Physical Therapy in Sport 5 (2004) 125–145

www.elsevier.com/locate/yptsp

Literature review

A systematic review of evidence for anterior cruciate ligament

rehabilitation: how much and what type?
May Arna Risberga,*, Michael Lewekb,c, Lynn Snyder-Macklerd
a
Orthopedic Center, Norwegian Research Center for Active Rehabilitation, Ullevaal University Hospital, Kirkeveien 166, 0407 Oslo, Norway
b
Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
c
Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, IL, USA
d
Department of Physical Therapy, University of Delaware, Newark, DE, USA
Received 11 February 2004; revised 24 February 2004; accepted 26 February 2004

Abstract
This paper provides an evidence-based review of the effectiveness of various rehabilitation programs that have been used for
surgically or non-surgically treated anterior cruciate ligament (ACL) injuries in adult patients. The methodological quality of the studies
was assessed using specific criteria. The databases disclosed 33 randomized clinical trials (RCTs). Several of the RCTs in this systematic
review have significant flaws, and limited evidence could be derived from them. The review of the literature revealed the following
evidence for ACL rehabilitation: Immediate weight-bearing after ACL reconstruction is useful, rehabilitation programs must be
monitored by a physical therapist, but continuously monitoring may not be necessary. The literature supports the use of closed kinetic
chain exercises at knee joint motions of less than 608 and open kinetic chain exercises with knee flexion angles greater than 408 for
quadriceps muscle strength training without increasing the strain on the ACL, and without increased stresses on the patellofemoral joint.
There is evidence that high intensity neuromuscular electrical stimulation in addition to volitional exercises significantly improves
isometric quadriceps muscle strength compared to volitional exercises alone. There is some evidence for neuromuscular training. Future
studies should focus on high quality RCTs, reporting randomization procedures, power calculations, compliance to intervention
programs, and long term follow-up results.
q 2004 Elsevier Ltd. All rights reserved.
Keywords: Rehabilitation; Anterior cruciate ligament; Review

1. Introduction activity levels. These objectives are based on the current

Appropriate treatment of injury to the anterior cruciate
ligament (ACL) remains controversial despite years of
intensive basic and clinical research. Surgical reconstruc-
tion of a ruptured ACL is common, and effective
rehabilitation programs are necessary for people with
ACL deficiency as well as for those following ACL
reconstruction. Currently, there is little consensus regarding
the optimal rehabilitation program following either ACL
injury or reconstruction.
Rehabilitation programs are designed to rebuild muscle
strength, reestablish joint mobility and neuromuscular
control, and to enable patients to return to pre-injury
* Corresponding author. Tel.: þ 47-4131-2776; fax: þ 47-2326-5667.
E-mail address: mayarnarisberg@hotmail.com (M. Arna Risberg).
1466-853X/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2004.02.003
knowledge of lower limb functional disabilities in indivi-
duals with ACL deficiency (Rudolph, Eastlack, Axe,
& Snyder-Mackler, 1998; Snyder-Mackler, Delitto, Bailey,
& Stralka, 1995) and patients undergoing ACL reconstruc-
tion (Barrett, 1991; DeVita, Hortobagyi, & Barrier, 1998;
Holm, Risberg, Aune, Tjomsland, & Steen, 2000; Risberg,
Holm, Tjomsland, Ljunggren, & Ekeland, 1999; Wojtys &
Huston, 2000). Physical therapy practice, once largely based
on clinical experience and theory, has changed considerably
over the last 10 –15 years to be increasingly based on higher
quality clinical research. The best or least biased evidence
of physical therapy effectiveness comes from randomized
clinical trials (RCTs) and systematic reviews, which have
increased dramatically over the past years.
The objective of this paper is to provide an evidence-
based review of the effectiveness of various rehabilitation
126 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
programs, including some specific exercise components,
that have been used for surgically or non-surgically treated
ACL injuries in adult patients.
2. Methods
2.1. Selection criteria for studies
RCTs were included for assessment if they evaluated the
effect of a particular rehabilitation program or the specific
exercises used within a rehabilitation program following
ACL injury or reconstruction. Studies were excluded if they
examined passive modalities, such as cryotherapy, continu-
ous passive motion, braces, or electrophysical agents (with
the exception of neuromuscular electrical stimulation for the
purpose of improving muscle strength). Cardiorespiratory or
general fitness responses to rehabilitation programs were
also excluded because the primary goal following ACL
rehabilitation is often the elimination of lower extremity
functional deficits.
The methodological quality of the studies was assessed
based on the method of randomization, power analysis,
assessor and participant blinding, the presence of baseline
data and the number of subjects lost to follow-up, a
thorough description of the interventions and recorded
compliance, the clinical relevance of the outcome
measurements included, and the presence of a sufficient
follow-up time. Some studies may fail to demonstrate an
effect because the exercises are ineffective, the time,
duration, or intensity of the exercises/program is not
adequate to provoke a response, or the subjects were not
compliant with the exercise protocol. In addition, the
long-term outcome after ACL injury is crucial based on
the reported 10-fold risk of developing osteoarthritis
compared to the normal population (Gillquist & Messner,
1999).
2.2. Databases and search strategy
Papers were identified from the following sources:
PubMed, Pedro, SPORTDiscus, and the Cochrane Library.
PubMed, The National Library of Medicine, includes over
14 million citations from biomedical articles dating back to
the 1950s. PEDro is the Physiotherapy Evidence Database
and an initiative of the Centre for Evidence-Based
Physiotherapy. It contains abstracts of randomized con-
trolled trials, systematic reviews, and clinical practice
guidelines in physical therapy. SPORTDiscus, provided by
the Sport Information Resource Centre, is a database
covering sport, fitness, and related disciplines. The
Cochrane Library includes the Cochrane Database of
Systematic Reviews, which is the main product from The
Cochrane Collaboration dedicated to providing accurate up-
to-date information on the effects of healthcare readily
available worldwide.
A PubMed search for ‘anterior cruciate ligament’ from
1966 to 2003 revealed 5562 publications. Search terms
included ‘exercise therapy’, ‘activities of daily living’,
‘rehabilitation’, and ‘anterior cruciate ligament’, and
narrowed the search to 993 papers. The search was then
limited to ‘randomized clinical trials’, revealing 98 papers.
Of these 98 RCTs, 65 were excluded because they failed to
meet the inclusion criteria for assessment. This left 32
papers to be included from PubMed in this systematic
review.
The search in SPORTDiscus identified seven RCTs, all
of which had been identified on the PubMed database. The
PEDro database identified 18 RCTs and one systematic
review using ‘anterior cruciate ligament’. Of the 18 clinical
trials, five failed to meet the inclusion criteria and were
excluded. The remaining 13 trials had also been identified
by the PubMed database. The systematic review identified
by the PEDro database was from 2002 and was also
identified by the Cochrane Library database (Thomson,
Handoll, Cunningham, & Shaw, 2002). This systematic
review included one study not identified by the PubMed
database (Ekstrand, 1990), therefore resulting in 33 papers
to be included in the current systematic review (see Table 1).
Furthermore, studies identified in the Cochrane database as
abstracts only were excluded. One RCT was excluded
because no details were given for criteria of referral to or for
a description of the physiotherapy program (Pickard,
Venner, Ford, & Todd, 1990).
Of the 33 RCTs included in this review, 28 examined
rehabilitation protocols after ACL reconstruction. In con-
trast to a rehabilitation program for patients with ACL
deficiency, rehabilitation programs for patients following
ACL reconstruction must consider the strain through the
new graft during various exercises as well as the graft’s
healing response. ACL strain values related to rehabilitation
exercises will therefore be included in this review.
Furthermore, RCTs from the literature search covered the
following areas of ACL rehabilitation:
† Rehabilitation protocols
† Supervised versus home-based rehabilitation programs
† Strength training:
* Open kinetic chain (OKC) and closed kinetic chain
(CKC) exercises
* Neuromuscular Electrical Stimulation (NMES)
† Neuromuscular training
† Specific exercises
3. ACL strain values related to rehabilitation exercises
Although evidence exists regarding the strain on the
ACL during various types of exercises (Beynnon &
Fleming, 1998; Beynnon et al., 1995; Beynnon et al.,
1997a) this evidence is limited and inconclusive on the
magnitude of loading that is detrimental to a graft following
Table 1
Chronological list of randomized control trials (RCT) based on the search criteria given for this study: from PubMed, Cochrane Library, Pedro, and SPORTDiscus

Authors S/C Intervention Intervention N Intervention Testing and Outcome measurements Results
(GROUP 1) (GROUP 2, 3, or 4) follow-up time

Fitzgerald et al. S NMES þ standard Standard rehabilitation 43 11 weeks 12 and 16 weeks Max isometric quadriceps Significant increase in quadriceps
(2003) rehabilitation strength, MVC strength at 12 weeks, borderline
significance at 16 weeks
ADLS ADLS significantly higher at 12
and 16 weeks for group 1
Knee pain (0–10 numeric No significant differences in pain
scale)
Liu-Ambrose et al. S Proprioceptive Isotonic strength 10 12 weeks 12.2 (strength Peak torque time hamstring Both training protocols influenced
(2003) training (PT) training (ST) training) 6.7 concentric and eccentric PeakTT

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(proprioceptive hamstring and
training) quadriceps torque
One-leg hop Proprioceptive training alone can
induce isokinetic strength gains
Lysholm score
Rebai et al. S NMES (80 Hz) NMES (20 Hz) 10 12 weeks Preoperatively MRI - Isokinetic quadriceps Quadriceps peak torque deficit
(2002) þ exercises þ exercises and 12 weeks strength (Cybex) of 21% in the 20 Hz group
after surgery and 34% in the 80 Hz
Isokinetic hamstring Deficit was significantly less
strength (Cybex) in the 20 Hz group than in the
80 Hz group
Isometric test in 75
degrees of knee flexion
Meyers et al. S Stair climbing Cycling 46 12 weeks 4 and 12 weeks Isokinetic quadriceps No deleterious effect of stair
(2002) strength climbing on knee isokinetic
performance or limb girth
measurements, and confirms
the use of stair climbing as a
viable adjunct/alternative to
cycle ergometry
Isokinetic hamstring
strength
Morrissey et al. S OKC strength CKC strength 43 4 weeks Pretraining and Knee pain (VAS score) No differences in knee pain
(2002) training training 6 weeks post were found between the
surgery treatment groups
Hughston Clinic
Questionnaire
Isotonic quadriceps
performance, knee
extensor machine
0–908
Isotonic knee and
hip extensor muscle
performance in CKC,
leg press machine

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Table 1 (continued)

Authors S/C Intervention Intervention N Intervention Testing and Outcome measurements Results
(GROUP 1) (GROUP 2, 3, or 4) follow-up time

Isokinetic hip
extensor test
Isometric quadriceps
and hamstring strength
Isokinetic knee extension
and flexion strength
Frosch et al. S Standard Extended exercise 35 30 mins 6 months and Lysholm Significant improved Lysholm
(2001) exercises program (3-5 times versus 11 months
(2-3 times per week for 150 150 mins post surgery

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per week minutes)
for 30 minutes)
KT-1000 Proprioception was significantly
improved
Proprioception Figure of eight significant
improvement
Figure of eight hop
Hooper et al. S OKC resistance CKC resistance 37 4 weeks 2 and 6 weeks Gait analysis during No significant differences
(2001) training training post surgery walking, stair ascent,
stair descent:
Knee angle
Moment
Power
Ageberg et al. C Supervised Self monitored- 63 5-8 months 6 weeks and 3, Stabilometry Persistently impaired postural control
(2001) postural traditional strength 12, and 36 months
control þ training
CKC exercises
One leg hop One-leg hop test was restored
in both groups
Isokinetic and isometric
quadriceps strength
Isokinetic and isometric
hamstrings strength
Lysholm
Morrissey S OKC CKC 36 4 weeks Pre and post Knee joint laxity: Knee No significant differences
et al. (2000) training: 2 and 6 Signature System between groups
weeks after surgery arthrometer
OKC compared to CKC led
to 9% increase in knee joint
laxity (CI: -8%-29%)
Mikkelsen et al. S CKC þ OKC Gp 2 -CKC þ 44 24 weeks Pre, 6 months, KT-1000 No significant differences in
(2000) (6 weeks) þ functional exercises mean 31months knee joint laxity
functional (just questionnaire)
exercises
Gp 3- Matched Isokinetic quad Significant increased quadriceps torque
control group
 Isokinetic Hamstring: A significantly higher number of
KinCom Questionnaire patients in group 1 returned to sports
(Satisfaction, Physical at the same level as before the injury
activity, Sports compared to group 2
participation)
Blanpied et al. S Standard program Lateral slide 14 6 weeks 8 and 14 weeks Isometric knee Significant improvements in the slide
(2000) (control group) exercise þ post surgery extension torque group for quadriceps strength
standard program
Isometric knee Lateral step height also improved
flexion torque in the slide group compared to the
control group
Maximum lateral
step up height

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Lateral step up fatigue
Zatterstrom et al. C Supervised Self monitored 100 5-8 months 3, 12 months Knee joint motion Transfer of 50% of the patients
(2000) postural control traditional strength (group 1) in group 2
þ CKC exercises training 12 months
(group 2)
One leg hop Significantly better results in all
muscle parameters and hop test
for group 1 at 12 months for the
male subjects (no such differences
where observed for the females)
Isokinetic and isometric
quadriceps strength
Isokinetic and isometric
hamstrings strength
Lysholm
Fitzgerald et al. C Standard training Standard 26 10 sessions Pre training, Number of giving ways Both programs enabled the subjects
(2000) program þ perturbation (within 5 post training, to go back to level 1 and 2 activities
program weeks) and 6 months
post training
4 hop tests Group 2 allowed for long-term
success of rehabilitation (6 months
post training)
KOS-ADL
Global rating-VAS score
Isometric muscle strength
Paternostro-Sluga S NMES (30 and Gp 2 - TNS (high) 49 6 weeks 6, 12, and 52 weeks Isometric testing for No statistical differences among groups
et al. (1999) 50 Hz) þ exercises þ exercises Gp quadriceps strength
3-Exercises (458) and isokinetic
testing for hamstring
strength
Tyler et al. (998) S Immediate Weight bearing 49 2 weeks Before 2 weeks EMG activity VMO There was no effect of weight bearing
weight bearing after 2 weeks and mean 7.3 on ROM,VMO knee stability
months after
(continued on next page)

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Table 1 (continued)

Authors S/C Intervention Intervention N Intervention Testing and Outcome measurements Results
(GROUP 1) (GROUP 2, 3, or 4) follow-up time

ROM 7 of 20 (35%) group 2 and

only 2 of 25
(8%) in group 1 reported
anterior knee
pain at follow-up
Knee joint laxity
Lysholm
Knee pain
Zatterstrom C Supervised Non supervised 100 6 weeks 6 weeks Pain at rest Improvement in muscle functions

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et al. (1998) in men in group 1
Pain during walking Other outcome no significant
differences
Giving way
Lysholm
Fischer S Home-based Clinical-based 54 6 vs. 24 PT Preop, 6, 12, ROM At the 6-month follow-up, no
et al. (1998) (6 PT visits) (24 PT visits visits (6 months) 18, and 24 weeks significant differences were found
Thigh atrophy
KT-1000 (at 6, 12,
18, 24 weeks)
4 hop tests (Noyes)
(24 weeks)
Lysholm (12 and
24 weeks)
Subjective health
status score
(24 weeks)
Beard and Dodd S Supervised Home-based 31 12 weeks Pre, 3, and Lysholm No differences between groups at
(1998) (knee class program 6 months 3 or 6 months postoperatively
twice a week)
þ home-based
program
IKDC Improved quadriceps and hamstring
strength in group 1, but no significant
differences between the groups
KT-1000 Higher knee joint laxity in group 2
Isokinetic muscle
strength, quadriceps
and hamstring
VAS
Schenck et al. S Clinic-based Home-based 37 6 weeks: 14.2 Pre, and post, ROM No differences in functional and
(1997) rehabilitation rehabilitation visits vs. 2.9 and follow- up subjective outcomes
program program visits at mean 21.6
(mean 14.2 (mean 2.9 visits) months
visits)
Lysholm Cost savings significant in group 2
 VAS
Hop test
KT-1000
SIP (Sickness
Impact Profile)
Lieber et al. S NMES Exercises 40 4 weeks Pre, 6, 8, 12, Isometric quadriceps Non significant
(1996) 24, and 52 weeks muscle strength
knee extension torque
Snyder-Mackler S High intensity Gp 2 - High-level 110 4 weeks Pre and post training Isometric quadriceps Group 1 and 3: quadriceps strength 70%
et al. (1995) NMES þ CKC volitional exercises strength, MVC
exercises þ CKC exercises
Gp 3 - High and Gait analysis, two Group 2: quadriceps strength 57%
low intensity NMES dimensional motion
þ CKC exercises analysis system

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Gp 4 - Low intensity Group 4: quadriceps strength 51%
NMES þ CKC exercises
No significant difference between
group 1 and 3
Significant difference between
treatment groups in the recovery of
the quadriceps and gait
(flexion-excursion)
Significant relationship between
recovery of the quadriceps and
flexion-excursion during stance
Bynum et al. S OKC CKC, using Sport Cord 100 24 weeks Pre and post: 3, 6, Lysholm Group 2 less patellofemoral pain
(1995) rehab program 9, 12, mean 19
months follow-up
ROM Group 2 significantly lower mean
knee joint laxity, side to side
difference
Patellofemoral pain
KT-1000
Satisfaction-survey
Hehl et al. (1995) S Isokinetic Control group 34 12 weeks Pre training program Isokinetic muscle By 18 weeks, evidence of a better
muscle training (standard training) (7 weeks), 6,12,18 quadriceps and recovery of muscle strength
þ standard months hamstrings strength
training
Knee joint laxity No significant difference in knee
laxity at six months
Snyder-Mackler S Portable, home Console (clinical) 52 4 weeks Pre and post training Isometric quadriceps Significant linear correlation between
et al. (1994) stimulator, low stimulators, strength MVC training intensity and quadriceps
intensity NMES high intensity NMES muscle torque
Higher intensities resulted in
significant higher quadriceps femoris
muscle torque
Tovin et al. (1994) S Traditional Exercises in water 20 8 weeks Preop, 2, 4, 6, KT-1000 Significantly higher Lysholm
rehabilitation (land) þ home exercises and after 8 weeks score in group 2
þ home exercises

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 132
Table 1 (continued)

Authors S/C Intervention Intervention N Intervention Testing and Outcome measurements Results
(GROUP 1) (GROUP 2, 3, or 4) follow-up time

Isometric and Significantly higher

isokinetic muscle isokinetic
strength (8 weeks) hamstring muscle strength at
8 weeks,
but no significant
differences
for the other strength
measurements at 8 weeks
ROM

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Thigh circumference
Lysholm (8 weeks)
Beard et al. (1994) C Proprioceptive Traditional strength 50 12 weeks Pre and post Reflex hamstring Both groups had a reduction in
training training program training contraction latency RHCL (significant difference
(RHCL) (indirect between the groups in favor of group 1)
measure of
proprioception)
Lysholm Same for Lysholm score
KT1000
Snyder-Mackler S NMES þ exercises Exercises 10 4 weeks Pre and post training Isometric quadriceps Group 1 significantly better
et al. (1991) and hamstring strength, isometric quadriceps strength
MVC
Two dimensional gait Group 1 significantly improved
analysis: cadence, velocity, gait parameters
stance time of involved
limb, flexion-excursion
during stance
KT1000
Draper and S NMES þ exercises Electromyography 30 6 weeks 1, 2, 4, and 6 weeks Isometric quadriceps The quadriceps femoris muscle
Ballard (1991) biofeedback þ exercises muscle torque isometric peak torque in the
(isokinetic dynamometer biofeedback group recovered at a
in 60 degrees of flexion significantly greater percentage
(Cybex)) of their non-operative limb
ROM
Ekstrand (1990) S Standard Extended rehabilitation 20 6 months vs. Preop, 6, 8, 10, Lysholm (6 months) No statistically significant
rehabilitation program (8 months) 8 months and 12 months differences in outcome between
program the two groups
(6 months)
Hop test (8,10,12 months)
Figure of eight test
(8, 10, 12 months)
Stryker laxity test
Only isokinetic quadriceps
muscle strength
Delitto et al. S NMES þ exercises Exercises 20 3 weeks Post training Isometric quadriceps and Significantly increased isometric
(1988) hamstring muscle torque quadriceps and hamstring muscle torque
at 65 degrees of flexion
(Cybex Isokinetic
dynamometer)
Wigerstad-Lossing S NMES (30 Hz) Exercises 23 6 weeks Preop and 6 Isometric quadriceps Significantly increased isometric
et al. (1988) þ exercises weeks muscle strength quadriceps muscle strength for group 1
CT Cross sectional area was significantly
less in group 2 (a greater reduction
of quadriceps muscle in group 2)
Sisk et al. (1987) S NMES þ exercises Exercises 22 6 weeks 7, 8, 9 weeks Isometric quadriceps No significant effect of adding
muscle strength using electrical stimulation
isokinetic dynamometer
(KIN-COM)

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Arvidsson S Cast: Isometric Cast: Isometric 38 6 weeks Pre op and CT No significant differences in
et al. (1986) muscle contraction muscle contraction 6 weeks after cross sectional area for men, but
and electrical for female: highly significant
stimulation differences in favor of the electrical
stimulation group. Vastus medialis
revealed significantly less atrophy
in group 1 with no differences for
vastus lateralis
-Biopsy -Biopsies from vastus lateralis cross
sectional area of the individual
muscle fibers decreased less in group 1,
but not significant

S, participants have gone through ACL surgery; C, participants are subjects with an ACL injury, treated conservatively; MVC, maximal voluntary isometric contraction; ADLS, activities of daily living score;
KOS-ADL, Knee outcome score for activities of daily living; NMES, neuromuscular electrical stimulation.

133
134 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
ACL reconstruction. Absence of strain is detrimental to
healing, as is excessive strain. It is important to design a
rehabilitation program for patients after ACL reconstruc-
tion that will both optimally load the ACL graft while
restoring lower extremity function. Historically, strenuous
rehabilitation exercises were not advocated immediately
after surgery because of concerns about graft healing.
Animal experiments suggested that an ACL graft required
at least 18 months to revascularize and heal (Hefti, Kress,
Fasel, & Morscher, 1991). Shelbourne and Nitz (1990)
published a large case series advocating immediate full
weight-bearing and restoration of full range of motion.
More aggressive rehabilitation programs resulted, and
concerns about deleterious effects on the graft were voiced.
Beynnon et al. (1997c) tested the linear stiffness and
ultimate failure load of the ACL graft of a man who died 8
months after reconstruction and found they were 90% of
the values for the uninjured knee. This was remarkably
higher than the results from earlier animal studies. The
more aggressive rehabilitation programs appeared to result
in better graft healing than reported in the animal studies.
The more aggressive protocols have also resulted from the
use of graft materials with biomechanical properties more
similar to the normal ACL, improved fixation strength,
greater evidence of the ACL strain values during
rehabilitation exercises, and the clinical evidence that
laxity does not increase following aggressive rehabilitation
programs (De Carlo, Shelbourne, McCarroll, & Rettig,
1992; Shelbourne, Klootwyk, Wilckens, & De Carlo,
1995). However, there are no published RCTs that evaluate
aggressive versus non-aggressive rehabilitation programs
following ACL reconstruction. Evidence from RCTs is
needed, and more knowledge is necessary to determine
how much load is sufficient and how much is detrimental to
the ACL graft.
4. Rehabilitation protocols
The duration of therapy treatments has been assessed in
two separate trials (Ekstrand, 1990; Frosch et al., 2001). The
first examined the duration of the entire program and the
second evaluated the duration of the individual treatment
sessions. In order to evaluate the duration of the entire
program, the effect of an extended 8-month rehabilitation
program was compared to a 6-month (control group)
rehabilitation program following ACL reconstruction
(Ekstrand, 1990). No significant differences were found
between the groups at 12 months after surgery. The mean
time for return to sport was 9 months for the extended
rehabilitation group and 6 months for the control group
based on the author’s criteria (full ROM and 90%
quadriceps muscle strength). A trend was noted towards
better knee joint stability in the 8-month group. Frosch et al.
(2001) examined the effect of a prolonged physical therapy
session rather than a prolonged program. The prolonged
session lasted 2.5 h for 3 –5 sessions/week, compared to a
standard rehabilitation program of 30 min, 2– 3 sessions/
week. In this case, the prolonged rehabilitation group
showed significantly improved function (Lysholm score and
joint position sense), as well as an earlier return to work.
The authors concluded that the extra cost of an intensive,
prolonged physical therapy program was justified due to the
earlier return to work and the improved knee function.
In a study by Tovin, Wolf, Greenfield, Crouse, and
Woodfin (1994) a comparison between a land-based
rehabilitation program and a water-based rehabilitation
program (hydrotherapy) was performed so that the exercises
in both programs were matched and only the rehabilitation
medium (water or land) differed between the groups. The
data indicated that the group using the water-based program
had significantly greater Lysholm scores following a 6-week
program, and that the water-based program was more
effective at reducing joint effusion. The two programs were
also equally effective in restoring quadriceps muscle
strength, but the land-based program yielded significantly
improved hamstring muscle strength.
The effect of immediate weight-bearing after ACL
reconstruction has been examined by Tyler, McHugh,
Gleim, and Nicholas (1998) in two groups of subjects.
The first group was prevented from weight-bearing for the
first 2 weeks after surgery, and the second group was
allowed to immediately bear weight as tolerated. Vastus
medialis oblique electromyography activity, knee extension
range of motion, knee stability, Lysholm score, and anterior
knee pain were then examined at a mean of 7.3 months after
surgery. The immediate weight-bearing group showed
significantly reduced anterior knee pain at follow-up.
These subjects also demonstrated a greater return of vastus
medialis oblique muscle activity at 2 weeks, however, this
difference was eliminated by the follow-up. The authors
concluded that immediate weight-bearing did not compro-
mise knee joint stability and resulted in diminished anterior
knee pain.
4.1. Methodological quality
Of the studies reviewed in this area, none included a
description of the power calculations, and only one study
stated the method of randomization. Tovin et al. (1994) used
a coin toss and altered pairs of subjects to create evenly
distributed groups over time. Groups were typically small,
ranging from 20 to 49 subjects (Ekstrand, 1990; Frosch et al.,
2001; Tovin et al., 1994; Tyler et al., 1998). None of the
studies blinded the patients, however, all but Ekstrand
(1990) blinded the testers to group assignment. Two studies
(Ekstrand, 1990; Tovin et al., 1994) included baseline data
for some of the outcome measurements, but important
outcome measurements such as functional knee scores and
muscle strength measurements were not included, and one
study failed to report any baseline data (Frosch et al., 2001).
The studies generally lost few subjects to follow up, ranging
 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
from none (Ekstrand, 1990) to two per group (Tyler et al.,
1998), however, only two studies had a follow-up time of at
least 1 year (Ekstrand, 1990; Frosch et al., 2001). The
rehabilitation program was well described in only one study
(Tovin et al., 1994) and only briefly described in the others
(Ekstrand, 1990; Frosch et al., 2001). Tyler et al. (1998) did
not record the amount of weight-bearing in the immediate
weight-bearing group. None of the trials reported compli-
ance data. The outcome measurements used in the studies
were determined to be clinically relevant outcome
measures.
4.2. Summary
The evidence for effectiveness of water-based programs
relies on only one study, and conclusive recommendations
therefore cannot be given. Previous studies have indicated
that patients with prolonged effusion after surgery (up to 3
months) had significantly worse long-term results (Risberg
et al., 1999). A water-based program could therefore be
recommended for patients with a prolonged effusion, but
new RCTs with sufficient sample size and recorded
compliance are necessary. The evidence for using a
prolonged therapy session or an extended rehabilitation
program after ACL reconstruction is insufficiently reported
in these studies.
5. Supervised and home-based rehabilitation programs
The effects of home-based, self-monitored rehabilitation
programs compared to clinic-based supervised rehabilita-
tion programs has been studied in subjects with ACL
reconstruction (Beard & Dodd, 1998; Schenck, Blaschak,
Lance, Turturro, & Holmes, 1997) as well as subjects with
an ACL rupture (Ageberg, Zatterstrom, Moritz, & Friden,
2001; Fischer, Tewes, Boyd, Smith, & Quick, 1998;
Zatterstrom, Friden, Lindstrand, & Moritz, 1998, 2000).
All rehabilitation programs described were led by physical
therapists, while the home-based programs included physi-
cal therapy visits for assessment, education, and
modification.
Three RCTs have compared a home-based rehabilitation
program to a supervised clinic-based program and each has
arrived at the same conclusion. Schenck et al. (1997)
compared a home-based rehabilitation program with a mean
of 2.9 physical therapy visits to a supervised clinic-based
program with a mean of 14.2 visits. The authors reported
that no significant differences were observed between the
groups, and indicated that a home-based program including
physical therapy visits for assessment, education, and
progression can be efficacious and cost-effective for adult
recreational athletes. The authors did suggest, however, that
this type of home-based program may be insufficient for
patients younger than 18 years old, or for high-performance
athletes. Beard and Dodd (1998) examined subjects after
135
ACL reconstruction to compare the efficacy of a home-
based rehabilitation program to a home-based program in
addition to a knee class twice weekly. The results were
similar to those of Schenck et al. (1997) indicating that
no additional benefit was evident from supervised exercise.
In addition, Fischer et al. (1998) compared two different 6
week-rehabilitation programs, and showed that a 5-visit
home-based rehabilitation program after ACL reconstruc-
tion was as sufficient as a rehabilitation program monitored
with a mean of 20 visits. Patient compliance was monitored
through an exercise booklet containing prescriptions,
diagrams, and timing of specific exercises and goals for
each rehabilitation phase. The authors concluded that
critical components for a successful home-based rehabilita-
tion program are careful selection of patients who will be
compliant and periodic supervision and follow-up with
physical therapy to ensure that each rehabilitation goal is
reached. Furthermore, they recommended the use of an
exercise booklet and a thorough follow-up with short and
long-term outcome assessment.
Home-based rehabilitation programs and supervised
clinic-based program in patients following ACL injury
have been compared. Zatterstrom et al. (1998, 2000)
followed such a population ðn ¼ 100Þ to evaluate the
efficacy of two non-operative rehabilitation programs, a
supervised and a self-monitoring rehabilitation program.
Assessments were done after 6 weeks (Zatterstrom et al.,
1998) and 12 months (Zatterstrom et al., 2000) following
ACL injuries. The patients in the self-monitored group were
given verbal and written instructions but did not receive any
additional visits to physical therapy for assessments or
progression during the 6 weeks of training. The self-
monitored training program in this study was described as
exercises in non-weight-bearing positions, training
isolated muscles in the injured leg selectively (Ageberg,
Zatterstrom, Moritz, & Friden, 2001). No differences
between the supervised and the self-monitoring programs
were observed after 6 weeks, except for improved quad-
riceps and hamstring performance in male subjects in the
supervised group (Zatterstrom et al., 1998). However, 49%
of the subjects in the self-monitored group required
supervision (training) after the 6 weeks because of reduced
ROM and thigh atrophy. The authors concluded that 6
weeks of rehabilitation was too short a time-period to obtain
normal mobility and restore knee function. The 12-month
long-term follow-up, however, confirmed the same trends as
the short-term follow-up. The results were based on an
intention-to-treat analysis, since as many as 49% of the
subjects in the self-monitored group changed to the
supervised group after 6 weeks. The authors concluded
that initial guiding during the early period of rehabilitation
is crucial. Sixty-three of these 100 patients underwent
additional testing at the 6-week, 12, and 36-month follow-
ups (Ageberg et al., 2001). A control group was also used to
evaluate postural control in subjects without injuries. They
reported that 25% of the subjects in the supervised group
136 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
and 22% of the subjects in the self-monitored group were
unable to maintain single limb stance for 20 s at the 6-week
follow-up. No significant differences in postural control
were observed between the two groups, however, impaired
postural control was found compared to the healthy control
group. The one-leg hop test revealed significantly improved
function in the supervised group compared to the self-
monitored group. They concluded that ACL deficient
subjects lack postural control even 36 months after ACL
injury, and that knee function, as evaluated with a one-leg
hop test, was normalized in the supervised group but not in
the self-monitored group.
5.1. Methodological quality
Information about methods of randomization was
available in all studies except for one (Fischer et al.,
1998). Details about assessor blinding were described only
in one study (Beard et al., 1998). Baseline data were given
for all of the trials, except for three studies on ACL-deficient
knees (Ageberg et al., 2001; Zatterstrom et al., 1998, 2000),
Beard and Dodd (1998) showed significant differences in
baseline data between groups; quadriceps and hamstring
muscle strength and Lysholm score. Five subjects were lost
to follow-up in the study by Beard and Dodd (1998) leaving
only 26 subjects for analysis at 6 months evaluation. They
noted that ‘number needed to treat’ was calculated, but no
information is given regarding how many they would need
compared to how many subjects they included. Ageberg
et al. (2001) reported that 36 subjects were left in the
supervised group, 14 had transferred from the self-
monitored group, leaving only 13 at a mean of 36 months
after injury. Fischer et al. (1998) reported no loss to follow-
up at 6 months, except for one subject excluded because of
foot surgery. Schenck et al. (1997) did not report lost to
follow-up.
Interventions were described in all the trials, most of
them defined as rehabilitation phases with type of exercises
and activities introduced at a specified time after surgery.
Three of the studies referred to a publication where the
entire rehabilitation program was described (Ageberg et al.,
2001; Zatterstrom et al., 1998, 2000). All the home-based
rehabilitation programs except for one (Zatterstrom et al.,
1998) included physical therapy visits for assessment and
for monitoring progress. The rehabilitation programs were
of various durations from 6 to 24 weeks (Fischer et al.,
1998; Zatterstrom et al., 2000).
Compliance was only measured in one study via the use
of a training log, a booklet containing all the exercises for
each week (Fischer et al., 1998). One study described that
nearly half of the patients required to change from the self-
monitored group to supervised training group (Zatterstrom
et al., 2000). Most of the studies used clinical relevant
outcome measurements, but some of the studies reported
only short-term follow-ups (Beard and Dodd, 1998; Fischer
et al., 1998; Zatterstrom et al., 1998). In one study
(Zatterstrom et al., 1998) the follow-up time was only
6 weeks. For protocols exceeding 6 months, functional knee
tests and muscle strength tests were included. Information
about return to work or activity and longer term follow-up
were not provided.
5.2. Summary
All of the above studies focused on physical therapy-
led programs with various amount of supervision by a
physical therapist. None of the studies evaluated the effect
of a physical therapy-led program versus a truly
unsupervised program. Collectively, these studies suggest
that patients undergoing ACL reconstruction may not
require rehabilitation to be continuously monitored by a
physical therapist, but some assessments, education,
instructions, and adjustments for progression are needed.
In the study that included the fewest physical therapy
visits (Zatterstrom et al., 1998), nearly half of the subjects
were crossed over to the supervised rehabilitation
program because of lack of functional progress. No
study evaluated programs without periodic assessment,
instructions, and monitoring of progression during
rehabilitation. The term ‘home-based training program’
is not a good description of the rehabilitation programs
evaluated in these studies. These programs are not solely
based on doing exercises at home, but they are programs
monitored by physical therapists, with systematical
assessments recorded by a physical therapist. Information
about statistical power calculations, assessor blinding, and
compliance is lacking.
6. Strength training
Although all lower extremity muscles must be included
in rehabilitation following ACL injury or reconstruction,
particular attention is paid to strengthening the quadriceps,
the most affected muscle in these situations. Quadriceps
muscle weakness remains one of the major challenges for
patients and their therapists and some studies have
demonstrated that quadriceps weakness can persist for
2 years after surgery (Risberg et al., 1999). In addition,
quadriceps strength is a significant outcome measure
for patient’s satisfaction following ACL reconstruction
(Risberg et al., 1999). As much as 71% of the variability in
the Cincinnati knee score can be explained by the variance
in pain and quadriceps muscle performance at 2 years
following ACL reconstruction (Risberg et al., 1999). Others
have demonstrated a significant relationship between
quadriceps strength and knee function during gait (Lewek,
Rudolph, Axe, & Snyder-Mackler, 2002; Snyder-Mackler
et al., 1995).
The American College of Sports Medicine recommended
that for uninjured individuals a minimum of 8 – 10
repetitions to fatigue twice a week will lead to a 2 –9%
 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
increase in strength per week depending on the initial
strength (American College of Sports Medicine, 1990). Any
increase in frequency or additional sets will elicit larger
strength gains (American College of Sports Medicine,
1990). Any improvement in muscular performance during
the initial 6 weeks after the start of strength training is likely
caused by neural adaptation, whereas further improvement
is likely due to gradual muscle hypertrophy (Kannus et al.,
1992). Exercises and interventions aimed at increasing
muscle strength following ACL injury should adhere to
recommendations based on evidence for muscle strength
training. Therefore, the intensity, frequency, and compli-
ance to a training protocol are of significance when
examining the evidence for strength training following
ACL injury or reconstruction. The patient’s individual goals
regarding the type and level of sports activities desired
should influence the recommendations for exercise fre-
quency for optimal resolution of lower limb dysfunction.
Intensive rehabilitation programs lasting more than 60 min
and at frequencies of 3 times or more per week might result
in higher dropout rates.
Several therapeutic interventions may be used for lower
extremity muscle strength training. Open and closed kinetic
chain exercises are the most common way of restoring
quadriceps muscle strength after ACL reconstruction.
Additionally, neuromuscular electrical stimulation
(NMES) has been used for quadriceps muscle strengthening
early after ACL reconstruction.
6.1. Open kinetic chain (OKC) or closed kinetic chain
(CKC) exercises
The classification of lower extremity strengthening
exercises is commonly referred to as either open kinetic
chain (OKC, non-weight-bearing) or closed kinetic chain
(CKC, weight-bearing) exercises. Exercises with the distal
segment of the limb fixed are referred to as CKC, whereas
exercises performed with the distal segment of the limb
movable are referred to as OKC. In the early 1990s a shift
away from OKC towards CKC exercises was observed for
ACL rehabilitation, because the most commonly used OKC
knee extensor strengthening exercises were thought to
increase ACL strain values (Arms, Pope, Johnson, Fischer,
& Arvidsson, 1984; Beynnon et al., 1998; Beynnon et al.,
1994; Beynnon, Fleming, Stankewich, Renstrom, & Nichols,
1997b; Henning, Lynch, & Glick, 1985). CKC exercises
were introduced as more functional exercises and thought to
protect the graft from excessive strain while restoring lower
extremity muscle strength. Clinical reports suggested that
CKC exercises were associated with enhanced knee function
(Bynum, Barrack, & Alexander, 1995; Prentice, 1994;
Shelbourne & Nitz, 1990; Tippett, 1992).
Quadriceps contraction near full extension imparts
significant strain to the ACL. Extension exercises are
capable of producing a range of ACL strain values
depending on knee flexion angle and the magnitude of
137
muscle contraction. In contrast, exercises that involve
isolated hamstring muscle contraction do not strain the
ACL at any knee position or magnitude of the muscle
contraction. Several authors who indirectly measured ACL
shear concluded that CKC exercises were safer than OKC
(Lutz, Palmitier, An, & Chao, 1993; Toutoungi, Lu,
Leardini, Catani, & O’Connor, 2000; Wilk et al., 1996;
Zheng, Fleisig, Escamilla, & Barrentine, 1998). One group
has directly examined the effect of OKC and CKC exercises
on the strain behaviour of the normal ACL in human
subjects while performing squatting and non weight-bearing
active knee flexion/extension (Beynnon et al., 1997b;
Fleming et al., 1998). The results indicated that the
maximum ACL strain during squatting (both with and
without elastic resistance) was not significantly different
from those obtained during active seated flexion/extension.
These data indicated that non weight-bearing and weight-
bearing exercises produce about the same amount of strain
on the ACL, suggesting that non-weight-bearing exercises
can be introduced as soon after reconstruction as weight-
bearing exercises.
Five RCTs were identified that examined the differ-
ence between CKC and OKC exercises. In the study by
Bynum et al. (1995) 100 subjects having gone through
ACL reconstruction were randomized into one of two 24-
week rehabilitation programs (OKC only or CKC only).
Patients in the CKC group demonstrated lower mean
knee joint laxity and improved satisfaction with the
outcome.
Mikkelsen, Werner, and Eriksson (2000) investigated the
addition of OKC exercise to a CKC rehabilitation program
following ACL reconstruction. For the first 6 weeks both
groups received rehabilitation consisting of flexibility
training, balance training, CKC exercises, and hamstring
training. After week 6, the OKC group incorporated
isokinetic concentric and eccentric quadriceps exercises.
Exercises were initiated from 90 to 40 degrees of knee
flexion, but gradual increase to 90– 108. Both rehabilitation
programs lasted for 6 months after surgery. No significant
differences in knee joint laxity or hamstring strength were
observed between the CKC and the CKC þ OKC groups. A
significant improvement in the CKC þ OKC group was
observed in quadriceps strength at 6 months after surgery
and significantly more subjects returned to sport in the
CKC þ OKC group compared to the CKC only group.
Hooper, Morrissey, Drechsler, Morrissey, and King
(2001) evaluated a 4-week OKC and CKC training program
started 2 weeks after ACL reconstruction. The kinematic
and kinetic differences during functional tasks such as
walking, stair ascents, and stair descents were assessed
between the two groups, however, no clinically relevant
differences during walking or stair climbing were observed.
Using the same patient cohort, Morrissey et al. (2000) later
reported that there was no difference in joint laxity or
anterior knee pain (Morrissey et al., 2002) between the OKC
and CKC groups in the early period following ACL
138 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
reconstruction. There was a concern that increased patello-
femoral joint pressure might occur during OKC exercises
that would lead to anterior knee pain. This was not observed,
however, and the finding contradicts a widely accepted
clinical belief that knee extensor OKC training is more
irritating to patellofemoral joint than CKC training.
6.1.1. Methodological quality
The methodological quality of the five randomized
clinical trials reviewed in this section varied considerably.
Morrissey et al. (2000) found no significant differences and
their findings could be influenced by the lack of statistical
power. Although the study reported power calculations for
60 subjects, the trial generated three different publications
presenting data from 36, 37, and 43 patients, respectively.
The other studies included 100 (Bynum et al., 1995) and 44
subjects (Mikkelsen et al., 2000), without reporting
statistical power calculations. Block randomization, using
blocks of 4, with blocks containing equal number of subjects
receiving OKC and CKC exercises was used in two studies
(Hooper et al., 2001; Morrissey et al., 2002). Randomization
by sealed and numbered envelopes and computer-generated
random numbers table was used in one study (Bynum et al.,
1995). Mikkelsen et al. (2000) reported that patients were
randomized into two groups of 22 subjects, each subject in
group 1 (CKC exercises) was matched to another patient in
group 2 (CKC þ OKC) for age, gender and activity level.
One study stated that it was a single blinded study with
blinded assessors (Morrissey et al., 2002). Although Hooper
et al. (2001) and Morrissey et al. (2000) did not report
assessor blinding, we expect both of these studies also to be
single blinded since the same patient population was
studied. In the study by Mikkelsen et al. (2000) details of
blinding procedures were not available, although same
examiners were used for pre-training and post-training
assessments. Bynum et al. (1995) noted that assessors were
blinded at the mean of 19 months follow-up. Blinding of the
participants was not considered possible.
Baseline data, including loss to follow-ups, are available
in all of the studies. Hooper et al. (2001) reported six
subjects lost to follow-up at 6 weeks post-surgery. Bynum
et al. (1995) reported three subjects not completing the
rehabilitation protocol, 12 subjects (six in each group) were
lost to follow-up at 1 year (total of 85 subjects returned for
follow up at 1 year). But only 64 subjects returned for the
objective evaluation with KT-1000 knee arthrometer, knee
range of motion (ROM), and patellofemoral pain. Mikkel-
sen et al. (2000) reported none lost to follow-up. The
rehabilitation protocols described the main differences
between the programs regarding different types of exercises.
Compliance was recorded in different ways. Three of the
studies used the same rehabilitation protocol, a 3 times a
week for 4 weeks intervention program, with short follow-
up (6 weeks) (Hooper et al., 2001; Morrissey et al., 2000,
2002). Compliance in these trials was set at a cut-off of
a minimum seven treatment sessions to be included in
the analyses. Three subjects did not comply with these
standards, and were accordingly excluded from the analysis.
The other two studies did not report any compliance criteria
or any details of how much the subjects really participated
in the 6-month intervention program (Bynum et al., 1995;
Mikkelsen et al., 2000), but Mikkelsen et al. (2000) reported
that all the subjects were supervised for 6 months during the
rehabilitation program at the hospital.
Relevant outcome measurements were included, but one
study reported insufficient anterior knee pain outcome
measurement (Bynum et al., 1995). Six-month follow-ups
may be too short an observation time to conclude that there
were no significant differences in knee joint laxity between
the two groups. Only two of the studies revealed
satisfactory follow-up time (Bynum et al., 1995; Mikkelsen
et al., 2000); the others (Hooper et al., 2001; Morrissey
et al., 2000, 2002) had a 6-week post-surgery observation
period which is too short to show any significant and
clinical relevant outcomes.
6.1.2. Summary
The concerns about possible negative effects on anterior
knee pain and joint laxity while using OKC exercises for
quadriceps strengthening were not supported by the results
from RCTs. Outcome measurement for patellofemoral
pain was unclear and not very well described. In addition,
a 6-week follow-up for evaluating knee joint laxity is
unlikely to be meaningful for a patient following ACL
reconstruction. There was one study with sufficient
statistical power and a long-term follow-up that showed
increased knee joint laxity after performing OKC exercises
(Bynum et al., 1995). However, there is a lack of knowledge
about how or what type of OKC exercises influenced the
increased knee joint laxity. In order to minimize the strain
on the ACL during quadriceps muscle strength training, the
knee should be maintained in less than 608 during CKC
exercises, and OKC exercises with knee angles greater than
408 of flexion are recommended (Beynnon & Fleming,
1998; Steinkamp, Dillingham, Markel, Hill, & Kaufman,
1993). Carefully controlled OKC exercises within the given
range of motion starting at week 6 postoperatively can
significantly improve quadriceps muscle strength without
harming the ACL graft (Beynnon et al., 1995; Heller &
Pincivero, 2003; Ross, Denegar, & Winzenried, 2001;
Snyder-Mackler et al., 1995).
6.2. Neuromuscular electrical stimulation for muscle
strengthening
NMES and voluntary muscle contraction are two
exercise modes widely used in rehabilitation to strengthen
skeletal muscle. Physiological differences between volun-
tary and electrically elicited muscle contraction have been
reported previously (Delitto et al., 1988). Briefly, in an
electrical elicited muscle contraction, a greater percentage
of Type II muscle fibers are recruited (Duchateau
 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
& Hainaut, 1988). In a voluntary contraction, smaller
motoneurones innervating Type I muscle fibers are
activated prior to the larger motoneurons innervating
Type II muscle fibers. Type II muscle fiber area may
therefore increase to a greater extent in subjects using
NMES than in those performing volitional contractions
(Wigerstad-Lossing et al., 1988). In electrically elicited
muscle contractions there are synchronous depolarizations,
compared to the asynchronous depolarization observed
during a voluntary contraction.
Twelve RCTs were identified that examined the effect of
NMES on quadriceps strength and/or functional outcomes
following ACL injury or reconstruction. Arvidsson, Arvids-
son, Eriksson, and Jansson, (1986) reported on the first RCT
to examine the effect of electrical stimulation after ACL
repair. After immobilization, 38 subjects received electrical
stimulation with a battery operated stimulator using a
frequency of 40 Hz. Patients received 30-minute treatments,
3 times per day for 5.5 weeks. No significant difference was
found in the male patients, but the female patients using
NMES showed a significant improvement.
Sisk, Stralka, Deering, and Griffen (1987) examined the
effect of prolonged daily NMES on quadriceps strength in
22 patients during the 6 weeks following ACL surgery.
They examined if the combination of NMES and volitional
exercises would produce greater isometric strength than
volitional exercises alone. The cast was windowed over the
distal quadriceps, so that electrical stimulation could be
started on day 3 or 4 postoperatively. The frequency was set
at 40 Hz and patients received stimulation for 8 h a day, 7
days a week for 6 weeks. The authors reported no difference
between the two groups at follow-up. Wigerstad-Lossing
et al. (1988) also examined the effect of NMES combined
with voluntary muscle contractions compared to a program
of volitional only exercises after ACL surgery. The NMES
group received electrical stimulation of the quadriceps
muscle 3 times a week, at a frequency of 30 Hz. The NMES
group lost less knee extension isometric muscle strength
than the volitional only group. In addition, the cross-
sectional area of the quadriceps muscle (as measured with
computed tomography) atrophied significantly more in the
control group compared to the NMES group during the
immobilization period.
Delitto et al. (1988) examined the effect of NMES
compared to volitional exercise to strengthen the thigh
muscles after ACL surgery in 20 patients. Both groups co-
contracted the quadriceps and hamstring muscles. The
training protocol consisted of either voluntary exercise or
electrical stimulation 5 days a week for 3 weeks for the first
6 weeks after ACL repair. A higher percentage of both
extension and flexion torque was observed in the NMES
group compared to the voluntary exercise group.
Draper and Ballard (1991) compared NMES and electro-
myographic biofeedback in 30 subjects for the recovery of
quadriceps femoris muscle function following ACL surgery.
The addition of either NMES or electromyographic
139
biofeedback was used in conjunction with a home program
of quadriceps muscle strengthening exercises for the first 4
weeks postoperatively. The authors reported a greater
recovery of isometric peak torque in the group using
biofeedback than by those using NMES. They suggested
that biofeedback may better facilitate the neural changes that
accompany strength gains compared with NMES.
Snyder-Mackler, Ladin, Schepsis, and Young (1991)
compared the changes in quadriceps muscle strength and
gait in 10 subjects after ACL reconstruction. Subjects were
divided into two groups: one performing volitional exercise
only and the other performing a combination of NMES and
volitional exercises together. Both groups exercised for
4 weeks. They found significant improvements in quad-
riceps strength and improved flexion-excursion during
stance in the group that received NMES. The authors also
reported a significant relationship between the gait par-
ameters and muscle strength.
A multicenter study of 110 subjects was conducted to
evaluate the effect of volitional only (CKC exercise) as well
as both high and low intensity NMES in patients after ACL
reconstruction (Snyder-Mackler et al., 1995). A comparison
between the volitional only group and the NMES groups
suggested that high intensity NMES in addition to volitional
exercises worked better in restoring quadriceps muscle
strength than volitional contractions alone (Snyder-Mackler
et al., 1995). Additionally, the low and high intensity NMES
data allowed for the establishment of a dose-response curve
for NMES regimens designed to improve quadriceps muscle
strength (Snyder-Mackler, Delitto, Stralka, & Bailey, 1994).
A significant linear correlation between training intensity
and quadriceps muscle torque was shown. There was no
correlation, however, between the electrically elicited
contraction force and quadriceps muscle recovery for the
group using the portable, low intensity stimulator. Subjects
training with console stimulators (clinical stimulators) were
able to train at higher intensities, resulting in larger
quadriceps femoris muscle torque. The authors suggested
that the use of high-intensity electrical stimulation was
necessary if the goal of treatment was the recovery of
quadriceps strength in the early phases of rehabilitation.
Lieber, Silver, and Daniel (1996) also evaluated the
effect of NMES and voluntary muscle contractions begin-
ning 2 –6 weeks after ACL reconstruction. The authors
reported that if the intensities were matched between the
groups, then NMES and volitional exercise were equally
effective.
Paternostro-Sluga, Fialka, Alacamliogliu, Saradeth, &
Fialka-Moser (1999) used a portable, battery powered
stimulation unit for NMES at 30 and 50 Hz. The authors
attempted to determine the effectiveness of NMES for the
knee extensors and flexors for preventing muscle weakness
after ACL reconstruction. No assistance to the electrically
elicited contraction was provided, and more aggressive
volitional exercises were used than in previous studies. The
authors concluded that the NMES provided no additional
140 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
benefit and that the increased quadriceps and hamstring
muscle strength was most likely due to the volitional
exercises.
Rebai et al. (2002) evaluated the effects of two NMES
protocols (80 and 20 Hz) combined with voluntary contrac-
tions in 10 subjects on the recovery of thigh muscles after
ACL reconstruction. The authors reported that at 12 weeks
after surgery the 20 Hz group had a 21% quadriceps strength
deficit and the 80 Hz group had a 58% deficit. In addition,
the 80 Hz group had a significantly greater increase in
subcutaneous fat volume when analyzed with magnetic
resonance imaging (MRI).
Fitzgerald, Piva, and Irrgang (2003) recently modified
the NMES protocol for patients who were unable to
tolerate isometric NMES contractions with the knee in 658
of knee flexion. This modified protocol may be suitable for
patients with patellofemoral problems and for clinicians
who do not have a dynamometer. It was reported that high
intensity NMES in addition to standard rehabilitation
exercises can significantly improve quadriceps muscle
strength and knee function at 12 and 16 weeks after ACL
reconstruction.
6.2.1. Methodological quality
Methods of randomization were not given for most of the
trials evaluated above. One study (Draper & Ballard, 1991)
described the randomization method as randomized match-
ing procedure, controlling for age and gender. Some of the
trials had small sample sizes (Draper, 1990; Delitto et al.,
1988; Rebai et al., 2002; Sisk et al., 1987; Snyder-Mackler
et al., 1991), others included between 30 and 52 subjects,
and only one had as many as 110 subjects (Snyder-Mackler
et al., 1995). Assessor blinding was stated in most of the
studies, but the participants were not blinded or likely not
(Delitto et al., 1988; Draper & Ballard, 1991; Fitzgerald
et al., 2003; Snyder-Mackler et al., 1991). Paternostro-Sluga
et al. (1999) reported that the assessor was blinded and that
subjects were blinded to type of electrical stimulation. Other
studies did not state if assessors or participants were blinded
(Sisk et al., 1987). Baseline data were only reported in one
trial (Fitzgerald et al., 2003). The other studies included no
baseline data, but just used group comparisons at follow-ups
or used the uninvolved leg as a control (Delitto et al., 1988;
Draper & Ballard, 1991; Paternostro-Sluga et al., 1999; Sisk
et al., 1987). Several studies reported short term follow-up
and none or very few subjects were lost to follow-up or non-
compliant to the intervention (Delitto et al., 1988; Draper &
Ballard, 1991; Sisk et al., 1987; Snyder-Mackler et al.,
1991). Those trials including longer follow-up times,
reported few subjects lost to follow-up (Fitzgerald et al.,
2003; Paternostro-Sluga et al., 1999). Interventions were
described in the studies, but the NMES protocols were
usually better described than the exercise-protocols.
Log sheets to record compliance to the NMES protocols
were common, but less frequently recorded was compliance
to the exercise protocols. Some authors noted that
compliance was impossible to record because of home
exercises (Delitto et al., 1988; Sisk et al., 1987), others
(Fitzgerald et al., 2003) established clinical milestones for
each rehabilitation phase and recorded the progression
based on the clinical milestones. Muscle strength measure-
ments were included in all the studies. But only one study
(Fitzgerald et al., 2003) included both muscle strength,
functional score, and pain outcome measurements, and one
trial included muscle strength measurements, gait variables,
and knee joint laxity measurement (Snyder-Mackler et al.,
1991). Some studies included only muscle strength
measurements (Delitto et al., 1988; Paternostro-Sluga
et al., 1999; Sisk et al., 1987). Others included CT
(Wigerstad-Lossing et al., 1988) and MRI (Rebai et al.,
2002). The studies reported 3–12 weeks intervention time and
most of the trials reported pre- and post-training testing with
no additional follow-ups. Only two studies had 1-year follow
up (Lieber et al., 1996; Paternostro-Sluga et al., 1999).
6.2.2. Summary
The wide variety of results regarding NMES might be
attributed to the large range of NMES parameters presented.
Parameters such as the frequency, intensity, pulse width,
stimulation time, and rest periods varied between the
different studies. For instance, Lieber et al. (1996) used a
rest time between contractions of 20 s. Others reported
using 50 s or more (up to 120 s) to provide the stimulated
muscle with sufficient time to recover between contractions.
Insufficient recovery time between contractions may reduce
the efficacy of NMES. Despite the range of parameters and
occasionally conflicting results, several conclusions can be
drawn from these studies. For instance, if gains are to be
made with NMES, then a high-intensity stimulation is
required to achieve an adequate stimulus to the large
quadriceps muscle. The reason that Paternostro-Sluga et al.
(1999) and Lieber et al. (1996) were unable to demonstrate a
difference was probably their use of portable, battery,
operated electrical stimulators which had previously been
shown to be unable to provide an adequate stimulus for the
restoration of quadriceps strength. Patient comfort and
safety, however, are essential if large electrically elicited
training contractions are to be used. Using NMES with the
knee flexed to 658 eliminates undesirable strain on the ACL,
and allows adequate stimulus to stimulate the large
quadriceps muscle. There is evidence that high intensity
NMES in addition to volitional exercises seems to have a
beneficial effect on isometric quadriceps muscle strength.
The initiation of NMES for muscle strengthening appears to
be important as well. Those that began high level NMES
treatments within the first week after surgery showed greater
improvements in quadriceps strength in the NMES group
compared to volitional exercise alone (Snyder-Mackler
et al., 1995), while others that waited for 2 – 6 weeks after
surgery did not (Lieber et al., 1996).
 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
7. Neuromuscular training
The biomechanics of the knee are altered after ACL
injury. Simply restoring mechanical restraints has been
shown to be insufficient for a satisfactory outcome (Seto,
Orofino, Morrissey, Medeiros, & Mason, 1988; Snyder-
Mackler, Fitzgerald, Bartolozzi, & Ciccotti, 1997), but
neuromuscular training may induce compensatory
alterations in muscle activity patterns to enhance the control
of abnormal joint translations during functional activities
(Wojtys et al., 2000). Neuromuscular training has therefore
become integrated into ACL rehabilitation protocols
(Fitzgerald, Axe, & Snyder-Mackler, 2000a; Risberg,
Mørk, Jenssen, & Holm, 2001). An inappropriate or delayed
neuromuscular response can result in dynamic instability
with recurrent episodes of joint subluxation. Therefore, both
mechanical stability and neuromuscular control are import-
ant for long-term functional outcome, and both aspects must
be considered in the design of a neuromuscular rehabilita-
tion program after ACL reconstruction.
Three RCTs were identified that examined the evidence
for neuromuscular training; two trials evaluated the effect of
a conservative rehabilitation program following ACL injury
(Beard, Dodd, Trundle, & Simpson, 1994; Fitzgerald, Axe,
& Snyder-Mackler, 2000b) and one trial was performed
with subjects following ACL reconstruction (Liu-Ambrose,
Taunton, MacIntyre, McConkey, & Khan, 2003). Beard
et al. (1994) examined the efficacy of two 12-week regimens
of rehabilitation; a program of muscle strengthening and a
program designed to improve hamstring contraction reflexes
for knees with ACL deficiency. Significant improvements in
reflex hamstring latency and knee function (Lysholm score)
were found in the neuromuscular training group compared
to the traditional strength training group.
Fitzgerald et al. (2000b) evaluated the efficacy of a
standard ACL rehabilitation program augmented with a
perturbation training program in individuals with ACL
rupture. Both the standard program and the standard
program augmented with perturbation training consisted
of 10 training session over 5 weeks. A screening exam was
used to identify subjects with good potential for success in
the conservative rehabilitation programs. Both training
programs allowed subjects to return to high-level physical
activities, but more subjects in the program using pertur-
bation training returned to high-level physical activities
without episodes of giving way.
Liu-Ambrose et al. (2003) examined the effects of a
neuromuscular training program compared to a strength
training program on neuromuscular function after ACL
reconstruction. The strength training program took place
twice weekly, for 12 weeks, and was supervised by a
physical therapist. The neuromuscular training group
demonstrated a greater percent change in isokinetic torques
than the strength training group, but both groups influenced
the peak hamstring torque time.
141
7.1. Methodological quality
Methods of randomization were given in one study as
random allocation using stratification on gender, time since
injury, frequency of sport, and frequency of giving way
(Beard et al., 1994). Another study stated that the subjects
were randomly assigned using a computer-generated
random number list (Fitzgerald et al., 2000b). The other
study (Liu-Ambrose et al., 2003) did not state method of
randomization. Power analyses were only included in one
trial (Liu-Ambrose et al., 2003), but with limited infor-
mation as to how many should have been included. Assessor
blinding was only stated in one study (Beard et al., 1994).
Baseline data were stated in all the studies. Seven subjects
were lost to follow-up in one study (Beard et al., 1994), two
subjects in the other study (Fitzgerald et al., 2000b), and
numbers were not stated in the last study (Liu-Ambrose
et al., 2003). Interventions were well described in all
the studies. The training programs lasted for 5 weeks
(Fitzgerald et al., 2000b) and 12 weeks (Beard et al., 1994).
Compliance was recorded either as number of sessions
completed in the different training protocols (Beard et al.,
1994; Liu-Ambrose et al., 2003), or as criteria for
completing the study (Fitzgerald et al., 2000b). Beard et al.
(1994) recorded compliance to the twice weekly for 12
weeks rehabilitation programs, but had no compliance data
for the recommended home program for both groups.
Relevant clinical outcome measurements were included, but
one of the studies should have included muscle strength data
(Beard et al., 1994). Follow-up time was insufficient,
ranging only from 12 to 24 weeks.
7.2. Summary
The evidence on neuromuscular training is limited based
on very few studies; however, they all reported promising
results for the effect of neuromuscular training. More long-
term outcomes should be included in future studies to assess
the effect of neuromuscular training and strength training for
the development of knee osteoarthritis.
8. Specific exercises
Very few specific exercises have been evaluated for
effectiveness in eliminating lower limb dysfunction. In fact,
only three RCTs were identified that provided evidence for
prescribing specific exercises (Blanpied et al., 2000; Hehl,
Hoellen, Wissmeyer, & Ziegler, 1995; Meyers, Sterling, &
Marley, 2002). Specific exercises have also been examined
for biomechanical and muscle activity purposes.
Hehl et al. (1995) examined the effect of adding
isokinetic strength training from the 7th to the 9th week
after ACL reconstruction or augmented repair. Significant
improvements in muscle strength were found in the group
that underwent supplementary isokinetic strength training,
142 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
and no significant differences in knee joint laxity were
observed at 6 months after surgery.
Blanpied et al. (2000) investigated how the incorporation
of a lateral slide exercise on a slide board compared to a
control group in a home-based program 8 weeks after ACL
reconstruction. The authors reported a significant 38%
increase in knee peak isometric extension torque, when
compared to the control group. However, the number of
lateral step-up repetitions to fatigue was not different from
the control group.
Meyers et al. (2002) examined the effect of stair climbing
as an alternative to cycling in patients with ACL
reconstruction. Subjects started with either stair climbing
or cycle ergometry at 4 weeks after ACL reconstruction.
The stair climbing or cycling program lasted for 8 weeks,
included 24 training sessions lasting from 15 min with
progression to 60 min. Subjects in both groups were without
surgical complications, had full weight-bearing, and a
symmetrical gait. No significant differences were found
between the two modalities and the authors concluded that
there were no deleterious effects with using stair climbing
versus cycle ergometery.
8.1. Methodological quality
Methods of randomization were not given in any of these
studies of specific exercises. Hehl et al. (1995) should
probably have included stratification at randomization
because they included two types of ACL surgery. No
studies included statistical power calculations, and one trial
included only 14 subjects (Blanpied et al., 2000). Assessor
and participant blinding were not stated in any of the three
trials. Baseline data was given in one study (Blanpied et al.,
2000) and not stated in another (Meyers et al., 2002).
Furthermore, post-training data for the most relevant
outcome measurement (quadriceps muscle strength) was
not reported. Only data for the uninjured leg was included.
Loss to follow-up was not reported in any of the three
studies (Blanpied et al., 2000; Hehl et al., 1995; Meyers
et al., 2002). The interventions were described, however no
studies reported compliance. Clinical relevant outcome
measurements were lacking in one trial (Hehl et al., 1995).
As reported above, Meyers et al. (2002) included isokinetic
muscle strength measurements only for the uninjured leg,
providing no data for the injured leg. The outcome
measurement ‘thigh circumference’ lacks sensitivity and
specificity, and would not be considered a valid outcome
measurement for thigh muscle strength. Sufficient follow-up
time was absent in two of the studies (Blanpied et al., 2000;
Meyers et al., 2002).
8.2. Summary
The findings of better recovery of muscle strength from
isokinetic strength exercises as a supplement to the standard
rehabilitation program requires confirmation, because of
the potential flaws in randomization (Hehl et al., 1995). The
effect of lateral slide exercise needs to be confirmed in a
RCT with adequate statistical power (Blanpied et al., 2000),
however, the preliminary data in this study seem promising.
The effect of stair climbing versus ergometer cycle needs to
be confirmed in a new RCT. All of the studies on specific
exercises have significant flaws, and little evidence could be
derived. New RCTs need to be repeated stating power
calculations, method of randomization, assessor blinding,
baseline data, and with sufficient follow-up time.
9. Conclusions
Evidence for effective ACL rehabilitation has been
assessed based on RCTs from six different areas: rehabilita-
tion protocols, home versus supervised rehabilitation, CKC
versus OKC exercises, NMES for quadriceps muscle
strengthening, neuromuscular training, and specific exer-
cises used within rehabilitation programs. Several of the
RCTs in this systematic review have significant flaws, and
limited evidence could be derived from them. Adequate
statistical power calculations are missing in nearly all the
trials. A description of the compliance to the exercise
protocols and the blinding procedures are lacking in many
of the trials. Compliance data is poorly reported, and
possibly one of the most important variables due to the dose-
response relationships for effectiveness. Evidence for
intensity, frequency, and duration is only reported in the
literature for muscle strengthening (American College of
Sports Medicine, 1990). Any study including interventions
using below the recommended frequency, intensity, and
duration for muscle strength training should be disregarded.
Dose-response curves for NMES are reported in one study
(Snyder-Mackler et al., 1994). Dose-response curves for
neuromuscular training is not known or described in any
studies. Sufficient follow-up times are lacking on most of
the trials and is a significant limitation to the development of
evidence-based rehabilitation recommendations. Long-term
follow-up is crucial for assessing the effectiveness of
rehabilitation programs following ACL injury and recon-
struction, as the most important long-term negative
consequence is the development of knee osteoarthritis.
One or two RCTs within each of the following four
rehabilitation areas have sufficient methodological quality
to be assessed as best evidence, however, none of the trials
have included all the criteria for high methodological
quality: home-versus supervised rehabilitation (Fischer
et al., 1998; Schenck et al., 1997), CKC versus OKC
(Bynum et al., 1995; Mikkelsen et al., 2000), NMES
(Snyder-Mackler et al., 1995), and neuromuscular training
(Beard et al., 1994).
Immediate weight-bearing after ACL reconstruction
can be recommended. The rehabilitation programs need to
be monitored by a physical therapist, but continuous
monitoring may not be necessary. Some level of physical
 M. Arna Risberg et al. / Physical Therapy in Sport 5 (2004) 125–145
therapy visits seem important to assess, educate, instruct,
and adjust the rehabilitation programs for progression.
The evidence for water-based rehabilitation program
needs to be confirmed, but for patients with effusion
problems the one RCT (Tovin et al., 1994) seems to
document the promising effect of hydrotherapy for ACL
reconstructed patients.
The literature supports the use of CKC exercises
selecting knee joint motions of less than 608, and OKC
exercises with knee angles greater than 408 of flexion for
quadriceps muscle strength training without increasing the
strain on the ACL, and without increased stresses on the
patellofemoral joint. OKC exercises seem to be favorable
for increasing quadriceps muscle strength, and carefully
controlled OKC exercises within the 40– 908 of flexion
starting at week 6 postoperatively could be recommended
based on the previously reported literature. However, there
is a need for long term follow-up studies to understand the
consequences of including OKC exercises early after ACL
reconstruction.
There is evidence that high intensity NMES in addition to
volitional exercises improves isometric quadriceps muscle
strength. Using NMES in 658 of knee flexion as described in
the studies, can be recommended without concern about
strain on the ACL.
The evidence for neuromuscular training is limited, but
all trials have reported promising results both for increased
knee function and increased neuromuscular control.
Although we lack dose-response evidence and long-term
follow-up studies, clinicians should incorporate neuromus-
cular training.
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