ACL Performance Enhancement Program Steven Traina, MD, Nathan Lilley, MPT, OCS, CSCS

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1 Nathan Lilley, MPT, OCS, CSCS, earned his Bachelors degree in Biology as well as his Masters degree in Physical Therapy from Rockhurst University in Kansas City, Missouri. Nate has been in the orthopedic clinical setting for the last 11 years. In 2005, Nate was recognized as a Board Certified Clinical Specialist in Orthopedic Physical Therapy from the American Physical Therapy Association. In addition, he is a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association. Nate is co-owner of Physio Pro Physical Therapy in Denver Colorado. His clinic specializes in orthopedic and manual physical therapy with a strong emphasis in sports medicine, and general care in youth through geriatric patient populations. Over the years, he has worked with numerous collegiate athletes as well as local professional athletes affiliated with the NBA, NHL, AFL, and PGA. He developed and implemented the Physio Pro ACL Performance Enhancement Program in Nate continues to promote wellness, injury prevention, and sports enhancement to the local community as well as many local youth athletic teams. Steven M. Traina, M.D., is a fellowship trained Board Certified Orthopedic Surgeon. He practices in Denver, Colorado with Western Orthopaedics. Dr. Traina has been serving as the team physician for the Denver Nuggets for the last 24 years and in the past has been a consultant for the Denver Broncos football team and the Colorado Avalanche hockey team. He has published and spoken extensively on sports medicine topics. 1

2 Exercise Protocol The following is an evidenced based Functional Testing Algorithm (FTA) protocol that has specific guidelines for progressing treatment based off selected objective criteria. Before entering the next phase of rehab, specific goals must be met. Specific functional tests must be completed with satisfactory results before the next phase of rehabilitation may begin. High intensity plyometrics are integrated into the final phase of the protocol. This portion of the program stems largely from the last 15 years of research coming from the Cincinnati Sports Medicine Research and Education Foundation. Our complete Impact protocol is outlined but please reference the training manual and DVD for a complete profile of the program. The entire protocol is derived from the latest research. All references can be found at the end of the DVD. Patients must commit themselves to a vigorous but four to six month rehab regime to help protect their new ACL before returning to unrestricted activities. The first seven weeks of rehab are not outlined. The standard ACL protocol for the first seven weeks should be at the hands of surgeon and physical therapist depending upon the severity of the patient s surgery. The program should not begin any sooner than eight weeks post op and the patient must meet the criteria in order to enter the performance enhancement program. Progression of the program is at the discretion of the therapist/physician. Sound clinical judgment is essential for progression. If the criteria are not met then standard therapy will continue until objective measures are adequate. There are a total of five phases of rehabilitation to complete before a return to competition can be considered. Although estimated time frames are outlined, not all patients will progress equally as there may be complicating factors that may hinder or expedite rehabilitation. Below are the criteria for progression through the various phases of our protocol. Anticipated timelines and suggested interventions are found on the following pages. Steven Traina, MD Western Orthopaedics Denver, Colorado Nathan Lilley, MPT, OCS, CSCS Physio Pro Denver, Colorado 2

3 Functional Testing Exercise No. of Reps/Time Squat Test 10 reps I min. Eccentric Step Down Test I min. (Ea. Leg) Broad Jump Test (Warm up: 2 x 50%, 2 x 75%), 3x 100% Single Leg Hop Test (Warm up: 2 x 50%, 2 x 75%), 3x 100% (Ea. Leg) Vertical Jump Assessment 3 x (Warm Up), 3 x 100% 3

4 Impact Phase A: Criteria Estimated Weeks 8 10 ROM Effusion Minimal to none, no joint line tenderness Strength 65% Quadriceps, 50% HS/Quad Ratio Special Testing Satisfactory Lachman/Drawer Test Functional Score >6 score on Cinti Knee Rating System Functional Testing 1min. Step Test >60% Satisfactory Squat Test, Step Down Test 4

5 Impact Phase A: Entry Level Plyometrics Estimated Weeks 8 10 Week 8 Shuttle Bilateral Shuttle Alternating Lateral Bounding in Place Slide Board 3 x 20 reps 3 x 20 reps 3 x 30 sec. 3 x 30 sec. Week 9 Shuttle Bilateral Shuttle Alternating Lateral Bounding in Place Slide Board Jog in Place High Knees in Place Gluteal Kicks in Place 3 x 20 reps 3 x 20 reps 3 x 30 sec. 3 x 30 sec. 3 x 30 sec. 3 x 30 sec. 3 x 30 sec. 5

6 Impact Phase B: Criteria Estimated Weeks ROM Effusion Minimal to none, no joint line tenderness Strength 70% Quadriceps, 60% HS/Quad Ratio Special Testing Satisfactory Lachman/Drawer Test Functional Score >6 score on Cinti Knee Rating System Functional Testing None 6

7 Impact Phase B: Transitional Plyometrics/Phase Level I Agility Estimated Weeks Week 10 Shuttle Bilateral Grid Jumps Shuttle Alternating Shuttle Unilateral Grid Hops Lateral Bounding in Place 3 Point Lateral Bounding with Rotation 20 reps CW, 20 reps CCW 2 x 20 reps 20 reps CW, 20 reps CCW 3 x 40 sec. 1 x 30 sec. R, 1 x 30 sec. L Week 11 Shuttle Bilateral Grid Jumps Shuttle Alternating Shuttle Unilateral Grid Hops Lateral Bounding in Place 3 Point Lateral Bounding with Rotation Step Work: Quick Feet Step Work: Ali Shuffle Step Work: Lateral Quick Feet Step Work: Lateral Skaters Return to Jogging Program (Treadmill) 20 reps CW, 20 reps CCW 2 x 20 reps 20 reps CW, 20 reps CCW 3 x 40 sec. 1 x 30 sec. R, 1 x 30 sec. L 1 x 30 sec. 1 x 30 sec. 1 x 30 sec. 1 x 30 sec. 3W 1J 1W 3J 3W 5J 1W 7

8 Impact Phase C: Criteria Estimated Weeks ROM Effusion Minimal to none, no joint line tenderness Strength 75% Quadriceps, 60 65% HS/Quad Ratio Special Testing Satisfactory Lachman/Drawer Test Functional Score >7 score on Cinti Knee Rating System Functional Testing No pain, gait deviation with 10min. jog 8

9 Impact Phase C: Level II Agility, Sport Specific Movement Estimated Weeks Dynamic Sports Routine Warm Up Jog in Place Giant Arm Circles Trunk Rotation Pelvic Circle Hip Circumduction Hip Step w/ Exaggerated Arm Swing Gluteal Kicks Skipping Bound Side Shuttle Cariokas High Knees Sprint/Back Pedal Ankle Hops sec. 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Leg) 10 sec. 9

10 Impact Phase C: Level II Agility, Sport Specific Movement Estimated Weeks Week 12 Jump Rope: Bilateral Jump Rope: Alternating Step Work: Quick Feet Step Work: Lateral Quick Feet Step Work: Ali Shuffle Step Work: Lateral Skaters Lateral Bounding with Rotation 3 Point Sport Cord: Forward Sport Cord: Backwards Sport Cord: 3 Point Lateral Bounding Week 13 1 x 1 min. 1 min. R, 1 min. L 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. R, 2 x 30 sec. L 2 x 20 reps (1/2 Speed) 2 x 20 reps (1/2 Speed) 2 x 30 sec. R, 2 x 30 sec. L Jump Rope: Bilateral Jump Rope: Alternating Step Work: Quick Feet Step Work: Lateral Quick Feet Step Work: Ali Shuffle Step Work: Lateral Skaters Lateral Bounding with Rotation 3 Point Sport Cord: Forward Sport Cord: Backwards Dynamic Sports Routine Agility Ladder: High Knees Agility Ladder: Lateral High Knees Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Ali Shuffle Agility Ladder: Icky Shuffle 1 x 1 min. 1 min. R, 1 min. L 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. R, 2 x 30 sec. L 2 x 20 reps (1/2 Speed) 2 x 20 reps (1/2 Speed) 1x 3x (Down & Back) 3x (Down & Back) 3x (Front Lead) (Down & Back) 3x (Back Lead) (Down & Back) 3x (Down & Back) 3x (Down & Back) 10

11 Impact Phase D: Criteria Estimated Weeks ROM Effusion Strength Special Testing Functional Score Functional Testing Within 90% contralateral limb Minimal to none, no joint line tenderness 75 80% Quadriceps, 50 70% HS/Quad Ratio Satisfactory Lachman/Drawer Test >7 score on Cinti Knee Rating System SL hop 50%, Broad Jump with sound mechanics 11

12 Impact Phase D: Level IIII Agility, Level Sport Specific Movement Estimated Weeks Dynamic Sports Routine Warm Up Jog in Place Giant Arm Circles Trunk Rotation Pelvic Circle Hip Circumduction Hip Step w/ Exaggerated Arm Swing Gluteal Kicks Skipping Bound Side Shuttle Cariokas High Knees Sprint/Back Pedal Ankle Hops sec. 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Leg) 10 sec. 12

13 Impact Phase D: Level III Agility, High Level Sport Specific Movement Estimated Weeks Week 14 Dynamic Sports Routine (Warmup) Sport Cord: Forward Sport Cord: Backwards Sport Cord: Lateral Shuffles Sport Cord: 3 Point Lateral Bounding w/ Rotation Agility Ladder: High Knees Agility Ladder: Lateral High Knees Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Lateral Quick Feet Ins & Outs 1x 2 x 20 reps (3/4 Speed) 2 x 20 reps (3/4 Speed) 1 x 20 reps R Lead, 1 x 20 reps L Lead 2 x 30 sec. (Ea. Side) 4x (Down & Back) 4x (Down & Back) 4x (Front Lead) (Down & Back) 4x (Back Lead) (Down & Back) Week 15 Dynamic Sports Routine (Warmup) Sport Cord: Forward Sport Cord: Backwards Sport Cord: Lateral Shuffles Sport Cord: 3 Point Lateral Bounding w/ Rotation Sport Cord: 3 Point Drill (Forward) Sport Cord: 3 Point Drill (Backwards) Agility Ladder: High Knees Agility Ladder: Lateral High Knees Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Ali Shuffle Agility Ladder: Icky Shuffle 1x 2 x 20 reps (3/4 Speed) 2 x 20 reps (3/4 Speed) 1 x 20 reps R Lead, 1 x 20 reps L Lead 2 x 30 sec. (Ea. Side) 20x 20x 4x (Down & Back) 4x (Down & Back) 4x (Front Lead) (Down & Back) 4x (Back Lead) (Down & Back) 4x (Down & Back) 4x (Down & Back) 13

14 Impact Phase E: Criteria Estimated Weeks ROM Effusion Strength Special Testing Functional Score Functional Testing Within 90% contralateral limb Minimal to none, no joint line tenderness 75 80% Quadriceps, 65 70% HS/Quad Ratio Satisfactory Lachman/Drawer Test >7 score on Cinti Knee Rating System SL hop 60%, Broach Jump with sound mechanics, Good form with Eccentric Step Down Test 14

15 Impact Phase E: Jump Program Estimated Weeks Dynamic Sports Routine Warm Up (Utilized all 6 weeks) Jog in Place Giant Arm Circles Trunk Rotation Pelvic Circle Hip Circumduction Hip Step w/ Exaggerated Arm Swing Gluteal Kicks Skipping Bound Side Shuttle Cariokas High Knees Sprint/Back Pedal Ankle Hops sec. 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Leg) 10 sec. 15

16 Impact Phase E: Jump Program Estimated Weeks Plyometrics Phase I: Week 16 Wall/Block Jump Broad Jump Squat/Vertical Jump 180/Half Spin Jump Lateral Bounding in Place Scissors/Rudder Jump Richochets Bilateral Back to Front Richochets Bilateral Side to Side 20 sec. 5 reps 20 sec. 20 sec. 20 sec. 20 sec. 20 sec. 20 sec. Plyometrics Phase I: Week 16 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 30 sec. 2 x 10 reps 2 x 10 reps 2 x 10 reps 5 sec. Hold 5x Thru ea. Position 3x (Down & Back) 2 x 10 reps 2 x 10 reps 25 Forward, 25 Backward 16

17 Impact Phase E: Jump Program Estimated Weeks Plyometrics Phase I: Week 17 Wall/Block Jump Broad Jump Squat/Vertical Jump 180/Half Spin Jump Lateral Bounding in Place Scissors/Rudder Jump Richochets Bilateral Back to Front Richochets Bilateral Side to Side 25 sec. 10 reps 25 sec. 25 sec. 25 sec. 25 sec. 25 sec. 25 sec. Plyometrics Phase I: Week 17 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 30 sec. 2 x 10 reps 2 x 10 reps 2 x 10 reps 5 sec. Hold 5x Thru ea. Position 3x (Down & Back) 2 x 10 reps 2 x 10 reps 25 Forward, 25 Backward 17

18 Impact Phase E: Jump Program Estimated Weeks Plyometrics Phase II: Week 18 Wall/Block Jump Tuck Jump Jump, Jump, Jump, Vertical Jump Squat/Vertical Jump Lateral Bounding for Distance Scissors/Rudder Jump Richochets Bilateral Back to Front Richochets Bilateral Side to Side Richochets Unilateral Back to Front Richochets Unilateral Side to Side Hop, Hop, Hop, Stick 30 sec. 30 sec. 5 reps 30 sec. 2 runs 30 sec. 30 sec. 30 sec. 30 sec. 30 sec. 5 reps Plyometrics Phase II: Week 18 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 40 sec. 2 x 12 reps 2 x 12 reps 2 x 12 reps 5 sec. Hold 8x Ea. Position 5x (Down & Back) 2 x 12 reps 2 x 12 reps 25 Forward, 25 Backward 18

19 Impact Phase E: Jump Program Estimated Weeks Plyometrics Phase II: Week 19 Wall/Block Jump Tuck Jump Jump, Jump, Jump, Vertical Jump Squat/Vertical Jump Lateral Bounding for Distance Scissors/Rudder Jump Richochets Bilateral Back to Front Richochets Bilateral Side to Side Richochets Unilateral Back to Front Richochets Unilateral Side to Side Hop, Hop, Hop, Stick 35 sec. 35 sec. 8 reps 35 sec. 4 runs 35 sec. 35 sec. 35 sec. 35 sec. 35 sec. 8 reps Plyometrics Phase II: Week 19 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 40 sec. 2 x 12 reps 2 x 12 reps 2 x 12 reps 5 sec. Hold 8x Ea. Position 5x (Down & Back) 2 x 12 reps 2 x 12 reps 25 Forward, 25 Backward 19

20 Impact Phase E: Jump Program Estimated Weeks Plyometrics Phase III: Week 20 Squat/Vertical Jump Jump Up, Jump Down, Vertical Jump Tuck Jump Scissors/Rudder Jump Jump Into Bounding for Distance Richochets Bilateral Back to Front Richochets Bilateral Side to Side Richochets Unilateral Back to Front Richochets Unilateral Side to Side Single Leg Hop, Hop, Hop, Stick 45 sec. 10 reps 35 sec. 40 sec. 3 runs Ea. Leg 35 sec. 35 sec. 35 sec. 35 sec. 8 reps Plyometrics Phase III: Week 20 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 50 sec. 2 x 15 reps 2 x 15 reps 2 x 15 reps 5 sec. Hold 10x Ea. Position 5x (Down & Back) 2 x 15 reps 2x 15 reps 25 Forward, 25 Backward 20

21 Impact Phase E: Jump Program Estimated Weeks Plyometrics Phase III: Week 21 Squat/Vertical Jump Jump Up, Jump Down, Vertical Jump Tuck Jump Scissors/Rudder Jump Jump Into Bounding for Distance Richochets Bilateral Back to Front Richochets Bilateral Side to Side Richochets Unilateral Back to Front Richochets Unilateral Side to Side Single Leg Hop, Hop, Hop, Stick 45 sec. 12 reps 40 sec. 45 sec. 4 runs Ea. Leg 40 sec. 40 sec. 40 sec. 40 sec. 10 reps Plyometrics Phase III: Week 21 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 50 sec. 2 x 15 reps 2 x 15 reps 2 x 15 reps 5 sec. Hold 10x Ea. Position 5x (Down & Back) 2 x 15 reps 2x 15 reps 25 Forward, 25 Backward 21

22 Return to Competition Criteria/Release Form Date of Test: Doctor: Dx: Age: Height: DOI: P/O Week: Sport/Position: Girth: R: 10cm 20cm Total: L: 10cm 20cm Total: Joint Exam: Broad Jump Norms: M % Height, F 80-90% Height #1 #2 #3 Ave. Percentile Quality P F G E Standing Vertical Jump Norms: M < 14:11, 14-16:16, 17-18:19, > 18:22 F < 14:10, 14-16:11, 17-18:13, > 18:15 Jump #1 Jump #2 Jump #3 Mean Jump Height Percentile Quality P F G E Single Hop For Distance Norms: M 90% Height, F 80% Height R #1 R #2 R #3 L #1 L #2 L #3 Total R Total L Hop Index Percentile Quality % P F G E 22

23 Return to Competition Criteria/Release Form Sport Specific Movements Quality Quality Forward/Backpedaling: P F G E Bounding: P F G E Side Shuttles: P F G E Shuttle Run: P F G E Carioca: P F G E High Knees: P F G E Gluteal Kicks P F G E Other: P F G E ROM Effusion Strength Special Testing Functional Score Functional Testing Pass Criteria Within 90% contralateral limb Minimal to none, no joint line tenderness 80 85% Quadriceps, 70 75% HS/Quad Ratio Satisfactory Lachman/Drawer Test >8 score on Cinti Knee Rating System SL hop 85%, Ability to pass sport specific movement & physician clearance Criteria Met ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Restrictions: Non Contact ( ) Release Pending MD Approval ( ) Contact with Brace ( ) Continue Therapy ( ) No Restrictions ( ) Evaluators Signature: Date: 23

24 Lower Extremity Functional Testing Record Date of Test: Doctor: Dx: Age: Height: DOI/DOS: P/O Week: Sport: Girth: R: 10cm 20cm Total: L: 10cm 20cm Total: % Joint Exam: Broad Jump Norms: M % Height, F 80-90% Height #1 #2 #3 Ave. Percentile Quality P F G E Standing Vertical Jump Norms: M < 14:11, 14-16:16, 17-18:19, > 18:22 F < 14:10, 14-16:11,: 17-18:13, > 18:15 Jump #1 Jump #2 Jump #3 Mean Jump Height Percentile Quality P F G E Single Hop For Distance Norms: M 90% Height, F 80% Height R #1 R #2 R #3 L #1 L #2 L #3 Total R Total L Hop Index Percentile Quality % P F G E 24

25 Lower Extremity Functional Testing Record Timed One Minute Eccentric Step Down Test "Step R L F. E. R. Quality P F G E Step Down Test Squat Test R + -- L + -- Sport Specific Movements Quality Quality Forward/Backpedaling: P F G E Bounding: P F G E Side Shuttles: P F G E Shuttle Run: P F G E Carioca: P F G E High Knees: P F G E Gluteal Kicks P F G E Other: P F G E Recommendations: ( ) Continue Current Phase ( ) Progress to Next Phase Evaluators Signature: Date: 25

26 has completed the on and is released to return to sport. Restrictions:

27 This material is intended for educational purposes only. Any medical information included herein has a mere informative purpose and shall not be used in any way as substitute for professional advice provided by a physician or liscenced health care provider. It is not meant to replace the judgement of trained surgeons on the appropriate treatment of their patients and may not be appropriate for all ACL patients. Biomet does not practice medicine and does not recommend any particular orthopedic implant or surgical technique for use on a specific patient. This program was developed by Steven Traina, MD and Nathan Lilley, MPT, OCS, CSCS. The surgeon who performs any implant procedure is responsible for determining and utilizing the appropriate techniques for implanting prosthesis in each individual patient. Biomet is not responsible for selection of the appropriate orthopedic implant. This handbook and all content, artwork, photographs, names, logos and marks contained in it are protected by copyright, trademarks and other intellectual property rights owned by Biomet or licensed to Biomet. This handbook must not be used, copied or reproduced in whole or in part for any purposes other than marketing by Biomet or its authorized representatives. Any other purposes are prohibited. Biomet hereby explicitly excludes any and all liability of any kind that might be triggered by the unauthorized use of this publication or the information herein. 27

28 References 1. Anderson et. al. Neuromuscular Activation in Conventional Therapeutic Exercises: Implications for Rehabilitation. Physical Therapy, 86(5): , Accelerated Rehabilitation Following ACL Reconstruction using Ipsilateral Patellar Tendon Graft Protocol printed from SportsMedRx.com, ACL Reconstruction Rehabilitation Program Protocol printed from htm#rp, George Davies, Arendt E. et al. Knee Injury Patterns Among Men and Woman In Collegiate Basketball and Soccer. NCAA data and review of literature, Am J Sports Med 23(6): , Barber-Westin, et. al. A Rigorous Comparison Between the Sexes of Results and Complications After ACL-R. Am J Sports Med, 25(4) , Beynnon BD, Johnson RJ. Anterior cruciate ligament injury rehabilitation in athletes. Biomechanicalconsiderations. Sports Medicine, 22(1): 54-64, Bolga, Keskula. Reliability of LE Functional Performance Tests. Journal of Orthopedic and Sports Physical Therapy, 26(3): , Caraffa et al. Prevention of Anterior Cruciate Ligament Injuries in Soccer. A prospective Controlled Study of Proprioceptive Training. Knee Surg Sports Trauma Arthosc 4 (1):19-21, Chemielewski T, Ferber R, Rehabiltation Considerations for the Female Athlete. Physical Rehabilitation of the Injured Athlete, 13: , Davies GJ, Heiderscheit B, Clark M. Open kinetic chain assessment and rehabilitation. Athletic Training: Sports health care perspectives, 1(4): , Davies GJ, Zillmer DA: Functional progression of exercise during rehabilitation in Knee Ligament Rehabilitation, Ellenbecker, , Davies G, Ellenbecker T, Closed Kinetic Chain Exercise Delay BS, Smolinski R, Wind WM, Bowman DS. Current practices and opinions in ACL reconstruction and rehabilitation: Results of a survey of the American Orthopaedic Society for Sports Medicine (Summary). Am J of Knee Surgery, 14(2): 85-91, Fagenbaum R, Darling W. Jump landing strategies in male and female college athletes and the implications of such strategies for ACL injury. Am J of Sports Med, 31: , Fernandez J, Sheilds N, Anterior Cruciate Ligament Reconstruction With Allograft. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder, 11: ,

29 References Cont. 16. Fitzgerald, KG. Open versus closed kinetic chain exercise: Issues in rehabilitation after anterior cruciate ligament reconstructive surgery. Physical Therapy, 77: , Gillette T, et.al. Anterior Cruciate Reconstruction. Rehabilitation for the Postsurgical Orthopedic Patient,12: , Glick K, Ashston K, Strain Gauge Studies: A Historical Review with Implications for Postoperative Anterior Cruciate Ligament Reconstruction. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder, , Griffin LY, et.al. Noncontact ACL Injuries: Risk Factors And Prevention Strategies, J Am Acad Ortho Surg. 8(3): , Griffis ND, Vequist SW, Yearout KM. Injury Prevention of the Anterior Cruciate Ligament. In AOS 15 th Annual Meeting, Taverse City, MI, 1989, American Orthopaedic Society For Sports Medicine. 21. Hewett T, et al. Effect of Neuromuscular Training On the Incidence of Knee Injuries in Female Athletes. A Prospective Study. Am J Sports Med. 27(6): , Hewett T, et al. Preventing Injury to the Anterior Cruciate Ligament. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder, 17: , Hewett T, et al. Plyometric Training In Female Athletes. Decreased Impact Forces and Increased Hamstring Torques. Am J of Sports Med 24(6): , Hewett et al. Understanding and Preventing Noncontact ACL Injuries. American Orthopaedic Society for Sports Medicine: Human Kinetics Kuechle DK, Pearson SE, Beach WR, et al. Allograft ACL reconstruction in patients over 40 years of age. Arthroscopy, 8: , Mandelbaum et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program In Preventing the Incidence of ACL Injuries in Female Athletes: a two year follow-up, Am j Sports Med, 33(7): Mangine RE, Kremchek TE. Evaluation-based protocol of the anterior cruciate ligament. J of Sport Rehab, 6: , Manske RC, Prohaska D, Livermore R. Anterior Cruciate Ligament Reconstruction Using Hamstring-Gracilis Tendon Graft. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder,10: , Manske RC et al. Complications in Anterior Cruciate Ligament Reconstruction. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder, 12: , McClay I, Ireland ML, ACL injuries-the Gender Bias. Journal Of Orthopedic and Sports Physical Therapy, 33(8): A2-A8, Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and CKC exercises for quads strengthening after ACL reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Sur, Sports Trau, Arthr, 8: ,

30 References Cont. 32. Muneta T, Sekiya I, Ogiuchi T, et al. Effects of aggressive early rehabilitation of the outcome of ACL reconstruction with multi-strand semitendinosus tendon. Internal Orthopaedics, 22: 352-6, Myklebust et al. Prevention of ACL injuries in Female Team Handball Players: A Prospective intervention Study Over Three Seasons, Clin J Sports Med, 13(2)71-78, Myer et. al. Neuromuscular Training Improves Performance and Lower Extremity Biomechanics in Female Athletes. Journal of Strength and Conditioning Research, 19(1): 51-60, Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS; Biomechanical Analysis of Human Ligament Grafts Used In Knee Ligament Repairs and Reconstructions. The Journal of Bone and Joint Surgery, 66A(3); p , Parsons L, et. al. Static vs. Dynamic Stretching on Vertical and Static Long Jump, Department of Physical Therapy, Wichita State University Risberg MA, Mork M, Jenssen HK, Holm I. Design and implementation of a neuromuscular training program following ACL reconstruction. J of Ortho and Sports Phy Ther, 31: , Risberg MA, Holm I. et. al. Neuromuscular Training Versus Strength Training During the First 6 Months After ACL Reconstruction: A Randomized Clinical Trial. Physical Therapy, 6: , Risberg MA, & Holm I. The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction: a randomized controlled clinical trial with 2 years of follow-up. The American Journal of Sports Medicine, 37(10), , Shelbume KB, Pandy MG. Determinants of cruciate-ligament loading during rehabilitation exercise. Clinical Biomechanics, 13: , Shelbourne DK, Rask BP: Controversies with anterior cruciate ligament surgery and rehabilitation. American Journal of Knee Surgery, 11(2): , Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two to nine year followup. Am J Sports Med. Nov-Dec;25(6):786-95, Tsaklis P, Abatzides G. ACL rehabilitation program using a combined isokinetic and isotonic strengthening protocol. Isokinetics Exercise Science,10: 211-9, Tyler T, Cuoco A. Plyometric Training and Drills. Physical Rehabilitation of the Injured Athlete,11: , Weber MD, Woodall WR Knee Rehabilitation. Physical Rehabilitation of the Injured Athlete, 15: , Wilk K, Andrews J et al. Rehabilitation After Anterior Cruciate Reconstruction in the Female Athlete. Journal of Athletic Training, 34(2) ,