Professional Documents
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T
Study Design: Case report. he fastest possible safe
Background: To present the rehabilitative course, decision-making, and clinical milestones that return to competitive
allowed a top-level professional soccer player to return to full competitive activity 90 days after games after anterior
surgery.
cruciate ligament
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Case Description: The patient was a 35-year-old forward player who sustained an isolated
complete tear of the left anterior cruciate ligament (ACL) in the midst of the competitive
(ACL) reconstruction
2001-2002 season. He was in contention for a position on the Italian World Cup Team that was to for a professional athlete is the
be played 135 days after his injury, only if he demonstrated that he could return to play at the goal of every sports rehabilitation
highest level before the team was selected. The patient underwent an arthroscopically assisted team. While there is no consensus
ACL reconstruction with a double-loop semitendinosus-gracilis autograft 4 days after the injury. of opinion about timing,23,26 surgi-
Eight days after surgery he began rehabilitation at a rate of 2 sessions a day, 5 days a week, plus 1 cal techniques, and rehabilitative
session every Saturday morning. These sessions were performed in a pool for aquatic exercises, in protocols after ACL rupture, sev-
a gymnasium for flexibility, coordination, and strength exercises, and on a soccer field for recovery
eral studies demonstrate that early
of technical and tactical skills, with continuous monitoring of training intensity.
Journal of Orthopaedic & Sports Physical Therapy®
Outcomes: The surgical technique and the progressive rehabilitation program allowed the patient accelerated and progressive proto-
to play for 20 minutes in an official First Division soccer game 77 days after surgery and to play a cols of rehabilitation do not ad-
full game 90 days after surgery. Eighteen months postsurgery, the player had participated in 62 versely affect functional recov-
First Division matches, scoring 26 times, and had received no further treatment for his knee. ery.12,13,21,22 The timetable for re-
Discussion: This case report suggests that early return to high-level competition after ACL turn to full activity after ACL re-
reconstruction is possible in some instances. Some factors that may have favored the early return construction has moved from
include optimal physical fitness before surgery, a strong psychological determination, an isolated longer than a year in the 1970s to
ACL lesion, a properly placed and tensioned graft, a personalized progression of volume and
a range of 4 to 9 months to-
intensity of exercise loads, and an appropriate density of rehabilitative training consisting of a mix
of gymnasium, pool, and field exercises. J Orthop Sport Phys Ther 2005;35:52-66.
day.11,12,22,24 Information about
resolution of impairments after
Key Words: ACL, knee, rehabilitation, semitendinosus ACL injur y (muscle strength,
range of motion [ROM], effusion)
1
Director, Isokinetic Education and Research Department, Bologna, Italy. is readily available in the litera-
2
Physical Therapy Clinician Specialist, Isokinetic Rehabilitation Centre, Bologna, Italy. ture, but there is little information
3
Sports Medicine Clinician Specialist, Isokinetic Rehabilitation Centre, Bologna, Italy.
4
Orthopaedic Surgeon, Rizzoli Orthopaedic Institute, Bologna, Italy. about how activity affects graft
5
Professor, Department of Physical Therapy and Biomechanics and Movement Science Interdisciplinary healing.1,3 While it is clear that
Program, University of Delaware, Newark, DE. immobilization adversely affects
Address correspondence to Giulio S. Roi, Education and Research Department Isokinetic, Via di
Casteldebole 8/4, 40132 Bologna, Italy. E-mail: gs.roi@isokinetic.com healing, appropriate levels of activ-
ity to optimally load the graft at
CASE REPORT
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CASE DESCRIPTION
formed with the patient in supine and the knee tation progression. At the time of the first examina-
relaxed in full extension. The examiner performs tion (POD 8), the patient had a trace effusion, pain
TABLE 1. Outcome measures during the rehabilitation period. Swelling was rated on a 0-to-3+ scale.
Days
Postoperative Event Pain Swelling Knee ROM Strength Functional
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
crutches
29 Medical check None 0/1+ 2°-0°-140° (full) - Running
38 Medical check None 0/1+ Full - Running and start
of on field reha-
bilitation
71 Medical check None 0 Full Isometric KE Individual soccer
–5%, compared exercises
to uninvolved
side; no differ-
ence in the 1
leg hop test
77 Medical check after None 0 Full - Game (20 min)
game
90 Medical check after None 0 Full - Game (90 min)
game
517 Medical check None 0 Full KE +3%; KF Individual and
+2% compared team soccer
to uninvolved exer cises
side at 90°/s
(isokinetic)
CASE REPORT
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Days 18-29
ROM Extension: prone leg hang and pendulum
Strength Active cocontractions of knee extensors and flexors (10 × 45 s, 15 s recovery); hip flexors and hip ab-
ductors: (3 kg, 6 × 15 rep, 15 s recovery); isometric hip adductors (10 × 45 s, 15 s recovery); seated
knee extension with tubing and with load from 45° to full extension (4 kg, 6 × 15 rep, 6 × 15 s); leg
press (elastic) eccentric modality
Proprioception Unstable surfaces, bipodal and monopodal for 10 min
Massage Lower limbs 30 min
Ice 15 min at the end of the session
Warming-up and Aerobic Stationary bicycling 10 min; stepper 5 min (level 1); treadmill walk 4 km/h 6% grade
Indoor Pool Walking 10 min, hip extension, flexion, abduction and adduction without and with float flipper; leg
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Days 30-42
ROM Flexion: heel slide, active assisted flexion
Strength Knee flexors (2 kg, 2 × 15 rep); wall slide (6 × 10 rep); seated knee extension (4 kg, 6 × 15 rep,
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
6 × 15 s); leg press (elastic) with 1 leg (6 × 10 rep); leg press with 1 leg (50 kg, 6 × 15 rep)
Proprioception Unstable surfaces monopodal, bouncer for 10 min
Massage Lower limbs 30 min
Ice 15 min at the end of the session
Warming-up and Aerobic Treadmill walk 10 min at 5.5 km/h 0% grade; running 10 min at 7 km/h, 0%-3% grade; stepper, 10 min
(level 6)
Indoor Pool Back swimming, stretching, crawl swimming with small board; exercises with small and long flippers;
forward, lateral skips; running in deep water without body weight, running in low water with weight
bearing; jumps, headings; free swimming
On-Field Rehabilitation -
Training With the Team -
Journal of Orthopaedic & Sports Physical Therapy®
Days 43-59
ROM Stretching exercises
Strength Knee flexors (2 kg, 2 × 15 rep); wall slide (6 × 10 rep); knee rotators (tubing, 8 × 40 rep); seated leg
extension (progressively up to 40 kg, from 90° to full extension, 8 × 10 rep; progressively up to 45 kg,
from 45° to full extension, 6 × 15 rep); isokinetic knee extension (300°/s, 6 × 10 rep), NMES 20 min
vastus lateralis and medialis
Proprioception Bouncer 10 min
Massage Lower limbs 30 min
Ice 15 min at the end of the session
Warming-up and Aerobic Treadmill walk 10 min at 5.5 km/h 0% grade; running 10 min at 7.5 km/h, 0-6% grade
Indoor Pool -
On-Field Rehabilitation Slow running, exercises for a correct running pattern; circular running, bends, changing directions,
sprint, decelerations, stop and go; anaerobic threshold running for 8 min
Training With the Team Tactical skills at game intensity
Days 73-90
ROM Stretching exercises
Strength Knee flexors (4 kg, 2 × 15 rep); hip internal rotators (tubing, 8 × 40 rep); leg press (70 kg, 6 × 10 rep
slow); leg extension (40 kg from 90° to full extension, 8 × 10 rep; 45 kg from 45° to full extension, 6
× 15 rep)
Proprioception Bouncer and proprioception exercises for 10 min
Massage Lower limbs 30 min
Ice -
Warming-up and Aerobic Treadmill walking 10 min at 5.5 km/h, 0%-3% grade
Indoor Pool -
CASE REPORT
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On-Field Rehabilitation Running, sprinting, changing direction, decelerations; individual technique with ball, team drills; small-
to large-sided soccer matches (2 to 2; 4 to 4), jumping, shooting, tackling; anaerobic threshold
running 20 min
Training With the Team Tactical skills at game intensity
Abbreviations: NMES, neuromuscular electrical stimulation; rep, repetitions.
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
rehabilitation facilities and personnel, much of what may be found among professional athletes, it may be
is presented has an impact on the discussion of different in those in less competitive situations.18
optimal loading of the ACL graft and rehabilitation In our patient we used a progressive rehabilitation
after ACL reconstruction in general. protocol focused on return of full knee extension,
This athlete underwent reconstruction less than 1 control of swelling, proper gait, and quadriceps
week after injury. While there is some controversy strengthening. During the rehabilitative program,
about the timing of ACL reconstruction following care was taken to restore muscular strength with
injury, early reconstruction is often performed in isometric, isotonic, and isokinetic training, performed
professional and top-level athletes when there is little according to the progressive-loading principle.19
Journal of Orthopaedic & Sports Physical Therapy®
swelling, full knee extension, and the ability to walk While most reports of accelerated rehabilitation have
without a limp.9,12,21 In this situation the rehabilita- used bone-patellar tendon-bone autografts as the
tion may progress well and the early reconstruction graft source, accelerated rehabilitation has also been
does not preclude an accelerated recovery. used in the cases of ACL reconstructed with ham-
Furthermore, the athlete presented to the rehabili- string graft.12,14 The medium- to long-term follow-up
tation center with only a trace effusion 8 days after studies, in which the 2 surgical techniques were
surgery. One week later, his ROM was 0° to 115°. compared, demonstrated that they have similar out-
This underscores an important theme of this presen- comes.7,16 The progressive rehabilitation program
tation: that objective criteria, rather than specific described here is likely appropriate for both graft
timetables, should guide clinical decision making. types.
This athlete was able to progress quickly. Others, with The concept of loading of the ACL graft is a
more severe impairments or impairments that rede- matter of great controversy. The most thorough study
velop with added workload, may take more time to of ACL graft biology is more than 30 years old and
progress through the program. Progressions that are reflects older surgical techniques and prolonged im-
time based, rather than criterion based, ignore these mobilization, which are both detrimental to the
interpersonal differences. knee.3 More recent basic science research, where
This athlete had an isolated lesion of the ACL, with isolated tendons under cyclic stress responded posi-
no concomitant ligamentous, meniscal, or chondral tively11 and where in a single case the graft-knee
injury. These results should not be generalized to complex was tested postmortem in an individual who
CASE REPORT
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100%
80%
>170
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
60% 160-170
150-160
40% 130-150
<130
20%
0%
Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Journal of Orthopaedic & Sports Physical Therapy®
FIGURE 5. Training intensity (percent of each rehabilitation session) at each heart rate for each session on the soccer field. Day 1
corresponds to postoperative day (POD) 38; day 21 corresponds to POD 86.
died 8 months after reconstruction,1 suggests that the monitor and periodic incremental treadmill tests to
graft may be responsive to stress. These consider- determine aerobic and anaerobic fitness as well as
ations led our surgical and rehabilitative team to training intensity is another innovation we present
conclude that graded, progressive loading of the ACL here. Overall fitness is often an afterthought and left
graft may facilitate graft healing and incorporation. to the team to perform after the athlete is discharged
While we cannot measure the graft response directly, from formal therapy. Maintaining the athlete’s fitness
this patient had continued positive responses to level at or near that required for competition cer-
progression of rehabilitation with no signs of joint tainly played a role in the rapid, successful return of
distress. this player to competitive soccer.
We introduce the in-field rehabilitation as a corner- In the literature there is 1 similar case where an
stone of accelerated functional recovery of profes- athlete returned to intercollegiate basketball 6 weeks
sional athletes. This innovation consists of sports- after ACL reconstruction.4 This athlete had recon-
specific exercises and drills performed in a playing struction using the contralateral patellar tendon as a
field under supervision of rehabilitative personnel, graft and returned to play an average of 29 of 40
without returning the player to the training control minutes of each game. His 2-year subjective outcomes
of his own sports team. The use of the heart rate were reportedly excellent. Despite the fact that a
and intensity of exercise loads, and an appropriate 11. Harner CD, Fu FH, Irrgang JJ, Vogrin TM. Anterior and
density of rehabilitative training, consisting in a mix posterior cruciate ligament reconstruction in the new
millennium: a global perspective. Knee Surg Sports
of gymnasium, pool, and field exercises for a total of Traumatol Arthrosc. 2001;9:330-336.
about 120 sessions over 12 weeks, may all have 12. Howell SM, Hull ML. Aggressive rehabilitation using
contributed to this positive outcome. hamstring tendons: graft construct, tibial tunnel place-
While the extent and likely timeline of the rehabili- ment, fixation properties, and clinical outcome. Am J
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tation provided here is not possible for the average Knee Surg. 1998;11:120-127.
13. Howell SM, Taylor MA. Brace-free rehabilitation, with
person after ACL reconstruction, we suggest that the early return to activity, for knees reconstructed with a
concepts of personalization of the program, objectiv- double-looped semitendinosus and gracilis graft. J Bone
ity of criteria for progression, and maintenance of Joint Surg Am. 1996;78:814-825.
fitness can be generalized to all patients. In fact, this 14. MacDonald PB, Hedden D, Pacin O, Huebert D. Effects
case represents a perfect progression, rather than a of an accelerated rehabilitation program after anterior
cruciate ligament reconstruction with combined
typical timeline, with rapid resolution of impairments semitendinosus-gracilis autograft and a ligament aug-
and excellent response to added workload. mentation device. Am J Sports Med. 1995;23:588-592.
15. Marcacci M, Molgora AP, Zaffagnini S, Vascellari A,
Journal of Orthopaedic & Sports Physical Therapy®
Invited Commentary
This article by Roi et al explains how a professional change at long-term follow-up 2 to 6 years after
soccer player was able to get back to performing at a surgery.1 It is this type of continued follow-up and
high level within 90 days after ACL reconstruction data analysis that allowed us to understand what
with a hamstring autograft. The authors are to be patients were able to do safely after surgery.
commended for their precise explanation of the I would be interested in knowing what type of data
exercises used to help this athlete regain not only the the surgeons had regarding previous patients’ abilities
level of knee function but also the level of aerobic to return to sports after ACL reconstruction with a
capacity needed to be able to perform well. hamstring graft and how they arrived at the current
The advantage of a case report is that an author is stage, where they felt this type of rehabilitation was
able to explain what is possible with a specific possible. Did the authors have a group of patients
technique or training method. As the authors men- who they observed returning quickly to sports, which
tioned, the timing of surgery and, especially, the then made them believe that this rehabilitation was
CASE REPORT
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timing of the return to activities, are quite controver- possible and also safe? Did the authors document
sial. The general feeling is that a quick yet safe return continued knee ligament stability in a large group of
to high-level sports after an ACL reconstruction is patients performing this type of rehabilitation? What
more possible with the use of a patellar tendon are the KT1000 stability results for this patient
autograft versus a hamstring graft. The logic behind population? How do we know that this rehabilitation
this feeling is that the patellar tendon autograft is safe with many patients of this type? Without a
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
provides bone-to-bone fixation, which provides for a group of patients whose data are closely monitored, I
quicker incorporation of the ACL graft than the could not recommend this rehabilitation be used with
tendon-to-bone fixation provided with the hamstring all patients receiving hamstring graft for ACL recon-
graft. struction. I make this statement cautiously because I
I was asked to comment on this article because of do believe an aggressive rehabilitation can be utilized
my experience with accelerated rehabilitation after with most graft sources, when the surgery is per-
ACL reconstruction with a patellar tendon autograft. formed correctly and the graft is placed in the right
The current ‘‘accelerated’’ rehabilitation that we use location. However, it is impossible to recommend a
with patients is something that has evolved through rehabilitation program based on a case report.
Journal of Orthopaedic & Sports Physical Therapy®
time. We performed continual data collection and Two important rehabilitation factors are absent
analysis of objective and subjective measurement, from this report. First, there is no description of how
then we made small advancements in the progression the patient was able to have full knee range of
of the rehabilitation program before we realized how motion so quickly after the injury to allow the
safe patients were with returning to sports quickly surgery to be performed so soon after the injury.
after surgery. This process involved a great deal of Secondly, the article does not describe what kind of
observation and reporting by patients as to what they rehabilitation exercises were performed during the
could and could not do while attempting to achieve first 8 days after surgery? I ask these questions
their goals. During this time, we continually mea- because it is the preoperative and early postoperative
sured ligament stability to make sure that the changes periods that I believe are the most important for
we made in rehabilitation did not result in graft achieving the optimum outcome after surgery.
loosening. For example, we determined that obtain- All patients, whether high-level athletes or the
ing normal hyperextension, even at the extreme of 8° average person attempting to get back to normal
to 15° of hyperextension, did not affect the ability to daily activities and light recreational activities, seek to
achieve and maintain stability, as measured with the have their knees return to normal after an injury.
manual maximum KT1000 test.3 We also determined Normal means that there is symmetry between legs
that the objective stability measured at the time when and knees. An athlete can perform only as well as the
patients achieved full knee range of motion com- leg with the least function. The patients need to have
pared with that of the contralateral knee did not full knee range of motion and full leg strength equal
but if stability is obtained at the cost of losing full The Shelbourne Clinic at Methodist Hospital
range of motion, full functional strength will never Indianapolis, IN
return. Strength can progress as fast as the patient is
able, but in the meantime the patient must be able to
maintain symmetrical knee motion and no swelling.
Given that patients’ knees react differently to leg- REFERENCES
strengthening exercises, the quickness of which this 1. Arnold T, Shelbourne KD. A perioperative rehabilitation
goal can be obtained is greatly variable. If range of program for anterior cruciate ligament surgery. Phys
motion decreases or significant swelling occurs, the Sportsmed. 2000;28:31-44.
Journal of Orthopaedic & Sports Physical Therapy®
amount of strengthening exercises should be re- 2. Rubinstein RA, Jr, Shelbourne KD, VanMeter CD, Mc-
Carroll JR, Rettig AC, Gloyeske RL. Effect on knee
duced. Conversely, aggressive strengthening can be stability if full hyperextension is restored immediately
performed if range-of-motion or swelling problems after autogenous bone-patellar tendon-bone anterior
do not occur. The patient described in this case cruciate ligament reconstruction. Am J Sports Med.
report was able to do aggressive strengthening but 1995;23:365-368.
did not develop swelling or a loss in range of motion. 3. Shelbourne KD, Klootwyk TE, Wilckens JH, De Carlo
MS. Ligament stability two to six years after anterior
The return to sporting activities within 90 days cruciate ligament reconstruction with autogenous patel-
after surgery is certainly possible for many athletes. lar tendon graft and participation in accelerated reha-
The rehabilitation program described in this case bilitation program. Am J Sports Med. 1995;23:575-579.
Invited Commentary
The clinical management of this thought-provoking protocol. The authors report no apparent ill effects
and unique case challenges several existing norms for on the graft or on subsequent joint function up to 2
managing ACL injuries. Return to full participation years following the injury.
in professional soccer only 90 days after injury was Immediate surgery after ACL injury, while still
made possible by doing surgery within days of injury, controversial, is not all that uncommon in high-level
then pursuing an extremely accelerated rehabilitation athletes. Several retrospective studies have suggested
CASE REPORT
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centrated on maintaining the subject’s elite condi- long-term effects of this regimen will be. There is
tioning with the use of a combination of pool and little evidence that ACL reconstruction prevents ar-
treadmill activities. He seemingly never had signifi- thritis, but evidence is equally limited that well-
cant loss of lower extremity strength or coordination. performed intra-articular ACL reconstruction
On day 71 his extension strength was 95% compared contributes to clinically significant degenerative joint
to that of the opposite knee. Quite apart from the disease. In our experience, a significant increase in
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
120 recorded therapy sessions during the 12-week laxity developing after 6 months postoperatively is
period of rehabilitation, it would be interesting to see seen only after reinjury, so it seems unlikely that this
an estimate of cost for use of the gym, pool, and graft will stretch if it has not already done so. If he
other infrastructure that contributed to his recovery. continues to play soccer, he is at risk for further
Even more interesting would be a rundown of the injury and possibly the development of arthritis. But
specific objectives in terms of lower extremity motion, if so, it seems doubtful that this would be attributed
strength, and control used in progressing his rehabili- to his early surgery or accelerated return to activity.
tation regimen. The paper suggests that objective Everyone would agree with the authors that a
criteria were used for progression of the exercise reasonable objective in returning athletes to sports
Journal of Orthopaedic & Sports Physical Therapy®
program, but those criteria are not specifically men- following ACL injury is to get them back as fast as
tioned either in the text or in the tables. That safely possible. This paper tells us what is possible,
information would be instructive if we are to use but not what is ‘‘safe.’’ The mere fact that something
clinical milestones in lieu of dates for advancing the is possible does not make it a good idea. A single
exercise regimen. case does not permit inferences even on other
In this particular patient, pain and swelling appar- professional athletes because, without additional sub-
ently were easily controlled with modalities and jects, we cannot determine the risk of failure or
medication. The progression of activities documented complications. It is impossible to say whether the
in Table 2 did not result in undue stretching of the athlete was simply lucky. I am aware of several
graft, as measured by ligament arthrometry using the well-publicized American professional athletes who
KT1000 with side-to-side comparisons of manual tried unsuccessfully to return to their preinjury levels
maximum force. While preoperative and initial post- within 3 to 4 months after an ACL tear and immedi-
operative arthrometry was not recorded to document ate reconstruction early in the season. One of them
changes in laxity over time, the postoperative mea- had a serious complication during a game 3 months
surement indicated similar laxity to the opposite after reconstruction; other athletes disappeared for
knee, which previously had undergone a more stan- months or years, and some never returned. But none
dard ACL postoperative rehabilitation protocol. His- of these cases has appeared in the peer-reviewed
tological studies have shown that tendons heal to literature as an example for others to consider. Surely
bone tunnels by formation of Sharpey’s fibers, and there have been other failures that we do not know
can understand and apply key principles of acceler- 7. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren
ated rehabilitation for the safe and rapid recovery of RF. Tendon-healing in a bone tunnel. A biomechanical
our own patients. Professional athletes like this one and histological study in the dog. J Bone Joint Surg Am.
1993;75:1795-1803.
clearly are willing to take enormous risks at times to 8. Sterett WI, Hutton KS, Briggs KK, Steadman JR. De-
get back onto the field. They make a perfect sample creased range of motion following acute versus chronic
for studies of early surgery followed by accelerated, anterior cruciate ligament reconstruction. Orthopedics.
goal-directed rehabilitation in order to test how 2003;26:151-154.
9. Yamakado K, Kitaoka K, Yamada H, Hashiba K,
quickly we can return them to the field, and at what Nakamura R, Tomita K. The influence of mechanical
risk. At the same time, more biomechanical studies stress on graft healing in a bone tunnel. Arthroscopy.
Journal of Orthopaedic & Sports Physical Therapy®
Authors’ Response
We thank Drs Fithian and Shelbourne for their of patients had International Knee Documentation
commentaries on our paper. They represent 2 differ- Committee scores of normal or nearly normal. All
ent but valid perspectives on the concept of return to but 2 regained full extension and those 2 individuals
play after ACL injury and reconstruction. We will had extension deficits of 3° or less. KT-1000 evalua-
endeavor in this response to provide the additional tion was less than 3 mm in 76% of patients, 3 to 5
information requested by the commentators and to mm in 18%, and more than 5 mm in 6%. Ninety
engage in a meaningful dialogue about this contro- percent of the patients resumed sport at the same
versial topic. level. The mean Tegner activity score was 8.1 (range
The surgery performed on this patient has been 5-10). Isokinetic testing demonstrated no weakness of
described by Professor Marcacci, Dr Zaffagnini, and the hamstring or quadriceps muscles. Our testing is
their colleagues, including an average 6.4-year ver y similar to the testing performed by Dr
follow-up of a high percentage of their active patients Shelbourne’s group. Our results, albeit with fewer
who underwent this procedure.7,8 Ninety-two percent patients, are similar except for strength measures.
CASE REPORT
successes help us test the limits of our practice and
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Dr Fithian asked for a clearer explanation of our This case also brings up the idea of when circum-
criteria for progression. The objective criteria consid- stances collide and doctors and patients make deci-
ered for progression were no knee pain, no increase sions that are influenced by timing of sport seasons,
in effusion, and continued increase in knee range of opportunities to ‘‘make’’ teams, or to play in very
motion. For the transition to the on-field rehabilita- important events. While this case demonstrated a
tion, the criteria were knee extensors force of at least once-in-a-lifetime opportunity for an athlete nearing
80% of the contralateral side and the capacity to run the end of his career, once-in-a-lifetime opportunities
at 8 to 10 km/h without symptoms for about 20 happen for young athletes daily in our practices. Most
minutes. The return to official competitions was athletes do not compete after high school and the
Journal of Orthopaedic & Sports Physical Therapy®
permitted, considering lack of subjective feeling of ability to return for a championship game or a
instability, a full recovery in soccer-specific drills, special competition is as unique a circumstance for
side-to-side difference in knee extensors isometric them as the World Cup was for our patient. What this
torques of less than 10%, aerobic threshold speed of case has demonstrated is (and here we respectfully
greater than 11 km/h, and anaerobic threshold speed disagree with Dr Fithian) that we should ‘‘try this at
of greater than 13.5 km/h. home’’ under careful supervision, with clear criteria
Both Dr Fithian and Dr Shelbourne caution that a for progression and not simply base our return to
case report is insufficient upon which to base prac- activity on time after surgery.
tice. We agree. Case reports do, however, allow for The cost of this rehabilitation is approximately $60
detailed explanation of the rehabilitation progression to $65 (US) per session, a cost of roughly $7000 (US)
and the performance, response, and outcome of the for the rehabilitation of this elite athlete. US profes-
patient. Ultimately, they allow us to describe what we sional athletes routinely receive this kind of care. In
do and from that description of practice, cases series, our rehabilitation network the rehabilitation we de-
randomized clinical trials, and practice guidelines scribed is used for all athletes after ACL reconstruc-
follow.3-5 tion. While everyone does not have access to 3
The issue of return to play after ACL reconstruc- sessions per day, there are some aspects of the
tion is complex. We think the extant evidence is that rehabilitation program that are generalizable to ACL
the graft is viable and responsive to stress at the time rehabilitation for all: the personalized progression of
of implantation and that current rehabilitation regi- volume and intensity of exercise loads and the new