It is the goal of every rehabilitation protocol to return the injured athlete to competition in the safest and most expedient way possible. This goal is especially important due to the competitive nature of athletics. The aggressiveness of the rehabilitation protocol can determine the time frame in which the athlete can safely return to competition. When dealing with the reconstructed ACL, this time frame can vary from as little as 16 weeks to as much as 12 months or longer. Protocols vary not so much with the exercises and goals, but with the time period in which they are accomplished. The main goals for most programs include: achievement of normal range of motion, weight-bearing, strengthening, and a functional return to activity (Shelbourne & Nitz, 1990). The following discussion deals with implementing an accelerated versus a conservative rehabilitation protocol of the surgically reconstructed ACL.

Conservative vs. Accelerated Treatment

Implementing a conservative rehabilitation protocol of the ACL, a return to full activity is predicted at approximately 9 to 12 months as described by De Carlo et al, 1992. At 9-12 months post-surgery, with full range of motion and completion of a functional exercise plan, athletes are allowed to return to full competition (De Carlo et al., 1992). Click here to see a detailed description of a common conservative treatment.

During the application of conservative protocols in the mid-1980's, patients were becoming increasingly impatient and began progressing through the rehabilitation at their own pace. These non-compliant patients were using their own judgement to determine how quickly to progress through the ACL rehabilitation protocol. It was observed from these patients that stronger, more functional knees were the result at the end of rehabilitation (De Carlo et al, 1992). From these observations, accelerated protocols were developed and applied to decrease the rehabilitation time after ACL reconstruction. A return to full activity in the accelerated programs generally occurs at 4 to 6 months but can be accomplished in as few as three. Click here to see a detailed description of a common accelerated treatment.

A retrospective comparison of intra-articular ACL patellar tendon-bone autograft reconstruction cases was conducted by Shelbourne & Nitz, 1990, in which conservative treatment in rehabilitation was compared to accelerated treatment. One hundred thirty eight conservative protocol patients were compared to 247 accelerated protocol patients. Comparisons included range of motion assessments, stability tests, and strength measurements. Results of this comparison indicated that an accelerated approach offered advantages over the traditional conservative approach in relation to patient satisfaction, compliance, return to activity, incidence of patellofemoral joint symptoms, and graft viability (Shelbourne & Nitz, 1990).

It was observed that full knee extension range of motion was achieved faster in the accelerated program. The emphasis on achieving knee extension in the accelerated program is evident, in opposition to the conservative protocol, which calls for more immobilization in the early phases post-surgery (Shelbourne & Nitz, 1990). Gaining full knee extension during recovery is very important in the functional outcome of the knee joint. Loss of extension after ACL reconstruction may have adverse functional effects that could cause an abnormal gait, quadriceps weakness, and/or patellofemoral pain (Fu et al., 1992).

Another advantage of the accelerated protocol is the increased use of closed kinetic chain exercise. Closed kinetic chain exercise involves the foot being in contact with a surface and the whole limb involved in weight bearing (Shelbourne & Nitz, 1990). This type of exercise has been observed to increase compression forces and decrease shear forces in the joint (Shelbourne & Nitz, 1990). This change in force was determined to help decrease anterior knee pain, and associated patellofemoral problems and increase patient confidence and knee stability (Shelbourne & Nitz, 1990). The increased weight bearing and stress on the graft is also important in the formation of new collagen and the increased organization of the grafted tissue (Shelbourne, et al., 1992).

Also evident in the accelerated protocol was a decrease in muscle atrophy and quadriceps strength came back faster than that of the conservative protocol (Shelbourne & Nitz, 1990). Motivation, pain tolerance, and edema control were found to be important factors in development of quad strength (Shelbourne & Nitz, 1990).

Analysis of tibial displacement, as measured by the KT-1000, between accelerated and conservative patients demonstrated equal or better values for the accelerated protocol compared to the conservative (Shelbourne & Nitz, 1990).

It was concluded by the authors that an accelerated approach to ACL rehabilitation offered advantages over a conservative approach without compromising the stability of the joint and putting the graft at risk (Shelbourne & Nitz, 1990).

Here are some sample rehabilitation programs that schools, physical therapy clinics, and doctors use: