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

(1)

One Surgeon. One Patient.SM

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 2001. 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.

(2)

Steven Traina, MD

Western Orthopaedics Denver, Colorado

Nathan Lilley, MPT, OCS, CSCS

Physio Pro Denver, Colorado

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.

(3)

3 2

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%

(4)

ROM 0–0–125

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

(5)

4 5

Estimated Weeks 8–10

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Shuttle–Bilateral 3 x 20 reps

Shuttle–Alternating 3 x 20 reps

Lateral Bounding in Place 3 x 30 sec.

Slide Board 3 x 30 sec.

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Shuttle–Bilateral 3 x 20 reps

Lateral Bounding in Place 3 x 30 sec.

Slide Board 3 x 30 sec.

Jog in Place 3 x 30 sec.

High Knees in Place 3 x 30 sec.

Gluteal Kicks in Place 3 x 30 sec.

Week 8

(6)

ROM 0–0–130

Strength 70% Quadriceps, 60% HS/Quad Ratio

Functional Testing None

(7)

6 7

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Shuttle–Bilateral Grid Jumps 20 reps CW, 20 reps CCW

Shuttle–Unilateral Grid Hops 20 reps CW, 20 reps CCW Lateral Bounding in Place– 3 Point 3 x 40 sec. Lateral Bounding with Rotation 1 x 30 sec. R, 1 x 30 sec. L

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Shuttle–Bilateral Grid Jumps 20 reps CW, 20 reps CCW

Shuttle–Unilateral Grid Hops 20 reps CW, 20 reps CCW Lateral Bounding in Place– 3 Point 3 x 40 sec. Lateral Bounding with Rotation 1 x 30 sec. R, 1 x 30 sec. L

Step Work: Quick Feet 1 x 30 sec.

Step Work: Ali Shuffle 1 x 30 sec.

Step Work: Lateral Quick Feet 1 x 30 sec. Step Work: Lateral Skaters 1 x 30 sec.

Return to Jogging Program (Treadmill) 3W–1J–1W–3J–3W–5J–1W

Week 10

(8)

ROM 0–0–135

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

(9)

8 9

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Jog in Place 20–30 sec.

Giant Arm Circles 20 reps (Ea. Direction)

Trunk Rotation 20 reps (Ea. Direction)

Pelvic Circle 20 reps (Ea. Direction)

Hip Circumduction 20 reps (Ea. Leg)

Hip Step w/ Exaggerated Arm Swing 15yds 2x

Gluteal Kicks 15yds 2x

Skipping Bound 15yds 2x

Side Shuttle 15yds 2x

Cariokas 15yds 2x

High Knees 15yds 2x

Sprint/Back Pedal 15yds 2x

Ankle Hops 10 sec.

(10)

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Jump Rope: Bilateral 1 x 1 min.

Jump Rope: Alternating 1 min. R, 1 min. L

Step Work: Lateral Quick Feet 2 x 30 sec.

Step Work: Lateral Skaters 2 x 30 sec. Lateral Bounding with Rotation–3 Point 2 x 30 sec. R, 2 x 30 sec. L Sport Cord: Forward 2 x 20 reps (1/2 Speed) Sport Cord: Backwards 2 x 20 reps (1/2 Speed) Sport Cord: 3 Point Lateral Bounding 2 x 30 sec. R, 2 x 30 sec. L

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Jump Rope: Bilateral 1 x 1 min.

Jump Rope: Alternating 1 min. R, 1 min. L

Step Work: Lateral Quick Feet 2 x 30 sec.

Step Work: Lateral Skaters 2 x 30 sec. Lateral Bounding with Rotation–3 Point 2 x 30 sec. R, 2 x 30 sec. L Sport Cord: Forward 2 x 20 reps (1/2 Speed) Sport Cord: Backwards 2 x 20 reps (1/2 Speed)

Dynamic Sports Routine 1x

Agility Ladder: High Knees 3x (Down & Back) Agility Ladder: Lateral High Knees 3x (Down & Back) Agility Ladder: Lateral Quick Feet Ins & Outs 3x (Front Lead) (Down & Back) Agility Ladder: Lateral Quick Feet Ins & Outs 3x (Back Lead) (Down & Back) Agility Ladder: Ali Shuffle 3x (Down & Back) Agility Ladder: Icky Shuffle 3x (Down & Back)

Week 12

(11)

10 11

ROM Within 90% contralateral limb

Strength 75–80% Quadriceps, 50–70% HS/Quad Ratio

Special Testing Satisfactory Lachman/Drawer Test Functional Score >7 score on Cinti Knee Rating System Functional Testing SL hop 50%, Broad Jump with sound mechanics

(12)

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Cariokas 15yds 2x

High Knees 15yds 2x

Ankle Hops 10 sec.

(13)

12 13

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Dynamic Sports Routine (Warmup) 1x

Sport Cord: Forward 2 x 20 reps (3/4 Speed) Sport Cord: Backwards 2 x 20 reps (3/4 Speed) Sport Cord: Lateral Shuffles 1 x 20 reps R Lead, 1 x 20 reps _{L Lead} Sport Cord: 3 Point Lateral Bounding w/

Rotation 2 x 30 sec. (Ea. Side)

Agility Ladder: High Knees 4x (Down & Back) Agility Ladder: Lateral High Knees 4x (Down & Back) Agility Ladder: Lateral Quick Feet Ins & Outs 4x (Front Lead) (Down & Back) Agility Ladder: Lateral Quick Feet Ins & Outs 4x (Back Lead) (Down & Back)

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Dynamic Sports Routine (Warmup) 1x

Sport Cord: Forward 2 x 20 reps (3/4 Speed) Sport Cord: Backwards 2 x 20 reps (3/4 Speed) Sport Cord: Lateral Shuffles 1 x 20 reps R Lead, 1 x 20 reps _{L Lead} Sport Cord: 3 Point Lateral Bounding w/

Rotation 2 x 30 sec. (Ea. Side)

Sport Cord: 3 Point Drill (Forward) 20x Sport Cord: 3 Point Drill (Backwards) 20x Agility Ladder: High Knees 4x (Down & Back) Agility Ladder: Lateral High Knees 4x (Down & Back) Agility Ladder: Lateral Quick Feet Ins & Outs 4x (Front Lead) (Down & Back) Agility Ladder: Lateral Quick Feet Ins & Outs 4x (Back Lead) (Down & Back) Agility Ladder: Ali Shuffle 4x (Down & Back) Agility Ladder: Icky Shuffle 4x (Down & Back)

Week 14

Week 15

(14)

ROM Within 90% contralateral limb Effusion Minimal to none, no joint line tenderness

Functional Testing SL hop 60%, Broach Jump with sound mechanics, Good form with _{Eccentric Step–Down Test}

(15)

14 15

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Cariokas 15yds 2x

High Knees 15yds 2x

Ankle Hops 10 sec.

(16)

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Wall/Block Jump 20 sec.

Broad Jump 5 reps

Squat/Vertical Jump 20 sec.

180/Half Spin Jump 20 sec.

Lateral Bounding in Place 20 sec.

Scissors/Rudder Jump 20 sec.

Richochets–Bilateral–Back to Front 20 sec. Richochets–Bilateral–Side to Side 20 sec.

Plyometrics Phase I: Week 16

Plyometrics Phase I: Week 16 Functional Strengthening

Exercise

No. of Reps/Time

Day 2

Day 4

Day 6

Hip Hinges: Sustained Isometric Squat 2 x 30 sec.

Cook Hip Lift 2 x 10 reps

Fire Hydrants 2 x 10 reps

Split Leg Squat/Chair Dip 2 x 10 reps

Isometric Plank x4 5 sec. Hold 5x Thru ea. Position Multidirectional Lunge 3x (Down & Back) Unilateral Straight Leg Dead Lift 2 x 10 reps Straight Leg Abduction with External Rotation 2 x 10 reps

(17)

16 17

Estimated Weeks 16–22 Plyometrics Phase I: Week 17

Plyometrics Phase I: Week 17 Functional Strengthening

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Broad Jump 10 reps

180/Half Spin Jump 25 sec.

Lateral Bounding in Place 25 sec.

Richochets–Bilateral–Back to Front 25 sec. Richochets–Bilateral–Side to Side 25 sec.

Exercise

No. of Reps/Time

Day 2

Day 4

Day 6

Isometric Plank x4 5 sec. Hold 5x Thru ea. Position Multidirectional Lunge 3x (Down & Back) Unilateral Straight Leg Dead Lift 2 x 10 reps Straight Leg Abduction with External

Rota-tion 2 x 10 reps

(18)

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Tuck Jump 30 sec.

Jump, Jump, Jump, Vertical Jump 5 reps

Lateral Bounding for Distance 2 runs

Richochets–Bilateral–Back to Front 30 sec. Richochets–Bilateral–Side to Side 30 sec. Richochets–Unilateral–Back to Front 30 sec. Richochets–Unilateral–Side to Side 30 sec.

Hop, Hop, Hop, Stick 5 reps

Plyometrics Phase II: Week 18

Plyometrics Phase II: Week 18 Functional Strengthening

Exercise

No. of Reps/Time

Day 2

Day 4

Day 6

Split Leg Squat/Chair Dip 2 x 12 reps Isometric Plank x4 5 sec. Hold 8x Ea. Position Multidirectional Lunge 5x (Down & Back) Unilateral Straight Leg Dead Lift 2 x 12 reps Straight Leg Abduction with External Rotation 2 x 12 reps

(19)

18 19

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Tuck Jump 35 sec.

Jump, Jump, Jump, Vertical Jump 8 reps

Lateral Bounding for Distance 4 runs

Richochets–Bilateral–Back to Front 35 sec. Richochets–Bilateral–Side to Side 35 sec. Richochets–Unilateral–Back to Front 35 sec. Richochets–Unilateral–Side to Side 35 sec.

Hop, Hop, Hop, Stick 8 reps

Plyometrics Phase II: Week 19

Plyometrics Phase II: Week 19 Functional Strengthening

Exercise

No. of Reps/Time

Day 2

Day 4

Day 6

Split Leg Squat/Chair Dip 2 x 12 reps Isometric Plank x4 5 sec. Hold 8x Ea. Position Multidirectional Lunge 5x (Down & Back) Unilateral Straight Leg Dead Lift 2 x 12 reps Straight Leg Abduction with External

Rota-tion 2 x 12 reps

(20)

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Jump Up, Jump Down, Vertical Jump 10 reps

Tuck Jump 35 sec.

Jump Into Bounding for Distance 3 runs Ea. Leg Richochets–Bilateral–Back to Front 35 sec. Richochets–Bilateral–Side to Side 35 sec. Richochets–Unilateral–Back to Front 35 sec. Richochets–Unilateral–Side to Side 35 sec. Single Leg Hop, Hop, Hop, Stick 8 reps

Plyometrics Phase III: Week 20

Plyometrics Phase III: Week 20 Functional Strengthening

Exercise

No. of Reps/Time

Day 2

Day 4

Day 6

Isometric Plank x4 5 sec. Hold 10x Ea. Position Multidirectional Lunge 5x (Down & Back) Unilateral Straight Leg Dead Lift 2 x 15 reps Straight Leg Abduction with External Rotation 2x 15 reps

(21)

20 21

Exercise

No. of Reps/Time

Day 1

Day 3

Day 5

Jump Up, Jump Down , Vertical Jump 12 reps

Tuck Jump 40 sec.

Jump Into Bounding for Distance 4 runs Ea. Leg Richochets–Bilateral–Back to Front 40 sec. Richochets–Bilateral–Side to Side 40 sec. Richochets–Unilateral–Back to Front 40 sec. Richochets–Unilateral–Side to Side 40 sec. Single Leg Hop, Hop, Hop, Stick 10 reps

Plyometrics Phase III: Week 21

Plyometrics Phase III: Week 21 Functional Strengthening

Exercise

No. of Reps/Time

Day 2

Day 4

Day 6

Isometric Plank x4 5 sec. Hold 10x Ea. Position Multidirectional Lunge 5x (Down & Back) Unilateral Straight Leg Dead Lift 2 x 15 reps Straight Leg Abduction with External

Rotation 2x 15 reps

(22)

#1 #2 #3 Ave. Percentile Quality P • F • G • E

Jump #1 Jump #2 Jump #3 Mean Jump _Height Percentile Quality P • F • G • E

R #1 R #2 R #3 L #1 L #2 L #3 Total R Total L Hop Index Percentile Quality % P • F • G • E

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 90-100% Height, F 80-90% Height _________

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” ________

Single Hop For Distance

(23)

22 23

ROM Within 90% contralateral limb

Functional Testing SL hop 85%, Ability to pass sport specific movement & physician _clearance 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

Pass Criteria Criteria Met ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

Restrictions: Non–Contact ( ) Release Pending MD Approval ( ) Contact with Brace ( ) Continue Therapy ( ) No Restrictions ( )

(24)

#1 #2 #3 Ave. Percentile Quality P • F • G • E

Jump #1 Jump #2 Jump #3 Mean Jump _Height Percentile Quality P • F • G • E

R #1 R #2 R #3 L #1 L #2 L #3 Total R Total L Hop Index Percentile Quality % P • F • G • E

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 90-100% Height, F 80-90% Height _________

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” ________

Single Hop For Distance

(25)

24 25

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

Evaluators Signature: _________________________________________________ Date: __________________

R L F. E. R. Quality

P • F • G • E Timed One Minute Eccentric

Step Down Test _____"Step

Step Down Test Squat Test

R + L +

--Recommendations: ( ) Continue Current Phase ( ) Progress to Next Phase

___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

(26)

ACL P

er

for

manc

e Enhanc

emen

t P

rog

ram

St

ev

en

Tr

aina, MD

, Na

than Lilley

, MPT

, OCS, CSCS

_______________________________________

has c

omplet

ed the A

CL P

er

for

manc

e Enhanc

emen

t P

on ________________________ and is r

eleased t

o r

etur

n t

o spor

_______________________________________

Restr

ic

tions:

(27)

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.

(28)

1. Anderson et. al. Neuromuscular Activation in Conventional Therapeutic Exercises: Implications for Rehabilitation. Physical Therapy, 86(5): 683-697, 2006

2. Accelerated Rehabilitation Following ACL Reconstruction using Ipsilateral Patellar Tendon Graft Protocol printed from SportsMedRx.com, 2003

3. ACL Reconstruction Rehabilitation Program Protocol printed from http://www.pt.armstrong.edu/davies/professoraasu.

htm#rp, George Davies, 2008

4. 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):694-701, 1995

5. Barber-Westin, et. al. A Rigorous Comparison Between the Sexes of Results and Complications After ACL-R. Am J Sports Med, 25(4) 514-525, 1997

6. Beynnon BD, Johnson RJ. Anterior cruciate ligament injury rehabilitation in athletes. Biomechanicalconsiderations. Sports Medicine, 22(1): 54-64, 1996

7. Bolga, Keskula. Reliability of LE Functional Performance Tests. Journal of Orthopedic and Sports Physical Therapy, 26(3): 138-142, 1997

8. 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, 1996

9. Chemielewski T, Ferber R, Rehabiltation Considerations for the Female Athlete. Physical Rehabilitation of the Injured

Athlete, 13: 315-328, 2004

10. Davies GJ, Heiderscheit B, Clark M. Open kinetic chain assessment and rehabilitation. Athletic Training: Sports health

care perspectives, 1(4): 347-370, 1995

11. Davies GJ, Zillmer DA: Functional progression of exercise during rehabilitation in Knee Ligament Rehabilitation, Ellenbecker, 345-360, 2000

12. Davies G, Ellenbecker T, Closed Kinetic Chain Exercise 2001

13. 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, 2001

14. 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: 233-240, 2003

15. Fernandez J, Sheilds N, Anterior Cruciate Ligament Reconstruction With Allograft. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder, 11:207-224, 2006

(29)

28 29

16. Fitzgerald, KG. Open versus closed kinetic chain exercise: Issues in rehabilitation after anterior cruciate ligament reconstructive surgery. Physical Therapy, 77: 1747-1754, 1997

17. Gillette T, et.al. Anterior Cruciate Reconstruction. Rehabilitation for the Postsurgical Orthopedic Patient,12: 207-226, 2001

18. 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, 239-244, 2006

19. Griffin LY, et.al. Noncontact ACL Injuries: Risk Factors And Prevention Strategies, J Am Acad Ortho Surg. 8(3): 141-150, 2000

20. Griffis ND, Vequist SW, Yearout KM. Injury Prevention of the Anterior Cruciate Ligament. In AOSSM 15th_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):699-706, 1999

22. Hewett T, et al. Preventing Injury to the Anterior Cruciate Ligament. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder, 17:319-336, 2006

23. Hewett T, et al. Plyometric Training In Female Athletes. Decreased Impact Forces and Increased Hamstring Torques. Am

J of Sports Med 24(6):765-773, 1996

24. Hewett et al. Understanding and Preventing Noncontact ACL Injuries. American Orthopaedic Society for Sports

Medicine: Human Kinetics. 2007

25. Kuechle DK, Pearson SE, Beach WR, et al. Allograft ACL reconstruction in patients over 40 years of age. Arthroscopy, 8: 845-853, 2002

26. 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):1003-1010

27. Mangine RE, Kremchek TE. Evaluation-based protocol of the anterior cruciate ligament. J of Sport Rehab, 6: 157-181, 1997

28. Manske RC, Prohaska D, Livermore R. Anterior Cruciate Ligament Reconstruction Using Hamstring-Gracilis Tendon Graft. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder,10:189-206, 2006

29. Manske RC et al. Complications in Anterior Cruciate Ligament Reconstruction. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder, 12:225-238, 2006

30. McClay I, Ireland ML, ACL injuries-The Gender Bias. Journal Of Orthopedic and Sports Physical Therapy, 33(8): A2-A8, 2003

31. 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: 337-42, 2000

(30)

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, 1998

33. 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, 2003

34. Myer et. al. Neuromuscular Training Improves Performance and Lower Extremity Biomechanics in Female Athletes.

Journal of Strength and Conditioning Research, 19(1): 51-60, 2005

35. 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); p344-352, 1984

36. Parsons L, et. al. Static vs. Dynamic Stretching on Vertical and Static Long Jump, Department of Physical Therapy, Wichita State University. 50-51

37. 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: 620-31, 2001

38. 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, 6:87 737-747, 2007

39. 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), 1958-66, 2009

40. Shelbume KB, Pandy MG. Determinants of cruciate-ligament loading during rehabilitation exercise. Clinical Biomechanics, 13: 403-413, 1998

41. Shelbourne DK, Rask BP: Controversies with anterior cruciate ligament surgery and rehabilitation. American Journal of

Knee Surgery, 11(2): 136-143, 1998

42. 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, 1997

43. Tsaklis P, Abatzides G. ACL rehabilitation program using a combined isokinetic and isotonic strengthening protocol. Isokinetics Exercise Science,10: 211-9, 2002

44. Tyler T, Cuoco A. Plyometric Training and Drills. Physical Rehabilitation of the Injured Athlete,11: 265-294, 2004 45. Weber MD, Woodall WR Knee Rehabilitation. Physical Rehabilitation of the Injured Athlete, 15: 396-408, 2004

46. Wilk K, Andrews J et al. Rehabilitation After Anterior Cruciate Reconstruction in the Female Athlete. Journal of Athletic