et al., 2012). A running progression is incorporated into the rehabilitation program when patients are at least 12 weeks out from ACL reconstruction and have met the criterion of 80% quadriceps strength index and have trace or less effusion. Patients are instructed to begin a graded running program that includes jogging and walking intervals for 2 miles (3.2 km) on level surfaces (either a running track or a treadmill). The program is progressed by increasing the jogging-to-walking-time ratio. At the beginning of the program, the ratio of jogging to walking distance is small (1:1). The ratio of jogging to walking distance, as well as the distance and pace, is gradually increased if the patient tolerates the previous stage without muscle soreness, joint pain, or effusion (see Table 4). For patients with an ACL injury who pursue nonoperative treatment, running progression may begin once they meet the criteria of no pain; effusion of less than trace grade; full-knee ROM; 70% quadriceps strength index; and pain-free, unilateral hopping on the injured limb (Fitzgerald, Axe, & Snyder-Mackler, 2000c). Upon successful completion of a running program, patients may progress to agility training. This program is similar to the agility program listed for nonoperative treatment. Agility training should consist of cutting and pivoting exercises of increasing intensity that simulate the demands of the patient’s sport. Agility exercises are incorporated into the ACL reconstruction rehabilitation program to improve the neuromuscular coordination of the lower extremity muscles and to increase patients’ ability to quickly change running directions (Fitzgerald, Axe, & Snyder- Mackler, 2000c). As running and agility programs are progressed toward return-to-sport training, a systematic approach for sport participation is recommended that accounts for pain and apprehension (see Table 5; Adams et al., 2012).
Table 4: Running Progression Stage 1 • Track : Jogs straights and walks curves for more than 2 miles. • Treadmill : Walks 0.1 mile and then jogs 0.1 mile; repeats 10 times. Stage 2 • Track : Jogs straights and then jogs more than 1 curve every other lap for 2 miles. • Treadmill : Alternates between walking 0.1 mile and jogging 0.2 mile for more than 2-mile distance. Stage 3 • Track : Jogs straights and then jogs more than 1 curve every lap for 2 miles. • Treadmill : Alternates between walking 0.1 mile and jogging 0.3 mile for more than 2-mile distance. Stage 4 • Track : Jogs 1.75 laps and then walks more than 1 curve for 2 miles. • Treadmill : Alternates between walking 0.1 mile and jogging 0.4 mile for more than 2-mile distance. Stage 5 • Track or Treadmill : Jogs for full 2 miles. Stage 6 • Track or Treadmill : Increases jogging to 2.5 miles. Stage 7 • Track or Treadmill : Increases jogging to 3 miles. Stage 8 • Track : Begins running straights and jogging curves. • Treadmill : Alternates between running and jogging every 0.25 mile. Note . Reprinted with permission. © 2013, Zakariya Nawasreh.
Table 5: Progression to Sport-Specific Activities Activity
Criteria for Progression
Action for Failing the Criteria Continue practicing agility training.
Stage 1
Agility training
Patients tolerate maximum effort of agility training with no pain or apprehension. Patients tolerate unopposed sport-specific activity with no pain or apprehension. Patients tolerate one-to-one opposed sport-specific activity with no pain or apprehension. Patients are advanced to full opponent activity practice with team.
Stage 2
Unopposed sport activity
Continue unopposed sport-specific activity. Continue one-to-one opposed sport- specific activity.
Stage 3
One-to-one opposed sport activity Full opponent activity with team
Stage 4
Note . Reprinted with permission. © 2013, Zakariya Nawasreh.
RETURN-TO-SPORT CRITERIA
Patients with an ACL injury are frequently counseled to undergo ACL reconstruction with the expectation of restored mechanical knee stability and normal knee function that facilitates return to their previous levels of sport activities (Marx et al., 2003; Myklebust & Bahr, 2005). However, reconstruction surgery does not ensure returning to previous levels of activity and incurring a second ACL injury is common after surgery (Ardern, Taylor, Feller, & Webster, 2014; Gobbi & Francisco, 2006; Paterno, Rauh, Schmitt, Ford, & Hewett, 2014; Webster & Feller, 2016; Wiggins et al., 2016). After ACL injury and reconstruction surgery, many patients continue to exhibit impaired knee function characterized by dynamic knee instability, anterior knee pain, joint effusion, reduced ROM, quadriceps strength deficits, reduced functional performance, neuromuscular dysfunction, and biomechanical maladaptations that may account for inferior patient outcomes and risk for second injury (Daniel et al., 1994; de Jong et al., 2007; Hartigan et al., 2010; Paterno et al., 2010; von Porat et al., 2004).
In patients who are managed operatively, the first several months following surgery are considered the time of greatest vulnerability for those attempting to return to their previous level of activity. Not only are functional performance deficits (Ardern et al., 2011b; Hartigan et al., 2010) and movement asymmetries commonplace (Hartigan et al., 2009; Paterno et al., 2010; Roewer et al., 2011), but reinjury risk is also highest during the first 12 months after ACL reconstruction (Laboute et al., 2010; Paterno et al., 2012; Webster & Feller, 2016; (Grindem et al., 2016). A study by F.W. Smith and colleagues (2004) reported that a group of patients who returned to their level of activity at 1 year after surgery experienced major knee problems in the reconstructed limb. Paterno and colleagues (2014) found that 50% of the second ACL injuries occurred during the first 72 athletic exposures (one athlete participating in one practice or game where the athlete is exposed to the possibility of athletic injury) that included participation in games or practice sessions in a pivoting or cutting sports. This issue might have resulted
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