One of the most common injuries in sport is Anterior Cruciate ligament rupture. This injury is significantly server and can lead to a vast amount of time loss post-injury. It is reported more than fifty percent of athlete fail to return to full fitness within the first 12 months post-injury (Ardern, Webster, Taylor, & Feller, 2011). The standard treatment of this injury is reconstructive surgery (ACLR) (Hewett, Di Stasi, & Myer, 2013). The return to play statistic following ACLR are especially despairing. Following the return to sport more than 1 in 4 players will suffer and succeeding re-rupture (Leys, Salmon, Waller, Linklater, & Pinczewski, 2012). In addition to this around 50% of athletes sustaining an ACL injury will go on to develop osteoarthritis within the following decade (Culvenor, Cook, Collins, & Crossley, 2013). In recent years there has been a significant advancement in the surgical procedure and outcomes. However, this improvement in surgery hasn’t been matched by the subsequent rehabilitation process (Hewett et al., 2013). The current process around ACLR rehabilitation is inconsistent and unclear. A large body of practitioners still bases their programs upon time-based criteria which have been shown to be outdated and inaccurate. These time-based goals often do not accurately match the functional status of the athlete. In addition, the reasons cited for these time-based criteria are considered irrelevant (Claes, Verdonk, Forsyth, & Bellemans, 2011). A lack of clear progression and targets for the rehabilitation process will be less efficient and more likely to have negative outcomes. There are 5 clear and defined stages of rehabilitation post ACL injury (Herrington, Myer, & Horsley,).

  1. Pre-Surgery

The aim of this phase in to put the athletes in the best condition prior to surgery. The primary targets are to reduce total knee effusion, regaining knee function and achieve full activation of surround musculature specifically the quadriceps. It has been shown that a failure to regain quadriceps activation can lead to significant strength discrepancies and have a negative effect on the post-surgical rehabilitation (Adams, Logerstedt, Hunter-Giordano, Axe, & Snyder-Mackler, 2012). During this phase, common activities and targets that may be used included straight leg raise with the aim of no lag. Effusion control using methods such as cryotherapy, massage, and compression. It may even be possible to have the patient complete some slow jogging during this phase.

  1. Post-Surgery Recovery

The primary aims post-surgery are to minimise effusion and regain as much range of motion as possible. The minimum acceptable target is 0-120 degree of knee movement. Small deficits in range of motion have been shown to servery effect outcome markers later in the process (Adams et al., 2012). Early increases in range of motion have a positive impact on reducing pain and swelling. This is important as an increased amount of effusion has been shown to lead to a significant reduction in quadriceps activation (Palmieri-Smith, Thomas, & Wojtys, 2008). The final aim of this phase in to start to active muscles and promote symmetric weight bearing. To achieve this, exercises such as bilateral box squats and glute bridges can be used as well as SLR and stand hamstring exercises. Once effusion has been reduced, range gained, and muscle activation achieved the athlete is ready to progress.

  1. Progressive limb loading

The aim of this phase of to progress the athletes from simple bilateral weight-bearing exercise to unilateral activities. Alongside this, the athlete should continue to strengthen key muscle groups. Full range of motion must be achieved in this phase and maintained, alongside this, there should be minimal effusion in response to activity (Jakobsen, Christensen, Christensen, Olsen, & Bandholm, 2010). The second aim that must be achieved in this phase is to achieve single leg balance (Myer, Paterno, Ford, Quatman, & Hewett, 2006)  and ability to demonstrate control and alignment in limb loading activities (Paterno et al., 2010). To assess balance a single leg stance test at differing knee angles should be used aiming to obtain upwards of 15s on a deformable pad. To achieve limb alignment, exercise including single leg squat, bilateral drop jump tests can be used using the QALSLS assessment tool (Herrington et al., ). Strength needs to be significantly progressed and aims should include 1.5 x Bodyweight single leg press (Cleather, Goodwin, & Bull, 2013), and 25 repetitions on gluteal, hamstring and calf capacity tests (Herrington et al., )

  1. Unilateral load acceptance

One a player is strong enough and has significant and equal lower limb muscle capacity they can progress onto unilateral loading. In this phase, the focus is on progressing athletes from bilateral load acceptance to single leg load acceptance exercises. This is the progress to multiple directions and amplitudes of movement. Key activities and objective markers in this second are as follows. Single leg hop for the distance should be achieving a limb symmetry index of 95% or more. Athletes who achieve limb symmetry in land tasks have been shown to be at reduced risk of re-injury(Paterno et al., 2010). In addition to hop for distance, there have been demonstrated a significant link between cross over hop performance and the prognosis of once the athlete returns to sport (Trulsson, Roos, Ageberg, & Garwicz, 2010). Therefore, it is advised that athletes score upwards of 90% in limb symmetry (Munro & Herrington, 2011). Following on from the previous phases, strength must continue to improve and rise. A previous study by (Lewek, Rudolph, Axe, & Snyder-Mackler, 2002)demonstrated that athletes who had greater strength (>90% LSI vs >90% LSI) has significantly better mechanics during walking and running performance. As such targets for strength in this phases include >2 x body weight 10 rep max single leg press, 10 rep single leg press >90% LSI and less that 10% deficit on pre-injury strength scores. Finally in this phase rate of force development must start to be addressed several studies (Angelozzi et al., 2012; Myer et al., 2012)showed that significant reductions in RFD were common post ACLR and lead to reduction in performance in speed and agility based task. As such an objective measure here would be 95% LSI for vertical hop test and 90% discrepancy with pre-injury countermovement jump.

  1. Sport Like Training

The final phase before athletes return to full training aims to develop that athlete’s ability to complete complex movement in multiple directions in response to random stimuli. These activities need to include landing, multi-direction movement, and change of direction specific to the demands of their sport. Players should aim to achieve speed and agility scores of equal to or greater than pre-injury scores. Finally, the athlete should be conditioned to handle the demands of fatigue and still be able to maintain good alignment and control once fatigued.






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Angelozzi, M., Madama, M., Corsica, C., Calvisi, V., Properzi, G., McCaw, S. T., & Cacchio, A. (2012). Rate of force development as an adjunctive outcome measure for return-to-sport decisions after anterior cruciate ligament reconstruction.Journal of Orthopaedic & Sports Physical Therapy, 42(9), 772-780.

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Leys, T., Salmon, L., Waller, A., Linklater, J., & Pinczewski, L. (2012). Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: A prospective study of hamstring and patellar tendon grafts.The American Journal of Sports Medicine, 40(3), 595-605.

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Paterno, M. V., Schmitt, L. C., Ford, K. R., Rauh, M. J., Myer, G. D., Huang, B., & Hewett, T. E. (2010). Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport.The American Journal of Sports Medicine, 38(10), 1968-1978.

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