Skiing

Management of ACL Ruptures in Skiers

Suegnet

Clinical Guidelines for the Management and Return to Competition of Professional Alpine Skiers Suffering from Anterior Cruciate Ligament (ACL) Rupture

Author: Suegnet Meyer

Introduction

Knee InjuryThe Anterior Cruciate Ligament (ACL) is the primary knee stabiliser that prevents anterior laxity of the tibia in relation to the femur and provides rotational knee stability (Negus et al., 2012). In the United States, approximately 200,000 Anterior Cruciate Ligament Reconstructions (ACLR) are performed annually at a cost of $3 billion (Brophy et al., 2009). Devastating evidence estimates up to 10% of professional alpine skiers will end their careers due to ACL ruptures or tears (Pujol et al., 2007).

Aim

This Clinical Guidance is aimed at Physiotherapists, Strength & Conditioning Coaches and Doctors to prevent and manage ACL ruptures during professional downhill, freestyle skiing and ski-cross during off-season.

Method

A search was performed on Cochrane Collaboration, the York Centre for Reviews and Dissemination, and the United States Agency for Health Care Policy and Research. These systematic reviews provided guidelines to create this evidence based tool. The level of evidence is graded according to criteria described by the Centre of Evidence Based Medicine Oxford United (CEBM) (http://www.cebm.net/). See Figure 1. Evidence strength was rated according to Guyatt et al. (1995).

Level 1 Evidence Level 1 Evidence
Level 2 Evidence Level 2 Evidence
Level 3 Evidence Level 3 Evidence

FIGURE 1: Level of evidence according to CEBM

Clinical Guidelines recommendations

Injury Incidence

No decline in ACL injuries and re-injury rates in professional alpine skiers is reported (Pujol, 2007). This statistics shows primary ACL injury rate at 5.7 per 100 skier-seasons with a 19% re-injury rate and a bilateral ACL injury incidence of 30.5%. During professional skiing, these injuries affect both sexes equally (Pujol, 2007; Westin et al., 2012). In contrast, more female recreational skiers sustain ACL injuries (Flørenes et al., 2009).

Injury Mechanism

Professional skiers endure deceleration from high speeds, jumping, cutting and pivoting, placing stress on the knees resulting in non-contact ACL injuries (Griffin et al., 2006). Injuries occur during hard landings when rigid ski boots induce tibial anterior drawer injuries (Natri et al., 1999; Flørenes, 2009), while the athletes assume seated posture and quadriceps contracts maximally (Johnson 1995). Bere et al., (2014) described the “slip-catch” mechanism: the skier loses balance backwards or inwards during turning. The inside edge of the outer ski catches the snow causing forced valgus and tibial internal rotation position.

Intervention

1. Conservative versus Surgical Management

Level 1 Evidence Cochrane reported inconclusive evidence of ACL injury management (Linko et al., 2005).
Using a pre-screening criteria can determine the ‘copers’ or ‘non-copers’, indicating who will return to sport (RTS) without surgery (Fitzgerald et al., 2000; Hurd et al., 2008; Logerstedt et al., 2010a). These potential ‘copers’ can be conservatively managed by perturbation neuromuscular training (NMT) (Fitzgerald, 2000). However, this will be a minority of skiers that may be considered for short term conservative management to complete a season (Fitzgerald, 2000).
Level 2 Evidence Anterior Cruciate Ligament Reconstruction (ACLR) is indicated for active adolescents with a good prognosis of 85% to RTS. It is unlikely for active adolescents to return to the same sporting level with conservative management only (Ramski et al., 2013).
Level 1 Evidence ACLR is cost-effective, at $38,121 per repair in comparison to rehabilitation alone that may include knee instability risk at $88,538. (Lubowitz et al., 2011; Mather et al., 2013).

Surgical management is indicated for active adolescents wanting to return to high level sport. ACLR is more cost-effective than rehabilitation only.

2. Timing of Surgery

Optimal surgical timing is controversial. Ideally the outcome must be optimised with minimal post-operative complications.
Level 2 Evidence A systematic review demonstrated surgery may be performed from 2 days post-trauma (Andernord et al., 2013). Another review found that ACLR can be performed from one week post-injury together with a moderately accelerated programme with a low post-operative stiffness risk (Kwok et al., 2013).
Level 1 Evidence Rapid surgical intervention after an acute ACL rupture may cause arthrofibrosis (Cosgarea et al., 1995; Mauro et al., 2008). Delaying surgery for high-level athletes, or athletes with increased knee instability post-injury, may cause secondary meniscal injuries and degenerative Osteoarthritis (OA) (Beynnon et al., 2005; Amin et al., 2008; Ajuied et al., 2013). Post-surgical complications include deep vein thrombosis (Ramos et al., 2008) and septic arthritis (Van Tongel et al., 2007).

Surgery should not be performed too soon due to arthrofibrosis risk but a lengthy delay may cause OA or meniscal injuries.

3. Prehabilitation

Prehabilitation aims to enhance postoperative outcome. Aims and criteria for progression to surgery include: Minimal knee swelling, full range of motion (ROM) including knee extension, normal gait and Quadriceps strength (Ditmeyer et al., 2002).
Level 1 Evidence A pre-operative 6-week home-based and gym programme consisting of NMT and strengthening programme resulted in enhanced postoperative outcomes. Pre-operative improvements (hop tests and quadriceps hypertrophy) were evident. These enhancements were still present 12-weeks post-operative (Shaarani et al., 2013).

A prehabilitation programme will enhance the post-operative outcome up to 12 weeks.

4. Surgical technique: Double-Bundle (DB) or Single-Bundle (SB) choice

The ACL consists of 2 distinct bundles. The ACLR is performed by drilling either a single or double tunnel through the tibia and femur, to pass the graft through.
Level 1 Evidence Cochrane reported no difference in outcome scores when performing SB compared to DB ACLR (Tiamklang et al., 2012; Bjornsson et al., 2013; Xu et al., 2013).
Level 2 Evidence A meta-analysis showed DB as the superior technique since it provides better rotational stability. This may not affect the functional outcome compared to SB (Li et al., 2014). DB may reduce re-rupture rates but is more invasive and technically demanding (Tiamklang, 2012).
Level 1 Evidence In the short term, DB is cost-effective due to low revision rates. However, long term follow-up is indicated (Paxton et al., 2010).

Effective DB technique improves rotational stability, less re-rupture rates and has short term cost-effectiveness, compared to SB technique.

5. Grafts Choices

Level 1 Evidence Cochrane reviews demonstrate no significant difference of knee stability is achieved when using either Hamstring (HT) or Patella tendon (BPTB) graft techniques (Liden et al., 2007; Maletis et al., 2007; Magnussen et al., 2011; Mohtadi et al., 2011).
Level 2 Evidence After discussion with the patient, the surgeon will choose the suitable graft. Consideration should be: type of sport, age, accelerated rehabilitation and RTS (Magnussen, et al., 2010; Rahr-Wagner, et al., 2014).
Level 2 Evidence The more frequently the surgeon performs ACLR the better the outcome. Surgeons with a lower volume ACLR (52 ACLR in 12 months) (Lyman et al., 2009). Hospitals hosting two or fewer ACLR monthly are 32% more likely to have a 90-day post-operative readmission, in contrast to hospitals performing more than 10 ACLR monthly (Lyman, 2009).

ACLR using HT and BPTB showed identical knee stability outcomes.

Different types of grafts

Various graft types are available:

  • Autografts
  • Allografts
  • Artificial grafts
a. Autografts (harvested from the patient)

Hamstring graft (HT)

  • Surgical suspension fixation is used. This may increase longitudinal movement between fixation point and graft resulting in bone tunnel enlargement, compromising knee stability (Webster et al., 2001).
  • Reduces knee flexion and internal rotation strength.
  • Takes longer to heal (9-12 weeks)(Weiler et al., 2002) causing later RTS.
  • Additional infection risk (Maletis et al., 2013b).
  • Although more popular due to lower donor morbidity, the revision rate during the first year is higher in youngsters (Maletis et al., 2013a; Persson et al., 2014), and re-rupture rate is (1.82 time higher) for the age group

Patella tendon graft (BPTB)

b. Allograft (harvested from external donor)

Level 3 Evidence ACLR performed with fresh frozen allograft that has not been chemically treated or irradiated, produced equivalent clinical outcome compared to autografts (Lamblin et al., 2013).

c. Artificial Grafts: Ligament Advance Reinforcement System (LARS)

LARS is a polyester graft that compares well to BPTB. It may be used in athletes performing high demanding sport with a 6-months RTS (Pan et al., 2013). It may cause post-operative synovitis (Klein et al., 1992). Uncertainty exists over long term OA risk (Pichon et al., 2007).

Autografts and untreated fresh frozen allografts produce similar clinical outcome.

6. Outcome measurement

Hop tests

Standardised functional outcome measures determine rehabilitation progression and RTS. The single-limb hop tests measure neuromuscular ability and dynamic knee stability, and demonstrates good test-retest reliability (ICC) in normal young subjects (Noyes et al., 1991; Ross et al., 2002).
Level 3 Evidence During ACL rehabilitation the hop tests measured with good reliability and validity (7.05% – 12.96%) (Reid et al., 2007).

Patient assessed health outcome

Various patient-assessed health instruments with varying validity, measures patients’ perception of the ACLR outcome.
Level 1 Evidence The Knee Injury and Osteoarthritis Outcome Score(KOOS) measures symptoms and disability with responsiveness values (MDC95) to change: pain, symptoms, daily living activities, sport and recreational and knee specific quality of life, but lacked addressing mental health domains(Garratt et al., 2004; Wright, 2009; Logerstedt et al., 2010a).
Level 1 Evidence International Knee Documentation Committee 2000 form(IKDC) is a joint-specific outcome that measures symptoms, function, and sports activity aimed at various knee ailments with good test-retest value especially in bigger groups (Collins et al., 2011; Logerstedt 2010a). However, Irrgang et al.(2006), demonstrated that due to higher MDC95- values, responsiveness may be compromised.
Level 1 Evidence The Knee Outcome Survey-Activities of Daily Living Scale(KOS-ALDS) is responsive to knee functional assessment with good test-retest (ICC 0.97) and minimal detectable changed values for MDC95 (Irrgang et al., 1998).

KOOS, IKDC or KOS-ALDS, and Hop tests may be used to assess pain, disability, function and clinical presentation changes during rehabilitation. Effective communication between the patient and the MDT will optimise rehabilitation and outcome to RTS.

Rehabilitation Interventions

7. Cryotherapy

Level 2 Evidence Cryotherapy is used for post-operative pain and swelling reduction and to promote knee ROM and drainage. Evidence confirmed the cryotherapeutic analgesic effect, however no change was shown for ROM or drainage (Raynor et al., 2005).

It is recommended that cryotherapy is used for pain relief immediate post-operative and ongoing during the first weeks of rehabilitation.

8. Therapeutic Exercise

Eccentric, concentric and NMT is used during rehabilitation to improve quadriceps contractions.
Level 1 Evidence Eccentric rehabilitation is effective to improve quadriceps strength. NMT improves motor learning in addition to strength training. Eccentric training improves quadriceps strength better than concentric exercises (Gokeler et al., 2013).

Rehabilitation should be a combination of concentric, eccentric, and NMT.

9. Accelerated Versus Non-accelerated rehabilitation

Shelbourne & Nitz (1990), described accelerated rehabilitation by initially aiming to restore full weight bearing, knee extension and optimising quadriceps activity.
Level 1 Evidence According to a study, 85% of participant with BPTB accelerated group (19-weeks) and non-accelerated BPTB group (32-weeks), showed almost equivalent anterior posterior laxity (1.3mm difference) after the first 3-months, postoperative. After the two year follow-up the outcome were again similar for both groups (Beynnon et al., 2011).

19-week accelerated rehabilitation is possible when using BPTB ACLR.

10. Open Kinetic (OKC) and Closed Kinetic Chain exercises (CKC)

OKC is performed while the foot is not planted, by performing leg extensor resistance training using ankle weights. OKC increases anterior tibial translation (Beynnon et al., 1997), which may result in increased graft stress causing knee laxity. However, OKC may increase quadriceps torque, resulting in accelerated rehabilitation and RTS.
During CKC the foot is supported by using a leg-press machine (Andersson et al., 2009). CKC promotes joint compression and knee stability (Beynnon et al., 1997).
Uncertainty exists in the quantity of quadriceps loading that can safely be applied to gain quadriceps strength improvements in HT graft rehabilitation. During the initial HT post-surgical phase, graft necrosis takes place causing optimum graft weakness at 6-8 weeks (Scheffler et al., 2008). HT graft stress would cause more instability and needs to be protected.
Level 1 Evidence OKC for HT graft, from 90-45° knee flexion can be safely performed from 4-weeks post-operatively without stressing the HT graft, resulting in improved quadriceps strength (Fukuda et al., 2013). Further studies should assess the frequency and magnitude of quadriceps activation allowed.

OKC exercises to strengthen quadriceps are allowed for HT at 4-weeks but is limited to 90-45° as it places stress on the graft, while CKC places less stress on the graft.

11. Neuromuscular training (NMT)

NMT is the facilitation of movement training progressions from single plane low intensity training to multi-planar complex power training, resulting in improved joint kinaesthesia, stability, acceleration and deceleration (Hewett et al., 2002). In addition, NMT reduces ACL re-injury (Johansson et al., 1991) and includes balance, proprioception and plyometrics.
Level 1 Evidence A combination of NMT and strengthening produce better outcomes than only strength training exercises after 6 months (Risberg et al., 2007) and also confirmed during 2 and 4 year follow-ups (Risberg & Holm 2009). NMT improved global knee function and pain relief, while strengthening improved hamstring strength after two years post-operative.

Rehabilitation should combine NMT and strength training to increase knee stability and movement coordination during supervised physiotherapy.

12. Neuromuscular Electrical stimulation (NMES)

Postoperative quadriceps inhibition is caused by arthrogenic muscle inhibition (Palmieri et al., 2004).
Level 1 Evidence Combining NMES and quadriceps exercises improves quadriceps contraction during the first 4 weeks post-operative (Kim et al., 2010).
NMES is not a substitute for muscle volitional exercises (Bax et al., 2005), but will promote quadriceps contraction initially.
Level 1 Evidence NMES compared to a standard post-operative strength programme improved the quadriceps strength of the NMES group by an average of 29% after 6-month follow-up (Feil et al., 2011). Inconclusive evidence exists to show whether NMES has any effect on functional performance or patient-orientated outcomes.

NMES may contribute to quadriceps contraction in the first weeks postoperatively, but patient-orientated outcomes may not be influenced.

13. Knee Bracing

Level 2 Evidence Post-surgical bracing (0-6 weeks) has no beneficial influence on ACLR outcome, pain or knee stability (Wright et al., 2008a, Andersson et al., 2009).
Level 2 Evidence No evidence was found that functional bracing reduces re-injury in 100 patients during land-based exercise (McDevitt et al., 2004).
Level 2 Evidence However, functional knee bracing may enhance the proprioceptive input during downhill ski (Nemeth et al., 1997). Functional bracing showed reduced ACL re-injury during 6 seasons. The non-braced skiers were 3.9 times more likely to re-injure than the braced skiers (Sterett et al., 2006).

Post-operative bracing has no role in ACLR. Functional bracing may be effective in downhill skiing.

14. Home–based rehabilitation versus supervised rehabilitation

The quality and cost of rehabilitation protocols are influenced by home-based versus supervised rehabilitation.
Level 2 Evidence Evidence showed no difference between home- and clinic-based groups assessed by knee ROM, laxity, strength and function (six months to one year) (Andersson et al., 2009).

A combined supervised- and home-programme will be more beneficial and cost effective during rehabilitation.

15. ACL Injury prevention and performance enhancing

Avoidance of knee compression, hip abduction torque and tibial internal rotation is essential for ski prevention programmes. By strengthening the hip abductor, extensor and hamstrings may contribute to protecting the knee against forces (Bere et al., 2014).
Level 2 Evidence Injuries may be reduced by NMT, educational tools and interventions (Gagnier et al., 2013). Awareness videos and training programmes reduce injuries in professional skiers (Ettlinger et al., 1995). These videos prevented injuries by teaching skiers to identify and respond correctly when at risk of sustaining injury.
Level 1 Evidence NMT should be implemented during the training of young female adolescents. This will counteract the neuromuscular deficiencies that develop at a later adolescent developmental phase, resulting in altered mechanics and injuries (Myer et al., 2013).
Level 1 Evidence Injury prevention is effective (Walden et al., 2012). Injury reduction of 64% was achieved (N=4564, between ages of 12-17). Injuries occurred at -0.07 (95% CI -0.13 to 0.001) per 1,000 playing hours in favour of the preventative group (Walden, 2012).
A preventative programme must be encouraged by all MDT members. The programme must have a duration of 10 to 20 minutes, thrice weekly during pre-season and once weekly during season (Grindstaff et al., 2006).
Level 2 Evidence Inconclusive evidence for the effectiveness and type of male injury prevention programmes exist (Alentorn-Geli et al., 2014).
Level 2 Evidence Numbers-needed-to-treat is between 108-120 training players to prevent one ACL injury (Sugimoto et al., 2012a). Further research to improve the screening process together with sport specific prophylactic programmes are required.
The correct ski binding should be used for the level of skier and be adjusted properly to reduce ACL injuries (Young et al., 1976).

Effective prevention programmes need to be sport specific. Preventative videos are effective to educate skiers.

References

  • Ajuied, A., Wong, F., Smith, C., Norris, M., Earnshaw, P., Back, D., & Davies, A. (2013). Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. American Journal of Sports Medicine, DOI: 10.1177/0363546513508376.
  • Alentorn-Geli, E., Mendiguchia, J., Samuelsson, K., Musahl, V., Karlsson, J., Cugat, R., & Myer, G.D. (2013). Prevention of non-contact anterior cruciate ligament injuries in sports. Part II: systematic review of the effectiveness of prevention programmes in male athletes. Knee Surgery, Sports Traumatology, Arthroscopy, 22(1): 16-25. DOI: 10.1007/s00167-013-2739-x.
  • Amin, S., Guermazi, A., Lavalley, M.P., Niu, J., Clancy, M., Hunter, D.J., Grigoryan, M., & Felson, D.T. (2008). Complete anterior cruciate ligament tear and the risk for cartilage loss and progression of symptoms in men and women with knee osteoarthritis. Osteoarthritis Cartilage, 16(8): 897-902.
  • Andernord, D., Karlsson, J., Musahl, V., Bhandari, M., Fu, F.H., Samuelsson, K. (2013). Timing of surgery of the anterior cruciate ligament. Arthroscopy, 29(11): 1863-1871. DOI: 10.1016/j.arthro.2013.07.270
  • Andersson, D., Samuelsson, K., & Karlsson, J. (2009). Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials. Arthroscopy, 25(6): 653–685.
  • Anderson, A.F., Snyder, R.B., Lipscomb, A.B. (2001). Anterior cruciate ligament reconstruction. A prospective randomised study of three surgical methods. American journal of Sports Medicine, 29(3): 272-279.
  • Bax, L., Staes, F., & Verhagen, A. (2005). Does neuromuscular electrical stimulation strengthen the quadriceps femoris? A systematic review of randomised controlled trials. Sports Medicine, 35(3): 191-212.
  • Bere, T., Flørenes, T.W., Nordsletten, L., & Bahr, R. (2014). Sex differences in the risk of injury in World Cup alpine skiers: a 6-year cohort study. British Journal of Sports Medicine, 48(1): 36-40. DOI: 10.1136/bjsports 2013-092206
  • Beynnon, B.D., Johnson, R.J., Abate, J.A., Fleming, B.C., & Nichols, C.E. (2005). Treatment of anterior cruciate ligament injuries, Part I. The American Journal of Sports Medicine, 33(10): 1579– 1602. DOI: 10.1177/0363546505279913
  • Beynnon, B.D., Johnson, R.J., Fleming, B.C., Stankewich, C.J., Renstrom, P.A., & Nichols, C.E. (1997). The strain behaviour of anterior cruciate ligament during squatting and active flexion-extension: a comparison of an open and closed kinetic chain exercise. American Journal of Sports Medicine, 25(6): 823-829.
  • Beynnon, B.D., Johnson, R.J., Naud, S., Fleming, B.C., Abate, J.A., Brattbakk, B., Nichols, C.E. (2011). Accelerated versus nonaccelerated rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind investigation evaluating knee joint laxity using roentgen stereophotogrammetric analysis. The American Journal of Sports Medicine, 39(12): 2536-2548. DOI: 10.1177/0363546511422349
  • Birmingham, T.B., Bryant, D.M., Giffin, J.R., Litchfield, R.B., Kramer, J.F., Donner, A., & Fowler, P.J. (2008). A randomized controlled trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 36(4): 648-655. DOI: 10.1177/0363546507311601
  • Bjornsson, H., Desai, N., Musahl, V., Alentorn-Geli, E., Bhandari, M., Fu, F., & Samuelsson, K. (2013). Is double-bundle anterior cruciate ligament reconstruction superior to single-bundle? A comprehensive systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. DOI: 10.1007/s00167-013-2666
  • Böhm, H., & Senner, V. (2008). Effect of ski boot settings on tibio-femoral abduction and rotation during standing and simulated skiing. Journal of Biomechanics, 41(3): 498-505. DOI: 10.1016/j.jbiomech.2007.10.019
  • Brophy, R.H., Wright, R.W., & Matava, M.J. (2009). Cost analysis of converting from single-bundle to double-bundle anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 37(4): 683-687. DOI: 10.1177/0363546508328121
  • Busam, M.L., Provencher, M.T. & Back, B.R. (2008). Complications of anterior cruciate ligament reconstruction with bone-patellar tendon-bone constructs. Care and prevention. The American Journal of Sports Medicine, 36(2): 379-394. DOI: 10.1177/0363546507313498
  • Button, K., van Deursen, R., & Price, P. (2006). Classification of functional recovery of anterior cruciate ligament copers, non-copers, and adapters. British Journal of Sports Medicine, 40(10): 853-85. DOI: 10.1136/bjsm.2006.028258
  • Collins, N.J., Misra, D., Felson, D.J., Crossley, K.M., & Roos, E.M. (2011). Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care & Research. 63(S11): S208-S228. DOI: 10.1002/acr.20632
  • Cosgarea, A.J., Sebastianielli, W.J., & DeHaven, K.E. (1995). Prevention of arthrofibrosis after ACL reconstruction using central third patellar tendon autograft. The American Journal of Sports Medicine, 23(1): 87-92.
  • Ditmeyer, M.M., Topp, R., & Pifer, M. (2002). Prehabilitation in preparation of orthopaedic surgery. Orthopaedic Nursing, 21(5): 43-51.
  • Ettlinger, C., Johnson, R., & Shealy J. (1995). A Method to help reduce the risk of serious knee sprains incurred in alpine skiing. The American Journal of Sports Medicine, 23(5): 531-537.
  • Feil, S., Newell, J., Minogue, C., & Paessler, H.H. (2011). The effectiveness of supplementing a standard rehabilitation program with superimposed neuromuscular electrical stimulation after anterior cruciate ligament reconstruction: a prospective, randomized, single-blind study. The American Journal of Sports Medicine, 39(6): 1238-1247. DOI: 10.1177/0363546510396180
  • Fitzgerald, G.K., Axe, M.J., & Snyder-Mackle, L. (2000). The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physically active individuals. Physical Therapy, 80(2): 128-140.
  • Flørenes, T.W., Bere, T., Nordsletten, L., Heir, S., & Bahr, R. (2009). Injuries among male and female World Cup alpine skiers. British Journal of Sports Medicine, 43, 973–978. DOI: 10.1136/bjsm.2009.068759
  • Fujimoto, E., Sumen, Y., Urabe, Y., Deie, M., Murakami, Y., Adachi N, & Ochi, M. (2004). An early return to vigorous activity may destabilize anterior cruciate ligaments reconstructed with hamstring grafts. Archives of Physical Medicine and Rehabilitation, 85(2): 298–302. DOI: 10.1016/S0003-9993(03)00621-X.
  • Fukuda, T.Y., Fingerhut, D., Moreira, V.C., Camarini, P.M.F., Scodeller, N.F., Duarte, A., Martinelli, M., Bryk, F.F. (2013). Open kinetic chain exercises in a restricted range of motion after anterior cruciate ligament reconstruction: a randomized controlled clinical trial. The American Journal of Sports Medicine, 41(4): 788-794.
  • Gagnier, J.J., Morgenstern, H., & Chess, L. (2013). Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis. The American Journal of Sports Medicine, 41(8): 1952-1962. DOI: 10.1177/0363546512458227
  • Garratt, A. M., Brealey, S., Gillespie, W. J., & DAMASK Trial Team (2004). Patient-assessed health instruments for the knee: a structured review. Rheumatology (Oxford, England), 43(11): 1414-1423. DOI: 10.1093/rheumatology/keh362
  • Gokeler, A., Bisschop, M., Benjaminse, A., Myer, G.D., Eppinga, P., & Otten, E. (2013). Quadriceps function following ACL reconstruction and rehabilitation: implications for optimisation of current practices. Knee Surgery, Sports Traumatology, Arthroscopy. DOI: 10.1007/s00167-013-2577-x
  • Grant, J.A. (2012). Does Accelerated Rehabilitation affect knee joint laxity after ACL reconstruction? Clinical Journal of Sport Medicine, 22(6): 523-524. DOI: 10.1097/JSM.0b013e318275d4f2
  • Grant, J.A., Mohtadi, N.G. (2010). Two- to 4-year follow-up to a comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 38(7): 1389-1394. DOI: 10.1177/0363546509359763
  • Grant, J.A., Tannenbaum, E., Miller, B.S., & Bedi, A. (2012). Treatment of combined complete tears of the anterior cruciate and medial collateral ligaments. Arthroscopy, 28(1): 110-122. DOI: 10.1016/j.arthro.2011.08.293
  • Griffin, L.Y., Albohm, M.J., Arendt, E.A., Bahr, R., Beynnon, B.D., Demaio, M., Dick, R.W., Engebretsen, L., Garrett, W.E., Hannafin, J.A., Hewett, T.E., Huston, L.J., Ireland, M.L., Johnson, R.J., Lephart, S., Mandelbaum, B.R., Mann, B.J., Marks, P.H., Marshall, S.W., Myklebust, G., Noyes, F.R., Powers, C., Shields, C., Shultz, S.J., Silvers, H., Slauterbeck, J., Taylor, D.C., Teitz, C.C., Wojtys, E.M., & Yu, B. (2006). Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting. The American Journal of Sports Medicine, 34(9): 1512–1532. DOI: 10.1177/0363546506286866
  • Grindstaff, T.L., Hammill, R.R., Tuzson, A.E., & Hertel, J. (2006). Neuromuscular control training programs and noncontact anterior cruciate ligament injury rates in female athletes: a numbers-needed-to-treat analysis. Journal of Athletic Training, 41(4): 450-456.
  • Guyatt, G.H., Sackett, D.L., Sinclair, J.C., Hayward, R., Cook, D.J., & Cook, R.J. (1995). Users’ guides to the medical literature IX. A method for grading health care recommendations. Evidence-Based Medicine Working Group. Journal of the American Medical Association, 274(22): 1800-1804.
  • Hewett, T. E., Ford, K.R., & Myer, G.D. (2006). Anterior cruciate ligament injuries in female athletes – part 2: a meta-analysis of neuromuscular interventions aimed at injury prevention. The American Journal of Sports Medicine, 34(3): 490-498. DOI: 10.1177/0363546505282619
  • Hewett, T.E., Paterno, M.V., & Myer, G.D. (2002). Strategies for enhancing proprioception and neuromuscular control of the knee. Clinical Orthopaedics and Related Research, 402, 76-94.
  • Hurd, W.J., Axe, M.J., Snyder-Mackler, L. (2008). A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 2, determinants of dynamic knee stability. The American Journal of Sports Medicine, 36(1): 48-56. DOI: 10.1177/0363546507308191
  • Irrgang, J.J., Anderson, A.F., Boland, A.L., Harner, C.D., Neyret, P., Richmond, J.C., Shelbourne, K.D. (2006). Responsiveness of the International Knee Documentation Committee Subjective Knee Form. The American Journal of Sports Medicine, 34: 1567-1573. DOI: 10.1177/0363546506288855
  • Irrgang, J.J., Snyder-Mackler, L., Wainner, R.S., Fu, F.H., & Harner, C.D. (1998). Development of a patient-reported measure of function of the knee. Journal of Bone and Joint Surgery [American Volume], 80(8): 1132–1145.
  • Johansson, H., Sjolander, P., & Sojka, P. (1991). A sensory role for the cruciate ligaments. Clinical Orthopaedics & Related Research, 268, 161-178.
  • Johnson, S.C. (1995). Anterior cruciate ligament injury in elite Alpine competitors. Medicine and Science in Sports and Exercise, 27(3): 323–327.
  • Kongtharvonskul, J., Attia, J., Thamakaison, S., Kijkunasathian, C., Woratanarat, P., & Thakkinstian, A. (2013). Clinical outcomes of double- vs single-bundle anterior cruciate ligament reconstruction: a systematic review of randomized control trials. Scandinavian Journal of Medicine and Science in Sports, 23(1): 1-14. DOI: 10.1111/j.1600-0838.2011.01439.x
  • Kim, K.M., Croy, T., Hertel, J., & Saliba, S. (2010). Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. Journal of Orthopaedic and Sports Physical Therapy, 40(7): 383-391. DOI: 10.2519/jospt.2010.3184
  • Klein, W., & Jensen, K.U. (1992). Synovites and artificial ligaments. Arthroscopy, 8(1): 116-124.
  • Kokmeyer, D., Wahoff, M., & Mymern, M. (2012). Suggestions from the field for return-to-sport rehabilitation following Anterior Cruciate Ligament Reconstruction: Alpine Skiing. Journal of Orthopaedic and Sports Physical Therapy, 42(4): 313-325. DOI: 10.2519/jospt.2012.4024
  • Kruse, L.M., Gray, B., & Wright, R.W. (2012). Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. Journal of Bone and Joint Surgery [American Volume], 94(19): 1737-174. DOI: 10.2106/JBJS.K.01246
  • Kwok, C.S., Harrison, T., & Servant, C. (2013). The optimal timing for anterior cruciate ligament reconstruction with respect to the risk of postoperative stiffness. Arthroscopy, 29(3): 556-565. DOI: 10.1016/j.arthro.2012.09.005
  • Lamblin, C.J., Waterman, B.R., & Lubowitz, J.H. (2013). Anterior cruciate ligament reconstruction with autografts compared with non-irradiated, non-chemically treated allografts. Arthroscopy, 29(6): 1113-1122. DOI: 10.1016/j.arthro.2013.01.022
  • Li, Y.L., Ning, G.Z., Wu, Q., Wu, Q.L., Li, Y., Hao, Y., & Feng, S.Q. (2014). Single-bundle or double-bundle for anterior cruciate ligament reconstruction: a meta-analysis. The Knee, 21(1): 28-37. DOI: 10.1016/j.knee.2012.12.004
  • Liden, M., Ejerhed, L., Sernert, N., Laxdal, G., & Kartus, J. (2007). Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: a prospective, randomized study with a 7-year follow-up. The American Journal of Sports Medicine, 35(5): 740-748. DOI: 10.1177/0363546506298275
  • Linko, E., Harilainen, A., Malmivaara, A., & Seitsalo, S. (2005). Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD001356. DOI: 10.1002/14651858.CD001356.pub3
  • Logerstedt, D.S., Snyder-Mackler, L., Ritter, R.C., Axe, M.J., Godges, J.J. (2010a). Knee stability and movement coordination impairments: knee ligament sprain. Journal of Orthopaedic and Sports Physical Therapy, 40(4): A1-A37. DOI: 10.2519/jospt.2010.0303
  • Logerstedt, D.S., Snyder-Mackler, L., Ritter, R.C., Axe, M.J. (2010b). Knee pain and mobility impairments: meniscal and articular cartilage lesions. Journal of Orthopaedic and Sports Physical Therapy, 40(6): A1-A35. DOI: 10.2519/jospt.2010.0304
  • Lubowitz, J.H., & Appleby, D. (2011). Cost-effectiveness analysis of the most common orthopaedic surgery procedures: knee arthroscopy and knee anterior cruciate ligament reconstruction. Arthroscopy, 27(10): 1317-1322. DOI: 10.1016/j.arthro.2011.06.001
  • Lyman, S., Koulouvaris, P., Sherman, S., Do, H., Mandl, L.A., Marx, R.G. (2009). Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. Journal of Bone and Joint Surgery [American Volume], 91(10): 2321-2328. DOI: 10.2106/JBJS.H.00539
  • Lysholm, J., & Gillquist, J. (1982). Evaluation of the knee ligament surgery results with special emphasis on use of a scoring scale. The American Journal of Sports Medicine, 10(3): 150-154.
  • MacDonald, P.B., Hedden, D., Pacin, O., & Huebert, D. (1995). Effects of an accelerated rehabilitation program after anterior cruciate ligament reconstruction with combined semitendinosus-gracilis autograft and a ligament augmentation device. The American Journal of Sports Medicine, 23(5): 588–592. DOI: 10.1177/036354659502300512.
  • Magnussen, R.A., Carey, J.L., & Spindler, K.P. (2011). Does autograft choice determine intermediate-term outcome of ACL reconstruction? Knee Surgery, Sports Traumatology, Arthroscopy, 19(3): 462-472. DPO: 10.1007/s00167-010-1277-z
  • Magnussen, R.A., Granan, L.P., Dunn, W.R., (2010). Cross-cultural comparison of patients undergoing ACL reconstruction in the United States and Norway. Knee Surgery, Sports Traumatology, Arthroscopy, 18(1): 98 105. DOI: 10.1007/s00167-009-0919-5
  • Magnussen, R.A., Lawrence, J.T., West, R.L., Toth, A.P., Taylor, D.C., & Garrett, W.E., (2012). Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy, 28(4): 526-531. DOI: 10.1016/j.arthro.2011.11.024
  • Maletis, G.B., Cameron, S.L., Tengan, J.J., & Burchette, R.J. (2007). A prospective randomized study of anterior cruciate ligament reconstruction: a comparison of patellar tendon and quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws. The American Journal of Sports Medicine, 35(3): 384-394.
  • Maletis, G.B., Inacio, M.C., Desmond, J.L., & Funahashi, T.T. (2013a). Reconstruction of the anterior cruciate ligament association of graft choice with increased risk of early revision. Bone and Joint Journal, 95(5): 623 628. DOI: 10.1302/0301-620X.95B5.30872
  • Maletis, G.B., Inacion, M.C., Reynolds, S., Desmond, J.L., Maletis, M.M., & Funahashi, T.T. (2013b). Incidence of postoperative anterior cruciate ligament reconstruction infections: graft choice makes a difference. The American Journal of Sports Medicine, 41(8): 1780-1785. DOI: 10.1177/0363546513490665
  • Mather, R.C., Koenig, L., Kocher, M.S., Dall, T.M., Gallo, P., Scott, D.J., Bach, B.R.J., Spindler, K.P., & MOON Knee Group (2013). Societal and economic impact of anterior cruciate ligament tears. Journal of Bone and Joint Surgery [American Volume], 95(19): 1751-1759. DOI: 10.2106/JBJS.L.01705
  • Mauro, C.S., Irrgang, J.J., Williams, B.A., Harner, C.D. (2008). Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence and etiology using IKDC criteria. Arthroscopy, 24(2): 146 153. DOI: 10.1016/j.arthro.2007.08.026
  • McDevitt, E.R., Taylor, D.C., Miller, M.D., Gerber, J.P., Ziemke, G., Hinkin, D., Uhorchak, J.M., Arciero, R.A., & Pierre, P.S. (2004). Functional bracing after anterior cruciate ligament reconstruction: a prospective, randomized, multicenter study. The American Journal of Sports Medicine, 32(8): 1887-1892.
  • Mohtadi, N.G., Chan, D.S., Dainty, K.N., & Whelan, D.B. (2011). Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database of Systematic Reviews, Issue 9, Art. No.: CD005960. DOI: 10.1002/14651858.CD005960.pub2
  • Myer, G.D., Schmitt, L.C., Brent, J.L., Ford, K.R., Foss, K.D.B., Scherer, B.J., Heidt, R.S., Divine, J.G., & Hewett, T.E. (2011). Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. Journal of Orthopaedic and Sports Physical Therapy, 41(6): 377-387. DOI: 10.2519/jospt.2011.3547
  • Myer, G.D., Sugimoto, D., Thomas S., & Hewett T. (2013). The influence of age on the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes – A meta-analysis. The American Journal of Sports Medicine, 41(1): 203-215. DOI: 10.1177/0363546512460637
  • Mulford, J.S., & Chen, D. (2011). Anterior cruciate ligament reconstruction: A systematic review of polyethylene terephthalate grafts. ANZ Journal of Surgery, 81(11): 785-789.
  • Natri, A., Beynnon, B.D., Ettlinger, C.F., Johnson, R.J., & Shealy, J.E. (1999). Alpine ski bindings and injuries. Current findings. Sports Medicine (Auckland, N.Z.), 28(1): 35-48.
  • Nemeth, G., Lamontagne, M., Tho, K., Eriksson, E. (1997). Electromyographic activity in expert downhill skiers using functional knee braces after anterior cruciate ligament injuries. The American Journal of Sports Medicine, 25(5): 635-664.
  • Negus, J., Fransen, M., Chen, J.S., Parker, D.A, March, L. (2012). Exercise-based interventions for conservatively or surgically treated anterior cruciate ligament injuries in adults. Cochrane Database of Systematic Reviews, Issue 10, Art. No.: CD010128. DOI: 10.1002/14651858.CD010128
  • Noyes, F.R., Barber, S.D., & Mangine, R.E. (1991). Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. American Journal of Sports Medicine, 19(5): 513–518.
  • Pan, X., Wen, H., Wang, L., & Ge, T., (2013). Bone–patellar tendon–bone autograft versus LARS artificial ligament for anterior cruciate ligament reconstruction. European Journal of Orthopaedic Surgery and Traumatology, 23(7): 819-823. DOI: 10.1007/s00590-012-1073-1.
  • Papageorgiou, C.D., Ma, C.B., Abramowitch, S.D., Clineff, T.D., & Woo, S.L. (2001). A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. The American Journal of Sports Medicine, 29(5): 620-626.
  • Palmieri, R.M., Tom, J.A., Edwards, J.E., Weltman, A., Saliba, E.N., Mistry, D.J., & Ingersoll, C.D. (2004) Arthrogenic muscle response induced by an experimental knee joint effusion is mediated by pre- and post-synaptic spinal mechanisms. Journal of Electromyography and Kinesiology, 14(6): 631–640.
  • Paxton, E.S., Kymes, S.M., & Brophy, R.H. (2010). Cost-effectiveness of anterior cruciate ligament reconstruction: a preliminary comparison of single-bundle and double-bundle techniques. The American Journal of Sports Medicine, 38(12): 2417-2425. DOI: 10.1177/0363546510375545
  • Persson, A., Fjeldsgaard, K., Gjertsen, J.E., Kjellsen, A.B., Engelbretsen, L., Hole, R.M., & Fevang, J.M. (2014). Increased Risk of revision with hamstring tendon grafts compared with patellar tendon grafts after anterior cruciate ligament reconstruction. American Journal of Sports Medicine, 42(2): 258-291.
  • Pichon, R.A., Augustovski, F., Alcaraz, A., Bardach, A., Ferrante, D., Garcia, M.S., Glujovsky, D., Lopez, A., Regueiro, A. (2007). Usefulness of synthetic graft in knee anterior cruciate ligament reconstruction. Buenos Aires: Institute for Clinical Effectiveness and Health Policy (IECS). Informe de Respuesta Rapida, 91.
  • Pujol, N., Blanchi, M.P., & Chambat, P. (2007). The incidence of anterior cruciate ligament injuries among competitive Alpine skiers: a 25-year investigation. The American Journal of Sports Medicine, 35(7): 1070-1074.
  • Rahr-Wagner, L., Thillemann, T.M., & Pedersen, A.B. (2014). Comparison of Hamstring Tendon and Patellar Tendon Grafts in Anterior Cruciate Ligament Reconstruction in a Nationwide Population-Based Cohort Study: Results from the Danish Registry of Knee Ligament Reconstruction. American Journal of Sports Medicine, 42(2): 278-284.
  • Ramski, D.E., Kanj, W.W., Franklin, C.C., Baldwin, K.D., & Ganley, T.J. (2013). Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment. The American Journal of Sports Medicine. DOI: 10.1177/0363546513510889
  • Ramos, J., Perrotta, C., Badariotti, G., & Berenstein, G. (2008). Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy. Cochrane Database of Systematic Reviews, Issue 4, Art. No.: CD005259. DOI: 10.1002/14651858.CD005259.pub3
  • Raynor, M.C., Pietrobon, R., Guller, U., Higgins, L.D. (2005). Cryotherapy after ACL reconstruction: a meta-analysis. The Journal of Knee surgery, 18(2): 123-129.
  • Renstrom, P.A., (2013). Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport: Recent evidence and a personal reflection. British Journal of Sports Medicine, 47(6): 367-372. DOI: 10.1136/bjsports-2012-091623
  • Reid, A., Birmingham, T.B., Stratford, P.W., Alcock, G.K., & Giffin, J.R. (2007). Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical Therapy, 87(3): 337–349. DOI: 10.2522/ptj.20060143
  • Roos, E.M., Roos, H.P., & Lohmander, L.S., (1998). Knee Injury and Osteoarthritis Score (KOOS)- development of a self-administrated outcome measurement. Journal of Orthopaedic Sports Physical Therapy. 28(2): 88-96.
  • Roos, E.M., Bremander, A.B., Englund, M., & Lohmander, L.S. (2008). Changes in self-reported outcomes and objective physical functions over 7 years in middle-aged subjects with or at high risk of knee osteoarthritis. Annals of Rheumatic Diseases, 67(4): 505-510.
  • Risberg, M.A., Holm, I, Myklebust, G., & Engebretsen, L. (2007). Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Physical Therapy, 87(6): 737-750.
  • Risberg, M.A., & Holm, I. (2009). The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction: a randomized controlled clinical trial with 2 years of follow-up. The American Journal of Sports Medicine, 37(10): 1958-1966. DOI: 10.1177/0363546509335196
  • Ross, M.D., Langford, B., & Whelan, P.J. (2002). Test-retest reliability of 4 single-leg horizontal hop tests. Journal of Strength and Conditioning Research, 16(4): 617-622.
  • Scheffler, S.U., Unterhauser, F.N., & Weiler, A. (2008). Graft remodelling and ligamentization after cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 16(9): 834-842. DOI: 10.1007/s00167-008-0560-8
  • Shaarani, S.R., O’Hare, C., Quinn, A., Moyna, N., Moran, R., & O’Byrne, J.M. (2013). Effect of prehabilitation on the outcome of anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 41(9): 2117-2127. DOI: 10.1177/0363546513493594
  • Shelbourne, K.D., & Nitz, P. (1990). Accelerated rehabilitation after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 18(3): 292-299.
  • Sterett, W.I., Briggs, K.K., Farley, T., & Steadman, J.R. (2006). Effect of functional bracing on knee injury in skiers with anterior cruciate ligament reconstruction: a prospective cohort study. The American Journal of Sports Medicine, 34(10): 1581-1585. DOI: 10.1177/0363546506289883
  • Sugimoto, D., Myer, G.D., McKeon, J.M., & Hewett, T.E. (2012a). Evaluation of the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a critical review of relative risk reduction and numbers-needed-to-treat analyses. British Journal of Sports Medicine, 46(14): 979 988. DOI: 10.1136/bjsports-2011-090895
  • Sugimoto, D., Myer, G.D., Bush, H.M., Klugman, M.F., Medina McKeon, J.M., & Hewett, T.E. (2012b). Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. Journal of Athletic Training, 47(6): 714-723. DOI: 10.4085/1062 6050-47.6.10.
  • Tegner, Y., & Lysholm, J. (1985). Rating systems in the evaluation of knee ligament injuries. Clinical Orthopaedics and Related Research, 198, 43-49.
  • Tiamklang, T., Sumanont, S., Foocharoen, T., Laopaiboon, M. (2012). Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults. Cochrane Database of Systematic Reviews, Issue 11. Art. No.: CD008413. DOI: 10.1002/14651858.CD008413.pub2
  • Van Ginckel, A., Verdonk, P., & Witvrouw, E. (2013). Cartilage adaptation after anterior cruciate ligament injury and reconstruction: implications for clinical management and research? A systematic review of longitudinal MRI studies. Osteoarthritis and Cartilage, 21(8): 1009-1024. DOI: 10.1016/j.joca.2013.04.015
  • Van Grinsven, S., Cingel, R.E.H., Holla, C.J.M., Van Loon, C.J.M. (2010). Evidence-Based rehabilitation following anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 18(8): 1128-1144. DOI: 10.1007/s00167-009-1027-2
  • Van Tongel, A., Stuyck, J., Bellemans, J., & Vandenneucker, H. (2007). Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. The American Journal of Sports Medicine, 35(7): 1059-1063. DOI: 10.1177/0363546507299443
  • Walden, M., Atroshi I, Magnusson H, Wagner P, Hagglund M., (2012). Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial. British Medical Journal, 344:e3042. DOI: 10.1136/bmj.e3042
  • Webster, K.E., Feller, J.A., & Hameister, K.A. (2001). Bone tunnel enlargement following anterior cruciate ligament reconstruction: a Randomised comparison of hamstring and patellar tendon grafts with 2 year follow-up. Knee Surgery, Sports Traumatology, Arthroscopy, 9(2): 86-91.
  • Weiler, A., Hiffman, R.F.G., Rehm, O., & Südkamp, N.P. (2002). Tendon Healing in a bone tunnel part 11: Histologic analysis after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep. Arthroscopy, 18(2): 124-135.
  • Westin, M., Alricsson, M., & Werner, S. (2012). Injury profile of competitive alpine skiers: a five-year cohort study. Knee Surgery, Sports Traumatology and Arthroscopy, 20(6): 1175-1181. DOI: 10.1007/s00167 012 1912 x
  • Wright, R.W., Preston, E., Fleming, B.C., Amendola, A., Andrish, J.T., Bergfeld, J.A., Dunn, W.R., Kaeding, C., Kuhn, J.E., Marx, R.G., McCarty, E.C., Parker, R.C., Spindler, K.P., Wolcott, M., Wolf, B.R., Williams, G.N. (2008a). A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and homebased rehabilitation. The Journal of Knee Surgery, 21(3): 217-224.
  • Wright, R.W., Preston, E., Fleming, B.C., Amendola, A., Andrish, J.T., Bergfeld, J.A., Dunn, W.R., Kaeding, C., Kuhn, J.E., Marx, R.G., McCarty, E.C., Parker, R.C., Spindler, K.P., Wolcott, M., Wolf, B.R., Williams, G.N. (2008b). A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. The Journal of Knee Surgery, 21(3): 225-234.
  • Wright, R.W. (2009). Knee injury outcomes measures. Journal of the American Academy of Orthopaedic Surgeons, 17(1): 31-39.
  • Xu, M., Gao, S., Zeng, C., Han, R., Sun, J., Li, H., Xiong, Y., Lei, G. (2013). Outcomes of anterior cruciate ligament reconstruction using single-bundle versus double-bundle technique: meta-analysis of 19 randomized controlled trials. Arthroscopy, 29(2): 357-365. DOI: 10.1016/j.arthro.2012.08.024
  • Yoo, J.H., Lim, B.O., Ha, M., Lee, S.W., Oh, S.J., Lee, Y.S., & Kim, J.G. (2010). A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes. Knee Surgery, Sports Traumatology, Arthroscopy, 18(6): 824-830.
  • Young, R., Aronsson, D., Johnson, R., Ettlinger, C., Shealy, J., (1976). The etiology of ski injuries: An eight year study of the skier and his equipment. The Orthopaedic clinics of North America, 7(1): 13-29.
  • Zätterström, R., Fridén, T., Lindstrand, A., Moritz, U. (2000). Rehabilitation following acute anterior cruciate ligament injuries–a 12-month follow-up of a randomized clinical trial. Scandinavian Journal of Medicine and Science in Sports, 10(3): 156-163.
  • Zhu, Y., Tang, R.K., Zhao, P., Zhu, S.S., Li, Y.G., Li, J.B. (2013). Double-bundle reconstruction results in superior clinical outcome than single-bundle reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 21(5): 1085-1096. DOI: 10.1007/s00167-012-2073-8
  • National Guideline Clearinghouse (NGC) (https://www.guideline.gov/). Accessed 16/2/2014.
  • Centre of Evidence based medicine Oxford United Kingdom (http://www.cebm.net) Accessed 16/2/2014.

Disclaimer

The contents of this article – Management of ACL Ruptures in Skiers, is aimed at medical professionals. It is provided here for informational purposes only and should not be treated as medical or health management advice. The materials herein are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor, physiotherapist or other health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article or website. Reliance on any information provided herein is solely at your own risk.

Copyright

The content of this article – Management of ACL Ruptures in Skiers, is copyright © 2016 of Suegnet Meyer and Meyer & Associates. Transmission or reproduction of the contents, beyond that allowed by fair use as defined in the copyright laws requires the written permission of the copyright owners.