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Contents

[edit] Background

What is the anterior cruciate ligament ?

The anterior cruciate ligament known as the ACL , is one of the four major ligaments that construct the human knee. The ligament sits anteriorly which means that it is located towards the front of the knee. The word cruciate means that the ligaments cross over one another. The ACL crosses over top of the posterior cruciate ligament. The word ligament refers to a band of connective tissue that connects bone to bone. In the case of the ACL, it connects the femur and the tibia. The Anterior Cruciate Ligament is typically 31-38mm in length and 11mm in width.

Although the ACL is known to be a tough band of connective tissue, it is quite susceptible to injuries. The Anterior Cruciate Ligament is a very common ligament that is either sprained or torn. In fact, the ACL is the most commonly injured ligament of the knee. The most common activities for injury of the ACL are agility sports do not involve contact. ACL sprains and tears are common in sports such as basketball, skiing, soccer, and football. ACL injuries occur often in these type of sports due to their fast speed and quick changes in direction. ACL injuries also occur from direct contact but these activities only accounts for approximately 30% of reported injuries (Griffin, 2000).


How are the injures classified?

Injuries to the Anterior Cruciate Ligament are either diagnosed as a sprain or a tear. The injury is classified as a sprain when the ligament can still provide support for the knee joint but the ligament has been stretched. The injury is diagnosed as a tear when the muscle fibers have physcially been torn, either partial or completely. ACL sprains have their own classification of grade 1, grade 2, and grade three sprains. Each grade progresses with a percentage of the fibres in the ligament torn. A complete tear of the ACL is classified as a grade three sprain where the ligament has been seperated into two peices.


Why is it important to learn more about this ligament?

The other ligaments of the knee are often able to repair themselves while the ACL cannot. Often ACL injuries will results to the patient needing to undergo surgery.

It is important we further our knowledge on the rehabilitation and the prevention of this injury because of its commonality among athletes. Approximately one percent of female athletes will suffer from an ACL injury before she graduates high school, according to Letha Y. Griffin, MD. ACL tears specifically also can limit people in the activities they are able to comfortably perform onward. These retched injuries can also cause issues such as early-onset knee arthritis.

[edit] History

[edit] 460-370 BC

Hippocrates of Kos, a Greek, was the first insinuate that there is a possible torn ligament, resulting from knee injuries.

[edit] 131-201 BC

Galen of Pergamon, also a Greek, he was the one that had introduced the name “ligament genu cruciata”.

[edit] 1836

Wilhelm Weber, a Physics Professor and Eduard Weber, a Anatomy and Physiology Professor discovered that the anterior cruciate ligament consists of two fibre bundles that have different pulls for a wide range of knee movement.

[edit] 1837

Robert Adams of Dublin was a surgeon who was the first person to have a written report about ACL injury. He had written about a case of a young drunken wrestler who had had died 24 days after injuring his knee. There was an autopsy done on the body of the 25 year-old, and it was found that the ACL had torn and had taken a piece of the tibia bone with it.

[edit] 1845

Amedée Bonnet, a Professor of Surgery had published a book called “Traité des maladies des articulation”. He is the first person to finally find distinct symptoms of ACL rupture. As he describes “In patients who have not suffered a fracture, a snapping noise, haemarthrosis, and loss of function are characteristic of ligamentous injury in the knee” (Bonnet , 1845). Being a Professor of Surgery, Bonnet was aware of the problems that immobility caused, therefore he had prescribed cold packs for the critical stage, then the using a brace to help them stabilize and use their to allow movement such as walking. Bonnet had come up with different designs to help stabilize the knee, for movement to eliminate stiffness. One design had a sliding frame and other had brace apparatus.

[edit] 1839-1841

James Stark, a general practitioner was a one of the first individuals to be quoted for ACL injuries, Stark described the common after effect of having an ACL tear from hearing the common snap to feeling your knee give way and lose all control of your knee. When treating his clients he was under the belief that without the ligaments it would render the knee “utterly useless” (Stark, 1850). Stark had prescribed 3 months of immobilization, then another 10 months of a semi-ridged brace, but unfortunately even though both clients went thru Stark regime they both did not regain their knee function.

[edit] 1875

Georgios C. Noulis, had written a description of what we now call a Lachman test.

[edit] 1876

Leopold Dittel of Vienna had conducted experiments on different knees to test different range of motions. He had discovered that the ACL almost always tore at the femoral insertion, and sometimes would take a piece of the tibia with it. He had come familiar with the other ligaments present within the knee, because of these experiments.

Paul Segond, a French surgon, had come to realize that there is a small spot present on the tibia, that usually means there is an ACL tear. He also had written down information about the symptoms of ACL injuries.

[edit] 1895

Authur Mayo-Robson, had conducted the very first every surgery to repair a torn ACL. The surgery was performed on a 41 year-old man. The femoral ligament were torn off and attached by catgut (cord made from animal intestines) ligatures. After 6 years it was found that the patient had regained his ability to use his knee without any difficulty, although sometimes there where limitations on the ability to flex the knee.

[edit] 1911

Rudolf Flick, had given great details about the ACL bundles and tension of the ACL, because of his information he had, the invention of graft for the ACL were later possible.

[edit] 1913

Hubert Goetjes, had written scientifical papers about 23 different cases of ACL injuries. Goetjes was able to determine which type of surgery would be necessary based on what type of ACL tear it was.

[edit] 1976

Joseph Torg had named the “Lachman test” after his mentor John Lachman.



From 1895 to today only minor adjustment to ACL surgery were done. There were adjustment to the method and materials used. Such as, Meniscus graphs were final abandoned by the end of the 1980's (Schindler, 2011). Extensor retinaculum and patellar tendon had been used from 1927 to today as a replacement (Schindler, 2011). This change was triggered by Jack Hughston, who had realized that the meniscus was an important contributor to the knee stability (Schindler, 2011).

[edit] Target Audience

Active individuals, particularly athletes between the ages of 15 and 35, are highly susceptible to injuring their ACL due to their lifestyles. Both males and females are at risk of an anterior cruciate ligament injury, as most aren’t caused by impact with a person or object. Whilst female athletes are more prone to ACL injuries due to hormonal and anatomical differences, the rate of males with this injury is higher due to their relatively larger concentration in amateur and professional sports (Hewitt et al., 2010). Tailored physical activity as a mode of rehabilitation is beneficial in the repair phase of these individuals with an ACL injury and hastens their return to play.


[edit] Research

[edit] Who Is At Risk?

ACL injuries occur in 1 out of 3000 Americans and are more prevalent in females according to research conducted by Nandra. These studies show that soccer and basketball are linked to more ACL injuries than others activities. Knowing this, preventative exercise programs should be included in athlete's training who partake in these sports. To review this data please refer to Nandra's article the link is below. [1] display text http://eds.b.ebscohost.com.proxy.library.brocku.ca/eds/pdfviewer/pdfviewer?sid=608a1338-d86c-49df-ae94-f7c429578a84%40sessionmgr115&vid=35&hid=115

[edit] Financial Barrier

The cost effectiveness of ACL reconstruction has been reviewed multiple times. A recent study conducted by Lubowitz and Appleby showed that the average cost is $12,740. ACL tears requiring surgery have become increasingly common, which shows the importance of finding the most cost effective method for repairing the injury. To see the cost effective study by Lubowitz and Appleby, use the following link. [2] display text http://journals2.scholarsportal.info.proxy.library.brocku.ca/details/07498063/v27i0010/1317_caotmcakaclr.xml Financial barriers of surgery may prevent a person from getting the medical intervention they need to repair and over come their injury. The importance of following a pre-operative exercise program pre-surgery is crucial. Pre-operative exercises help to maintain mobility and range of motion. The risk of developing scar tissue and osteo arthritis increase with no physical activity, however limiting weight bearing exercise is necessary. Aquatic exercise is recommended to help maintain the patient's pre operative strength and range of motion.

[edit] Prevention of ACL Injury

The prevention of ACL injuries is mainly conducted through exercise training. Donnely et al. have reviewed multiple studies and concluded that focusing on these 3 areas had the best results:

  1. Balance (on unstabilized surfaces)
  2. Plyometric Training (jumping and landing, step ups, single and double leg)
  3. Resistance Training (focus on Quadriceps and Hamstrings)

These exercises showed a reduced internal rotation of the knee and a reduction of load on the ACL, which help to prevent ACL injuries. Donnely's article can be found in Research in Sports Medicine: An International Journal. [C.J. Donneley, B.C. Elliot, T. R. Ackland, T.L.A. Doyle, T.F. Beiser, C.F.Finch, J.L. Cochrane, A.R. Dempse &D.G.Llyod (2012) An Anterior Cruciate Ligament Injury Prevention Framework: Incoprating the Recent Evidence, Research In Sports Medicine: An International Journal, 20:3-4,239-262. ] [C.J. Donneley, B.C. Elliot, T. R. Ackland, T.L.A. Doyle, T.F. Beiser, C.F.Finch, J.L. Cochrane, A.R. Dempse &D.G.Llyod (2012) An Anterior Cruciate Ligament Injury Prevention Framework: Incoprating the Recent Evidence, Research In Sports Medicine: An International Journal, 20:3-4,239-262. display text]

[edit] Rehabilitation Program

A clinical review of current rehabilitation programs outlines the gaps and the ineffectiveness of some rehab programs. Lee Herrington, Gregory Myer and Ian Horsley have noticed a trend in elite athletes in a variety of sports that have returned to play after an ACL reconstruction. They noted that between 30%-44% of these athletes were not able to compete at the same level prior to injury (Herrington et al., 2013). Herrignton et al proposed that this was due to a lack of defined goals in the athletes rehab programs. Rehab programs tend to focus on a time line of what an athlete should be able to do at week__ post surgery. Herrrington says the focus should be when they are ready, they are ready. The current programs tend to focus on regaining strength, however Herrington thinks that neurmuscular and symmeterial movements should also be evluated in the recovery of an athlete. Herrington et al. outline the 6 stages of ACL injury rehabilitation:

  1. Pre OP
  2. Post OP Recovery
  3. Progressive Limb Loading
  4. Unilateral Load Acceptance
  5. Sport Specific Task Training
  6. Unrestricted Sport Specific Training

To read more about the six stages of rehabilitation and to learn the specific exercise goals and how the stages are evaluated, please read the full article. [Physical Therapy in Sport: Task based rehabilitation protocol for elite athletes following Anterior Cruciate Ligament Reconstruction: a clinical commentary. Vol. 14 (2013) 188-198.] [Physical Therapy in Sport: Task based rehabilitation protocol for elite athletes following Anterior Cruciate Ligament Reconstruction: a clinical commentary. Vol. 14 (2013) 188-198. display text]

[edit] Recovered And Ready To Return To Play

The importance of getting back to a physically active lifestyle is essential for everyday life. A study conducted at the University of Toronto examined patients reasons for not returning to sport. Tjong et al. were compelled by the statistic that only 63% of patients return to their pre-injury level of sport after ACL reconstruction. Their study involved 31 patients who had ACL reconstruction and a 2 year follow up with no re-injuries. Interviews were conducted to qualitative establish the reasons why they did not return to play or what they had to overcome in order to return to play. The study found 3 major reasons :

  1. Fear (reinjury, pain, financial loss if reinjuried)
  2. Priorities (family or work commitments changed)
  3. Personality( self motivation)

(Tjong,V et al, 2013) [Tjong, V, Murnaghan, M, Nyhof-Young,J, Ogilvie-Harris, D(2013) A Qualitative Investigation of the Decision to Return to Sport After Anterior Cruciate Ligament Reconstruction To Play or Not to Play, The American Journal of Sports Medicine, 42-2,336-342. ] Having identified the main reasons why patients do not return to sport, researchers and medical professionals can find ways to help patients overcome these barriers and help them find another method of staying physically active.

[edit] Existing Physical Activity Programs

Since tearing or injuring the ACL is so common in athletes there are numerous programs that have been created to decrease injury time and increase injury prevention. There are numerous rehab clinics that provide activity programs and routines that will help with the treatment injured ACLs.

[edit] Westwood Point Clinic

1) The Westwood point clinic has an extensive eight-week program that outlines exercises to strengthen and increase mobility and function of the knee post surgical repair. The aim of the program is to get the knee back to 90% after eight weeks of treatment. This program is extremely important because it focuses on strengthening the muscle in just eight weeks after surgery. This program is great for the rehabilitation of the ACL because there is a specific schedule patients have to follow for eight-weeks. For more information about this program their website is: http://www.westwoodpt.com/services/sports-medicine/acl-rehab-program/

[edit] Oakville Soccer Association

2) Ontario Soccer Association The Ontario Soccer Association practices the prevention of tearing the knee muscle. The program was put together by people who have actually injured their ACL and they provide great tips and advice how to avoid the injury. “The components that make up the program are warm up, stretching, strengthening, proprioception, plyometrics and sport specific agility runs to address potential issues in strength and coordination of the stabilizing muscles around the knee joint. Technique of each of the exercises is crucial and must be observed” (Ontario Soccer Association). During this physical exercise it is extremely important for the participant to have a correct posture and a slow landing. This program is to be completed at least three times a week to ensure effectiveness. For more information, their website is: http://www.ontariosoccer.net/Programs/HighPerformancePlayer/StrengthAndConditioning/ACLPreventionProgram/tabid/5724/language/en-US/Default.aspx

[edit] HealthLinkBC

3) HealthLinkBC is a clinic in British Columbia that specializes in treating injured knees. They have a customized and extensive program that is designed to fit your lifestyle and injury. A doctor or a physiotherapist design a physical rehabilitation program based on your lifestyle. They take into consideration your previous activity level, physical fitness and the extent of your ACL injury. The program is then created and flexibility, strengthening and endurance activities are based on you. This program includes treatment with a physiotherapist and home treatment. This is a great service because many injuries are house-bounded. They create day-plans for you to follow which include a healthy diet and an exercise routine. This program is tended to last 4 to 8 weeks depending on how severe the injury is. For more information about this program, their website is: http://www.healthlinkbc.ca/kb/content/otherdetail/hw28263.html

[edit] Emory HealthCare

4)Emory HealthCare is a clinic created by Dr. John Xerogeanes, as well as physical therapists Mike Newsome and Dan Kraushaar. They created a treatment program to guide an injured athlete through each of the phases of rehabilitation after an ACL injury. What is great about this program is they have put together information about treatment and exercises for every possible injury scenario. The program is divided into 3 steps: prehabilitation, surgical recovery and return to play. Prehabilitation is the first step after injuring you ACL. This step is focused on retaining range of motion, reduce the swelling of the knee and retaining muscle size and strength. Emory HealthCare has developed specific exercises and activities for these goals to be reached. The second step is surgical recovery. This step can be passed if the patient did not have surgical reconstruction on their knee. This step includes what the patient should be doing post-op surgery and certain exercises they should be doing to decrease injury time. The final step is returning to play. This stage is divided into 5 steps that describe when you should return to certain activities. The first step is the jogging phase which you are allowed to return to in 3-4 months after surgery. The second step is the agility phase, which you are allowed to return to in 4-5 months and the drill phase is 5-6 months. The last 2 steps are the returning to practice phase, which is 6-7 months, and the returning to competition phase, which is 7-8 months. With this program return to sport should occur in approximately 7 months. For more information about this program, their website is: http://emoryhealthcare.org/acl-program/index.html

[edit] Fowler Kennedy Sport Medicine Clinic

5) The Fowler Kennedy Sport Medicine Clinic offers an program that is essential for full recovery. This program provides the patient with instructions, direction, rehabilitation guidelines in order for them to reach their goals. Their physiotherapist will make their best professional judgment to determine to approiate treatment and exercises for their specific patient. Depending on the muscle tears, articular cartilage trauma and bone bruising will result in a specific activity guideline made completely for the patient. This program occurs over a 6 month period and is divided into 7 categories. Each category has a specific goal and physical activity exercise. Each category also incorporates the patient’s range of motion, flexibility, strength, endurance and cardiovascular fitness. This program is a great program for athletes or pateints that need a specific guidline to follow in order for their recovery. For more information about this program, visit their website at: http://fowlerkennedy.com/wp-content/uploads/2013/04/ACL_Reconstruction_Protocol.pdf


[edit] Best Practice Activity Suggestions

During all of these exercises do not push yourself to far. These exercises are for strengthening and stretching your muscle.

[edit] Heel Slide

Sit on a hard surface with your legs straight in front of you. Sitting on a hardwood floor with an exercise mat is suggested. Lie down, and roll onto your side that is opposite to your injured knee. With the leg that is injured, slowly slide the heel of your foot towards your buttock. You will feel a slight tension on your quad and your knee. This exercise stretches your muscles in your knee and also helps to strengthen it. Hold this stretch for about 15 to 20 seconds, or until you feel uncomfortable. Return to starting position and do this exercise 7 more times.

All information was obtained from Summit Medical Group http://www.summitmedicalgroup.com/library/adult_health/sma_anterior_cruciate_ligament_sprain_exercises/

Image:A_patient_doing_the_physical_exercise_-heel_slide_Photo_on_2014-03-17_at_11.02_AM_-3.jpg


A patient doing the physical exercise - heel slide

[edit] Passive Knee Extension

This exercise is intended for patients that are unable to extend their knee fully. This exercise will help assist you in extending your knee. Sit on a hard surface with your legs straight in front of you. Sitting on a hardwood floor with an exercise mat is suggested. Roll up a towel or some sort of soft material that is about 6 inches off the ground. Lye on your back and place the rolled-up towel under your heel of your injured knee. Relax your leg muscle and let gravity slowly straighten and stretch your knee. Holding this position for 2 minutes will have the most success. Repeat this exercise 2 or 3 more times. Feeling discomfort during this exercise is common but stretching your knee muscle everyday will decrease injury time. Do this exercise several times a day, everyday.

All information was obtained from Summit Medical Group http://www.summitmedicalgroup.com/library/adult_health/sma_anterior_cruciate_ligament_sprain_exercises/


Image:A_patient_doing_the_physical_exercise_-_passive_knee_extensionPhoto_on_2014-03-17_at_11.04_AM_-2.jpg


A patient doing the physical exercise - passive knee extension

[edit] Wall Squat using a Ball

For this exercise you will need a sturdy wall so you will be able to stand with your back, shoulders and head against it. For proper form for this exercise, look straight ahead. Keep your shoulders relaxed and your legs should be approximately 3 feet away from the wall. Place any type of ball behind your back; this can include an exercise ball or even a soccer ball. Standing with your legs shoulder width apart, slowly squat down to a 45-degree angle. Your legs should never be parallel to the ground, you want to strengthen your knee muscle but you do not want to push to hard. Hold this squatting position for about 10-15 seconds and then slowly rise back up. Repeat this exercise 6-7 more times.

All information was obtained from Summit Medical Group http://www.summitmedicalgroup.com/library/adult_health/sma_anterior_cruciate_ligament_sprain_exercises/

[edit] Balance and Reach Exercise

For this exercise you will need a sturdy chair, the chair will provide support if you need it. Stand next to the chair with your injured knee furthest from it. Stand on your injured leg by raising your other leg behind you. Keep your leg in this position. With the hand that is farther away from the chair, reach forward in front of you by bending at the waist. Do not bend your knee when you do this as it will defeat the purpose of the stretch. Do this 11 more times. To make this exercise more of a challenge, push the chair further away so you will have to reach farther in front of you. To make this exercise even more challenging reach the hand that is farther away from the chair across your body toward the chair. The farther you reach, the more challenging the exercise becomes.

All information was obtained from Summit Medical Group http://www.summitmedicalgroup.com/library/adult_health/sma_anterior_cruciate_ligament_sprain_exercises/


Image:Balance_and_ReachPhoto_on_2014-03-17_at_11.07_AM.jpg


A patient doing the physical exercise - balance and reach

[edit] Knee Stabilization

This exercise involves a resistance band, however any soft material that has resistance will work. For this exercise you will need to be close to a door that can easily be opened or shut. Wrap one side of the resistance band around the ankle of your injured leg. Tie the other side of the elastic to the other side of the door, preferably at ankle height. There are 3 different activities to this exercise. For the first activity stand about 4 feet away while facing the door. Stand on the leg that is not injured and bend your knee slightly. Stay standing in this position while you more your injured leg straight back behind you. During this exercise make sure you keep your thigh muscles tight. Do this first activity 11 more times. Next, turn your body 90 degrees so the leg without tubing is closest to the door. You should not be facing the door at this point. Stay standing straight on both legs and move your injured leg outwards. Do this second activity 11 more times. Lastly, turn another 90 degrees so your back is towards the door. Stay standing straight on both legs and move your injured leg out in front of you. Do this third activity 11 more times. For this exercise you can hold onto a chair if you need help with balance. This exercise is supposed to strengthen and challenge your knee muscle. Do not push yourself too hard, be careful during all exercises and activities.

All information was obtained from Summit Medical Group http://www.summitmedicalgroup.com/library/adult_health/sma_anterior_cruciate_ligament_sprain_exercises/


[edit] Future Directions

[edit] Anatomical Discovery

Jack Satinzinger wrote an article about the discovery of the Anterior Lateral Ligament by two Belgian doctors in November 2013. This could help patients who have ACL reconstruction but still have pivot shift occurring. To learn more about the ALL discovery follow the link below. [3] display text http://www.healthtalk.umn.edu/2013/11/27/new-knee-ligament-opens-the-door-to-improved-treatment-of-acl-injuries/ Understanding that they are 2 ligaments responsible for the correct knee kinematics to prevent pivot shifting is crucial for developing a correct ACL tear repair. This anatomical discovery opens new fields of research for new reconstruction treatments and developing more specific exercise treatments.

[edit] New Approaches to Treatment

Research conducted by Mendis, Lynch Davis et al, showed that patients in post reconstruction had a myostatin hormone that was linked with muscles weakness and muscle atrophy. This is the leading cause of osteoarthirtis. This discovery has lead to research in drug therapies that inhibit myostatin in hopes of reducing muscle weakness and to hopeful have a full recovery after ACL reconstruction. To read the full article use the following link. [ http://journals1.scholarsportal.info.proxy.library.brocku.ca/pdf/03635465/v41i0008/1819_cicbomaclrar.xml] display text http://journals1.scholarsportal.info.proxy.library.brocku.ca/pdf/03635465/v41i0008/1819_cicbomaclrar.xml

Lightspeed therapy is a new treatment in ACL tear injuries. Lightspeed combines physiotherapy exercises with low intensity laser therapy. The laser therapy has been linked to increase circulation, lymphatic drainage and cellular repair. Several clinics are using the new treatment method and are claiming healing times are 4 to 10 times faster. To learn more about Lightspeed treatments check out the following link: [4] display text Faster healing times will reduces muscle atrophy in patients and will help them to maintain muscular strength improving their chances of returning to sport at the same level of competition.

Advancements in stem cell research has led to ACL repairs without surgical intervention. Not all patients are candidates for this procedure, as it is dependent on the severity of the tear. The regenexx is a injection of stem cells and platelets using a needle arthroscopy with fluorescent lighting to target the Anterior Cruciate Ligament. To learn more about the Regenexx treatment use the following link: [5] display text http://www.regenexx.com/regenexx-acl-repair-for-torn-anterior-cruciate-ligament/

  1. REDIRECT [[6]]

[edit] New Focus To Exercise Strength Training

A study conducted by Hsiao,Chou,Hsu and Lue shows clinics and rehabilitation programs for ACL injuries the need to focus on strengthening at specific degrees of knee flexion.

    • 70 degrees
    • 90 degrees

They also recommend focusing on low speeds of isokinetic contraction (Hsiao et al, 2014). This leads to future applications of new rehab programs geared more specific to go through the whole range of motion. This study was inspired by patients who returned to play but still had pain doing everyday tasks such as stairs. [Hsiao,S,Chou, P, Hsu, H, Lue, Y (2014) Changes of Muscle Mechanics Associated With Anterior Cruciate Ligament Deficiency and Reconstruction, Journal of Strength and Conditioning Research 28-2, 390-400.] [Hsiao,S,Chou, P, Hsu, H, Lue, Y (2014) Changes of Muscle Mechanics Associated With Anterior Cruciate Ligament Deficiency and Reconstruction, Journal of Strength and Conditioning Research 28-2, 390-400. Display text]

Jump training is a new approach that coaches and trainers should incorporate into all athletic training. A session of 15 mins just 3 times per week can greatly reduce an athlete's chance of getting an ACL injury according to a Herrington and Comfort's study in 2013. Herrington and Comfort's study outlines a jump program that focuses on correct landing position. [Herrington, L & Comfort, P (2013) Training for Prevention of ACL Injury: Incorporation of Progressive Landing Skill Vhallenges Into a Program, Strength and Conditioning Journal 35-6, 59-65. ] [Herrington, L & Comfort, P (2013) Training for Prevention of ACL Injury: Incorporation of Progressive Landing Skill Vhallenges Into a Program, Strength and Conditioning Journal 35-6, 59-65. Display text]


[edit] External Links

[edit] Notes and References

ACL prevention program. (2014). Ontario Soccer Association. Retrieved March 18, 2014 from http://www.ontariosoccer.net/Programs/HighPerformancePlayer/StrengthAndConditioning/ACLPreventionProgram/tabid/5724/language/en-US/Default.aspx

ACL rehab program. (2014). Westwood Physical Therapy. Retrieved March 21, 2014 from http://www.westwoodpt.com/services/sports-medicine/acl-rehab- program

ACL rehabilitation program. (2014). Emory Healthcare. Retrieved March 18, 2104 from http://emoryhealthcare.org/acl-program/index.html

Clapis, P. & White, T. (2012). Anterior cruciate ligament (ACL) injury exercises. Summit Medical Group. Retrieved March 18, 2014 from http://www.summitmedicalgroup.com/library/adult_health/sma_anterior_cruciate_ligament_sprain_exercises/

Donnelly, C., Elliot B., Ackland, T., Doyle, T., Beiser, C., Finch, J., Cochrane, A., Dempse & Llyod, D. (2012). An anterior cruciate ligament injury prevention framework: Incorporating the recent evidence. Research in Sports Medicine, 20, 239-262.

Herrington, L. (2014). Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: A clinical commentary. Physical Therapy in Sport, 14, (4), 188-198. Retrieved March 18, 2014 from http://www.researchgate.net/publication/256478603_Task_based_rehabilitation_

Herrington, L. & Comfort, P. (2013). Training for prevention of ACL injury: Incorporation of progressive landing skill challenges into a program. Strength and Conditioning Journal, 35, (6), 59-65. Retrieved March 19, 2014 from http://ovidsp.tx.ovid.com.proxy.library.brocku.ca/sp

Hewitt, T.E., Ford, K.R., Hoogenboom, B.J., & Myer G.D. (December, 2010). Understanding and preventing ACL injures: Current biomechical and epidemiological considerations – Update-2010. North American Journal of Sports Physical Therapy, 5, (4), 234-251.

Hsiao, S., Chou, P., Hsu, H., Lue, Y. (2014). Changes of muscle mechanics associated with anterior cruciate ligament deficiency and reconstruction. Journal of Strength and Conditioning Research, 28, (2), 390-400. Retrieved March 19, 2014 from http://ovidsp.tx.ovid.com.proxy.library.brocku.ca/sp

Lubowitz, J., Appleby, D. (2011). Cost-effectiveness analysis of the most common orthopaedic surgery procedures: Knee arthroscopy and knee anterior cruciate ligament reconstruction. The Journal of Arthroscopic and Related Surgery, 27, (10), 1317-1322.

Mendias, C., Lynch, E., Davis, M., Enselman, E., Harning, J., Dewolf, P., Makki, T. & Bedi, A. (2013). Changes in circulating biomarkers of muscle atrophy, inflammation and cartilage turnover in patients undergoing Anterior Cruciate Ligament reconstruction and rehabilitation. The American Journal of Sports Medicine, 41, (8), 1819-1826. Retrieved March 19, 2014 from

Nandra, R., Najran, P., Matharu, G., Porter, K., Ashraf, T. & Greaves, I. (2013). A review of anterior cruciate ligament injuries and reconstructive techniques: Part 1. Basic Science Trauma, 15, (2), 107-115.

Orthopedic care. (2014). Fowler Kennedy Sport Medicine Clinic. Retrieved March 18, 2014 from http://fowlerkennedy.com/patient-care-education/orthopaedic-care/

Physical rehabilitation for ACL injuries. Healthlink BC .Retrieved March 18, 2014 from http://www.healthlinkbc.ca/kb/content/otherdetail/hw28263.html

Physiotherapy for knee injuries & knee pain. (2008). LightSpeed Physiotherapy Inc. Retrieved March 18, 2014 from http://www.lightspeedphysio.com/knee_injury_physiotherapy_mississauga.htm

Regenexx-ACL Right for you? (2013). Regenexx .Retrieved March 18, 2014 from http://www.regenexx.com/2013/10/acl-surgery-alternative/

Satzinger, J. (2013). New Knee Ligament Opens the Door to Improved Treatment of ACL Injuries. Health Talk University of Minnesota's Academic Health Centre. Retrieved March 18, 2014 from http://www.healthtalk.umn.edu/2013/11/27/newknee

Tjong, V., Murnaghan, M., Nyhof-Young, J., & Ogilvie-Harris, D. (2013). A qualitative investigation of the decision to return to sport after anterior cruciate ligament reconstruction to play or not to play. The American Journal of Sports Medicine, 42, (2), 336-342.

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