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From PEKN 1P93 Winter 2014: Group 25: Treatment Rehab

[edit] Treatment and Rehabilitation of the ACL Background

The anterior cruciate ligament (ACL) is the ligament that holds the femur and tibia together. ACL injuries are most commonly seen in athletes of low-impact, noncontact sports. The importance of the ACL has been emphasized in athletes who require stability in running, cutting, and kicking^[1]. A greater prevalence for ACL injury is found in females compared with males, some have implicated that female hormones have a negative impact on ligament strength, as well as the width of a woman’s pelvis increasing stress on ACL ^[2]. ACL tears can also happen through slips and falls in older individuals, and are seen mostly in people over 40 due to wear and tear of the ligaments.

Like any ligament injury, the ACL may be partially (Grade I), significantly (Grade II), or completely (Grade III) torn. In acute ACL injuries, the lateral meniscus is more commonly torn, and in chronic ACL tears, the medial meniscus is usually torn^[3]. An ACL tear can be determined by a popping noise heard after impact, weakness in the knee, swelling, and severe pain.

An ACL injury may develop into long-lasting and recurrent problem that leads to an unstable knee. This can occur if an ACL injury was present in the past, if it has not been treated, or if it has been treated unsuccessfully. ACL deficiency can cause damage to the joint, including osteoarthritis.

Treatment options must be tailored to a patient's preoperative level of activity. People with acute ACL injuries usually begin treatment with a physical rehab program. Rehab exercises build strength and flexibility in the muscles on the front of the quadriceps and strengthen and tighten the muscles in the hamstrings. Most people return to their normal activities after a few weeks of rehab^[4]. More severe ACL injuries may need several months of rehab or surgery followed by several months of rehab to regain your knee strength, and stability. Approximately 60,000-75,000 ACL reconstructions are performed annually in the United States, with a success rate of 75-95%.

[edit] History of The ACL

Dr. William Clancy 1974^[11]

The Difference in Bone Structure Between Men and Women^[15]

[edit] Men Vs. Women

Even though ACL injuries are common in men, women are three times more likely to have an ACL injury than the average man. Women differ from men in many ways but one of the main differences is the bone structure. A woman's ACL is smaller than a man's and thus is more prone to injury. A smaller ligament has less available surface area to be able to connect to the bone and ultimately will not perform well or be as strong.^[16] Women have a wider set of hips and this creates a larger Q angle, which is the angle from your kneecap to the prominent bone at the front of your hips. ^[17] The greater the angle, the more stress that will be placed o the medial portion of your knees. If girls present a "knock-kneed" appearance, this could be considered an early warning sign for potential problems down the road.^[18] Women's connective tissues are also more lax, leading to less overall joint stability and with escalating estrogen levels the situation only becomes worse.^[19] Women also tend to be less neuromuscular than males, so landing jumps for example may lead to poor landing mechanics and bad positioning. This is a main reason why athletic trainers and team physicians advise female athletes to adapt an ACL conditioning program.

History has proven that earlier treatment for an ACL injury has had a major career changing outcome. However, now with the reconstruction of the ACL using Clancy's Procedure, athletes have a much higher success rate for being able to play and participate in sports again. Learning from pervious mistakes is extremely important. If it wasn't for learning that by casting an ACL injury after surgery that a patient would need to rebuild all leg muscle, continuing to be an athlete would be extremely difficult. Therefore even though rigorous dynamic movement, such as jumping or quick changes in directions are the number one cause in ACL injuries, physical activity and strengthening exercises have been found to be the number one treatment and a successful rehabilitation method used to regain power again.

[edit] Target Audience

Due to the fact that most ACL injuries can occur in a non-contact situation (meaning that it can occur just from a swift change in direction and not from coming into contact with another person), the target audience can generally be any male/female athlete typically between the ages of 17-30.^[20] Now this injury is not specifically limited to this age group, it can also occur to older men and women because as the body ages, its structural stability and strength decreases and is more vulnerable to injury. A simple fall could possibly result in an ACL injury depending on the characteristics of the fall. It has been stated that women have a 4-10 times higher chance of suffering an ACL injury than men.^[21] Although a clear reason why this is true has not been discovered, it has been speculated that it stems from differences in anatomy, alignment of the knee, how taut the ligaments are or muscle strength. Some examples of sports that ACL injuries occur most often are basketball, soccer, football, tennis and rugby.^[22]

[edit] Research

Current research has shown that there is a minimum amount of proven programs for ACL prevention. There is more research being done on how to treat an ACL tear or injury than preventing the incident from occurring in the first place.

Article 1 on Prevention of ACL Injury, Part I: Injury Characteristics, Risk Factors and Loading Mechanism suggests that there are proposed internal and external risk factors. The proposed external risk factors include: the type of competition; shoe/ surface interface; knee bracing; and weather. The proposed internal risk factors include: lower extremity alignment; femoral intercondylar notch size; posterior tibial plateau slope; intrinsic ACL material properties; patella tendon-tibia shaft angle; ACL elevation angle; hormonal variation; and neuromuscular control related biomechanical related factors. Of the internal risk factors, the neuromuscular control related biomechanics can be modified for prevention of primary as well as secondary injuries. The studies done on biomechanics show that women tend to perform high risk athletic tasks such as landing, cutting or deceleration with significantly different movement patterns in all three planes of movement than men. Females also tend to experience greater forces and torques at the knee. Overall, even with internal and external risk factors, females have a tendency to restrict sagittal plane motion and increase motion in the frontal and coronal planes resulting in increased loading on the knee and the ACL.^[23]

Article 2 on The Effectiveness of Injury-Prevention Programs in Reducing the Incidence of Anterior Cruciate Ligament Sprains in Adolescent Athletes’ main focus is to observe if lower extremity injury prevention programs can prevent the rate of ACL injuries in adolescent athletes. The injury prevention programs incorporating a warm-up, balance exercises, plyometric exercises, strength and power exercises, and emphasis on technique showed a significant reduction in ACL injuries.^[24]

Article 3 on Evaluation of the effectiveness of Neuromuscular Training to Reduce Anterior Cruciate Ligament Injury in Female Athletes: a Critical Review of Relative Risk Reduction and Numbers-Needed- to-Treat-Analyses was a study that reviewed twelve neuromuscular training studies that were meant to decrease ACL injuries in female athletes. Studies were done on high school female athletes, mainly soccer players, using various exercise programs in between 2-4 times a week which consisted of 15-20 minute sessions. Structured programs consisting of plyometrics, basic warm-up, stretching, strengthening for trunk and lower extremities and education of technique and skills were implemented during sessions. Neuromuscular training could reduce ACL injury by approximately 43.8% in female athletes. This study concluded that neuromuscular training may reduce non-contact ACL injury risks and overall ACL injury risks.^[25]

Article 4 on Prevention of ACL Injury Part II: Effects of ACL Injury Prevention Programs on Neuromuscular Risk Factors and Injury Rate shows the effects of various injury prevention programs on neuromuscular risk factors such as: injury education; feedback training; strength training; plyometric training; multicomponent training; and balance and propioception training. During the injury education technique, a total of 133 female high school basketball players and 12 coaches were taught the anatomy and function of the knee, possible risk factors for ACL injury, appropriate landing techniques and prevention strategies. The players and coaches knowledge of ACL injury increased and the percentage of good landings significantly increased. The feedback training technique had conducted studies within itself with one group of subjects receiving instructions regarding their landing technique and the second group relying only on their own feeling to land softly in a drop landing task. The feedback group decreased their sound reaction force after training while the second group showed no change. Another feedback study showed subjects how to appropriately position the support foot and position in cutting tasks. Subjects significantly reduced peak valgus moment during the landing phase. In the strength training study, subjects used a 9-week training program to increase thigh and hip muscle strength in female athletes. Results showed an increase in hip abduction angle and a decrease in peak knee anterior shear force. Plyometric training was found to be more effective in being able to produce positive alterations in neuromuscular characteristics associated with ACL injury. Therefore, plyometric training is considered a key component for ACL injury prevention programs.^[26]

Article 5 on Neuromuscular Changes following an Injury Prevention Program for ACL Injuries conducted a 10 week program that was given to 10 healthy female soccer players ages 19-20, designed to analyze lower extremity kinetics and kinematics. Prior to training, participants completed five running stop-jump trials. That same test was conducted at the end of the 10 week training program to compare results. Results showed a decrease in knee abduction angle for 80% of the participants. If reduction of knee abduction is possible through strength training, a reduction in ACL injuries could result.^[27][28]

[edit] Existing Physical Activity Programs

According to Ericsson, after an ACL injury, the majority of active adults regain physical performance and muscle strength after a structured exercise program, however poor physical performance at the end of a rehabilitation predicted worse patient-reported outcomes regardless of the treatment they received. ^[29] Some physical activity programs that address ACL and knee injuries;

1. Massachusetts General Hospital Sports Medicine - Mass General Hospital has a mission of following the needs of the patients and their families to deliver the very best and safe health care in a compassionate environment. ^[30] They believe that educating the individual about injuries is very important in order to reduce the rates of the injury happening again, and therefore education is very important to this institution. Their exercise program is designed as a physical therapy treatment for someone who has torn their ACL. This program outlines the different stages of treatment and levels of strengthening exercises. There are step by step physical activities that can be accomplished from the first six weeks after surgery, and then onwards to keep the muscles around the knee strengthened to prevent re-injury. This program places great emphasis on strengthening the muscles around the knee, and keeping the individual physically active while recovering. ^[31] http://www.massgeneral.org/ortho/services/sports/rehab/Acute%20ACL%20injury%20rehab.pdf
2. Action For Healthy Kids - This is a program designed to help children in participating and staying healthy at a young age. In order to prevent ACL injuries, learning about how to prevent them are extremely important. Action for Healthy Kids educate school leaders, public health officials, parents and student to increase their knowledge of nutrition and physical activity best practices for schools. They also make programs and incorporate them within school boards in order to keep students active. This program is a great program to keep children healthy and fit, and hopefully they are able to recognize the importance of a healthy lifestyle in order to prevent ACL injuries. Especially in girls. By implementing these programs, children's strength in their legs and their overall health is increased and therefore this program is a great form of ACL tear prevention. http://www.actionforhealthykids.org/what-we-do
3. Seniors in Motion - Those over 65 with poor mobility should perform physical activities to enhance balance, increase muscular strength, and prevent falls. Activities that offer a variety of endurance, strength-building and flexibility benefits are ideal. Endurance activities including walking, hiking, swimming, and cycling benefit the heart, lungs and circulatory system greatly. Flexibility activities such as stretching, yoga, and even yard work keep joints agile. Increased flexibility allows for senior independence. Strength activities include lifting weights or soup cans, using the stairs, or sitting down and standing up repeatedly. These will strengthen muscles and improve balance, which will help to prevent falls, the leading cause of death from injury in people over 65. Studies have found that weight training can reverse muscle weakness even among people in their 90s ^[32]. http://www.csep.ca/CMFiles/Guidelines/CSEP-InfoSheets-older%20adults-ENG.pdf
4. Chester Knee Clinic & Cartilage Repair Centre - The Chester Knee Clinic and Cartilage Repair Centre's philosophy on ACL rehabilitation following surgery has continuously evolved following previous patients and documented results.^[33] The continue to modify and alter their protocol to improve the outcome of the final reconstruction surgery.^[34] Their ultimate goal is for someone who undergoes re-constructive ACL surgery to be able to achieve full range of motion of the knee, excellent stability, overall strength and just to regain the general function of the knee.^[35] This program involves two main phases: Phase 1 is the "Preoperative" phase and Phase 2 is the "Postoperative" phase.^[36] Both phases incorporate the concepts of regaining full range or motion and strength of the knee joint so that the patient will eventually be able to resume everyday tasks.^[37] http://www.kneeclinic.info/rehab_markdecarlo.php
5. St. John's Musculoskeletal Rehabilitation - This program offers interdisciplinary care to a wide range of the population. These patients are more commonly recovering from elective surgeries or other complex orthopaedic conditions.^[38] This program provides extensive rehabilitation, as well as education and treatment for underlying problems. ^[39] Patients may have undergone knee replacements, or have suffered from an ACL injury however there is individual or group therapy provided that focuses on improving function and mobility to easily reintegrate the individual into the community. ^[40] Experts in the medical and rehabilitation fields individually customize rehabilitation programs that meet the needs of the patient. With functional goals, care plans and discharge timelines in place, this is a great rehabilitation program that exists in the Greater Toronto Area.^[41] http://sunnybrook.ca/content/?page=sjr-patvis-prog-msk

[edit] Best Practice Activity Suggestions

In order to fully rehabilitate an ACL injury, strengthening the muscles around the knee are extremely important. In order to strengthen these muscles one must participate in physical activity to achieve their full physical potential. Individuals heal at different rates and therefore some exercises to rehabilitate an ACL injury may take longer for some people compared to others. However, there are many effective ways to include physical activity to address ACL injuries here as some of the most common methods used with evidence that they work in no particular order.

1. Swimming - Swimming is a stress free environment when it comes to the rehabilitation of an ACL injury. By participating in light kicks within the pool and practicing flexion and extension of the knee, the individual will be able to gain strength back. ^[42] Swimming has many benefits, especially in regard to rehabilitation. Swimming creates buoyancy, resistance and cooling effects while in the water. While participating in water therapy an individual can improve their flexibility and strength, increase their muscular balance, their heart muscles become stronger, increases circulation and most importantly swimming is a great way to rehabilitate muscles and ligaments. ^[43]
   

   

   Rehabilitation Swimming for an injured ACL. Photo taken by author
2. Strengthening Exercises - Strengthening muscles around your knee are extremely important in order to prevent re-injury and to gain maximum potential. Some exercises that are highly recommended to strengthen the ACL include, quadriceps setting, which maintains muscle tone in the thigh and straighten the knee. Heel slides which are used to regain flexion of the knee. Hip abductions, chair squats and step-ups. ^[44] Therefore, physical activity is being utilized while performing this strengthening exercises to keep the individual healthy and fit during rehabilitation of the ACL.
3. Stationary Bicycle - by utilizing a stationary bicycle it allows for the knee joint to move and increases knee flexion. This is very important for the rehabilitation of the ACL. An individual is more likely to perform a full cycle backwards before they can complete a full cycle forward. ^[45] While using the bicycle the individual can proceed at any speed and to their own comfort. The stationary bicycle also allows for your heart rate to be increased and therefore participate in physical activity while rehabilitating the knee.
4. Surgery - Although there is great debate on whether rehabilitation of the ACL is more convenient and effective than having the ACL reconstruction surgery, many athletes decide to go ahead with the surgery to increase their likelihood of returning to sports.^[46] When considering rehabilitation versus surgery, rehabilitation costs are much more expensive than the surgery itself, especially if the individual is not covered for physical therapy through their career.^[47] When having the reconstruction surgery the odds of continuing an athletic career or just for leisure are highly increased, compared to the odds of rehabilitation because the ACL cannot reconstruct itself. Therefore, by having surgery physical activity can be maintained.
5. Yoga - Yoga, with some modifications can be quite healing for a variety of reasons. ACL injuries are most often associated with soft-tissue injuries and therefore by increasing irrigation of the circulatory system to the synovial fluid will provide better nutrition to the soft tissue.^[48] There is no sudden movements in Yoga and everything is held particularly still. Yoga is particularly helpful for strengthening the supportive tissues of the knee, it is also relaxing and is a great way to stay healthy after an ACL injury. Therefore by participating in Yoga, the individual is able to modify the poses in order to keep from doing deep squats and pivoting and therefore can still have an effective way of physical activity.^[49]

[edit] Future Directions

Currently in ACL reconstructive surgery, a graft is used to replace the torn ligament. The most common grafts are auto-grafts, which uses a part of your own body ^[50]. Common tendons used are the patellar tendon (found in the kneecap), but recently there has been a slow shift in graft choice, as hamstring tendons are being used as well ^[51]. Orthopedic surgeons are suggesting that using the hamstring as a graft is less stressful on the patient, and showed improved fixation techniques ^[52]. Many patients experience impaired function morbidity at the donor site including secondary knee pain and patellar tendonitis ^[53]. This has become a major problem autograft reconstruction and has lead to the investigation of allograft reconstruction. Allograft reconstruction is when a graft is taken from a deceased donor. Allograft reconstruction eliminates any donor site shortcomings, yet is not considered advantageous because there is a limited supply of donor tissue. The risk of disease transmission, as well as tissue rejection is also an issue. In an attempt to overcome these concerns, the use synthetic prosthetic ligaments research began over 30 years ago and continues today in hopes of eliminating donor site morbidity and reducing the risk of disease transmission and supply shortages ^[54].

The Ligament Advanced Reinforcement System (LARS) artificial ligament consists of fibers made of polyethylene terephthalate (PET). This artificial ligament has the ability to mimic the natural ligamentous structure and reduce shearing forces in the knee. They are also designed to encourage tissue ingrowth ^[55]. Although investigations into the use of the LARS artificial ligament have been encouraging, concerns regarding the risk of rupture remain and long-term follow-up studies must be conducted in the future. Advances in tissue engineering combined with developments in molecular biology and gene therapy may provide improved options for the ACL injured patients, leading to a greater potential to restore its pre-injury state ^[56].

[edit] External Links

Rehabilitation After ACL Surgery http://orthopedics.about.com/od/aclinjury/p/rehab.htm

Prevention of ACL Injuries in Adolescent Female Athletes http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/prevention-acl-injuries-adolescent-female-athletes

ACL Rehab Exercises http://sportsmedicine.about.com/cs/knee_injuries/a/aa082603a.htm

Anterior Cruciate Ligament Injury (ACL) http://orthosurg.ucsf.edu/patient-care/divisions/sports-medicine/conditions/knee/anterior-cruciate-ligament-injury-acl/

ACL Injury Prevention http://www.goodhealthus.com/articles/ghme-aclinjuryprevention.htm

[edit] Notes and References

1. ↑ Anterior Cruciate Ligament Tear. (n.d.). Washington Orthopaedics & Sports Medicine. Retrieved March 20, 2014, from http://www.wosm.com/index.php/health-library/orthopaedic-conditions-and-treatments/127-anterior-cruciate-ligament-tear
2. ↑ McAlindon, R. (n.d.). ACL Injuries in Women. Hughston. Retrieved March 21, 2014, from http://www.hughston.com/hha/a_11_3_2.htm
3. ↑ Anterior Cruciate Ligament Tear. (n.d.). Washington Orthopaedics & Sports Medicine. Retrieved March 20, 2014, from http://www.wosm.com/index.php/health-library/orthopaedic-conditions-and-treatments/127-anterior-cruciate-ligament-tear
4. ↑ "Anterior Cruciate Ligament (ACL) Injuries-OrthoInfo - AAOS." OrthoInfo. N.p., n.d. Web. 20 Mar. 2014. <http://orthoinfo.aaos.org/topic.cfm?topic=a00549>
5. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
6. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
7. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
8. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
9. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
10. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
11. ↑ Conferencistas Plenario, 2013 Retrieved from http://www.congresoaaot.org.ar/conferencistas.php
12. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
13. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
14. ↑ Gabler, N. (2013, December 10). The nastiest injury in sports. Grantland. Retrieved from http://grantland.com
15. ↑ Mejia, M. (2012). A pound of prevention: Minimizing your risk for ACL injuries. IL Women. Retrieved from http://women.insidelacrosse.com
16. ↑ Mejia, M. (2012). A pound of prevention: Minimizing your risk for ACL injuries. IL Women. Retrieved from http://women.insidelacrosse.com
17. ↑ Mejia, M. (2012). A pound of prevention: Minimizing your risk for ACL injuries. IL Women. Retrieved from http://women.insidelacrosse.com
18. ↑ Mejia, M. (2012). A pound of prevention: Minimizing your risk for ACL injuries. IL Women. Retrieved from http://women.insidelacrosse.com
19. ↑ Mejia, M. (2012). A pound of prevention: Minimizing your risk for ACL injuries. IL Women. Retrieved from http://women.insidelacrosse.com
20. ↑ Werdo, B. Anterior Cruciate Ligament Tear (ACL). Retrieved March 23, 2014 from http://www.medicinenet.com/torn_acl/article.htm
21. ↑ McAlindon, R. ACL Injuries in Women. Retrieved March 23, 2014 from http://www.hughston.com/hha/a_11_3_2.htm
22. ↑ McAlindon, R. ACL Injuries in Women. Retrieved March 23, 2014 from http://www.hughston.com/hha/a_11_3_2.htm
23. ↑ Dai, B., Herman, D., Liu, H., Garrett, W. E., & Yu, B. (2012). Prevention of ACL Injury, Part I: Injury Characteristics, Risk Factors, and Loading Mechanism. Research In Sports Medicine,20(3/4), 180-197. doi:10.1080/15438627.2012.680990
24. ↑ Paszkewics, J., Webb, T., Waters, B., McCarty, C., & Van Lunen, B. (2012). The Effectiveness of Injury- Prevention Programs in Reducing the Incidence of Anterior Cruciate Ligament Sprains in Adolescent Athletes. Journal of Sport Rehabilitation,21(4), 371-377.
25. ↑ Sugimoto, D., Mver, G. D., McKeon, J. M., & Hewett, T. E. (2012). Evaluation of the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a critical review of relative risk reduction and numbers-needed-to-treat analyses. British Journal Of Sports Medicine,46(14), 979-988. doi:10.1136/bjsports-2011-090895
26. ↑ Dai, B., Herman, D., Lui, H., Garrett, W. E., & Yu, B. (2012). Prevention of ACL Injury Part II: Effects of ACL Injury Prevention Programs on Neuromuscular Risk Factors and Injury Rate. Research in Sports Medicine,20(3/4), 198-222. doi:10.1080/15438627.2012.680987
27. ↑ McCann, R., Cortes, N., VanLunen, B., Greska, E., Ringleb, S., & Onate, J. (2011). Neuromuscular Changes following an Injury Prevention Program for ACL Injuries. International Journal Of Athletic Therapy & Training, 16(4)16-20
28. ↑ Eldar, E., & Ayvazo, S. (2009). Educating through the physical - Rationale. Education & Treatment of Children, 32, 471-486. Available online: [1]
29. ↑ Ericsson, Y. B., Roos, E. M., & Frobell, R. B. (2013). Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of reconstruction and predictive value at 2 and 5 years. British journal of sports medicine, 47(15), 980-985.
30. ↑ Sports Medicine. (2014). Exercises after injury to the ACL of the knee. Massachusetts General Hospital. Retrieved from http://www.massgeneral.org
31. ↑ Sports Medicine. (2014). Exercises after injury to the ACL of the knee. Massachusetts General Hospital. Retrieved from http://www.massgeneral.org
32. ↑ Healthy living - Physical activity needs of seniors-Heart and Stroke Foundation of Canada. (n.d.). heartandstroke.ca. Retrieved March 23, 2014, from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484257/k.EB1C/Healthy_living__Physical_activity_needs_of_seniors.htm
33. ↑ De Carlo, M. Accelerated ACL Reconstruction Rehabilitation Program. Chester Knee Clinic. Retrieved March 23, 2014 from http://www.kneeclinic.info/rehab_markdecarlo.php
34. ↑ De Carlo, M. Accelerated ACL Reconstruction Rehabilitation Program. Chester Knee Clinic. Retrieved March 23, 2014 from http://www.kneeclinic.info/rehab_markdecarlo.php
35. ↑ De Carlo, M. Accelerated ACL Reconstruction Rehabilitation Program. Chester Knee Clinic. Retrieved March 23, 2014 from http://www.kneeclinic.info/rehab_markdecarlo.php
36. ↑ De Carlo, M. Accelerated ACL Reconstruction Rehabilitation Program. Chester Knee Clinic. Retrieved March 23, 2014 from http://www.kneeclinic.info/rehab_markdecarlo.php
37. ↑ De Carlo, M. Accelerated ACL Reconstruction Rehabilitation Program. Chester Knee Clinic. Retrieved March 23, 2014 from http://www.kneeclinic.info/rehab_markdecarlo.php
38. ↑ Sunnybrook Health Sciences Centre. (2014). Musculoskeletal Rehabilitation. University of Toronto. Retrieved from http://sunnybrook.ca
39. ↑ Sunnybrook Health Sciences Centre. (2014). Musculoskeletal Rehabilitation. University of Toronto. Retrieved from http://sunnybrook.ca
40. ↑ Sunnybrook Health Sciences Centre. (2014). Musculoskeletal Rehabilitation. University of Toronto. Retrieved from http://sunnybrook.ca
41. ↑ Sunnybrook Health Sciences Centre. (2014). Musculoskeletal Rehabilitation. University of Toronto. Retrieved from http://sunnybrook.ca
42. ↑ Friedberg, P, R. (2013). Patient information: Anterior cruciate ligament injury (beyond the basics). Wolters Kluwer Health. Retrieved from http://www.uptodate.com
43. ↑ Bucknell, University. (2014). Swimming Information. Bucknell University. Retrieved from https://www.bucknell.edu
44. ↑ Sports Medicine. (2014). Exercises after injury to the ACL of the knee. Massachusetts General Hospital. Retrieved from http://www.massgeneral.org
45. ↑ Sports Medicine. (2014). Exercises after injury to the ACL of the knee. Massachusetts General Hospital. Retrieved from http://www.massgeneral.org
46. ↑ KidsMD Health Topics. (2014). Anterior cruciate ligament (ACL) injury. Boston Children’s Hospital. Retrieved from http://www.childrenshospital.org
47. ↑ KidsMD Health Topics. (2014). Anterior cruciate ligament (ACL) injury. Boston Children’s Hospital. Retrieved from http://www.childrenshospital.org
48. ↑ Noa, B. (2012). Bikram questions: ACL and MCL tears. Bikram Yoga Vancouver. Retrieved from http://www.bikramyogavancouver.com
49. ↑ Noa, B. (2012). Bikram questions: ACL and MCL tears. Bikram Yoga Vancouver. Retrieved from http://www.bikramyogavancouver.com
50. ↑ Blahd, W. (2012, April 5). Anterior Cruciate Ligament (ACL) Surgery. WebMD. Retrieved March 22, 2014, from http://www.webmd.com/a-to-z-guides/anterior-cruciate-ligament-acl-surgery
51. ↑ Renström, P. (n.d.). New trends in ACL reconstruction. Healio Orthepedics Today. Retrieved March 23, 2014, from http://www.healio.com/orthopedics/knee/news/print/orthopaedics-today-europe/%7Bdac36617-7f02-4c45-ad38-455785e7f82f%7D/new-trends-in-acl-reconstruction
52. ↑ Renström, P. (n.d.). New trends in ACL reconstruction. Healio Orthepedics Today. Retrieved March 23, 2014, from http://www.healio.com/orthopedics/knee/news/print/orthopaedics-today-europe/%7Bdac36617-7f02-4c45-ad38-455785e7f82f%7D/new-trends-in-acl-reconstruction
53. ↑ Mascarenhas, R., & MacDonald, P. (2008, June 5). Anterior cruciate ligament reconstruction: a look at prosthetics - past, present and possible future. National Center for Biotechnology Information. Retrieved March 23, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2322926/
54. ↑ Mascarenhas, R., & MacDonald, P. (2008, June 5). Anterior cruciate ligament reconstruction: a look at prosthetics - past, present and possible future. National Center for Biotechnology Information. Retrieved March 23, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2322926/
55. ↑ Mascarenhas, R., & MacDonald, P. (2008, June 5). Anterior cruciate ligament reconstruction: a look at prosthetics - past, present and possible future. National Center for Biotechnology Information. Retrieved March 23, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2322926/
56. ↑ Mascarenhas, R., & MacDonald, P. (2008, June 5). Anterior cruciate ligament reconstruction: a look at prosthetics - past, present and possible future. National Center for Biotechnology Information. Retrieved March 23, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2322926/

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