Journal of Orthopaedic & Sports Physical Therapy

2OOl;3l (ll):620-631

Design and Implementation of a

~eu~omuscular Training Program Following
Anterior Cruciate Ligament ~econstruction
May Arna Risberg, P7; PhD
Marianne Msrk, PTZ
Hanne Krogstad )enssen, PTZ
lnger Holm, P7; PhD3
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Neuromuscular training programs are increasingly integrated into clinical practice for enhance control of abnormal joint
lower extremity rehabilitation. A few rehabilitation programs have been evaluated for translation during functional activ-
patients with anterior cruciate ligament (ACL) deficiency and for injury prevention, but there ities by inducing compensatory al-
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

is limited scientific evidence of the effect of neuromuscular training following ACL terations in muscle activity pat-
reconstruction. Therefore, a neuromuscular training program was developed for patients after terns.
ACL reconstruction. The objective of the neuromuscular training was to improve the ability The objectives of neuromuscu-
to generate a fast and optimal muscle firing pattern, to increase dynamic joint stability, and lar training are to improve the
to relearn movement patterns and skills necessary during activities of daily living and sports nervous system's ability to gener-
activities. The main areas considered when designing the postoperative rehabilitation ate a fast and optimal muscle fir-
program after ACL reconstruction were: ACL graft healing and ACL strain values during ing pattern, to increase dynamic
exercises, proprioception and neuromuscular control, and clinical studies on the effect of joint stability, to decrease joint
neuromuscular training programs. The rehabilitation program consists of balance exercises, forces, and to relearn movement
Journal of Orthopaedic & Sports Physical Therapy®

dynamic joint stability exercises, jump traininglplyometric exercises, agility drills, and sport- patterns and skills. The exercises
specific exercise. The patients exercise 3 times a week for 6 months. The scientific and are designed to induce compensa-
clinical evidence for the rehabilitation program are described and the main exercises in the tory changes in muscle activation
program are outlined. patterns and facilitate dynamic
/ Orthop Sports Phys Ther 200 1;3 1 :62O-631. joint stability in patients with ACL
Key Words: dynamic joint control, knee surgery, proprioception injury. The goal is to achieve a
state of "readiness" of muscles to
respond to joint forces resulting
in enhanced motor ~ontrol.".~"
euromuscular training has become integrated into clini- Several studies have evaluated
cal practice for both upper and lower extremity rehabili- outcome after ACL reconstruc-
t a t i ~ n .According
~ ~ . ~ ~ to the definition of neuromuscular tion,2.6.'>2~2H..90..92.4".[Link].73 but
control, neuromuscular training could be defined as very few have evaluated the effect
training enhancing unconscious motor responses by stim- of different rehabilitation pro-
ulating both afferent signals and central mechanisms responsible for dy- grams following ACL
namic joint control. The biomechanics of the knee are altered after an- Only a few studies have evaluated
terior cruciate ligament (ACL) injury, but neuromuscular training may the effect of neuromuscular train-
ing, and most of those have fo-
Center for Clinical Research, Ullevaal University Hospital, Oslo, Norway. cused on either subjects with ACL
Department for Physical and Rehabilitation Medicine, Ullevaal University Hospital, Oslo, Norway.
deficient knee^^:'^.^^ or the effect
Biomechanics laboratory, National Hospital Orthopaedic Center, University of Oslo, Norway.
Send correspondence to May Arm Risberg, Center for Clinical Research, Ullevaal University Hos- of training on injury preven-
pital, 0407, Oslo, Norway. E-mail: mrisberg@[Link] tion. lH,.36.37.71
 Ihara and N a k a ~ a m awere
~ ~ the first to evaluate ries decreased significantly in female athletes com-
neuromuscular training consisting of balance exer- pared to male athletes.36
cise and perturbation training. Four subjects with To our knowledge, no studies have been published
ACMeficient knees who had "giving way" symptoms on the effect of neuromuscular training after ACL re;
went through a training program 4 times per week construction. Current research on the effect of neuro-
for 3 months. The patients were compared to a con- muscular training, knowledge about graft healing af-
trol group of 5 subjects. Significant improvement was ter ACL reconstruction (bone-patellar tendon-bone
found in peak torque time and rising torque value of graft), research on proprioception and neuromuscu-
the hamstrings in the training group compared to lar control, and our clinical experience with patients
the control group. These researchers concluded that who have ACL reconstruction were considered dur-
the training program apparently had the potential to ing the design of our rehabilitation p r ~ g r a m . ~ "
shorten the time lag of muscular reaction.
Beard et alRstudied 50 subjects with ACMeficient EVIDENCE GUIDING THE DEVELOPMENT OF THE
knees randomly assigned to a proprioceptive training NEUROMUSCULAR REHABILITATION PROGRAM
program or a traditional strength training program.
FOLLOWING ANTERIOR CRUCIATE LIGAMENT
The proprioceptive program included balance, dy-
namic joint stability, and perturbation training. Both RECONSTRUCTION
programs were performed using circuit training. The main topics for developing the neuromuscular
Warm-up and stretching preceded and followed the rehabilitation program following ACL reconstruction
exercise circuit. The neuromuscular training pro- involve: (1) graft healing response and ACL strain
gram consisted of 1 hour of intensive training 2 values during exercises, (2) function of ligament
times per week for 12 weeks and a home exercise
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mechanoreceptors, and (3) neuromuscular control.

program. The exercises were performed in weight- However, evidence in this field is limited and incon-
bearing positions. The traditional strength training clusive, and there are many conflicting and contro-
program included the same number of training ses- versial areas. Following our discussion of the 3 main
sions, but the exercises were mostly performed in topics, the different types of training included in the
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

non-weight-bearing positions with the objective of in- rehabilitation program are described, and the main
creasing the strength of lower limb muscles. No at- exercises for each type of training are outlined. The
tempt was made to increase speed of contraction. An entire rehabilitation program is described in the A p
indirect measurement of proprioception, the reflex pendix.
hamstring contraction latency, was used in addition
to Lysholm functional score and knee joint laxity.
The study demonstrated a significant improvement
Graft Healing Response and Anterior Cruciate
in the neuromuscular training group for mean ham- Ligament Strain Values During Exercises
string contraction latency and for Lysholm functional
Journal of Orthopaedic & Sports Physical Therapy®

The goal of the rehabilitation program after ACL

score compared to the traditional strength training reconstruction is to restore joint motion and lower
group. limb performance, and regain muscle strength to the
Fitzgerald et studied 26 patients with acute preinjury level without producing excessive graft
ACL rupture. The patients were randomly assigned strain during healing of the graft. In contrast to de-
to a standard rehabilitation program with or without velopment of a rehabilitation program for patients
perturbation training exercises. Adding the perturba- with ACL deficiency, the graft healing responses and
tion training to the standard rehabilitation program ACL strain values during exercises have to be consid-
reduced the risk of continued episodes of giving way ered in the design of a rehabilitation program for
of the knee during sports activities and maintained patients after ACL reconstruction.
the knee function at the 6-month follow-up com- Experimental studies of healing of the ACL graft
pared to the patients in the standard rehabilitation have demonstrated that the graft requires a long
program. time to revascularize and heal.'-J5Therefore, the ACL
Hewett et al" developed a jump/plyometric train- graft has been considered vulnerable during the first
ing program to evaluate the effect of the training weeks after ACL reconstruction.1~4~ccording to re-
program on landing mechanics and lower extremity sults from animal studies, strenuous rehabilitation ex-
strength in female athletes. The program was de- ercises should not be included immediately after sur-
signed to decrease landing forces by teaching neuro- gery, and aggressive rehabilitation programs should
muscular control during landing and to increase ver- not start immediately after ACL r e c o n s t r ~ c t i o n . ' ~ ~ ~
tical jump height. The same group did a prospective However, experience from use of graft materials with
study where a jump training program was included biomechanical properties similar to the normal
to reduce the risk of knee injuries in athletes.% ACL,'* adequate fixation ~trength;~' and clinical evi-
Their study showed that the incidence of knee inju- dence of no increased laxity after aggressive rehabili-

J Orthop Sports Phys Therevolume 31 .Number 11 .November 2001 62 1

 tation program^^^.^^^^^ have led many to recommend position as well as for initiating reflex muscle con-
aggressive rehabilitation programs. But evidence for traction about the knee.s1
the remodeling process in the human ACL graft is The decrease of proprioceptive sense in the ACL
unknown. A previous study by our group demonstrat- deficient knee has been well e ~ a m i n e d . ~ Bar- .~~.~~.~~
ed that linear stiffness properties and ultimate failure rack et a14 demonstrated a significant decrease in
load of a human ACL graft 8 months after recon- kinesthesia of 37% in patients after complete ACL
struction were about 90% of the values for the unin- rupture and concluded that patients who sustained a
jured knee.13 That case study indicated that strenu- complete ACL tear may experience a decline in pro-
ous exercises could at least be introduced 8 months prioceptive function contributing to the progressive
after ACL reconstruction. instability and disability often observed after this in-
The effect of different rehabilitation exercises on jury. Moreover, Corrigan et alZ0and MacDonald et
the healing response of an ACL graft is still unclear. a14Rreported a significant increase of 39% and 21%.
However, different strain values of the ACL have respectively, in the threshold to detection of passive
been reported for different rehabilitation exercis- motion in ACMeficient knees. Beynnon et all4 also
es.lOJ1.m Beynnon et all1 studied the effect of weight- reported a significant decrease in kinesthetic aware-
bearing and non-weight-bearing exercises on strain ness in ACLdeficient knees.
behavior of the normal ACL in human subjects while Different results of the effect of ACL surgery on
performing squatting and active flexionextension of proprioception have been r e p ~ r t e d . ~ . MacDon-
~~.~"~~
the leg. They showed that maximum ACL strain val- ald et a14%tudied proprioception in subjects with
ues obtained during squatting did not differ from ACL reconstruction and found that proprioception
those obtained during active flexionextension. Fur- did not improve after reconstruction when compared
thermore, the strain values during squatting were un- to subjects with ACMeficient knees. Barrett5 studied
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affected by the application of elastic resistance dur- joint position sense in subjects with ACLdeficient,
ing the exercise. These data indicate that non- ACL-reconstructed, and normal knees and reported
weight-bearing and weight-bearing exercises produce significantly poorer joint position sense in ACL-re-
about the same amount of strain, suggesting that constructed knees compared to normal knees, but
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

non-weight-bearing exercises can be introduced as significant improvement compared to ACMeficient

early as weight-bearing exercises after ACL recon- knees. Lephart et examined patients with ACL
struction. However, weight-bearing exercises have reconstruction 11 to 26 months after surgery and ob-
been shown to produce a more favorable functional served a significant increase in threshold to detec-
outcome and are usually recommended." tion of passive motion at near extension in recon-
Beynnon et all2 evaluated the effect of an aggres- structed knees. These results were confirmed by a re-
sive versus a nonaggressive rehabilitation p r ~ g r a m . ~ cent study by Fischer-Rasmussen and Jensen,2%ho
These rehabilitation programs were designed based found decreased proprioception of the knee joint in
on their previous studies of ACL strain values for dif- people with both ACMeficient and ACL-reconstruct-
Journal of Orthopaedic & Sports Physical Therapy®

ferent rehabilitation exercises. The program includ- ed knees. Fremerey et alw recently published a pro-
ed the same exercises, but one group started the ex- spective longitudinal study evaluating proprioception
ercises at week 2 and the other group at week 6. Pre- (joint position sense) after ACL reconstruction and
liminary results indicated that prescribing exercises found impaired proprioception 3 months after sur-
early after ACL reconstruction (accelerated rehabili- gery compared with preoperative findings. Six
tation program) may increase knee joint laxity, but months postoperatively, the proprioception was re-
no significant differences were found regarding pa- stored to near full extension and flexion, whereas
tient perception of knee function. Other nonran- proprioception in the midrange position was still im-
domized clinical trials on aggressive rehabilitation paired. A strong correlation ( r = 0.76) was found be-
programs have concluded that these programs are ef- tween proprioception and patient satisfaction.
fective and d o not produce increased knee joint laxi- Results from studies evaluating proprioceptive defi-
ty.63 Based on these conflicting results, more evi- cits after ACL reconstruction vary. This can partly be
dence from clinical randomized trials is needed. explained by the recent evidence of the timing of
reinnervation of the graft (postoperatively) and the
Function of Ligament Mechanoreceptors wide variety of tests used to evaluate proprioception.
It has been demonstrated that free patellar tendon
Anatomical studies have demonstrated the exis- grafts in dogs are partly reinnervated 6 months after
tence of mechanoreceptors in the human ACL.'j".61 [Link] no innervation was observed in
Pitman et aP2 used arthroscopic procedures to pro- the ACL grafts immediately after surgery, histological
vide direct evidence for the presence of active pro- examination of the graft tissue 6 months after sur-
prioceptive receptors within the intact ACL of the gery revealed that all 6 grafts contained neural ele-
human knee. Animal studies have shown that these ments with equal numbers of mechanoreceptors and
particular receptors are specific for detecting joint free nerve endings. Other animal studies have con-

J Orthop Sports Phys [Link] 31 .Number 1 1 .November 2001

 firmed that mechanoreceptors regenerate gradually affect neuromuscular control.55Several studies have
after ACL r e c o n ~ t r u c t i o nHuman
.~ studies have con- reported differences in neuromuscular performance
firmed the results of these animal studies. Ochi et in ACMeficient and reconstructed knee~.'-~"eard
alm found that sensory reinnervation in the recon- at a17 studied the reflex hamstring contraction laten-
structed ACL was closely related to the function of cy in subjects with reconstruction preoperatively and
the knee. then postoperatively at 3 and 6 months. There was a
Barrett3 identified the recovery of proprioception significant improvement in the neuromuscular con-
as the most important factor for a functionally good trol following reconstruction of the ACL, but only
result after ACL reconstruction. Co et all9 reported a for those with poor proprioception prior to surgery.
significant difference in proprioception between Huston and WojtysSRevaluated possible predisposing
ACLreconstructed and normal knees but concluded neuromuscular factors for ACL injuries in athletes of
that the results were not clinically significant because both sexes compared to nonathletes. Female athletes
the reconstructed and the normal knees both per- required significantly more time to generate maxi-
formed better than the normal control knees. They mum hamstring muscle torque than male athletes. A
suggested that training could restore much of the different muscle recruitment order was found in a
loss in proprioception because the subjects with re- limited subgroup of female athletes. Furthermore,
construction went through a rehabilitation program significant differences in the recruitment order of
for both knees. the lower extremity muscles were observed between
The contribution of joint receptors to kinesthesia males and females. In a recent study, Wojtys and
and position sense has been a matter of debate, and Huston7' found significantly impaired neuromuscular
the topic has frequently been revie~ed.~' Evidence function 12 to 18 months after ACL reconstruction,
exists for a significant influence of muscle afferents although 80% of the subjects believed that they had
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and ligamentous joint afferents on position and regained their preoperative functional level. Quadri-
movement sense. There are also reasons to believe ceps and hamstring muscle reaction time were identi-
that there might be considerable variation among fied as the best indicators of subjective knee func-
different individuals in the use of joint afferent infor- tion.
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

m a t i ~ nand
, ~ there might be inherent differences Some patients with ACL injuries compensated well
among subjects. Possible genetic differences among for their loss of the knee stabilizer (copers), but oth-
different individuals have been studied.39This re- ers did not ( n o n c o p e r ~ ) .Rudolph
~ . ~ ~ et a15%denti-
search has included an assessment of the subjects' fied movement strategies in copers and noncopers
abilities and enduring characteristics or traits."Vhe and found that copers had movement strategies simi-
"single subject" designs differ from the experimental lar to those of uninjured subjects. Copers stabilized
approach in which differences among individuals are their knee with a greater contribution from the an-
ignored in order to concentrate on the average per- kle plantar flexors, indicating that the significance of
formances of larger groups of subjects. More re- gastrocnemius muscles as contributors to dynamic
Journal of Orthopaedic & Sports Physical Therapy®

search on individual differences would contribute to knee joint stability should be emphasized during the
the knowledge of the effect of rehabilitation and rehabilitation program. The noncopers showed a re-
training programs. duction in range of motion and external knee flex-
ion moment, but no evidence of quadriceps avoid-
Neuromuscular Control ance gait was found. Neither copers nor noncopers
had any reduction in quadriceps activation.
Simply restoring mechanical restraints is not
enough for a functional recovery of the kneeM,".% THE NEUROMUSCULAR REHABILITATION
because the coordinated neuromuscular controlling PROGRAM
mechanism required during daily living and sport-
specific activities would be neglected. Rehabilitation The rehabilitation program consists of balance ex-
programs cannot alter a mechanical knee joint insta- ercises, dynamic joint stability exercises, plyometric
bility but may affect the neuromuscular control and exercises, agility drills, and sport-specific exercises.
the dynamic joint stability. A lag in the neuromuscu- The program is divided into 6 phases of 3 to 5 weeks
lar reaction time can result in dynamic joint instabili- each (Appendix). Specific exercises are described for
ty with recurrent episodes of joint subluxation and each week in the rehabilitation protocol. Most pa-
deterioration. Therefore, both mechanical stability tients in our rehabilitation program are ready to
and neuromuscular control are probably important progress at the speed given in the protocol, but not
for long-term functional outcome, and both aspects all patients will be able to progress at the same pace.
must be considered in the design of a neuromuscu- Patients who sustain pain, swelling, or range of mo-
lar rehabilitation program after ACL reconstruction. tion deficits undergo treatments until these impair-
Injury to the ACL has been shown to result in al- ments are resolved. Criteria used to determine readi-
tered somatosensory information that may adversely ness for progression include no increased pain or

J Orthop Sports Phys [Link] 31 .Number 11 .November 2001

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Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

FIGURE 1. Dynamic joint stability exercise using the "star."

swelling and the ability to maintain postural control exercise on a flat, even surface, the exercise is made
of the position before movements are superimposed more challenging by changing the surface to balance
on the position. The patients first need to be aware mats, a wobble board, or a trampoline. Furthermore,
of the position of the body in space before tolerating sensory feedback is challenged by excluding vision,
Journal of Orthopaedic & Sports Physical Therapy®

movements into space or reacting to a perturbation. challenging the vestibular system through changing
When the patient is able to successfully perform the the base of support, and using distractions, such as a

I
I
?
FIGURE 2. (A) Balance reach leg. (B)Balance reach arm.

624 J Orthop Sports Phys [Link] 31 .Number I l *November 2001

 "ti

FIGURE 3. Lunge exercise using the "star."

ball or sudden and unexpected change in movement Balance Training

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directions. No knee braces are used following the

knee surgery o r during the rehabilitation program. Berg9 described "balance" as the ability to main-
tain a position, the ability to voluntarily move, and
the ability to react to a perturbation. All of these
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

components are important for neuromuscular con-

trol. To distinguish between balance training, dynam-
ic joint stability training, and perturbation training,
balance training is used in this rehabilitation pro-
gram for exercises pertaining to the first part of the
definition (the ability to maintain a position). Ac-
cordingly, "balance training" exercises focus on
awareness of posture and the position of the body in
space with the aim of maintaining equilibrium with-
out changing the base of support. Balance exercises
Journal of Orthopaedic & Sports Physical Therapy®

include the double and single leg stance on even,

flat surfaces, on a balance mat, on a wobble board,
and on a trampoline.
Three sensory systems contribute to the mainte-
nance of balance: the visual, the vestibular, and the
somatosensory (ie, proprioceptive) . Any of these sys-
tems may dominate, and all are context d e ~ e n d e n t . ~ '
Balance seems to affect both the injured leg and the
uninjured leg in patients with ACL deficiency. Zatter-
strom et a177found significant disturbance of balance
in both the injured leg and the uninjured leg after
ACL rupture compared with a reference group of
normal subjects. Values of the uninjured leg were
normalized after 3 months of training, but the in-
jured leg still showed increased body sway. Normal
balance parameters on the injured side were found
at examination after 12 months and persisted up to
36 months posttraining.

Dynamic Joint Stability Training

-..... . .,-. .- ......:.-
1,. ;i-
--Tyr?..'..-.
-
..a,,-.;., '
:. I " <..,A.
Exercises aimed at the second part of Berg's defi-
FIGURE 4. Step-up exercise on a wobble board. nition,Qhe ability to voluntarily move, address dy-

J Orthop Sports P h y [Link] 31 Number I 1 e November 2001 625

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Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

FIGURE 5. Series of plyometric training jumps.

namic joint stability training in our rehabilitation as with different kinds of surfaces, visuals, or distrac-
program. The concept of dynamic joint control train- tions).
ing was first introduced in 1986.5" Dynamic joint stability exercises are done by using
Journal of Orthopaedic & Sports Physical Therapy®

Several of the exercises included in the dynamic balance reach leg (Figure 2A) and balance reach
joint stability training use vectors on the floor, called arm (Figure 2B) on an even, flat surface, on a bal-
the "star" (Figure 1 ) . to reference the start and the ance mat, and on a wobble board; lunge exercises
direction of the exercises described by Gary W. Gray and lunge exercises with weights; step-up (Figure 4)
in 1995.35The 8 vectors are 45 degrees apart. The and stepdown exercises; squatting exercises with and
patient is oriented on the vectors in reference to the without weights on an even surface, a balance mat, a
lower extremity that is being exercised and in refer- wobble board, and a trampoline; and squatting exer-
ence to the direction of the exercise. Successful re- cises on 1 leg.
turn is pointed out for each exercise.
The exercises are performed in the frontal, sagit- JumpTraining, Plyometric Training, and Sport-Specific
tal, and diagonal planes. The star is used for the 1- Training
leg stance on the floor with a balance mat and a
wobble board. It is used with the step-up and s t e p Jump training is used for exercises involving j u m p
down exercises in 3 different directions. Further- ing in addition to exercises aimed at improving or
more, it is used for the balance reach leg exercise changing technical performance, especially during
(Figure 2A) and the balance reach arm exercise (Fig- landing. Plyometric training is sometimes synony-
ure 2B). The star is also used for the lunge exercise mous with jump training. The term plyometric is de-
(Figure 3) where the movements are performed in fined as "quick and powerful movement involving
the 3 different planes. The exercises can be changed prestretching the muscle and activating the stretch-
by varying the planes of motion, the range of motion shortening cycle to produce a subsequently stronger
(ankle, knee, or hip), the loading (use of bars), the concentric c o n t r a c t i ~ n . "During
~ hopping, energy is
speed, and the amount and type of feedback (tactile, first stored and thereafter released in a manner simi-

J Orthop Sports Phys Ther-Volume 31 .Number 1 1 .November 2001

 lar to a spring. These exercises are used to facilitate es in a neuromuscular training program affect im-
quick changes in directions and to improve muscle pairments or disabilities in both patients with ACL
power (strength per unit time). deficiency and those who have ACL reconstruction.
Agility training programs are designed to allow the
patient to adapt to quick changes in directions, ac-
celeration and deceleration, and cutting activities. REFERENCES
Shuttle runs are used to expose the lower extremity
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in the context of playing situations. ments after anterior cruciate ligament reconstruction. Am
J Sports Med. 1993;2 1 :264-270.
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clude 2- and 1-legjumps on the trampoline, balance dence of reinnervation of free patellar tendon autograft
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as 180-degree jumps, vertical jumps, scissors jumps, Sports Med. 1997;25:196-202.
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6. Beard DJ, Dodd CA. Home or supervised rehabilitation
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ball catching, throwing, passing, and kicking).

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struction on proprioception in the anterior cruciate liga-
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

We allow patients to begin sports activities when

(1) they can tolerate the full speed agility training ment deficient knee [abstract].Orthopaedic Transactions.
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less than 15% muscle strength deficit (isokinetic ception enhancement for anterior cruciate ligament de-
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Beynnon BD, Fleming BC, Johnson RJ, Nichols CE, Ren-
To monitor the rehabilitation program and record strom PA, Pope MH. Anterior cruciate ligament strain be-
Journal of Orthopaedic & Sports Physical Therapy®

compliance, each week the patient and the physical havior during rehabilitation exercises in vivo. Am J Sports
therapist record the exercises, the amount of time Med. 1995;23:24-34.
carrying out each exercise, and the amount of time Beynnon BD, Johnson RJ, Fleming BC, Stankewich CJ,
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terior cruciate ligament during squatting and active flex-
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Beynnon BD, Ryder SH, Konradsen L, Johnson RJ, John-
CONCLUSIONS son K, Renstrom PA. The effect of anterior cruciate liga-
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proprioceptive sensibility in anterior cruciate ligament-
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There is also a need to evaluate what kind of exercis- erties of primate vascularized vs. nonvascularized patellar

J Orthop Sports Phvs [Link] 31 *Number 1 I -November 2001

 tendon grafts; changes over time. J Orthop Res. 1989;7: transected anterior cruciate ligament in the rabbit. J Bone
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APPENDIX

Descriptions of the Rehabilitation Exercises

The rehabilitation program starts the second week after surgery, 3 times a week for 6 months. Only the new
exercises that are introduced each week are described below. The involved leg is used if nothing else is stated.

Phase 0: Early Postoperative Phase

Weeks 1-2
Goal: full passive knee extension and reduced swelling.
Patients are hospitalized for 1 to 3 days. After discharge from the hospital and until the rehabilitation pre
gram starts at the outpatient clinic, patients d o a home program with the main focus o n restoring full range
o f motion and reducing swelling. T o reduce swelling, the patient should keep the leg elevated, repeat ankle
plantar flexiondorsiflexion range o f motion exercises, and perform isometric quadriceps and hamstrings ex-

J Orthop Sports Phys Therevolume 31 -Number 11 .November 2001 629

 ercises. Crutches are used to improve gait and to reduce swelling. Full knee extension is the most important
goal the first week. Gravity is used to restore full knee extension by using 2 chairs, with the leg elevated on a
hard pillow under the heel when sitting or with the leg elevated on the edge of the bed in supine position.

Phase 1: Walking Phase

Weeks 2-4
Goals: normal walking pattern; controlled balance double limb support; controlled balance single limb
support; controlled dynamic stability of the uninvolved leg.
Crutches are used with weight-bearing as tolerated until 2 to 4 weeks after surgery. The criterion for discon-
tinuing the use of crutches is no limping. Weight-bearing exercises are started as early as possible. If full
weight-bearing is not tolerated during squatting exercises, counterweights are used to avoid swelling or pain.
Cold therapy (glacier packs) is applied for 15 minutes immediately after training as long as swelling is present.
* Stationary bicycle to improve range of motion and reduce swelling
* Walking exercises on the floor
* Walking exercises on a treadmill to improve gait patterns after discontinuing crutches
* Squatting exercises: if the patient has persistent swelling or pain, squatting exercises are performed in a
pulley apparatus with the use of counterweights
* Gastroc exercises: standing heel rising exercise
* Single leg stance exercise, startingon the uninvolved leg
* Single leg stance, involved leg
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* Balance reach leg exercise and balance reach arm exercises on uninvolved leg
* Lunge exercises: anterior, anterior/lateral, lateral, posterior/lateral, and posterior directions on uninvolved leg
* Step-up exercises: anterior, lateral, posterior, starting with uninvolved leg
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Phase 2: Balance and Dynamic Joint Stability Phase

Weeks 5-8
Goals: controlled balance double limb support, uneven surface; controlled balance single limb support,
uneven surface; controlled dynamic stability, double limb support; controlled dynamic stability, involved leg;
step-up and stepdown; squatting, 2 legs; sideways and backwards walking.
Week 5
Journal of Orthopaedic & Sports Physical Therapy®

* Single leg stance eyes closed

* Single leg standing on balance mat, appropriate knee and hip position
* Wobble board, 2 legs
* Balance reach leg, involved leg
* Balance reach arm, involved leg
* Step-up, both legs
Week 6
* Backwards and sideways walking on treadmill
* Wobble board, 2 legs with badweights
* Wobble board, 2 legs, throwing ball
* Wobble board, 1 leg
* Stepdown, uninvolved leg
Week 7
* Single leg stance, trampoline, throwing ball
* Step-up and stepdown, involved leg, different direction
* Balance reach leg, balance reach arm, balance mat, and wobble board
Week 8
* Lunge exercise with bars/weights
* Single leg stance, trampoline, throwing ball, different directions (front, back, and sideways)
* Single leg stance, balance mat, throwing ball
* Step-up, wobble board
J Orthop Sports Phys [Link] 31 .Number 11 .November 2001
 Phase 3: Muscle Strength Phase

Weeks 9-12
Goal: increased muscle strength.
* Slide board exercises
* Single leg stance with weights, eyes closed
* Wobble board single leg, eyes closed
* Squatting exercises, wobble board
* Squatting exercises with weights, increased knee flexion
* Lunge exercises with weights, increased knee flexion
* Stepup with weights, increased height and weights
* Jumps: 2 legs, trampoline
Phase 4: Running Phase

Weeks 13-16
Goals: running; controlled jumps, 2 legs, trampoline; controlled jumps, 2 legs, turns, trampoline.
* Running on trampoline
* Running on treadmill
* Running or jogging outdoors
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* Jump training: 2 legs, trampoline, increased knee flexion

* 180degree jump on trampoline
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Phase 5: Jumping Phase

Weeks 17-1 9
Goals: running sideways and backwards; controlled cutting, slow speed; controlled jumping, 2 legs, flat,
even surface; controlled bounding for distance; controlled jumps on steps.
* Running backwards
* Bounding for distance
* Jumps: 2 legs, 18Odegree turns, flat, even surface
Journal of Orthopaedic & Sports Physical Therapy®

* Jumps: up and down from a step

* Running: figure-of-eight, stopturn-run
* Agility drills, slow speed
Phase 6: Plyometric and Agility Training Phase

Weeks 20-24
Goals: controlled single leg jumps; controlled vertical jumps; controlled cutting, full speed; controlled
sport-specific activities.
* Single leg jumps, trampoline
* Single leg jumps, balance mat
* Single leg jumps, anterior posterior, lateral, flat, even surface
* Vertical jumps
* Scissorsjumps
* Series of jumps: 2-footed jump onto & to &inch step. Jump off step with 2 feet, then vertical jump
* Agility drills, full speed on a moveable standing platform
* Sport-specific tasks are added during the agility training depending on the kind of sport the patients may
return to

J Orthop Sports Phys Ther*Volume 31 .Number 11 .November 2001