Traditional vs Accelerated
Kathryn A. Koshansky, MS, ATC
Athletic Training Program Chair
School of Health Technology & Management
Stony Brook University
May 11, 2012
nCertified Athletic Trainer = 29 yrs
nChair of SBU Athletic Training Program
nState Education Board for Athletic Training
nNATA D2 Advanced Education Committee
nFormer SBU Assistant AD for Sports
nIdentify examples of ACL RTP that are
shared in the media.
nDiscuss the common in ACL rehabilitation
protocols used over the past 30 years.
nProvide insight to the concept of being
n Former NFL wide receiver Jerry Rice famously made a
comeback 3 ½ months after undergoing ACL
reconstruction in 1997; In his first game back, he
fractured his kneecap (where the ACL graft was taken
from). This new injury ended his season.
n 35-year-old forward player; isolated complete ACL tear; competitive
2001-2002 season; contention for a position on the Italian World
Cup Team that was to be played 135 days after his injury, only if he
demonstrated that he could return to play at the highest level before
the team was selected.
n ACL surgery 4 days after the injury. 8 days after surgery he began
rehabilitation at a rate of 2 sessions a day, 5 days a week, plus 1
session every Saturday morning. Sessions involved pool (aquatic
exercises), gymnasium (flexibility, coordination, & strength
exercises), and soccer field (technical and tactical skills)
n The surgical technique and the progressive rehabilitation program
allowed the patient to play for 20 minutes in an official First Division
soccer game 77 days after surgery and to play a full game 90 days
after surgery. 18 months post surgery, the player had participated in
62 First Division matches, scoring 26 times, and had received no
further treatment for his knee.
Three months removed from a torn ACL, Detroit Lions running
back Kevin Smith says he’s on schedule in rehabbing his
knee. But he also says that he’s not running yet and not sure
how long it will be before he’s back to full speed: “My leg is
feeling good and I think I’m right on schedule,” Smith wrote on
his personal web site. “I’m just taking it day-by-day, doing my
rehab every day and lifting. It’s time to get back into it.
Football season is going to come back around real fast.
There’s no timeline for my knee, I just know that I don’t want
to waste a single day,” Smith wrote. “I rehab with a purpose,
every day I find the focus to get myself right. My time is
coming really soon.” March 2010
n When is it safe to Return to Play?
nIf it were that easy… we all may be out of
jobs, or have much less stress in our jobs!
nThe patient (and their family, coaches, etc)
have all the answers
nEach patient is the perfect patient
nNot going to happen!
We’ve Heard it All…
n “When’s the quickest I can get back to activity?”
n “I have to be back by …”
n “My friend so & so got back to activity …”
n “At xyz college so & so got back to playing …”
n “I’m committed to my rehab!”
n “You don’t know me, I’m a quick healer!”
Where are we in 2012?
We are living in a world of INSTANT GRATIFICATION!
ACL Rehab Timeline
n“Surgical stability is easily reproducible,
long-term patient satisfaction is difficult to
guarantee.” Shelbourne, 2006
nDamaged structures in addition to ACL
nBone will have meaningful incorporation
by 6-8 weeks
nSoft tissue healing to bone with fibrous
tissue or scar may take up to 12 weeks
where it's relying on the screws alone
before the fibers start growing into bone
Goals of ACL Rehabilitation
nReturn the patient back to activity as soon
as possible but also as safely as possible
nReach symmetry between knees:
nRange of Motion
nSuccessfully pass RTP testing
Traditional (early 1980’s)
Accelerated (late 1980’s)
Cascade of events outlines a systematic rehabilitation program that emphasizes the return to symmetrical knee motion that
includes hyperextension. ROM, range of motion. Shelbourne & Klotz, 2006
Perioperative Phases of Rehabilitation. Shelbourne & Klotz, 2006
nYou've lived it!
nWhat works for you and your patient?
Critical input from..
n Physician (surgeon)
n Certified Athletic Trainer
n Physical Therapist
n Athlete (+/- parents)
n +/- Coach
nTo return earlier there is a higher failure
nIt's the patient's call but they have to live
with the consequences
nRehabilitation program is NOT going to
follow the same timeline for each athlete
nEvery athlete is different
nRehabilitation should be “Patient Driven”!
Take Home Message
nProtocol should be built on criteria-based
progression rather than time-based
progression; with the knowledge of graft
nIf your athlete is not playing sports at 6
months… stop expecting that something is
n Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, Nichols CE. Accelerated versus nonaccelerated
rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind investigation evaluating
knee joint laxity using roentgen stereophotogrammetric analysis. Am J Sports Med. 2011 Dec;39(12):2536-48. Epub 2011
n Decarlo MS, Shelbourne KD, McCarroll JR, Rettig AC. Traditional versus Accelerated Rehabilitation following ACL
Reconstruction: A One-Year Follow-Up. J Orthopaedic Sports Physical Therapy. 1992;15(6):309-16.
n Roi GS, Creta D, Nanni G, Marcacci M, Zaffagnini S, Snyder-Mackler L. Return to Official Italian First Division Soccer
Games Within 90 Days After Anterior Cruciate Ligament Reconstruction: A Case Report. Journal of Orthopaedic & Sports
Physical Therapy. 2005;35(2): 52-66.
n Pezzullo, David & Fadale P. Current Controversies in Rehabilitation After Anterior Cruciate Ligament Reconstruction. Sports
Medicine and Arthroscopy Review. 2010; 18(1); 43-47.
n Shaw T. Accelerated rehabilitation following anterior cruciate reconstruction. Physical Therapy in Sport. 2002; 3: 19-26.
n Shah VM, Andrews JR, Flesig, GS, McMichael CS, Lemak LJ. Return to Play After Anterior Cruciate Reconstruction in
National Football League Athletes. American Journal of Sports Medicine. 2010; 38(11):2233-2239.
n Shelbourne KD & Klotz C. What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total
knee symmetry after anterior cruciate ligament reconstruction. Journal of Orthopaedic Science. 2006;11:318-325.
n ACL Protocols from: Dr. Stuart Cherney (All-Sport Orthopaedic Surgery)
Dr. James Paci and Dr. James Penna (SBU Department of Orthopaedics)