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Multiligament knee injuries (MLKIs) are debilitating injuries that increasingly occur in young athletes. Return to sport (RTS) has historically been considered unlikely due to the severity of these injuries. Reporting in the literature regarding objective outcomes following MLKI, including RTS, is lacking, as are clear protocols for both rehabilitation progressions and RTS testing. RTS following MLKI is a complex process that requires an extended recovery duration compared to other surgery types. Progressions through postoperative rehabilitation and RTS should be thoughtful, gradual, and criterion based. After effective anatomic reconstruction to restore joint stability, objective measures of recovery including range of motion, strength, movement quality, power, and overall conditioning guide decision-making throughout the recovery process. It is important to frame the recovery process of the athlete in the context of the severity of their injury, as it is typically slower and less linear. Improved reporting on objective outcomes will enhance our understanding of recovery expectations within this population by highlighting persistent deficits that may interfere with a full recovery, including RTS.
Multiligament knee injuries (MLKIs) are defined as a tear of 2 or more of the major knee ligaments, which include the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament or fibular collateral ligament (FCL).
MLKIs are often associated with knee dislocation, defined as a rupture of both cruciates with or without additional grade III injury to one of the collaterals.
Disruption of the popliteal artery and/or common peroneal nerve (CPN) constitutes a medical emergency that can have devastating consequences if unrecognized.
MLKIs are often associated with high-energy trauma such as a motor vehicle accidents or fall from a height; however, nearly 50%, occur through a low-velocity mechanism, most commonly sport.
Rates of MLKI caused by skiing sports and ball sports are as high as 29.4% and 6.9%, respectively. In the same cohort, motor vehicle accidents only accounted for 19.2% of all injuries.
Given the severity of MLKI and the complexity of multiligament knee reconstruction (MLKR), return to sport (RTS) has historically been considered highly unlikely. RTS data have been inconsistent and incomplete, but existing evidence cites a RTS rate of 53%,
While surgical proficiency with MLKR has improved, RTS may be hindered by concerns regarding long-term joint health. MLKI patients show high rates of concomitant injury to articular cartilage (28.3%-48%) and menisci (37.3%-55%) at the time of initial injury and a high prevalence of radiographic osteoarthritis (OA) (23%-87%) following the injury.
Objective measures such as strength, balance, and power or laboratory-based reporting on functional movement patterns (squatting, hopping) are rarely reported within this population. These measures often form the central criteria for RTS decisions, as seen in the more common knee injury scenario of ACL rupture.
A pair-matched comparison of return to pivoting sports at 1 year in anterior cruciate ligament-injured patients after a nonoperative versus an operative treatment course.
Such measures are the pillars of healthy human movement and athletic function and are ill-defined in the existing MLKI literature, which makes it difficult to interpret reported outcomes such as the progression of knee OA or rates of RTS. Given the reported links between OA progression and quadriceps muscle weakness
we cannot isolate MLKR as a singular causative factor for OA, but rather it is likely part of a spectrum of contributing factors which may include persistent muscular weakness and faulty movement patterns.
Effective early rehabilitation followed by appropriate progressions in both exercise program design and intensity are required for RTS, yet such rehabilitation guidelines specific to MLKI are sparse within the literature.
In addition, specific guidelines for RTS within this population have not been defined with associated objective criteria. The purpose of this text is as follows: (1) define the rehabilitation process following MLKR, with an emphasis on end-stage rehabilitation and RTS progressions; (2) define objective criteria, including descriptions of performance testing protocols, used to guide progressions through each phase of therapy, including re-entry into higher-level training and sport; and (3) describe current reported functional patient outcomes in more detail, including RTS, defining gaps in the literature, and areas for future research.
Postoperative Rehabilitation
Phase 1: “Recovery” (0-8 Weeks Postoperatively)
Initiation of rehabilitation on day 1 following surgical reconstruction has been reported to be safe and improves postoperative outcomes.
The primary goals in this earliest stage are limb protection (bracing and crutches), symptom management, protected range of motion (ROM), quadriceps muscle activation, and return to general wellness baseline (sleep, mood, energy, and nutrition). In addition, the clinician must monitor the patient closely for postoperative complications including arthrofibrosis, nerve injury (particularly the CPN),
Incidence and outcome of popliteal artery injury associated with knee dislocations, ligamentous injuries, and close to knee fractures: A nationwide population based cohort study.
Cryocompressive therapy, elevation, manual lymphatic drainage, and compression garments may all be used to manage postoperative pain, joint effusion, and generalized limb edema.
Non–weight-bearing is enforced for the first 6 weeks with gait with a knee immobilizer worn to protect the knee. Patients who undergo posterior cruciate ligament reconstruction (PCLR) transition into a dynamic PCL brace once swelling has sufficiently resolved to minimize posterior tibial translation (PTT) forces. Patients with other ligament reconstruction transition into a hinged brace once weight-bearing resumes.
Flexion is limited to 90° for the first 2 weeks to protect healing grafts. Passive ROM is recommended initially after PCLR, FCL reconstruction, or biceps femoris tendon repair to minimize PTT forces on the healing PCL grafts, reduce tension at the fibular head (where tunnel drilling and distal graft anchor occurs for FCL reconstruction), or to avoid direct pulling through the repaired biceps femoris tendon, respectively.
ROM is performed in prone for the first 2 weeks after PCLR, also to reduce PTT due to tibial sag related to supine positioning (Fig 1). Stretching into knee hyperextension is initially discouraged following reconstruction of the PCL, FCL, or posterolateral corner (PLC) reconstruction to limit tension on grafts of structures that natively resist knee hyperextension.
Minimum 10-year results after anterior cruciate ligament reconstruction: How the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery.
Patellofemoral mobilizations are encouraged along with frequent quadriceps muscle contractions to limit the development of excessive suprapatellar adhesions.
Utility of neuromuscular electrical stimulation to preserve quadriceps muscle fiber size and contractility after anterior cruciate ligament injuries and reconstruction: A randomized, sham-controlled, blinded trial.
Open-chain resistive exercises are initially limited or modified, because quadriceps activation at greater than 60° knee flexion can induce PTT and less than 30° can induce anterior tibial translation, which may excessively load the healing grafts.
Neuromuscular electrical muscular stimulation is encouraged for maximizing quadriceps muscle motor unit recruitment and has been shown to improve quadriceps function and outcomes following surgery.
Utility of neuromuscular electrical stimulation to preserve quadriceps muscle fiber size and contractility after anterior cruciate ligament injuries and reconstruction: A randomized, sham-controlled, blinded trial.
Blood flow restriction is a valuable modality used to mitigate muscle atrophy and strength loss and is shown to be safe and effective in appropriate populations.
By the end of this phase, patients should exhibit full knee extension and 110 to 120° of knee flexion, be able to perform consecutive repetitions of straight leg raising with no extensor lag, and demonstrate good tolerance for progressive intensity with other beginning strengthening exercises. This indicates readiness for weight-bearing progression and gait training.
Transition Phase: “Acclimation to Load” (8-10/12 Weeks)
The transition phase is the link between the Recovery and Rebuild phases. This phase has 2 main goals: (1) Progress to full weight-bearing with a non-antalgic gait pattern. (2) Prepare the joint to accept load to facilitate tolerance for future strength exercise progressions in subsequent phases. Patients acclimate to walking without crutches and may initiate basic weight bearing exercises. An effusion may still be present but must be nonreactive before phase progression.
Middle- and Late-Phase Rehabilitation: “Rebuild” and “Restore”
After the athlete successfully completes the transitional phase and tolerates basic joint loading, they can proceed to the next phases of rehabilitation. The focus is now on fully resolving any remaining ROM deficits, initiating cardiovascular and work capacity training, re-establishing tolerance to joint and tissue loading, building muscle mass with progressive resistance exercise, and reintegrating the athlete into their sporting environment. Examples of therapy activity progressions can be found in Table 1.
Table 1Therapy Activity Progression Guidelines
Exercise Task
Minimum Time to Begin
Knee ROM Goals
Strength Goals
Ability Goals
Cycle with no resistance (with resistance)
6 wk (10 wk)
PROM extension 0°, flexion 120°
Able to rotate on bike
External loading application
12 wk
Tolerates single-leg body weight exercise
Basic footwork and jumping, OKC Hamstring, CKC exercise <70° KF
4 mo
AROM squat <70° KF
>65% quad LSI and PkTq/BW
25 SL squat from 60° KF at 60 bpm
Return to run progression
5 mo
Extension within 2°, flexion within 10°
75% quad LSI
90 Single leg pogo hops; anterior Y balance within 8 cm
Hopping, sprinting, cutting and pivoting progressions, sport specific tasks
6 mo
Extension full, flexion within 5°
25 SL squat from 90° at 60 bpm; anterior Y balance within 4 cm; Stress radiographs negative
Return to unrestricted training
9 mo
Extension full, flexion within 5°
90% quad LSI and PkTq/BW;
90%: SLH, TH, Y balance, SLDJ; T-test within norms
AROM, active range of motion: LSI, limb symmetry index; PkTq/BW, peak torque relative to body weight; PROM, passive range of motion; ROM, range of motion; SLDJ, single leg drop jump; SLH, single leg hop; TH, triple hop.
All athletes may have the opportunity to return to sport following MLKI; however, the level of sport will depend on previous level of function, tolerance to rehab progressions, complexity of the injury and surgery, and the presence of nerve and/or vascular involvement with their initial injury. Realistic expectations should be discussed early in the recovery process. A CPN injury can affect lower extremity muscle function and recovery is typically slow, influenced by the initial injury severity, with 87.3% of patients with partial CPN palsy reported to experience a full functional recovery compared with only 38.4% of patients with complete palsy.
If complete palsy persists, a tendon transfer may be needed in the months following surgery to achieve some level of active dorsiflexion. Return to high-level cutting and pivoting following a tendon transfer may not be advised; however, certain sports (ie, downhill skiing) may be possible.
Individuals with a vascular injury experience worse long-term functional outcomes
The effect of a vascular disruption on ligamentous healing is unclear, but it is the author’s experience that these patients have increased postoperative laxity in general on stress radiographs compared with patients without a vascular injury. Articular cartilage health may be affected by MLKI and surgery. At a median of 12.7 years following a MLKR, radiographic OA was present in 42% of operated knees compared with only 6% on the contralateral side,
Arhos EK, Thoma LM, Grindem H, Logerstedt D, Risberg MA, Snyder-Mackler L. Association of quadriceps strength symmetry and surgical status with clinical osteoarthritis 5 years after anterior cruciate ligament rupture [published online October 7, 2020]. Arthritis Care Res (Hoboken). doi: 10.1002/acr.24479.
highlighting the importance of sound rehabilitation and load progressions, especially for the quadriceps muscles within patients recovering from this more complex injury and surgery.
“Rebuild” (10 Weeks-6 Months)
At 10 weeks postsurgery, the rehabilitation emphasis changes from basic recovery from surgery to rebuilding the athlete’s knee in terms of biomechanics, proprioception, and movement patterns outside of linear gait progressions. Generalized weakness and muscular atrophy are still present, most notably at the quadriceps and hamstring muscles, due to non–weight-bearing status, postoperative arthrogenic quadriceps inhibition, and the strict “hamstring-off” passive ROM precaution in the early phases. Therefore, loading progressions for regaining muscle strength and size are emphasized during this stage. Recovery goals for 4 months postoperative are listed in Table 2.
Table 2Sport Performance Testing Details and Goals
Add: Hop tests as appropriate per recovery status (SLHD, THD)
•
Repeat baseline tests
•
Add/repeat: Hop tests (SLHD, THD)
Goals (for lower-extremity functional testing)
Y-balance: ≤8 cm SSD 1 leg rise test (from 60° KF) @ 60 bpm: able to complete 25 consecutive reps
Y-balance: ≤4 cm SSD 1 leg rise test (from 90° KF): able to complete 25 reps Hop testing: ≥80% LSI
Y-balance: ≤4 cm SSD (Raw score relative to limb length within 10% of age/sex-matched norm values) 1 leg rise test (from 90° KF): able to complete 25 reps Hop Testing: ≥90% LSI (Raw score within 10% of age/sex-matched norm values)
Biomechanics lab tests
•
Isometric dynamometer quadriceps muscle strength
•
Repeat/add: Isometric quad strength, isokinetic quadriceps and hamstring muscle strength
•
Add: hop testing with motion capture over force plates as appropriate
If the athlete had a PCL or PLC reconstruction, open-chain hamstring strengthening is avoided. Hamstring activation beyond 30° of knee flexion induces PTT, which could be detrimental to a healing PCLR or PLC,
so strengthening from 6 weeks to 4 months involves submaximal effort exercises in shallow knee flexion angles. Open-chain quadriceps strength exercises are critical to isolate the muscle and recover strength. Closed-chain or weight-bearing quadriceps strengthening through squat, step-up, or lunge drills is initially limited to a depth of 70° of knee flexion to avoid the PTT that occurs in deeper squatting angles.
Squat technique should ensure adequate knee over toe mechanics (Fig 2) to maximize quadriceps muscle activation, with gradual progressions that honor joint or tendon symptoms.
Fig 2Knee over toes position with “kickstand” squat.
The Nordic hamstring exercise (Fig 3) is incorporated last due to the kneeling position and high levels of muscle activation, which can be contraindicated initially following PCLR. Athletes are now able to progress closed chain knee flexion loading (i.e., squatting) deeper than 70°. Single-leg loading is a focus of early strength training to minimize potential movement compensations, due to weakness, associated with double leg loading. Examples of closed-chain loading progressions are detailed in Table 3.
Strengthening strategies are employed at various points along the force velocity curve, beginning with loaded isometrics, which are safe and nonirritating on the joint and can elicit strength improvements
; exertion levels should progress over time. Eccentric and heavy slow resistance exercises, which include slow eccentric, isometric, and concentric phases, are incorporated next. Heavy slow resistance exercise has been shown to be beneficial for patellar tendinopathy
Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review.
; it is not uncommon for athletes who have had a patellar tendon autograft to experience some level of anterior knee pain, similar to patellar tendinopathy, following their MLKR. Blood flow restriction for the purpose of pain control can also be incorporated.
As strength and capacity improve, speed of movement increases, beginning with the concentric component. Loaded, quick movements with a shorter amortization phase are incorporated last.
Load Monitoring
Once external loads are tolerated, the overload principle is applied by progressively increasing load over time to increase strength.
Traditional periodization concepts are applied in early phases with greater repetition counts and lower loads, and later phases with lower reps and greater load; however, additional strategies outside the periodization framework have value. To maximize the effectiveness of each lifting session, self-monitoring parameters, commonly referred to as “autoregulation,” are used. Subjective ratings of perceived exertion and repetitions in reserve following a set as well as velocity-based training methods have shown to be useful to tailor workout intensity per recovery between sets.
Effects of subjective and objective autoregulation methods for intensity and volume on enhancing maximal strength during resistance-training interventions: A systematic review.
Effects of subjective and objective autoregulation methods for intensity and volume on enhancing maximal strength during resistance-training interventions: A systematic review.
Early initiation of work capacity and energy system development is vital for general activity preparedness and to gradually increase tolerance to repeated exercise bouts at a progressively greater capacity, as required for sport. Exercise sessions should progress in duration, intensity and work to rest ratios, while avoiding single session or weekly spikes in volume of work completed.
Workout intensity can be monitored through exertion scales or other means (i.e., wearable technologies). Intensity should increase gradually for safe and successful return to pre-injury activity and conditioning levels.
The ability to produce maximum force is different than producing force at a high rate. Preinjury strength levels have been shown to return sooner than rate of force development (RFD) following ACL reconstruction,
so a similar, if not greater, delay or depression in recovery of RFD is likely following MLKR. RFD training can begin as early as 4 months postoperation and can progress from higher speed “making” isometrics to quick concentric or eccentric “braking” activities using the stretch-shortening cycle. The importance of RFD, including more comprehensive training descriptions, have been described in detail elsewhere.
ACL injury has been shown to alter the nervous system’s ability to interpret somatosensory information, causing heavier reliance on visual feedback, so it is expected that a MLKI will have equal or more somatosensory deficits.
Principles of motor learning are incorporated into all stages of rehabilitation to normalize nervous system functioning. An external focus of attention is a primary guiding strategy where the athlete is asked to focus on something other than their knee while performing an exercise. An external focus can expedite learning by facilitating automatic movements and thus depressing intracortical inhibition of voluntary muscle activation.
Principles of motor learning to support neuroplasticity after ACL injury: Implications for optimizing performance and reducing risk of second ACL injury.
Simple cognitive distractions like verbalizing a color or number displayed on a cell phone app, or having the athlete count backwards simultaneously with exercise, can begin early in recovery.
“Restore” (6 Months to 1+ Year)
The care plan following MLKR is typically extended, with increased time off school or work and an increased strain on resources such as insurance coverage, economics, transportation, and in-home support.
The layout and duration of the Restore phase will vary, depending on the level of sport, the ability to continue with frequent rehabilitation visits, and the level of involvement of secondary providers. If an athlete is competing at the high school, collegiate, or professional level, coordination with their athletic trainer and strength coach is important as physical therapy visits taper in frequency. Small group training sessions, outside of insurance-covered therapy appointments, have become a popular option to provide supervised, higher-level training progressions in the later phases of recovery. The downside of this practice is the potential exclusion of athletes with fewer economic resources.
A return to running progression begins once the athlete attains sufficient quadriceps strength, masters preparatory running drills, and meets performance targets with clinical testing (Table 2). Recently, Iwame et al.
reported that those individuals who met a cutoff value for quad strength divided by body weight of 1.45 Nm/kg had success with return to jogging, highlighting the importance of strength for normal running gait. A minimum period of 4 weeks with a jogging buildup program should be completed before the initiation of straight-line sprint progressions.
Transition from linear movements to change of direction tasks should begin with rounded turns, then gradually move to sharper angled cutting and greater speeds. Cognitive demands and sport-specific tasks are incorporated per readiness. The “control-chaos continuum,” as described by Taberner et al.,
progresses the athlete from slow, controlled preplanned movements to fast, chaotic reactive sport-specific movements in the “on-field” environment. As the athlete moves through the Restore phase, they should see an increasing volume of load, skill, and physical fitness training while alternating difficult days with easier days to allow for recovery.
On-field rehabilitation part 2: A 5-stage program for the soccer player focused on linear movements, multidirectional movements, soccer-specific skills, soccer-specific movements, and modified practice.
Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player's risk of subsequent injury.
As such, sport-specific training and within-sport participation is incorporated on a gradual continuum.
Testing for RTS
While there is no solid agreement on the best RTS criteria, a battery of tests including objective strength testing, single-leg hop testing and validated subjective questionnaires is advocated to assess overall readiness.
Likelihood of ACL graft rupture: Not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture.
Our MLKI RTS testing protocol (Table 2) mimics those used within the ACL population, as protocols specific to MLKI have yet to be defined or validated. Testing at our center is performed at 4, 7, and 10 months after surgery. Typical RTS testing time points are at 3, 6, 9 months,
Compensatory strategies that reduce knee extensor demand during a bilateral squat change from 3 to 5 months following anterior cruciate ligament reconstruction.
but the increased trauma and restrictions during early rehabilitation in this population warrants testing at later time points.
Strength Testing
Measurement of muscle function, specifically isolated quadriceps performance, can reveal deficits otherwise disguised though compensation strategies within functional movement testing. Our center tests both isometric and isokinetic strength using an isokinetic dynamometer. Quadriceps isometric strength is evaluated at 90° of knee flexion (Fig 4) at each time interval, while isokinetic quadriceps and hamstrings strength is evaluated at 60 deg/s at only the 7- and 10-month test intervals due to the hamstring precautions in early rehabilitation. A goal of >90% limb symmetry index is recommended for both quadriceps and hamstring strength at time of RTS.
Likelihood of ACL graft rupture: Not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture.
Relative strength (strength compared with an athlete’s body weight) has shown to be a good predictor of patient-reported knee function and may be a better indicator for dynamic knee–joint stability and absorption of joint loads during activity.
A number of tasks have been used to assess kinematic and kinetic compensation strategies in athletes after injury, such as double-leg squat, single-leg squat (SLS), double-leg jump, and single-leg forward hop (SLFH).
Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport.
Lower extremity kinematic analysis in male athletes with unilateral anterior cruciate reconstruction in a jump-landing task and its association with return to sport criteria.
Therefore, examining these same mechanics within the MLKI population is of interest. The goal for MLKI athletes is to exhibit less than a 10% deficit in SLFH distance and peak knee flexion during both SLS and SLFH landings. In addition, the surgical limb should achieve deep knee flexion, defined as >75°, during peak knee flexion in SLS and SLFH landings. Asymmetrical limb-loading and decreased functional knee stability have been shown to be associated with quadriceps weakness and likeliness to RTS
The influence of quadriceps strength asymmetry on patient-reported function at time of return to sport after anterior cruciate ligament reconstruction.
The Knee injury Osteoarthritis Outcome Score, International Knee Documentation Committee 2000 Subjective Knee Form, and the ACL-Return to Sport after Injury are traditional PROMs consistently reported in ACL literature and have shown to be strongly associated with RTS objective measures.
Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport.
Progression of the psychological ACL-RSI score and return to sport after anterior cruciate ligament reconstruction: A prospective 2-year follow-up study from the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST).
The ACL-Return to Sport after Injury , validated within the ACL population, includes questions regarding emotional well-being, physical performance confidence, and appraisal of risk. According to Sadeqi et al.,
Progression of the psychological ACL-RSI score and return to sport after anterior cruciate ligament reconstruction: A prospective 2-year follow-up study from the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST).
those who score ≥60 at 6 months postsurgery will likely return to the preinjury level at 2 years after surgery. Greater confidence in performance combined with less fear have been shown to distinguish those who do and do not RTS.
No PROMs have been validated in the MLKI population. Studies including Knee injury Osteoarthritis Outcome Score and International Knee Documentation Committee 2000 Subjective Knee Form outcomes often report on data collected years after surgery and are not specific to RTS.
This step will look different for each athlete depending on their surgery, previous level of function, and goals. ACL reconstruction literature has shown that returning to sport before 9 months may lead to a greater rate of reinjury.
Young athletes who return to sport before 9 months after anterior cruciate ligament reconstruction have a rate of new injury 7 times that of those who delay return.
Similar research regarding recommended RTS timelines does not exist specific to MLKR. At our center, athletes are educated that return to play will likely take 12 to 18 months. Managing expectations is important in this population, given poor existing reports on RTS (53% of patients with MLKR return to any level of sport, and 22% return to high-level sport).
The specific ligaments involved may make a difference as well. Fifty athletes from the National Football League were observed following MLKR to find that 70.8% of ACL/MCL tears and 55.6% of ACL with PCL or FCL involvement returned to play at 305.1 ± 58.9 and 459.2 ± 245.1 days, respectively. Return to previous performance was 43.5% for ACL/MCL and 18.5% for ACL with PCL or FCL. In comparison, a case series of 165 National Football League athletes reported an 82.4% return to play rate when undergoing an isolated ACL reconstruction.
and MLKI research lacks both foundational objective measures and population specific validated PROMs. Only one study was found that measured strength, reporting 84% quadriceps and 90% hamstring limb symmetry indices at 24 months postoperatively.
These quadriceps strength outcomes at 2 years postoperatively are substandard and raise concern, as most athletes seek to return to sport within 12 months from surgery. To our knowledge, no study has examined jumping or hopping performance following MLKR. Only gait analyses have been conducted, however, often years after surgery. MLKI patients exhibited slower gait, shorter steps, and altered knee kinematics compared with healthy controls.
Our RTS testing protocol, including goal values, is illustrated in Table 2.
Conclusions
MLKIs can be debilitating for athletes. Historically, return to play after a MLKI has been out of the question; however, with the advancement of surgical proficiency using an anatomic reconstruction, the prognosis for recovery following MLKI has changed.
With the initiation of rehabilitation on day 1 after surgery, effective progressions through a comprehensive rehabilitation process, and realistic expectations regarding timelines, RTS is possible. It is important to consider the extent of the injury to set appropriate expectations for recovery and RTS. Objective outcomes reporting and guidelines for rehabilitation progressions to return an athlete to sport following MLKR are lacking. RTS testing following MLKR should be criterion based and use a combination of strength, functional, and subjective testing. The rehabilitation process following MLKR is typically slower overall, and RTS phases will be longer. The process can be physically and mentally taxing for the patient and practitioner; however, by following a conservative approach with deliberately cautious phase progressions a successful, safe return to sport is possible.
A pair-matched comparison of return to pivoting sports at 1 year in anterior cruciate ligament-injured patients after a nonoperative versus an operative treatment course.
Incidence and outcome of popliteal artery injury associated with knee dislocations, ligamentous injuries, and close to knee fractures: A nationwide population based cohort study.
Minimum 10-year results after anterior cruciate ligament reconstruction: How the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery.
Utility of neuromuscular electrical stimulation to preserve quadriceps muscle fiber size and contractility after anterior cruciate ligament injuries and reconstruction: A randomized, sham-controlled, blinded trial.
Arhos EK, Thoma LM, Grindem H, Logerstedt D, Risberg MA, Snyder-Mackler L. Association of quadriceps strength symmetry and surgical status with clinical osteoarthritis 5 years after anterior cruciate ligament rupture [published online October 7, 2020]. Arthritis Care Res (Hoboken). doi: 10.1002/acr.24479.
Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review.
Effects of subjective and objective autoregulation methods for intensity and volume on enhancing maximal strength during resistance-training interventions: A systematic review.
Principles of motor learning to support neuroplasticity after ACL injury: Implications for optimizing performance and reducing risk of second ACL injury.
On-field rehabilitation part 2: A 5-stage program for the soccer player focused on linear movements, multidirectional movements, soccer-specific skills, soccer-specific movements, and modified practice.
Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player's risk of subsequent injury.
Likelihood of ACL graft rupture: Not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture.
Compensatory strategies that reduce knee extensor demand during a bilateral squat change from 3 to 5 months following anterior cruciate ligament reconstruction.
Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport.
Lower extremity kinematic analysis in male athletes with unilateral anterior cruciate reconstruction in a jump-landing task and its association with return to sport criteria.
The influence of quadriceps strength asymmetry on patient-reported function at time of return to sport after anterior cruciate ligament reconstruction.
Progression of the psychological ACL-RSI score and return to sport after anterior cruciate ligament reconstruction: A prospective 2-year follow-up study from the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST).
Young athletes who return to sport before 9 months after anterior cruciate ligament reconstruction have a rate of new injury 7 times that of those who delay return.
The authors report the following potential conflicts of interest or sources of funding: R.F.L. reports grants and other from Ossur and Smith & Nephew, and other from Linvatec and Arthrex, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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