Return to Official Italian First Division

Soccer Games Within 90 Days After

Anterior Cruciate Ligament Reconstruction:
A Case Report
Giulio S. Roi, MD 1
Domenico Creta, MD 2
Gianni Nanni, MD 3
Maurilio Marcacci, MD 4
Stefano Zaffagnini, MD 4
Lynn Snyder-Mackler, PT, ScD, ATC, SCS, FAPTA 5
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T
Study Design: Case report. he fastest possible safe
Background: To present the rehabilitative course, decision-making, and clinical milestones that return to competitive
allowed a top-level professional soccer player to return to full competitive activity 90 days after games after anterior
surgery.
cruciate ligament
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Case Description: The patient was a 35-year-old forward player who sustained an isolated
complete tear of the left anterior cruciate ligament (ACL) in the midst of the competitive
(ACL) reconstruction
2001-2002 season. He was in contention for a position on the Italian World Cup Team that was to for a professional athlete is the
be played 135 days after his injury, only if he demonstrated that he could return to play at the goal of every sports rehabilitation
highest level before the team was selected. The patient underwent an arthroscopically assisted team. While there is no consensus
ACL reconstruction with a double-loop semitendinosus-gracilis autograft 4 days after the injury. of opinion about timing,23,26 surgi-
Eight days after surgery he began rehabilitation at a rate of 2 sessions a day, 5 days a week, plus 1 cal techniques, and rehabilitative
session every Saturday morning. These sessions were performed in a pool for aquatic exercises, in protocols after ACL rupture, sev-
a gymnasium for flexibility, coordination, and strength exercises, and on a soccer field for recovery
eral studies demonstrate that early
of technical and tactical skills, with continuous monitoring of training intensity.
Journal of Orthopaedic & Sports Physical Therapy®

Outcomes: The surgical technique and the progressive rehabilitation program allowed the patient accelerated and progressive proto-
to play for 20 minutes in an official First Division soccer game 77 days after surgery and to play a cols of rehabilitation do not ad-
full game 90 days after surgery. Eighteen months postsurgery, the player had participated in 62 versely affect functional recov-
First Division matches, scoring 26 times, and had received no further treatment for his knee. ery.12,13,21,22 The timetable for re-
Discussion: This case report suggests that early return to high-level competition after ACL turn to full activity after ACL re-
reconstruction is possible in some instances. Some factors that may have favored the early return construction has moved from
include optimal physical fitness before surgery, a strong psychological determination, an isolated longer than a year in the 1970s to
ACL lesion, a properly placed and tensioned graft, a personalized progression of volume and
a range of 4 to 9 months to-
intensity of exercise loads, and an appropriate density of rehabilitative training consisting of a mix
of gymnasium, pool, and field exercises. J Orthop Sport Phys Ther 2005;35:52-66.
day.11,12,22,24 Information about
resolution of impairments after
Key Words: ACL, knee, rehabilitation, semitendinosus ACL injur y (muscle strength,
range of motion [ROM], effusion)
1
Director, Isokinetic Education and Research Department, Bologna, Italy. is readily available in the litera-
2
Physical Therapy Clinician Specialist, Isokinetic Rehabilitation Centre, Bologna, Italy. ture, but there is little information
3
Sports Medicine Clinician Specialist, Isokinetic Rehabilitation Centre, Bologna, Italy.
4
Orthopaedic Surgeon, Rizzoli Orthopaedic Institute, Bologna, Italy. about how activity affects graft
5
Professor, Department of Physical Therapy and Biomechanics and Movement Science Interdisciplinary healing.1,3 While it is clear that
Program, University of Delaware, Newark, DE. immobilization adversely affects
Address correspondence to Giulio S. Roi, Education and Research Department Isokinetic, Via di
Casteldebole 8/4, 40132 Bologna, Italy. E-mail: gs.roi@isokinetic.com healing, appropriate levels of activ-
ity to optimally load the graft at

52 Journal of Orthopaedic & Sports Physical Therapy

 each stage of healing have not been determined.
The pressure to return elite professional athletes to
preinjury competitive levels is immense. The intensity
at which they must perform upon return to competi-
tion presents additional burdens to the athlete and
the rehabilitation professionals. The athlete, being a
professional, however, allows for more frequent and
more intense (hours per day) rehabilitation to facili-
tate return to play. Indiscriminate acceleration of
rehabilitation can be dangerous; therefore, in sports
medicine, the answer to the question ‘‘How soon can
he/she return to play?’’ must always be ‘‘As fast as
safely possible.’’
The purpose of this case report is to detail the
evaluation, rehabilitation, and functional recovery of
a top-level athlete following an isolated ACL injury.
While the extent and intensity of the rehabilitation is
not typical, there are some aspects of the progression
of this athlete that are generalizable to ACL rehabili-
tation for all. Thus we present the rehabilitative
course, decision-making, and clinical milestones that
allowed a professional soccer player to return to full
competitive activity in the Italian First Division 90
days after surgery.

CASE REPORT
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CASE DESCRIPTION

A forward soccer player (age, 35 years; height, 176

cm; mass, 76 kg) sustained a complete tear of his left
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ACL during the 59th minute of a professional league

game during the 2001-2002 season. The mechanism
of injury was noncontact and there were no concomi-
tant ligament or cartilage injuries. The day after the
FIGURE 1. The tendons’ tibial insertions are maintained. The graft is
injury the player was unable to walk without a limp, passed through the tibial tunnel, out the ‘‘over the top’’ position of
walked with crutches without weight bearing, had a the femur, inserted from the outside in through a femoral tunnel,
grade 3 (2+) effusion, had full knee extension, had a back through the tibial tunnel, and fixed with a transosseous suture.
knee flexion deficit of 15°, had a pain score between (Reprinted with permission from Marcacci et al.15)
Journal of Orthopaedic & Sports Physical Therapy®

2 and 3 on a 1-to-10 scale, had a positive (++)

Lachman test, and had a positive (+) Drawer test.
After the injury and until surgery, the patient was
self-treated with ice, rest, and elevation.
While typically the athlete would have not at-
tempted to return until the next competitive season,
he was in contention for a position on the Italian
World Cup Team that was to be played 135 days after
his injury, only if he could demonstrate that he could
return to play at the highest level before the team
was selected.
He had played soccer in the Italian First Division
(Serie A) since the 1986 season and had played on 3
previous Italian World Cup teams. Throughout his
career he suffered multiple lower extremity contu-
sions, sprains, and muscle strain injuries typical of
soccer players who play at the highest level. He had
not previously injured his left knee, but had under-
gone a right ACL reconstruction 16 years ago.
Surgery
He underwent an arthroscopically assisted ACL
reconstruction with a double-loop semitendinosus-
gracilis autograft 4 days after the injury (Figure 1).15
The tendons were harvested maintaining their tibial
insertion. Sutures were tightened at the free proximal
tendon ends to obtain a sufficient strength to trac-
tion. The tibial tunnel was located in the medial,
posterior part of the ACL tibial insertion. For the
femoral tunnel, the knee was flexed around 130° and
the guide pin was advanced until it passed the
femoral cortex. The exit point in the lateral aspect of
the femur was immediately above the end of the
lateral femoral condyle. After the lateral incision, the
tendons were passed ‘‘over the top.’’ The correct
placement was found by palpating the posterior
tubercle of the lateral femoral condyle with a finger.
The stitches on the free end of the tendons were tied

J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005 53

 onto the passing suture that was pulled through the
knee joint into the over-the-top position. A suture
loop was introduced into the joint through the
anteromedial portal using a suture passer and then
pulled into the femoral tunnel under the
arthroscopic view. The stitches on the free end of the
tendons were looped again onto the passing suture,
which was pulled through the femoral tunnel, knee
joint, and tibial tunnel to retrieve the graft from the
tibial incision. The combined gracilis and
semitendinosus tendons were then tensioned and
secured with a transosseus suture knot. This tech-
nique attempts to reproduce the kinematic effect of
both anteromedial and posterolateral bundle of the
ACL with a 4-bundle reconstruction.15
Initial Examination
Patient evaluation and identification of rehabilita-
tion outcomes were performed on postoperative day
(POD) 8, POD 11, and then weekly until discharge.
During each examination, effusion was evaluated
using a stroke test and a 0-to-4 scale where grades of
0 to 1 (0 to trace effusion) were necessary to allow
rehabilitation progression. The stroke test is per-
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several strokes upward from the medial joint line
towards the suprapatellar pouch in an attempt to
move effusion from the medial aspect of the knee.
The examiner then strokes downward on the lateral
side of the knee from the suprapatellar pouch
towards the lateral joint line, observing the medial
aspect of the knee in an effort to appreciate a fluid
wave emanating from the suprapatellar pouch. If no
wave is produced with the downward stroke, there is
no effusion present (0). If the downward stroke
produces a small wave on the medial side of the
knee, the effusion is given a ‘‘trace’’ (grade 1) rating;
a larger bulge is given a 1+ (grade 2) rating. If the
effusion returns to the medial side of the knee
without a downward stroke, the effusion is given a 2+
(grade 3) rating. The inability to move the effusion
out of the medial aspect of the knee equates to a 3+
(grade 4) rating.2
ROM was assessed using a large (30-cm), clear
plastic universal goniometer. Pain was assessed using
a verbal rating scale of 1 to 10, where 1 is defined as
no pain and 10 as maximum pain. Functional mile-
stones were also assessed. The presence of knee pain
or loss of ROM were criteria for slowing the rehabili-

formed with the patient in supine and the knee tation progression. At the time of the first examina-
relaxed in full extension. The examiner performs tion (POD 8), the patient had a trace effusion, pain

TABLE 1. Outcome measures during the rehabilitation period. Swelling was rated on a 0-to-3+ scale.
Days
Postoperative Event Pain Swelling Knee ROM Strength Functional
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

–3 Medical check 1 d Knee (3/10) 2+ 2°-0°-125° - Walk with

after injury crutches
0 Surgery - - - - -
8 Medical check before Knee flexors 1+ 10°-80° - Walk with
start of rehabilitation muscles (3/10) crutches
11 Medical check Knee flexors 1+ 5°-105° - Walk with
muscles (2/10) crutches
15 Medical check None 1+ 0°-115° - Walk with 1
crutch
24 Medical check None 0/1+ 0°-125° - Walk without
Journal of Orthopaedic & Sports Physical Therapy®

crutches
29 Medical check None 0/1+ 2°-0°-140° (full) - Running
38 Medical check None 0/1+ Full - Running and start
of on field reha-
bilitation
71 Medical check None 0 Full Isometric KE Individual soccer
–5%, compared exercises
to uninvolved
side; no differ-
ence in the 1
leg hop test
77 Medical check after None 0 Full - Game (20 min)
game
90 Medical check after None 0 Full - Game (90 min)
game
517 Medical check None 0 Full KE +3%; KF Individual and
+2% compared team soccer
to uninvolved exer cises
side at 90°/s
(isokinetic)

Abbreviations: KE, knee extensors; KF, knee flexors.

54 J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005

 (rating 3) only to the knee flexors, and knee ROM left knee showed no pain, no swelling, normal ROM,
was from 10° to 80° of flexion. He walked with a left knee extensors force of at least 80% of the
crutches, applying partial weight bearing, and was not right side, as measured isometrically on an electrome-
immobilized in a brace (Table 1). chanical dynamometer at 80° of knee flexion, and
successful completion of a running progression run-
Intervention ning at 8 to 10 km/h without symptoms for about 20
minutes. On the soccer field, sport-specific drills,
After surgery the patient was instructed in a home
such as sprinting, changing direction, jumping, drib-
exercise program that included rest, elevation, ice (2
bling, and kicking, were begun at submaximal inten-
to 3 times a day for 20 minutes), passive and active
sity. The athlete did not use any knee brace.13
ROM exercises, and neuromuscular electrical stimula-
During each rehabilitative session on the soccer
tion of the quadriceps using a battery-powered stimu-
field, the patient wore the heart rate monitor
lator with his knee in full extension.
(Sportester; Polar Electro, Kempele, Finland) to con-
Eight days after surgery the patient began super-
trol the metabolic intensity of the rehabilitative train-
vised rehabilitation. The frequency of his rehabilita-
ing. The first few weeks, the emphasis was on aerobic
tion sessions was twice a day, 5 days a week, plus 1
training; anaerobic training was incrementally in-
weekend session every Saturday morning. The details
creased thereafter by increasing the number of min-
of the rehabilitation program are listed in Table 2.
utes of training at heart rates above that at which the
Generally, there were specific interventions address-
anaerobic threshold is reached. All sessions on the
ing ROM, strength, proprioception, pain, swelling,
rehabilitation soccer field were of a 120-minute dura-
and aerobic fitness in each rehabilitation session.
tion.
After the sutures were removed the patient began
After 1 week of training on the soccer field (POD
water exercises that comprised approximately half of
45), aerobic and anaerobic thresholds were assessed
the sessions during weeks 3 through 5 (Table 2). The
by an incremental treadmill-running test, starting at 7
rehabilitative work in the pool incorporated sports-
km/h, with increments of 2 km/h every 3 minutes

CASE REPORT
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specific drills, such as heading drills (Figure 2), in

until anaerobic threshold was reached, as indicated
preparation for transition to rehabilitation on the
by a capillary blood lactate concentration of greater
soccer field. In the first 4 weeks, the hamstrings were
than 4 mmol/L (assessed by Lactate Analyzer YSI
treated as if affected by a severe muscle tear, because
1500 Sport [Yellow Spring Corporation, Yellow
of the surgical trauma related to harvesting of the
Springs, OH]). From the relationships between heart
graft. Massage and flexibility exercises were allowed
rate, lactate, and running speed (Figure 3) it is
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

and only isometric hamstring-strengthening exercises

possible to identify the reference heart rates that
were performed.
allow the patient to control the metabolic intensity of
One week after the first evaluation (POD 15), the
the workout (Figures 4 and 5).8 The patient’s aerobic
left knee ROM was from 0° to 115° of flexion, and
threshold was 10.3 km/h and anaerobic threshold
the patient had pain (rating 2) only to the knee
was 13.1 km/h. His anaerobic value prior to the 1994
flexors and a trace (grade 1) effusion. We therefore
World Championships was 12.9 km/h.
began a treadmill walking/running progression to
The return to official competitions was permitted,
facilitate a return to running. Criteria for progression
considering: lack of subjective feeling of instability, a
were no knee pain, no increase in effusion, and
full recovery in soccer-specific drills, a KT1000 score
Journal of Orthopaedic & Sports Physical Therapy®

continued increase in knee ROM. Distance grade and

speed progressed as listed in Table 2.
A unique aspect of this program was the attention
to maintaining an overall fitness level compatible with
playing soccer at the premier level. At 1 month after
surgery, the patient had full ROM (2°-0°-140°), and 0
to trace effusion. He was then progressed to running
on the treadmill in preparation for returning to
high-level activity. Running in the pool, swimming
with resistance, and walking at a fast pace on an
incline were all used to increase aerobic capacity. The
goal of the program was to achieve elite levels of
aerobic and anaerobic fitness at the time of return to
competition. The mean (±SD) aerobic threshold
running speed for elite forwards in soccer is 11.8 ±
1.4 km/h and the anaerobic threshold speed is 14.1 ±
1.4 km/h.20
General and sport-specific drills on a soccer field
began 39 days after surgery as the examination of the
of less than 2-mm difference from the other side, an
aerobic threshold speed greater than 11 km/h, an
anaerobic threshold speed greater than 13.5 km/h,
and a side-to-side difference in knee extensors isomet-
ric torques of less than 10% at 80° of knee flexion.
OUTCOMES
The player returned to an official competitive
game 77 days after surgery. At that time, the func-
tional recovery was completed, but the conditioning
training was still incomplete (note that total time of a
soccer game is 90 minutes). From the data collected
during the rehabilitative sessions on the soccer field,
we estimated that he would be able to play at the
First Division intensity for about 45 to 60 minutes
without fatigue. Therefore, he was allowed to play
during the last 20 minutes of the game, scoring twice.

J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005 55

 TABLE 2. Details of the rehabilitation program. Knee rotators are exercised while seated.
Postoperative
Days/Treatment
Categories Regimen
Days 8-17
ROM Extension: prone leg hang and pendulum
Strength Active cocontractions of knee extensors and flexors (10 × 45 s, 15 s recovery); hip flexors and hip ab-
ductors (2 kg, 6 × 15 rep, 15 s recovery); isometric hip adductors (10 × 45 s, 15 s recovery); knee
extension from 45° to 0° (2 kg, 6 × 15 rep, 6 × 15 s); leg press (elastic) eccentric modality
Proprioception -
Massage Lower limbs 30 min
Ice 15 min at the end of the session
Warming-up and Aerobic Stationary bicycling with low seat position 10 min
Indoor Pool -
On-Field Rehabilitation -
Training With the Team -

Days 18-29
ROM Extension: prone leg hang and pendulum
Strength Active cocontractions of knee extensors and flexors (10 × 45 s, 15 s recovery); hip flexors and hip ab-
ductors: (3 kg, 6 × 15 rep, 15 s recovery); isometric hip adductors (10 × 45 s, 15 s recovery); seated
knee extension with tubing and with load from 45° to full extension (4 kg, 6 × 15 rep, 6 × 15 s); leg
press (elastic) eccentric modality
Proprioception Unstable surfaces, bipodal and monopodal for 10 min
Massage Lower limbs 30 min
Ice 15 min at the end of the session
Warming-up and Aerobic Stationary bicycling 10 min; stepper 5 min (level 1); treadmill walk 4 km/h 6% grade
Indoor Pool Walking 10 min, hip extension, flexion, abduction and adduction without and with float flipper; leg
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press with floats; running in deep water without body weight

On-Field Rehabilitation -
Training With the Team -

Days 30-42
ROM Flexion: heel slide, active assisted flexion
Strength Knee flexors (2 kg, 2 × 15 rep); wall slide (6 × 10 rep); seated knee extension (4 kg, 6 × 15 rep,
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

6 × 15 s); leg press (elastic) with 1 leg (6 × 10 rep); leg press with 1 leg (50 kg, 6 × 15 rep)
Proprioception Unstable surfaces monopodal, bouncer for 10 min
Massage Lower limbs 30 min
Ice 15 min at the end of the session
Warming-up and Aerobic Treadmill walk 10 min at 5.5 km/h 0% grade; running 10 min at 7 km/h, 0%-3% grade; stepper, 10 min
(level 6)
Indoor Pool Back swimming, stretching, crawl swimming with small board; exercises with small and long flippers;
forward, lateral skips; running in deep water without body weight, running in low water with weight
bearing; jumps, headings; free swimming
On-Field Rehabilitation -
Training With the Team -
Journal of Orthopaedic & Sports Physical Therapy®

Days 43-59
ROM Stretching exercises
Strength Knee flexors (2 kg, 2 × 15 rep); wall slide (6 × 10 rep); knee rotators (tubing, 8 × 40 rep); seated leg
extension (progressively up to 40 kg, from 90° to full extension, 8 × 10 rep; progressively up to 45 kg,
from 45° to full extension, 6 × 15 rep); isokinetic knee extension (300°/s, 6 × 10 rep), NMES 20 min
vastus lateralis and medialis
Proprioception Bouncer 10 min
Massage Lower limbs 30 min
Ice 15 min at the end of the session
Warming-up and Aerobic Treadmill walk 10 min at 5.5 km/h 0% grade; running 10 min at 7.5 km/h, 0-6% grade
Indoor Pool -
On-Field Rehabilitation Slow running, exercises for a correct running pattern; circular running, bends, changing directions,
sprint, decelerations, stop and go; anaerobic threshold running for 8 min
Training With the Team Tactical skills at game intensity

56 J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005

 TABLE 2 (continued)
Postoperative
Days/Treatment
Categories Regimen
Days 60-72
ROM Stretching exercises
Strength Knee flexors (3 kg, 2 × 15 rep); knee internal rotators (tubing, 8 × 40 rep); seated leg extension (40 kg
from 90° to full extension, 8 × 10 rep; 45 kg from 45° to full extension, 6 × 15 rep); isokinetic knee
extension (300°/s, 4 × 20 rep), NMES 20 min vastus lateralis and medialis
Proprioception Bouncer and proprioception exercises for 10 min
Massage Lower limbs 30 min
Ice -
Warming-up and Aerobic Treadmill walking 10 min at 5.5 km/h, 0%-3% grade
Indoor Pool -
On-Field Rehabilitation Running, individual and collective technique with soccer ball; dribbling, submaximal shooting;
anaerobic threshold running for 20 min
Training With the Team Tactical skills at game intensity

Days 73-90
ROM Stretching exercises
Strength Knee flexors (4 kg, 2 × 15 rep); hip internal rotators (tubing, 8 × 40 rep); leg press (70 kg, 6 × 10 rep
slow); leg extension (40 kg from 90° to full extension, 8 × 10 rep; 45 kg from 45° to full extension, 6
× 15 rep)
Proprioception Bouncer and proprioception exercises for 10 min
Massage Lower limbs 30 min
Ice -
Warming-up and Aerobic Treadmill walking 10 min at 5.5 km/h, 0%-3% grade
Indoor Pool -

CASE REPORT
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On-Field Rehabilitation Running, sprinting, changing direction, decelerations; individual technique with ball, team drills; small-
to large-sided soccer matches (2 to 2; 4 to 4), jumping, shooting, tackling; anaerobic threshold
running 20 min
Training With the Team Tactical skills at game intensity
Abbreviations: NMES, neuromuscular electrical stimulation; rep, repetitions.
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

We also employed a countermovement jump test

where the athlete performed a maximal vertical
jump, first on 2 legs, then on the uninvolved leg,
followed by the involved leg. There was no difference
in vertical jump height (0.20 m) or flight time (0.404
seconds) between limbs.
At 18 months after surgery, isokinetic testing at
90°/s revealed a quadriceps index of 103% (221
Journal of Orthopaedic & Sports Physical Therapy®

Nm/215 Nm) and a hamstring index of 102% (188

FIGURE 2. The heading drills were performed in the pool in
preparation for transition to the rehabilitative soccer field.
Nm/185 Nm) on bilateral comparison. KT-2000 test-
ing (maximum manual force) performed 18 months
after surgery was 6.5 mm on the involved side versus
6 mm on the other side. He had played in 62 First
Division matches since his return, scoring 26 times,
and had received no further treatment for this knee.

He participated in training with his team and contin- DISCUSSION

ued rehabilitation for an additional 2 weeks. At that
time, 90 days after ACL reconstruction, he partici-
pated in a full game, the last game of the champion-
ship, scoring 1 goal.
The outcome at the end of the rehabilitation
period, 90 days after surgery, was full ROM, isometric
quadriceps strength 95% of the contralateral side, no
reports of instability, KT-1000 side-to-side difference
of less than 2 mm, aerobic threshold speed at 11.8
km/h, and anaerobic threshold speed at 13.9 km/h.
This case report suggests a high rehabilitation
potential after ACL reconstruction in an elite athlete.
This soccer player underwent arthroscopically assisted
ACL reconstruction with a hamstrings autograft and
after 10 weeks of rehabilitation returned to play in a
limited capacity and played a full game 90 days after
surgery. Two years later, he continues to play soccer
at the highest level and has a stable knee by objective
testing and self-report. While the breadth and inten-

J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005 57


FIGURE 3. The incremental running test for assessing aerobic and
anaerobic thresholds. The relationship between heart rate (HR, in
beats per minute [bpm]) and speed (km/h) is indicated with clear
dots. The relationship between capillary blood lactate concentra-
tions (mmol/L) and speed (km/h) is indicated with solid dots. The
aerobic and anaerobic thresholds are indicated with vertical lines in
correspondence of capillary blood lactate concentrations of 2
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mmol/L (at 13 km/h, with a heart rate equal to 154 bpm) and 4
mmol/L (at 15.3 km/h, with a heart rate equal to 172 bpm).
sity of the rehabilitation described here may only be
possible with an individual who has the resources
(time and money) to invest in unlimited access to
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
rehabilitation facilities and personnel, much of what
is presented has an impact on the discussion of
optimal loading of the ACL graft and rehabilitation
after ACL reconstruction in general.
This athlete underwent reconstruction less than 1
week after injury. While there is some controversy
about the timing of ACL reconstruction following
injury, early reconstruction is often performed in
professional and top-level athletes when there is little
Journal of Orthopaedic & Sports Physical Therapy®
swelling, full knee extension, and the ability to walk
without a limp.9,12,21 In this situation the rehabilita-
tion may progress well and the early reconstruction
does not preclude an accelerated recovery.
Furthermore, the athlete presented to the rehabili-
tation center with only a trace effusion 8 days after
surgery. One week later, his ROM was 0° to 115°.
This underscores an important theme of this presen-
tation: that objective criteria, rather than specific
timetables, should guide clinical decision making.
This athlete was able to progress quickly. Others, with
more severe impairments or impairments that rede-
velop with added workload, may take more time to
progress through the program. Progressions that are
time based, rather than criterion based, ignore these
interpersonal differences.
This athlete had an isolated lesion of the ACL, with
no concomitant ligamentous, meniscal, or chondral
injury. These results should not be generalized to
58
those with more complicated injuries. In addition,
there is an individual variability in responding to the
healing process and rehabilitative protocols. Some
patients have a very slow recovery with respect to
others, despite the same precautions and care in
surgical and rehabilitative therapies. The surgery and
rehabilitation of the athlete presented here pro-
ceeded without any complication. Our most impor-
tant measure of overtaxing the knee was effusion.
Swelling or knee effusion are important factors in
slowing rehabilitation because they inhibit muscular
recruitment.5 Effusion was scored 1+ in the first days
after surgery and trace or lower (0-1+), without
increments, during the entire rehabilitation period.14
Again, we believe this underscores the importance of
using a criterion-based rather than a time-based
approach to progression of rehabilitation.
The early return to official competitive activity may
also have been a result of 2 intangibles: the fitness of
the athlete/status of the knee before surgery and the
mood status/mental preparation for the surgery and
rehabilitation.17,25 This professional soccer player had
been involved in the First Division Championship for
many years, where he trained about 5 days every week
for approximately 11 months every year. He was in
the midst of the competitive season when his injury
occurred. The patient was also highly motivated to
quickly return to play. He had previously experienced
other surgical and rehabilitative interventions and
therefore knew what to expect. While this situation
may be found among professional athletes, it may be
different in those in less competitive situations.18
In our patient we used a progressive rehabilitation
protocol focused on return of full knee extension,
control of swelling, proper gait, and quadriceps
strengthening. During the rehabilitative program,
care was taken to restore muscular strength with
isometric, isotonic, and isokinetic training, performed
according to the progressive-loading principle.19
While most reports of accelerated rehabilitation have
used bone-patellar tendon-bone autografts as the
graft source, accelerated rehabilitation has also been
used in the cases of ACL reconstructed with ham-
string graft.12,14 The medium- to long-term follow-up
studies, in which the 2 surgical techniques were
compared, demonstrated that they have similar out-
comes.7,16 The progressive rehabilitation program
described here is likely appropriate for both graft
types.
The concept of loading of the ACL graft is a
matter of great controversy. The most thorough study
of ACL graft biology is more than 30 years old and
reflects older surgical techniques and prolonged im-
mobilization, which are both detrimental to the
knee.3 More recent basic science research, where
isolated tendons under cyclic stress responded posi-
tively11 and where in a single case the graft-knee
complex was tested postmortem in an individual who
J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005
 FIGURE 4. Heart rate (HR) pattern during a rehabilitative session in the soccer field 74 days after surgery. The session lasted 115 minutes,
with HR between 120 and 170 beats per minute (bpm). S2 is the HR corresponding to the aerobic threshold; S4 is the HR corresponding to
the anaerobic threshold.

CASE REPORT
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100%

80%

>170
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

60% 160-170
150-160
40% 130-150
<130
20%

0%
Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Journal of Orthopaedic & Sports Physical Therapy®

FIGURE 5. Training intensity (percent of each rehabilitation session) at each heart rate for each session on the soccer field. Day 1
corresponds to postoperative day (POD) 38; day 21 corresponds to POD 86.

died 8 months after reconstruction,1 suggests that the
graft may be responsive to stress. These consider-
ations led our surgical and rehabilitative team to
conclude that graded, progressive loading of the ACL
graft may facilitate graft healing and incorporation.
While we cannot measure the graft response directly,
this patient had continued positive responses to
progression of rehabilitation with no signs of joint
distress.
We introduce the in-field rehabilitation as a corner-
stone of accelerated functional recovery of profes-
sional athletes. This innovation consists of sports-
specific exercises and drills performed in a playing
field under supervision of rehabilitative personnel,
without returning the player to the training control
of his own sports team. The use of the heart rate
monitor and periodic incremental treadmill tests to
determine aerobic and anaerobic fitness as well as
training intensity is another innovation we present
here. Overall fitness is often an afterthought and left
to the team to perform after the athlete is discharged
from formal therapy. Maintaining the athlete’s fitness
level at or near that required for competition cer-
tainly played a role in the rapid, successful return of
this player to competitive soccer.
In the literature there is 1 similar case where an
athlete returned to intercollegiate basketball 6 weeks
after ACL reconstruction.4 This athlete had recon-
struction using the contralateral patellar tendon as a
graft and returned to play an average of 29 of 40
minutes of each game. His 2-year subjective outcomes
were reportedly excellent. Despite the fact that a

J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005 59

 soccer player may be substituted only 1 time and the
pattern of the intensity of the game is intermittent
without resting pauses,6 the athlete described in our
report also successfully returned to competition
quickly after ACL reconstruction. Early return to
competitive team activity is possible when the athlete
must remain in the game, provided a complete
functional recovery of the injured limb has occurred.
The individual variability in responding to surgical
and rehabilitative therapies is a very difficult matter
to assess and needs further investigation.
CONCLUSIONS
This case report suggests that the surgical tech-
nique and progressive rehabilitation program used
after ACL reconstruction, including on-field rehabili-
tation with continuous monitoring of training inten-
sity, 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.
Optimal physical fitness before the surgery, a strong
psychological determination, an isolated or
noncomplicated ACL lesion, a properly placed and
tensioned graft, a personalized progression of volume
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and intensity of exercise loads, and an appropriate
density of rehabilitative training, consisting in a mix
of gymnasium, pool, and field exercises for a total of
about 120 sessions over 12 weeks, may all have
contributed to this positive outcome.
While the extent and likely timeline of the rehabili-
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tation provided here is not possible for the average
person after ACL reconstruction, we suggest that the
concepts of personalization of the program, objectiv-
ity of criteria for progression, and maintenance of
fitness can be generalized to all patients. In fact, this
case represents a perfect progression, rather than a
typical timeline, with rapid resolution of impairments
and excellent response to added workload.
Journal of Orthopaedic & Sports Physical Therapy®
ACKNOWLEDGMENTS
The authors would like to thank Claudio Carlotti,
Simone Maretti, and Antonio Tamisari for their
support and assistance in obtaining the data for this
report, and Wendy Hurd, PT, MS, for her assistance
with reviewing and editing the manuscript.
REFERENCES
1. Beynnon BD, Risberg MA, Tjomsland O, et al. Evalua-
tion of knee joint laxity and the structural properties of
the anterior cruciate ligament graft in the human. A
case report. Am J Sports Med. 1997;25:203-206.
2. Chmielewski TL, Mizner RL, Padamonsky W, Snyder-
Mackler L. Knee. In: Kolt G, Snyder-Mackler L, eds.
Physical Therapies in Sport and Exercise. London, UK:
Churchill Livingstone; 2003:379-398.
60
3. Clancy WG, Jr, Narechania RG, Rosenberg TD,
Gmeiner JG, Wisnefske DD, Lange TA. Anterior and
posterior cruciate ligament reconstruction in rhesus
monkeys. J Bone Joint Surg Am. 1981;63:1270-1284.
4. DeAndrade JR, Grant C, Dixon AS. Joint Distension and
Reflex Muscle Inhibition in the Knee. J Bone Joint Surg
Am. 1965;47:313-322.
5. De Carlo M, Shelbourne KD, Oneacre K. Rehabilitation
program for both knees when the contralateral
autogenous patellar tendon graft is used for primary
anterior cruciate ligament reconstruction: a case study.
J Orthop Sports Phys Ther. 1999;29:144-153; discussion
154-149.
6. Ekblom B. Applied physiology of soccer. Sports Med.
1986;3:50-60.
7. Eriksson K, Anderberg P, Hamberg P, et al. A compari-
son of quadruple semitendinosus and patellar tendon
grafts in reconstruction of the anterior cruciate ligament.
J Bone Joint Surg Br. 2001;83:348-354.
8. Foster C, Fitzgerald DJ, Spatz P. Stability of the blood
lactate-heart rate relationship in competitive athletes.
Med Sci Sports Exerc. 1999;31:578-582.
9. Graf BK, Ott JW, Lange RH, Keene JS. Risk factors for
restricted motion after anterior cruciate reconstruction.
Orthopedics. 1994;17:909-912.
10. Hannafin JA, Arnoczky SP, Hoonjan A, Torzilli PA.
Effect of stress deprivation and cyclic tensile loading on
the material and morphologic properties of canine
flexor digitorum profundus tendon: an in vitro study.
J Orthop Res. 1995;13:907-914.
11. Harner CD, Fu FH, Irrgang JJ, Vogrin TM. Anterior and
posterior cruciate ligament reconstruction in the new
millennium: a global perspective. Knee Surg Sports
Traumatol Arthrosc. 2001;9:330-336.
12. Howell SM, Hull ML. Aggressive rehabilitation using
hamstring tendons: graft construct, tibial tunnel place-
ment, fixation properties, and clinical outcome. Am J
Knee Surg. 1998;11:120-127.
13. Howell SM, Taylor MA. Brace-free rehabilitation, with
early return to activity, for knees reconstructed with a
double-looped semitendinosus and gracilis graft. J Bone
Joint Surg Am. 1996;78:814-825.
14. MacDonald PB, Hedden D, Pacin O, Huebert D. Effects
of an accelerated rehabilitation program after anterior
cruciate ligament reconstruction with combined
semitendinosus-gracilis autograft and a ligament aug-
mentation device. Am J Sports Med. 1995;23:588-592.
15. Marcacci M, Molgora AP, Zaffagnini S, Vascellari A,
Iacono F, Presti ML. Anatomic double-bundle anterior
cruciate ligament reconstruction with hamstrings.
Arthroscopy. 2003;19:540-546.
16. Marder RA, Raskind JR, Carroll M. Prospective evalua-
tion of arthroscopically assisted anterior cruciate liga-
ment reconstruction. Patellar tendon versus semiten-
dinosus and gracilis tendons. Am J Sports Med.
1991;19:478-484.
17. Morrey MA, Stuart MJ, Smith AM, Wiese-Bjornstal DM.
A longitudinal examination of athletes’ emotional and
cognitive responses to anterior cruciate ligament injury.
Clin J Sport Med. 1999;9:63-69.
18. Paulos LE, Wnorowski DC, Beck CL. Rehabilitation
following knee surgery. Recommendations. Sports Med.
1991;11:257-275.
19. Reid DC. Sports Injury Assessment and Rehabilitation.
New York, NY: Churchill Livingstone; 1992.
20. Roi GS, Perondi F, Venturati G, et al. Frequenza
cardiaca ed allenamento nel gioco del calcio. SdS.
2000;49:47-51.
21. Shelbourne KD, Gray T. Anterior cruciate ligament
reconstruction with autogenous patellar tendon graft
J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005
 followed by accelerated rehabilitation. A two- to nine-
year followup. Am J Sports Med. 1997;25:786-795.
22. Shelbourne KD, Nitz P. Accelerated rehabilitation after
anterior cruciate ligament reconstruction. Am J Sports
Med. 1990;18:292-299.
23. Shelbourne KD, Patel DV. Timing of surgery in anterior
cruciate ligament-injured knees. Knee Surg Sports
Traumatol Arthrosc. 1995;3:148-156.
24. Sherman MF, Lieber L, Bonamo JR, Podesta L, Reiter I.
Invited Commentary
This article by Roi et al explains how a professional
soccer player was able to get back to performing at a
high level within 90 days after ACL reconstruction
with a hamstring autograft. The authors are to be
commended for their precise explanation of the
exercises used to help this athlete regain not only the
level of knee function but also the level of aerobic
capacity needed to be able to perform well.
The advantage of a case report is that an author is
able to explain what is possible with a specific
technique or training method. As the authors men-
tioned, the timing of surgery and, especially, the
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timing of the return to activities, are quite controver-
sial. The general feeling is that a quick yet safe return
to high-level sports after an ACL reconstruction is
more possible with the use of a patellar tendon
autograft versus a hamstring graft. The logic behind
this feeling is that the patellar tendon autograft
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
provides bone-to-bone fixation, which provides for a
quicker incorporation of the ACL graft than the
tendon-to-bone fixation provided with the hamstring
graft.
I was asked to comment on this article because of
my experience with accelerated rehabilitation after
ACL reconstruction with a patellar tendon autograft.
The current ‘‘accelerated’’ rehabilitation that we use
with patients is something that has evolved through
Journal of Orthopaedic & Sports Physical Therapy®
time. We performed continual data collection and
analysis of objective and subjective measurement,
then we made small advancements in the progression
of the rehabilitation program before we realized how
safe patients were with returning to sports quickly
after surgery. This process involved a great deal of
observation and reporting by patients as to what they
could and could not do while attempting to achieve
their goals. During this time, we continually mea-
sured ligament stability to make sure that the changes
we made in rehabilitation did not result in graft
loosening. For example, we determined that obtain-
ing normal hyperextension, even at the extreme of 8°
to 15° of hyperextension, did not affect the ability to
achieve and maintain stability, as measured with the
manual maximum KT1000 test.3 We also determined
that the objective stability measured at the time when
patients achieved full knee range of motion com-
pared with that of the contralateral knee did not
J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005
The long-term followup of primary anterior cruciate
ligament repair. Defining a rationale for augmentation.
Am J Sports Med. 1991;19:243-255.
25. Smith AM. Psychological impact of injuries in athletes.
Sports Med. 1996;22:391-405.
26. Sterett WI, Hutton KS, Briggs KK, Steadman JR. De-
creased range of motion following acute versus chronic
anterior cruciate ligament reconstruction. Orthopedics.
2003;26:151-154.
change at long-term follow-up 2 to 6 years after
surgery.1 It is this type of continued follow-up and
data analysis that allowed us to understand what
patients were able to do safely after surgery.
I would be interested in knowing what type of data
the surgeons had regarding previous patients’ abilities
to return to sports after ACL reconstruction with a
hamstring graft and how they arrived at the current
stage, where they felt this type of rehabilitation was
possible. Did the authors have a group of patients
who they observed returning quickly to sports, which
then made them believe that this rehabilitation was
CASE REPORT
possible and also safe? Did the authors document
continued knee ligament stability in a large group of
patients performing this type of rehabilitation? What
are the KT1000 stability results for this patient
population? How do we know that this rehabilitation
is safe with many patients of this type? Without a
group of patients whose data are closely monitored, I
could not recommend this rehabilitation be used with
all patients receiving hamstring graft for ACL recon-
struction. I make this statement cautiously because I
do believe an aggressive rehabilitation can be utilized
with most graft sources, when the surgery is per-
formed correctly and the graft is placed in the right
location. However, it is impossible to recommend a
rehabilitation program based on a case report.
Two important rehabilitation factors are absent
from this report. First, there is no description of how
the patient was able to have full knee range of
motion so quickly after the injury to allow the
surgery to be performed so soon after the injury.
Secondly, the article does not describe what kind of
rehabilitation exercises were performed during the
first 8 days after surgery? I ask these questions
because it is the preoperative and early postoperative
periods that I believe are the most important for
achieving the optimum outcome after surgery.
All patients, whether high-level athletes or the
average person attempting to get back to normal
daily activities and light recreational activities, seek to
have their knees return to normal after an injury.
Normal means that there is symmetry between legs
and knees. An athlete can perform only as well as the
leg with the least function. The patients need to have
full knee range of motion and full leg strength equal
61
 to the contralateral normal limb. Our ongoing re-
search tells us that patients who have even a few
degrees loss of normal hyperextension in the knee
are less satisfied with their result than patients who
have normal hyperextension. Therefore, our rehabili-
tation program revolves around doing what is neces-
sary to achieve this goal. The emphasis of the
preoperative rehabilitation and early postoperative
rehabilitation is on achieving full knee range of
motion, good leg control, and no swelling. When
these goals are achieved before surgery, they are
certainly much easier to obtain after surgery.
The current ACL rehabilitation we use with pa-
tients is knee based and not time based.2 Each step of
the rehabilitation involves goals that must be met
before the patient’s rehabilitation is advanced to the
next level. The rate at which patients go through
these steps varies greatly, mostly due to the difference
in individual goals and lifestyle.
The first and foremost goal is to achieve full
symmetrical knee range of motion. This goal is
accomplished by using a cold/compression device to
minimize a hemarthrosis from developing, doing
specific exercises for knee range of motion, and by
keeping our patients in bed rest for the first 5 days
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after surgery. I strongly believe that a knee that has
no swelling and full range of motion will feel normal
to the patient, and daily activities will become easy for
the patient.
The next goal of obtaining full leg strength will
eventually return if full range of motion is obtained;
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
but if stability is obtained at the cost of losing full
range of motion, full functional strength will never
return. Strength can progress as fast as the patient is
able, but in the meantime the patient must be able to
maintain symmetrical knee motion and no swelling.
Given that patients’ knees react differently to leg-
strengthening exercises, the quickness of which this
goal can be obtained is greatly variable. If range of
motion decreases or significant swelling occurs, the
Journal of Orthopaedic & Sports Physical Therapy®
amount of strengthening exercises should be re-
duced. Conversely, aggressive strengthening can be
performed if range-of-motion or swelling problems
do not occur. The patient described in this case
report was able to do aggressive strengthening but
did not develop swelling or a loss in range of motion.
The return to sporting activities within 90 days
after surgery is certainly possible for many athletes.
The rehabilitation program described in this case
Invited Commentary
The clinical management of this thought-provoking
and unique case challenges several existing norms for
managing ACL injuries. Return to full participation
in professional soccer only 90 days after injury was
made possible by doing surgery within days of injury,
then pursuing an extremely accelerated rehabilitation
62
report involves a frequent and intense program that
is dependent upon assistance from a physical thera-
pist or athletic trainer. The patient was a professional
athlete, which is similar to a workman’s compensation
situation, wherein that patient needs to be able to
return to work as soon as possible. Most patients do
not have this type of resource for rehabilitation. A
quick return to sports after surgery can also be
achieved by only a limited amount of physical therapy
visits (4-7), as long as the patient has a good
understanding of the goals and has access to leg-
strengthening machines. I believe the intensive reha-
bilitation in this case report was needed because of
the level of physical condition the athlete needed to
achieve to be able to play professional soccer.
To make progress in postoperative rehabilitation
for ACL reconstruction, we need case reports like this
one to stimulate us to consider what might be
possible. I encourage all surgeons and physical thera-
pists to find their surgical procedure and rehabilita-
tion protocol limits. Rather than slow every patient
down, discover how your successful patients were able
to achieve their goals quickly and safely. The results
of this case report have to be encouraging to sur-
geons performing ACL reconstruction with hamstring
grafts. Although the results of this single case are
interesting to know, I encourage the authors to
further document a large population in which these
results can be obtained.
K. Donald Shelbourne, MD
The Shelbourne Clinic at Methodist Hospital
Indianapolis, IN
REFERENCES
1. Arnold T, Shelbourne KD. A perioperative rehabilitation
program for anterior cruciate ligament surgery. Phys
Sportsmed. 2000;28:31-44.
2. Rubinstein RA, Jr, Shelbourne KD, VanMeter CD, Mc-
Carroll JR, Rettig AC, Gloyeske RL. Effect on knee
stability if full hyperextension is restored immediately
after autogenous bone-patellar tendon-bone anterior
cruciate ligament reconstruction. Am J Sports Med.
1995;23:365-368.
3. Shelbourne KD, Klootwyk TE, Wilckens JH, De Carlo
MS. Ligament stability two to six years after anterior
cruciate ligament reconstruction with autogenous patel-
lar tendon graft and participation in accelerated reha-
bilitation program. Am J Sports Med. 1995;23:575-579.
protocol. The authors report no apparent ill effects
on the graft or on subsequent joint function up to 2
years following the injury.
Immediate surgery after ACL injury, while still
controversial, is not all that uncommon in high-level
athletes. Several retrospective studies have suggested
J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005
 that surgery done immediately after injury was associ-
ated with postoperative stiffness compared to recon-
structions delayed up to 6 weeks.1,2,9 But 2 recent
papers have shown no effect of timing alone in
patients who had recovered full range of motion
before ACL reconstruction.4,8 No published study on
this question is well controlled, prospective, and
blinded, and therefore the literature remains incon-
clusive. In practice, many leading orthopedists agree
that preoperative motion, and not time from injury,
most likely is the key factor in determining whether
there is elevated risk of stiffness postoperatively. In
the present case the injury was limited to the ACL
alone, with no cartilage or joint surface injury.
Preoperative range of motion was documented only
on the day after injury, at which time he had full
extension and lacked 15° of flexion with a moderate
effusion. Two-bundle hamstring ACL reconstruction
was performed 3 days later. The patient’s range of
motion was 0° to 115° on postoperative day 15, and
on day 29 it was fully restored; so immediate surgery
in this individual caused no problems for return of
flexibility.
The highly accelerated postoperative regimen con-
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centrated on maintaining the subject’s elite condi-
tioning with the use of a combination of pool and
treadmill activities. He seemingly never had signifi-
cant loss of lower extremity strength or coordination.
On day 71 his extension strength was 95% compared
to that of the opposite knee. Quite apart from the
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
120 recorded therapy sessions during the 12-week
period of rehabilitation, it would be interesting to see
an estimate of cost for use of the gym, pool, and
other infrastructure that contributed to his recovery.
Even more interesting would be a rundown of the
specific objectives in terms of lower extremity motion,
strength, and control used in progressing his rehabili-
tation regimen. The paper suggests that objective
criteria were used for progression of the exercise
Journal of Orthopaedic & Sports Physical Therapy®
program, but those criteria are not specifically men-
tioned either in the text or in the tables. That
information would be instructive if we are to use
clinical milestones in lieu of dates for advancing the
exercise regimen.
In this particular patient, pain and swelling appar-
ently were easily controlled with modalities and
medication. The progression of activities documented
in Table 2 did not result in undue stretching of the
graft, as measured by ligament arthrometry using the
KT1000 with side-to-side comparisons of manual
maximum force. While preoperative and initial post-
operative arthrometry was not recorded to document
changes in laxity over time, the postoperative mea-
surement indicated similar laxity to the opposite
knee, which previously had undergone a more stan-
dard ACL postoperative rehabilitation protocol. His-
tological studies have shown that tendons heal to
bone tunnels by formation of Sharpey’s fibers, and
J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005
that the ‘‘fit’’ of the graft in the tunnel, as well as
forces applied to the graft, affect the quality and type
of tissue at the bone graft interface.2,5,7,9 In a dog
study, at 12 weeks postoperatively all grafts failed by
in-substance failure rather than pull-out of the tun-
nel.7 In the present case, the surgical technique left
the 2 hamstring tendons attached at their native
insertions on the tibia. Theoretically, this might
improve the initial fixation strength; but I don’t
believe this technique has been compared to others
biomechanically, so we can’t know that for certain.
The stretching of grafts during rehabilitation is a
concern even after the graft is firmly healed within
the tunnels; but there is little information on whether
this is due to excessive rather than insufficient stress
on the remodeling graft. More work clearly is needed
in this area because it is quite possible that, as long as
fixation strength and tissue yield strength are not
exceeded, controlled stress on the graft during the
remodeling phase could actually be beneficial. I am
aware of only 1 study evaluating the effects of force
application on healing in the bone tunnels, and that
study examined qualitative histology only.9
Obviously we also cannot know for certain what the
CASE REPORT
long-term effects of this regimen will be. There is
little evidence that ACL reconstruction prevents ar-
thritis, but evidence is equally limited that well-
performed intra-articular ACL reconstruction
contributes to clinically significant degenerative joint
disease. In our experience, a significant increase in
laxity developing after 6 months postoperatively is
seen only after reinjury, so it seems unlikely that this
graft will stretch if it has not already done so. If he
continues to play soccer, he is at risk for further
injury and possibly the development of arthritis. But
if so, it seems doubtful that this would be attributed
to his early surgery or accelerated return to activity.
Everyone would agree with the authors that a
reasonable objective in returning athletes to sports
following ACL injury is to get them back as fast as
safely possible. This paper tells us what is possible,
but not what is ‘‘safe.’’ The mere fact that something
is possible does not make it a good idea. A single
case does not permit inferences even on other
professional athletes because, without additional sub-
jects, we cannot determine the risk of failure or
complications. It is impossible to say whether the
athlete was simply lucky. I am aware of several
well-publicized American professional athletes who
tried unsuccessfully to return to their preinjury levels
within 3 to 4 months after an ACL tear and immedi-
ate reconstruction early in the season. One of them
had a serious complication during a game 3 months
after reconstruction; other athletes disappeared for
months or years, and some never returned. But none
of these cases has appeared in the peer-reviewed
literature as an example for others to consider. Surely
there have been other failures that we do not know
63
 about. Frankly, I doubt this case would have been
written up if the outcome had not been so . . . report-
able. Indeed, the most noteworthy aspect of the
present case is its success against seemingly terrific
odds. And that is really the point.
No one knows the limits of how rapidly we can
rehabilitate an athlete postoperatively because there
are so many variables associated with ACL reconstruc-
tion, such as the security of fixation, quality of the
bone, and the quality of the graft during healing and
remodeling. We know that preoperative factors
(range of motion, strength, conditioning) are all
important in predicting outcomes following ACL
reconstruction. The patient in this case was a highly
trained, motivated, and disciplined athlete in top
physical form at the time of reconstruction. To the
extent that you can pick your outcomes by selecting
your patients well, conditions seem to have been
ideally suited for success.
So, should we try this at home? Not yet. But the
case points out questions needing further study.
There is little question that few of us can match the
resources and raw materials that contributed to this
patient’s excellent outcome, nor does it seem worth
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the expense except in rare circumstances. I hope that
the authors will develop hypotheses from this case
and apply them in well-designed and -controlled
studies, with blinded assessment, not to mention full
disclosure of failures as well as successes, so that we
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
can understand and apply key principles of acceler-
ated rehabilitation for the safe and rapid recovery of
our own patients. Professional athletes like this one
clearly are willing to take enormous risks at times to
get back onto the field. They make a perfect sample
for studies of early surgery followed by accelerated,
goal-directed rehabilitation in order to test how
quickly we can return them to the field, and at what
risk. At the same time, more biomechanical studies
Journal of Orthopaedic & Sports Physical Therapy®
are needed to help us understand the tolerance of
Authors’ Response
We thank Drs Fithian and Shelbourne for their
commentaries on our paper. They represent 2 differ-
ent but valid perspectives on the concept of return to
play after ACL injury and reconstruction. We will
endeavor in this response to provide the additional
information requested by the commentators and to
engage in a meaningful dialogue about this contro-
versial topic.
The surgery performed on this patient has been
described by Professor Marcacci, Dr Zaffagnini, and
their colleagues, including an average 6.4-year
follow-up of a high percentage of their active patients
who underwent this procedure.7,8 Ninety-two percent
64
grafts and fixation during accelerated rehabilitation
that aims to prevent loss of lower extremity strength
and control.
Donald C. Fithian, MD
Director, San Diego Sports Medicine Fellowship
Southern California Permanente Medical Group
Assistant Clinical Professor, Orthopedics, University of
California San Diego
REFERENCES
1. Graf BK, Ott JW, Lange RH, Keene JS. Risk factors for
restricted motion after anterior cruciate reconstruction.
Orthopedics. 1994;17:909-912.
2. Greis PE, Burks RT, Bachus K, Luker MG. The influence
of tendon length and fit on the strength of a tendon-
bone tunnel complex. A biomechanical and histologic
study in the dog. Am J Sports Med. 2001;29:493-497.
3. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss
of motion after anterior cruciate ligament reconstruc-
tion. Am J Sports Med. 1992;20:499-506.
4. Hunter RE, Mastrangelo J, Freeman JR, Purnell ML,
Jones RH. The impact of surgical timing on postopera-
tive motion and stability following anterior cruciate
ligament reconstruction. Arthroscopy. 1996;12:667-674.
5. Liu SH, Panossian V, al-Shaikh R, et al. Morphology
and matrix composition during early tendon to bone
healing. Clin Orthop. 1997;253-260.
6. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation
of motion following anterior cruciate ligament recon-
struction. A case-control study. Am J Sports Med.
1991;19:620-624; discussion 624-625.
7. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren
RF. Tendon-healing in a bone tunnel. A biomechanical
and histological study in the dog. J Bone Joint Surg Am.
1993;75:1795-1803.
8. Sterett WI, Hutton KS, Briggs KK, Steadman JR. De-
creased range of motion following acute versus chronic
anterior cruciate ligament reconstruction. Orthopedics.
2003;26:151-154.
9. Yamakado K, Kitaoka K, Yamada H, Hashiba K,
Nakamura R, Tomita K. The influence of mechanical
stress on graft healing in a bone tunnel. Arthroscopy.
2002;18:82-90.
of patients had International Knee Documentation
Committee scores of normal or nearly normal. All
but 2 regained full extension and those 2 individuals
had extension deficits of 3° or less. KT-1000 evalua-
tion was less than 3 mm in 76% of patients, 3 to 5
mm in 18%, and more than 5 mm in 6%. Ninety
percent of the patients resumed sport at the same
level. The mean Tegner activity score was 8.1 (range
5-10). Isokinetic testing demonstrated no weakness of
the hamstring or quadriceps muscles. Our testing is
ver y similar to the testing performed by Dr
Shelbourne’s group. Our results, albeit with fewer
patients, are similar except for strength measures.
J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005
 While we share the Shelbourne group’s concern for
restoring knee extension, we are also very concerned
with quadriceps strength at the time of return to play
and our program and criteria for progression reflect
that emphasis. The most recent published work from
the Shelbourne group demonstrates that they regu-
larly return subjects to play with significant
quadriceps deficits (25%-30%).9 We do not.
The question of how the patient was able to have
full knee range of motion so quickly after the injury
and what he did for the 8 days after surgery (prior to
beginning his outpatient regimen) are related. The
patient was largely quiet during this period. After
surgery he was instructed in a home exercise pro-
gram with rest and aggressive elevation, passive and
active range of motion exercises, ice, and
neuromuscular electrical stimulation of the
quadriceps for 2 to 3 hours every day, using a battery
powered stimulator with his knee in full extension.6
This is similar to the program of 1 week of bed rest,
range of motion, and aggressive elevation advocated
by the Shelbourne group again, with the exception of
the quadriceps strength emphasis.
One cannot discount the role that each patient’s
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unique biology plays in the healing process. This
patient had very little swelling and no setbacks as the
rehabilitation progressed. This in and of itself is
remarkable, but essentially independent of the sur-
gery and rehabilitation process. We were fortunate to
have a motivated patient who was also a great healer.
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Dr Fithian asked for a clearer explanation of our
criteria for progression. The objective criteria consid-
ered for progression were no knee pain, no increase
in effusion, and continued increase in knee range of
motion. For the transition to the on-field rehabilita-
tion, the criteria were knee extensors force of at least
80% of the contralateral side and the capacity to run
at 8 to 10 km/h without symptoms for about 20
minutes. The return to official competitions was
Journal of Orthopaedic & Sports Physical Therapy®
permitted, considering lack of subjective feeling of
instability, a full recovery in soccer-specific drills,
side-to-side difference in knee extensors isometric
torques of less than 10%, aerobic threshold speed of
greater than 11 km/h, and anaerobic threshold speed
of greater than 13.5 km/h.
Both Dr Fithian and Dr Shelbourne caution that a
case report is insufficient upon which to base prac-
tice. We agree. Case reports do, however, allow for
detailed explanation of the rehabilitation progression
and the performance, response, and outcome of the
patient. Ultimately, they allow us to describe what we
do and from that description of practice, cases series,
randomized clinical trials, and practice guidelines
follow.3-5
The issue of return to play after ACL reconstruc-
tion is complex. We think the extant evidence is that
the graft is viable and responsive to stress at the time
of implantation and that current rehabilitation regi-
J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005
mens help rather than hinder healing. If the conven-
tional wisdom of ACL rehabilitation held, then most
grafts would be failing given current treatment regi-
mens and timetables. They are not. The issue of
safety is an interesting one. What is Dr Fithian’s
evidence that this return was not safe? Graft rupture
or other consequential incident (eg, patellar fracture
after bone-patellar tendon-bone autograft) in the
early postoperative period is noteworthy largely be-
cause it is rare. Osteoarthritis occurs after ACL
reconstruction at similar rates to those who do not
undergo reconstruction and return to play, but there
is no evidence to suggest that this incidence is higher
in those who return earlier.2 In fact there is evidence
that there is no difference in incidence of
osteoarthritis after reconstruction based on return to
activity.1 Dr Fithian’s comments about professional
athletes who fail after early return after ACL injury is
an important point, but, like this case, anecdotal; the
successes are generally quieter.
Dr Fithian is correct: in the literature, ‘‘reportable’’
cases are typically successful cases. We rarely publish
our failures and negative results, even in large-scale
research reports, run into ‘‘publication bias.’’ But the
CASE REPORT
successes help us test the limits of our practice and
challenge important assumptions about rehabilitation
and conventional wisdom. As he points out, these
questions are begging for testing in studies with clear
research designs, not merely via descriptions of prac-
tice.
This case also brings up the idea of when circum-
stances collide and doctors and patients make deci-
sions that are influenced by timing of sport seasons,
opportunities to ‘‘make’’ teams, or to play in very
important events. While this case demonstrated a
once-in-a-lifetime opportunity for an athlete nearing
the end of his career, once-in-a-lifetime opportunities
happen for young athletes daily in our practices. Most
athletes do not compete after high school and the
ability to return for a championship game or a
special competition is as unique a circumstance for
them as the World Cup was for our patient. What this
case has demonstrated is (and here we respectfully
disagree with Dr Fithian) that we should ‘‘try this at
home’’ under careful supervision, with clear criteria
for progression and not simply base our return to
activity on time after surgery.
The cost of this rehabilitation is approximately $60
to $65 (US) per session, a cost of roughly $7000 (US)
for the rehabilitation of this elite athlete. US profes-
sional athletes routinely receive this kind of care. In
our rehabilitation network the rehabilitation we de-
scribed is used for all athletes after ACL reconstruc-
tion. While everyone does not have access to 3
sessions per day, there are some aspects of the
rehabilitation program that are generalizable to ACL
rehabilitation for all: the personalized progression of
volume and intensity of exercise loads and the new
65
 concept of the appropriate density of rehabilitative
training, consisting in a mix of gymnasium, pool, and
field exercises (not only for professional athletes). In
particular, in our article we focused on the early-
conditioning program and the on-field rehabilitation,
which are the 2 main interventions that permitted
the player early return to competition.
Again, we thank Dr Fithian and Dr Shelbourne for
their thoughtful commentaries on our case report.
The opportunity to engage in thoughtful dialogue
about this important topic helps bring clarity to the
controversy surrounding return to play after ACL
reconstruction.
Giulio S. Roi, MD
Isokinetic Education and Research Department
Bologna, Italy
Domenico Creta, MD
Isokinetic Rehabilitation Centre
Bologna, Italy
Gianni Nanni, MD
Isokinetic Rehabilitation Centre
Bologna, Italy
Downloaded from www.jospt.org at on February 28, 2018. For personal use only. No other uses without permission.
Maurilio Marcacci, MD
Rizzoli Orthopaedic Institute
Bologna, Italy
Stefano Zaffagnini, MD
Rizzoli Orthopaedic Institute
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Bologna, Italy
Lynn Snyder-Mackler, PT, ScD
University of Delaware
Newark, DE
Journal of Orthopaedic & Sports Physical Therapy®
66
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J Orthop Sports Phys Ther • Volume 35 • Number 2 • February 2005