Surgical and Rehabilitation Protocols

Anatomic single-bundle ipsilateral hamstring ACL reconstruction was performed by use of suspensory fixation on the femoral side (EndoButton CL Ultra; Smith & Nephew) and interference fixation with a cannulated screw on the tibial side. The femoral tunnel was drilled via the anteromedial portal.

All patients were provided with the same rehabilitation protocol and guidelines. In the first 3 postoperative weeks, patients were encouraged to reduce knee swelling using rest, ice, compression, and elevation. Full weightbearing was permitted from the first postoperative day, and knee range of motion exercises, including active terminal knee extension, active knee flexion, and prone leg hanging exercises, were commenced. Beginning at 3 weeks, stationary bike, wall squats, straight-leg raises, forward lunges, and hamstring curls were introduced. At 5 weeks, a gymnasium program commenced that included leg press (both double- and single-leg concentric and eccentric), half squats, stationary bike, rowing machine, cross-trainer and step-machine, hamstring curls, bridging (both double and single), calf raises, exercise ball drills for core stability, and leg extensions (after 8 weeks). At 10 weeks, hopping and landing drills were commenced if there was no effusion. At 16 weeks, patients were typically allowed to return to sports-specific drills and activities, including kicking, dribbling, and controlled change of direction. At 26 weeks, patients were encouraged to increase training intensity. No patients had returned to unrestricted sports participation at this time. Return-to-sports clearance was made by the treating surgeon based on the absence of swelling, an essentially full range of motion, a stable knee on clinical examination, good quadriceps strength on clinical examination, control of a single-leg step-down, and the patient’s confidence in his or her knee. A minimum of 4 weeks of unrestricted training was required before return to competitive sports. Although return to sports was criterion-driven, patients would typically return to sports between the 12- and 14-month marks.