal quality of movement and neuromuscular control side to side before progressing to non-contact scrimmages

Contact Practice Contact Practice

Must pass return to sport criteria before initiating contact drills No symptoms and equal quality of movement and neuromuscular control side to side before progressing to full practice Need coaches input to determine if the player is “back to where they were pre-injury” Must pass return to sport criteria before initiating contact drills No symptoms and equal quality of movement and neuromuscular control side to side before progressing to full practice Need coaches input to determine if the player is “back to where they were pre-injury”

Return to Sport Criteria Return to Sport Criteria

Functional testing at 85% of uninvolved Isokinetic testing at 85% of uninvolved Satisfactory performance with sport specific testing Minimal symptoms with testing and no joint effusion Functional testing at 85% of uninvolved Isokinetic testing at 85% of uninvolved Satisfactory performance with sport specific testing Minimal symptoms with testing and no joint effusion

Return to Full Game Status Return to Full Game Status

Will already be participating in contact practice Equal quality of movement and neuromuscular control side to side Minimal symptoms and no joint effusion Should pass all team fitness criteria Should have at least 2 full weeks of contact practice before playing Will already be participating in contact practice Equal quality of movement and neuromuscular control side to side Minimal symptoms and no joint effusion Should pass all team fitness criteria Should have at least 2 full weeks of contact practice before playing

Other Considerations Other Considerations

Meniscal Repair

• Avoid flexion past 90° in weight bearing for

first 6 weeks

• Avoid pivoting/twisting with flexion in weight

bearing

• Weight bearing as tolerated in full extension

for 3-4 weeks

• Continue brace for first 6 weeks; limited to

90° of flexion with ambulation

• Look to initiate running in 3-4 months

Meniscal Repair

• Avoid flexion past 90° in weight bearing for

first 6 weeks

• Avoid pivoting/twisting with flexion in weight

bearing

• Weight bearing as tolerated in full extension

for 3-4 weeks

• Continue brace for first 6 weeks; limited to

90° of flexion with ambulation

• Look to initiate running in 3-4 months

Other Considerations Other Considerations

Bone Bruise

• Limit weight bearing early on
• Good candidate for aquatic rehab

Chondral Lesion

• Need to know what procedure if any was performed
• If micro fracture procedure or osteochondral grafting

done, will be a restriction in their weight bearing status early on

• Need to limit shear forces

Bone Bruise

• Limit weight bearing early on
• Good candidate for aquatic rehab

Chondral Lesion

• Need to know what procedure if any was performed
• If micro fracture procedure or osteochondral grafting

done, will be a restriction in their weight bearing status early on

• Need to limit shear forces

Conclusion Conclusion

Rehab based on

• bjective findings

and measurable goals versus time frames Make rehab sport/activity specific Consider biological healing times of concomitant procedures Rehab based on

• bjective findings

and measurable goals versus time frames Make rehab sport/activity specific Consider biological healing times of concomitant procedures

Thank You Thank You

References References

• Bach BR Jr, Boonos CL: Anterior cruciate ligament reconstruction.

AORN J. 2001 Aug;74(2):152-64

• Buss DD, Warren RF, Wickiewicz TL, Galinat BJ, and Panariello R:

Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. Results after twenty-four to forty-two months J Bone Joint Surg Am 1993 75: 1346-1355.

• Fitzgerald GK: Open versus closed kinetic chain exercise: issues in rehabilitation

after anterior cruciate ligament reconstructive surgery. Phys Ther. 1997 Dec;77(12):1747-54.

• Falconiero RP, DiStefano VJ, Cook TM: Revascularization and ligamentization of

autogenous anterior cruciate ligament grafts in humans.

• Arthroscopy. 1998 Mar;14(2):197-205.
• Grontvedt T, Engebretsen L, Benum P, Fasting O, Molster A, Strand T: A

prospective, randomized study of three operations for acute rupture of the anterior cruciate ligament. Five-year follow-up of one hundred and thirty-one patients. J Bone Joint Surg Am. 1996 Feb;78(2):159-68.

• Martin SD, Martin TL, Brown CH: Anterior cruciate ligament graft fixation.

Orthop Clin North Am. 2002 Oct;33(4):685-96.

• McFarland, E: ACL Update: The Biology of Anterior Cruciate Ligament
• Reconstructions. Orthopedics 1993 April;16(4)
• Bach BR Jr, Boonos CL: Anterior cruciate ligament reconstruction.

AORN J. 2001 Aug;74(2):152-64

• Buss DD, Warren RF, Wickiewicz TL, Galinat BJ, and Panariello R:

Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. Results after twenty-four to forty-two months J Bone Joint Surg Am 1993 75: 1346-1355.

• Fitzgerald GK: Open versus closed kinetic chain exercise: issues in rehabilitation

after anterior cruciate ligament reconstructive surgery. Phys Ther. 1997 Dec;77(12):1747-54.

• Falconiero RP, DiStefano VJ, Cook TM: Revascularization and ligamentization of

autogenous anterior cruciate ligament grafts in humans.

• Arthroscopy. 1998 Mar;14(2):197-205.
• Grontvedt T, Engebretsen L, Benum P, Fasting O, Molster A, Strand T: A

prospective, randomized study of three operations for acute rupture of the anterior cruciate ligament. Five-year follow-up of one hundred and thirty-one patients. J Bone Joint Surg Am. 1996 Feb;78(2):159-68.

• Martin SD, Martin TL, Brown CH: Anterior cruciate ligament graft fixation.

Orthop Clin North Am. 2002 Oct;33(4):685-96.

• McFarland, E: ACL Update: The Biology of Anterior Cruciate Ligament
• Reconstructions. Orthopedics 1993 April;16(4)

References References

• Rougraff B, Shelbourne KD, Gerth PK, Warner J: Arthroscopic and

histologic analysis of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am J Sports Med. 1993 Mar-Apr;21(2):277-84.

• Scranton PE Jr, Lanzer WL, Ferguson MS, Kirkman TR, Pflaster

DS:Mechanisms of anterior cruciate ligament neovascularization and ligamentization.

• Arthroscopy. 1998 Oct;14(7):702-16.
• Snyder-Mackler L, Delitto A, Stralka SW, Bailey SL: Use of electrical

stimulation to enhance recovery of quadriceps femoris muscle force production in patients following anterior cruciate ligament reconstruction. Phys Ther. 1994 Oct;74(10):901-7.

• Shelbourne KD, Nitz P Accelerated rehabilitation after anterior cruciate

ligament reconstruction. Am J Sports Med. 1990 May-Jun;18(3):292-9. PMID: 2372081

• Wilk KE, Reinold MM, Hooks TR: Recent advances in the rehabilitation of

isolated and combined anterior cruciate ligament injuries. Orthop Clin North Am. 2003 Jan;34(1):107-37

• Rougraff B, Shelbourne KD, Gerth PK, Warner J: Arthroscopic and

histologic analysis of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am J Sports Med. 1993 Mar-Apr;21(2):277-84.

• Scranton PE Jr, Lanzer WL, Ferguson MS, Kirkman TR, Pflaster

DS:Mechanisms of anterior cruciate ligament neovascularization and ligamentization.

• Arthroscopy. 1998 Oct;14(7):702-16.
• Snyder-Mackler L, Delitto A, Stralka SW, Bailey SL: Use of electrical

stimulation to enhance recovery of quadriceps femoris muscle force production in patients following anterior cruciate ligament reconstruction. Phys Ther. 1994 Oct;74(10):901-7.

• Shelbourne KD, Nitz P Accelerated rehabilitation after anterior cruciate

ligament reconstruction. Am J Sports Med. 1990 May-Jun;18(3):292-9. PMID: 2372081

• Wilk KE, Reinold MM, Hooks TR: Recent advances in the rehabilitation of

isolated and combined anterior cruciate ligament injuries. Orthop Clin North Am. 2003 Jan;34(1):107-37