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N Am J Sports Phys Ther. 2008 November; 3(4): 212–225.
PMCID: PMC2953342

Surgical Treatment and Rehabilitation of Combined Complex Ligament Injuries

Richard L. Romeyn, MD,a Jason Jennings, DPT, ATC,b and George J. Davies, DPT, MEd, PT, SCS, ATC, FAPTAc

Abstract

This article is a description of the surgical treatment and rehabilitation of combined complex ligament injuries. A background will be provided, and information on the combined complex knee injuries, selected aspects of surgical treatments, and rehabilitation strategies will be presented. Combined complex ligament injuries are devastating injuries and are not very common compared to other knee injuries. No meta-analysis or systematic review studies exist regarding the best treatments for these patients. This article's emphasis is on the stages in the rehabilitation program with documentation of the scientific and clinical rationale for the treatment techniques in each stage. Treatment interventions are described and documented with the limited evidence available in treating these patients. Guidelines for treatment, surgery, and a clinical protocol for treating patients with combined complex ligament injuries are provided for the practicing clinician to use as a template for treating these complicated patients.

Keywords: knee dislocation, multi-ligament, knee injury

INTRODUCTION

Historically, knee dislocation and traumatic multi-ligament knee injury (MLKI) was usually managed with prolonged immobilization. The tradeoff for stability was significant knee stiffness. Surgical intervention was performed, not to restore limb function, but as an attempt to avoid the gangrene and life-threatening sepsis which all too often followed vascular compromise in the pre-antibiotic era. In 1824, Sir Astley Cooper stated that “there are scarcely any accidents to which the body is liable, which more imperiously demand immediate amputation than these.”1

Although the first reported description of surgical repair was by Thomas Annandale in 1881,2 few advances were made for many decades. Improved techniques to address vascular injury evolved during the Korean and Vietnam Wars and made limb salvage possible. Then in 1963, Kennedy3 published the first attempt to systematically define the pathophysiology of the dislocated or multi-ligament injured knee, and his work stimulated interest in the problem. Initial reports suggested that reasonable outcomes could be obtained with non-operative management, and that those results were comparable to surgical intervention.311 However, during that era, the typical surgical treatment involved the re-approximation of the cruciate and collateral ligaments with suture, rather than reconstruction with grafts, as well as other techniques that are now of historical interest only. As the technique and success rate of single cruciate ligament reconstruction evolved, so too did application of reconstruction occur for patients with MLKI. More recent authors have consistently reported superior results with an approach combining reconstruction of cruciate ligament insufficiency with repair or reconstruction of collateral ligament disruption.1237

The decision for surgical versus non-operative treatment must still be individualized, however, as not all patients are candidates for operative intervention. Success is dependent on not only that portion of treatment which occurs in the operating room, but also that which is related to patient enthusiasm and compliance afterward. Both the ability of the surgeon to manage a complex and demanding procedure and the full cooperation of the patient during a lengthy convalescence are mandatory. Elements such as patient age and fitness, associated injuries, pre-injury level of function, and availability of appropriate physical therapy must be considered. For example, MLKI's sustained during athletic participation typically occur in well-conditioned individuals who are already familiar with physical training and rehabilitation and are motivated to return to a level of function for which knee stability is crucial. In contrast, the risk/benefit ratio for multiple trauma patients is higher. The high-energy dislocations of motor vehicle injury are more likely to involve individuals with multi-system injury or those unaccustomed to regular physical exercise. These individuals may be unable or unmotivated to participate in the lengthy and arduous rehabilitation necessary to maximize their recovery. Rather than improving their prognosis, well-intentioned surgical stabilization may instead increase the likelihood of permanent disabling knee stiffness.

Four guiding principles apply to the elective surgical treatment of MLKI:

  1. Never jeopardize the life of the patient or the viability of the limb to improve the chance of obtaining a stable knee.
  2. Residual laxity is easier to treat than arthrofibrosis.
  3. When in doubt regarding patient fitness, compliance, coping skills, or tissue quality - delay or avoid surgery.
  4. The goal of surgery, regardless of pathology, is the restoration of all instability patterns with adequate tissue and methods of fixation such that range of motion (ROM) can be allowed early in the postoperative course.

Although a detailed description of surgical technique is beyond the scope of this paper, some specific points that bear on postoperative recovery and rehabilitation merit emphasis. Most of the same principles also apply to patients where non-operative treatment is elected. Optimal treatment of the patient with MLKI requires a team approach. The physical therapist should read and understand the operative report, comprehend the ramifications of specific aspects of the surgical procedure, and communicate with the surgeon before beginning treatment.

No uniformity of opinion exists with respect to the optimal timing of surgery and the specifics of ligament repair/reconstruction. Shelbourne and Carr31 have recommended initial non-operative treatment for anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL)/medial collateral ligament (MCL) injuries when PCL laxity is grade II or less and PCL reconstruction alone if PCL laxity is grade III. Their approach is predicated on the belief that the PCL and MCL have “intrinsic” abilities to heal, that residual laxity is preferable to stiffness, and that ACL reconstruction can be performed electively if necessary as a secondary procedure once ROM is re-established.31 Others have recommended that most patients with MLKI be treated by initial brace immobilization followed by simultaneous arthroscopic bi-cruciate ligament reconstruction in 4 to 6 weeks.14,26,3840 Any residual collateral ligament laxity is later treated with reconstructive techniques.

Currently, most authors recommend simultaneous bicruciate and collateral ligament reconstruction/repair performed at approximately 14 days from injury unless extenuating circumstances exist.16,17,24,25,28 By this time, post-injury edema and the acute post-traumatic inflammatory response will have largely subsided and the ROM will have been at least partially restored. However, anatomic definition of the collateral ligaments and capsule still remains possible. The senior author has consistently followed this approach and believes that bi-cruciate ligament reconstruction allows the most accurate centering of the tibia on the femur and minimizes stress on repaired collateral ligaments; that cruciate and collateral reconstructions are complimentary, and thus best performed during a single surgery; and that delayed reconstruction of significant structural injury to the posterior medial or posterior lateral corners can not consistently match the quality of the end result obtained with acute surgical treatment. However, this approach assumes exacting surgical technique, tissue fixation that will tolerate aggressive rehabilitation, and appropriate patient compliance.

Although the majority of patients with MLKI can be managed on an elective basis, immediate surgery is indicated when the injury is compound (a wound communicates through the skin with the deep tissue or joint);9,21,41 associated vascular injury occurs;4244 displaced intra-articular fractures exist requiring open reduction and internal fixation;4547 and a complex dislocation occurs (usually posterolateral), wherein interposed capsule prevents concentric reduction of the dislocation.4851 In these instances, definitive attention to the ligament pathology is delayed to be treated on an elective basis once the health of the limb is assured.

Three additional scenarios may mandate surgical intervention earlier than usual.

First, abnormally displaced structures (locked meniscus, flipped collateral ligaments);28 second, cruciate ligament avulsions from bone (as apposed to the typical interstitial disruption);15,32,52 and third, extensor mechanism disruption (quadriceps or infrapatellar tendon rupture).28

When early definitive surgery is not advisable, application of an external fixator or a hinged cast brace may be recommended. The spanning external fixator is often the best choice for patients who will be treated non-operatively. This technique provides good stability of the knee joint, is readily adjustable, and allows excellent access to open wounds and assessment of neurovascular status. Fixation pins must be placed far enough away from the joint and in such a manner that the pin tracks will not compromise incision placement for future knee surgery. If a non-operative approach is elected as the definitive treatment, the external fixator is maintained in place for six weeks before ROM exercises are begun. Serial radiographs should be obtained to confirm that a perfectly concentric reduction has not been lost during the period of immobilization. Recently, articulated hinged external fixation has also been proposed as a routine supplement for post-operative protection.53

Several graft options are available for cruciate ligament reconstruction. Ipsilateral autografts (patellar tendon for the PCL and semitendenosis/gracilis for the ACL) can be used, but harvest of these grafts increases the morbidity of an already severely traumatized knee. Contralateral auto-grafts can be utilized, especially if the patient will not allow the use of allograft tissue, but their use does, at least theoretically, compromise a perfect knee and harvesting requires additional operative time. The success rates obtained using allograft tissue in the reconstruction of isolated ACL and PCL injuries has been documented to approach that of autografts, and their use in the multiple-ligament-injured knee has decided advantages.16,25,5457 Donor site morbidity is eliminated and a second surgeon or assistant can prepare the grafts while the primary surgeon prepares the knee, thus saving significant operative time. The only drawbacks to allograft use are potential disease transmission, limited availability, and cost.54,5860 The patellar tendon is frequently utilized for ACL reconstruction and the Achilles tendon for PCL reconstruction. However, quadriceps, tibialis anterior, tibialis posterior, and semitendenosis muscle tendon allografts are also commercially available and can be utilized for either cruciate or collateral ligament reconstructions.

SURGICAL ALGORITHM

A suggested surgical algorithm for patients with MLKI is as follows:

  1. A focused evaluation of the pattern and magnitude of ligament laxity is repeated under anesthesia to confirm the initial clinical impression and the findings suggested by pre-operative magnetic resonance imaging (MRI). Although MRI is an important tool to assist in both the diagnosis and planning of these complex injuries, the test is neither 100% sensitive nor specific. Special MRI technique is required to sensitively assess the posterolateral corner, which is not well seen on standard images. Even the best MRI study can occasionally be misleading, with partial PCL or collateral ligament injury misrepresented as being complete.6164
  2. Arthroscopy is used to confirm the expected pathology and to address meniscal or chondral injury. If residual concerns exist about the integrity of the capsule to contain fluid, or if any intra-operative indication of fluid extravasation exist, the arthroscopy is performed dry.
  3. Incisions to expose and isolate collateral ligament pathology are made. The specific incision chosen depends upon the structures that are to be repaired or reconstructed. It is important to maintain the widest possible spacing of incisions to minimize wound healing complications.
  4. Controversy continues regarding the optimal technique of both ACL and PCL reconstruction. Traditionally, PCL reconstruction has been performed utilizing a graft routed into and out of the knee via tibial and femoral tunnels. If this trans-tibial technique is utilized, the tunnel must be positioned as vertically as possible for optimal mechanical advantage and to avoid the tibial tunnel made for ACL reconstruction. The tunnel should exit the posterior cortex of the tibia well distal to the PCL insertion. Several authors currently advocate PCL reconstruction performed with the graft fixated directly to it's tibial insertion site, thus avoiding the need for the graft to traverse the “killer turn” from a tibial tunnel into the knee. 28,33,6569 This “inlay” technique is performed via a posterior medial incision and direct soft tissue dissection to reach the popliteal fossa. Still other authors have advocated the use of double-bundle, rather than single-strand, grafts in order to best replicate the normal PCL anatomy of separate anterolateral and posteromedial bundles.16,7074 In this case, two separate tunnels are drilled in the femur, one for each graft strand.
    Recently, modifications in the technique of ACL reconstruction have also been suggested. These modifications emphasize the advantage of viewing the femoral insertion from a medial arthroscopic portal to best appreciate that anatomy, and then placing the femoral tunnel low enough on the lateral wall of the intracondylar notch to replicate both functional bundles.7582 This technique places the tunnel closer to 9 or 3 o'clock on the wall of the intracondylar notch, rather than the previously accepted 10 or 2 o'clock position. Such tunnel placement may mandate that the femoral tunnel be drilled separately (through an anteromedial portal with the knee hyperflexed, or with an outside-in guide), rather than by working through the tibial tunnel. It has also been recently proposed that the ACL be reconstructed with separate tibial and femoral tunnels for each of its two functional bundles. Although the advantages of two bundle reconstructions have been demonstrated by several authors in respect to isolated ACL reconstruction, the applicability of this technique, with the far greater complexity and time requirements, has not been tested in respect to more complex knee instabilities.8386
    Generally, the tibial tunnel or inlay site for the PCL is prepared first, followed by the tibial tunnel for the ACL. The femoral tunnels for the PCL and ACL are made subsequently.
  5. The PCL is the cornerstone of multi-ligament reconstruction.87 Once the tunnels are ready, the PCL graft is passed and anchored securely at one end (which may be either the femoral or tibial end, dependent upon the technique utilized). The knee is then cycled through repeated arcs of motion to ensure that the graft is well settled. The knee is then maintained carefully in neutral rotation and between 80-90 degrees of flexion while the graft is then tensioned and fixation of the opposite end is completed. The surgeon must ensure that the anatomic anterior step-off of the tibia has been re-established.
  6. Next, the ACL graft is passed, anchored at the femoral end, and then fixed at the tibial end with the knee at or near neutral extension. The ACL can be properly tensioned only after the joint has been “centered” by reestablishment of physiologic PCL stability. If the ACL were tensioned first, avoidance of constraining the knee in a position of posterior tibial subluxation is difficult.
  7. Once bi-cruciate ligament stability has been reestablished, collateral laxity can be re-evaluated. The surgeon will generally have a realistic expectation of whether collateral ligament repair or reconstruction will be necessary based upon the examination under anesthesia and exploration of the pathology earlier in the case.
    Approximately one half of the MCL injuries associated with MLKI will need further repair or reconstruction.28,40 Severe valgus injury generally requires that the surgeon address laxity involving the posterior capsule, posterior oblique area of the posteromedial corner, and mid-medial capsular ligaments.38,39,8892 Care must be taken to avoid over-advancement of the posterior oblique ligament, which may result in a flexion contracture. Avulsion of the distal superficial MCL has less healing potential than proximal lesions and may require attachment to the tibia deep to the pes anserinus expansion.39,90 Moderate interstitial laxity in the superficial MCL can be treated by recession of the femoral insertion, although severe disruption may require reconstruction utilizing the autogenous semitendenosus or an allograft.88,93
    Lateral and posterolateral corner injuries are more complex than those on the medial side, and have generated a great number of opinions as to the timing and technique of surgery.34,94112 To a significant extent, the technique chosen will reflect the specifics of the pathology, as a very wide range of injury pattern exist. However, an accumulating body of evidence suggests that primary reconstruction may not always be enough to ensure long term stability, even if done early, and that primary reconstruction with grafts is frequently necessary to obtain a stable knee.95,98,103,105,107,111 The plethora of technical options for lateral-sided ligament reconstruction reflects the fact that care is still evolving. However, all authors emphasize the importance of an isometric repair and reconstruction.
  8. After surgery, the injured knee is immobilized in extension. Cryotherapy may be helpful in the control of post-operative discomfort. An interferential electrical stimulation unit for pain and swelling is also frequently utilized. The cuff and electrode pads are applied in the operating room.

REHABILITATION

The rehabilitation of patients with combined complex knee injuries has paralleled the advances in the surgical techniques of the MLKI. These techniques, which emphasize the anatomical restoration of injured tissue, present the therapy team with an unmatched opportunity for optimal functional rehabilitation. However, no two instances of MLKI are exactly alike. Therefore, rehabilitation programs must be “customized” to the individual patient, and ongoing communication between the surgeon and the rehabilitation team is imperative to assure successful outcomes.

Detailed rehabilitation protocols for patients with MLKI have seldom been published.113115 Furthermore, due to the uniqueness of each MLKI, randomized trials have not been performed. The strategies in the rehabilitation of the patient with MLKI may seem to be diametrically opposed as in the case of protecting both the reconstructed ACL and PCL, thereby creating significant challenges for the clinician. The progression of rehabilitation should occur in a logical sequence and include the following considerations:

  1. Protection of ligament grafts and repaired tissues
  2. Interventions to decrease pain, reflex inhibition, effusion, and edema
  3. Measures to maximize ROM
  4. Initiate, facilitate, and enhance neuromuscular control
  5. Improve proprioception
  6. Enhance dynamic stability of the knee through exercises and functional activities114

SCIENTIFIC BASIS AND BIOMECHANICS OF KNEE REHABILITATION FOR THE PATIENT WITH MLKI

Clinicians should incorporate both open kinetic chain (OKC)116124 and closed kinetic chain (CKC)125132 exercises into the rehabilitation of patients with MLKI. No studies exist that have discussed the specific ligamentous strains with MLKI. Consequently, all studies have researched CKC and OKC forces in isolated ligament injuries; therefore, this information will be applied to the MLKI. Furthermore, co-contraction exercises, particularly for patients with MKLI, may be protective to all the healing structures by stabilizing the knee joint.125127,133,134

The following is a list of recommended “safe” guidelines regarding isolated ACL and PCL initial OKC and CKC exercises. However, because of the complexity of MLKI, these guidelines will need to be customized based on concomitant injured structures, surgical procedures, and the patient's response to rehabilitation.114

OKC knee extension

  • 90-30 degrees for ACL rehabilitation
  • 90-0 degrees for PCL rehabilitation

OKC knee flexion

  • Full range of motion for ACL rehabilitation
  • Contraindicated for PCL rehabilitation, in the early phases

CKC exercises

  • 0–60 degrees for ACL and PCL rehabilitation

These ROM restrictions will be combined to form the basis of the rehabilitation program. Obviously these restrictions may be lifted as soft tissue healing allows during the rehabilitation process.114

Phase I (Weeks 1–6): Protective Phase

This early phase of the post-operative course is quite constant, irrespective of the specifics of the pattern of MLKI and the surgical technique employed. The priority is to protect the reconstructed and repaired tissues, while implementing strategies to reduce pain, effusion and edema, regain ROM, and initiate/facilitate muscle function. During this phase of rehabilitation, a long-leg brace is utilized. For the first 4–6 weeks, this brace is locked in extension while maintaining a strict non-weight bearing status. Dependent upon a variety of factors, including patient compliance and the type of reconstruction/repair, partial weight bearing status may be initiated during weeks 4–6. However, controlled non-weight bearing early is encouraged, generally beginning approximately one week after surgery, but with a proximal pad or counterforce support on the proximal tibia to minimize the effects of gravity and to prevent posterior tibial sag.114 Arms et al135 demonstrated increased strain on the PCL as the knee flexes, with maximum strain recorded at 100 degrees. Therefore, knee flexion past 90 degrees is not allowed during the first 6 weeks of the rehabilitation program.

Facilitate Soft Tissue Healing.

A predictable progression of soft-tissue healing response occurs after severe trauma and surgical intervention. The initial phase of acute inflammation is followed within a week by phases that include collagen fibroplasia, maturation, and then remodeling. During the acute inflammatory phase, various physical therapy modalities are effective in decreasing the severity of pain and effusion and, thus, facilitate a healing response. Soft tissue healing is a long process, with the latter three stages each taking weeks at a time. During soft tissue healing, it is important that the appropriate stresses be imposed on injured tissues to promote physiologic healing responses, minimize negative changes, and facilitate the proliferation and alignment of collagen fibers.114

Decrease Pain and Effusion.

Both pain and the presence of an effusion significantly delay ROM gains and quadriceps muscle function. Spencer et al136 demonstrated that as little as 20–30 mL of fluid in the knee joint can retard the contraction of the vastus medialis oblique muscle. Various modalities (cryotherapy, interferential electrical stimulation, etc.) may supplement pharmacological therapy in decreasing post-surgical pain, effusion, and edema, and lead to improved neuromuscular control early in the rehabilitation process.

Restore Full Physiological Extension.

Full physiologic ROM is necessary for normal function of the knee. Prolonged immobilization is associated with many detrimental effects to the joint and surrounding structures, including the development of intra-articular and peri-articular adhesions, arthrofibrosis with loss of joint motion, degradation of hyaline cartilage, and decreased bone mass. The goal is the steady and gradual return of motion.114

Obtaining extension must take precedence during the initial phases of rehabilitation. The goal is to gain at least neutral extension by the end of the second week. This goal will be most difficult when injury patterns involve MCL pathology. Additionally, the repaired or reconstructed PCL comes under increasing stress as the knee goes into hyperextension. The PCL/posterior lateral corner combination injuries are especially vulnerable, as the lateral structures also come under increasing tension with terminal extension secondary to the “screw-home” phenomena.114 To quantitatively document the ROM, a measurement of knee extension via heel height difference is taken, where 1 centimeter in heel height is equal to approximately 1 degree.137,138

Oftentimes, additional treatment interventions need to be performed to achieve full ROM. For patients with hypomobilities, utilization of the total end range time (TERT) stretching formula is instituted. The TERT formula is used to create plastic deformation of the non-contractile tissue.139140 This formula is based on the product of intensity, duration, and frequency. The intensity is the maximal stretch intensity the patient can tolerate based on comfort.140

Active warm-up.

In the early stages of rehabilitation this is modified based on soft tissue healing constraints (active assistive range of motion (AROM), short arc exercises, etc).

Heat in a stretched position.

The first TERT is applied.

Mobilization/ROM.

Hypomobility of patella-femoral cephalic glide interferes with the normal function of the extensor mechanism which may lead to loss of active and passive ROM or a quadriceps muscle lag. Patella-femoral caudal glides are utilized to increase knee flexion. In the single cruciate ligament reconstruction surgeries, mobilization of the tibio-femoral articulation is rarely necessary for patients who have had MKLI surgeries.114

Static stretching or proprioceptive neuromuscular facilitation (PNF) contract-relax.

Oftentimes, the musculo-tendinous unit also adaptively shortens which also leads to flexibility deficits. The static portion of the stretches should be held for 30 seconds for younger patients.141153 However, if the patient is older than 60, greater benefits are obtained maintaining the stretch position for 60 seconds.144 Moreover, PNF techniques, such as contract-relax/hold-relax, can be included as part of the treatment program.

Therapeutic exercise.

Passive range of motion (PROM) can only be utilized and maintained if adequate neuromuscular control exists.

Total leg strengthening (TLS).145146

Dynamic stabilization exercises for the entire lower extremity should be performed, which also includes core stability exercises.

Ice in a stretched position.

The second TERT is applied at the completion of the physical therapy treatment session.147

Home exercise program (HEP).

The patient will perform a third TERT.

Initiate Neuromuscular Control to Prevent Reflex Inhibition.

Quadriceps muscle weakness and atrophy in the initial stages post-operatively is unavoidable, but must be addressed immediately in order for the patient to meet their rehabilitation goals. Isometric quadriceps sets are initiated post-operatively day one, with a progression to a straight leg raise without the brace once adequate neuromuscular control is obtained. As previously discussed, various modalities are utilized to decrease the post-operative pain and effusion which are inevitable in all patients with MLKI. Quadriceps muscle sets can be supplemented with electrical stimulation to augment strength.148 Additionally, the use of biofeedback may be particularly useful in this population.

Enhance Neuromuscular Proactive Control and Stability: Exercise Progression Continuum.

Exercise progression forms the foundation of the exercise program. The continuum stages are as follows:149

  • Sub-maximal intensity pain-free multiple angle isometrics
  • Maximal intensity multiple angle isometrics
  • Sub-maximal intensity short arc exercises
  • Maximal intensity short arc exercises
  • Full ROM sub-maximal intensity exercises
  • Full ROM maximal intensity exercises
  • Plyometric exercises
  • Functional specificity exercises

During Phase I, the emphasis is on the first three stages of this exercise progression. Total leg strength145146 can also be performed, but caution must be taken when using the entire lower extremity and long lever arms, since total leg strength may put stresses on the healing ligaments.114

Improve Proprioception/Kinesthesia.

Knee proprioception and kinesthesia are disrupted by injury.150 Mechanoreceptors within the cruciate ligaments are injured during the ligament failure of MLKI and do not regenerate into the reconstructed grafts. In addition, receptors within the collateral ligaments and capsule are damaged to varying degrees. Specific exercises that are safe for the healing structures early in the rehabilitation program may facilitate the remaining intact mechanoreceptors to compensate for those that are absent. Various exercises that may be used at this time include angular joint replication training, end ROM reproduction training, and perturbation training.114,151

Phase II (6-12 Weeks): Guarded Protection

In Phase II, continued protection of repaired and reconstructed tissue is necessary, although progressive guarded stresses are imposed as the rehabilitation program continues. The patient may generally be allowed full weightbearing in their post-surgical brace at the beginning of the sixth week. Patients must have at least active neutral extension and no evidence of a quad lag to assume full weight bearing. A normal gait pattern is necessary to dispense with crutches. The long-leg post-operative brace is discontinued when the patient begins to ambulate without crutches at approximately 6-8 weeks.114

A functional brace is worn for all activities of daily living until approximately 12 weeks post-operative. It is highly recommended that patients who plan to return to athletic activity or manual labor utilize the brace for those specific activities for at least 18 months after surgery. At the present time, no published studies exist that assess the efficacy of functional braces after MKLI. Nevertheless, it appears to be important to provide the patient with external support because muscle function and proprioception are deficient during the early stages of recovery from these devastating injuries.114

Restore Full Physiological ROM.

Neutral extension should have been obtained by the end of the sixth week. The goal of the second phase of rehabilitation is to achieve physiological knee extension of the involved extremity equal to the uninvolved. Application of the TERT formula is continued if needed. Ideally, flexion should gradually increase until ROM is symmetrical to the uninvolved side by weeks 8-12. However, consistently obtaining full flexion may be difficult. If neutral extension and flexion to 125 degrees have not been obtained by week 12 and gains in ROM have plateaued, surgical intervention in selective patients with MLKI is considered.

Improve Proprioceptive/Kinesthesia.

Proprioceptive/kinesthesia exercises are advanced in a systematic fashion. Unlike isolate ligamentous injuries, the rate of progression for these exercises varies considerably between patients with MLKI. Suggested progression is as follows:152154

  • Partial weight bearing (PWB) - Full weight bearing (FWB)
  • Double-leg exercises - Single-leg exercises
  • Single plane tilt board - Multiple plane tilt board
  • Eyes open - Eyes closed
  • Perturbation training (proactive)

Increase Muscular Strength, Power, and Endurance.

An important part of the rehabilitation program for the patient with a MKLI is dynamic stability, which helps protect the knee joint and compensates for any residual impairments. Core stability training can also be included for a comprehensive rehabilitation program. As previously described, the exercise progression forms the foundation of the exercise program. In Phase II, the emphasis to enhance neuromuscular dynamic stability is on stages 3-6 of the exercise progression continuum.114

After knee surgery, patients have a tendency to unload their surgical extremity. Neitzel et al155 have demonstrated that patients continued to unload the surgical limb for at least six months, and then normalized their weight bearing by one year. Based on these findings, patients are encouraged to begin single leg exercises earlier in the rehabilitation program.

Phase III (12-24 Weeks): Improve Proprioception/Kinesthesia

Exercises from phase II are continued with the addition of more aggressive progressions such as perturbation training exercises. These exercises are progressed from submaximal to maximal, slow to fast, and known (proactive) to unknown (reactive) patterns. At approximately week 24, low intensity agility drills may be initiated. Exercises such as controlled acceleration and deceleration, slideboard, and jumping rope form the foundation of these exercises.114, 129

Increase Muscular Strength, Power, and Endurace.

In the later phases of rehabilitation, the resistive exercises for both CKC and OKC exercises use the principles of progression and overload.156158 The OKC limitations are as follows:114

Weeks 12-18

    • 30-90 degrees for resisted knee extension exercises (at about week 12-depending on joint stability, patellofemoral joint chondrosis, surgical repairs, comorbidities, and doctor approval)
    • Resisted knee flexion exercises are contraindicated at this time secondary to the stress placed on the PCL

Weeks 18-24

    • 0-90 degrees for resisted knee extension exercises (at about week 18-depending on joint stability, surgical repairs, patello-femoral joint chondrosis, comorbidities, and doctor approval)
    • 90 degrees for resisted knee flexion exercises (at about week 18-depending on joint stability, surgical repairs, co-morbidities, and doctor approval)

A combination of concentric and eccentric exercises should be included in the rehabilitation because most functional activities use both modes of muscle actions. To improve muscular power, the patient exercises at fast speeds with maximum effort activities. Progression may include faster speed isokinetic training and functional training activities using more dynamic exercises, such as low intensity plyometric exercises.114

Enhance Neuromuscular Reactive Stability.

Neuromuscular reactive training is important to provide dynamic stability of the knee. Development of normal functional patterns is one of the goals of the training program. During this phase, the primary motor learning responses re-develop and activities progress from a conscious to an unconscious level where the responses occur automatically. Primary muscles involved in the compensatory patterns (quadriceps, hamstrings, and gastrocnemius muscles) following ACL injuries are important in helping the patient return to various activities.159163 Therefore, a patient with a MKLI may also need to rely on some of these compensatory patterns to create the dynamic stability for the knee. However, because of the complexity of the MKLI, differences exist in the way the patients are going to compensate to provide dynamic knee stability. Consequently, as previously discussed, the rehabilitation program needs to be customized to each individual patient.114

Phase IV (>24 Weeks): Functional Specificity and Return to Activities

A functional testing algorithm (FTA) is used to evaluate and progress a patient through the rehabilitation program. This phase focuses on the last few stages of the exercise progression continuum. The details and specific criteria are described by Davies and Zillmer.163 The FTA progresses the athlete through a series of stages, with each one becoming progressively more difficult. The patient must pass through each stage in a systematic process in order to progress to higher levels of functional activities. If the patient fails a test of the FTA, the rehabilitation program is then focused upon that area until the deficit is adequately addressed.114

SUMMARY

No randomized controlled trial studies exist regarding the optimum surgical and rehabilitation guidelines for a patient following MLKI. Furthermore, these studies would be difficult considering the complexity and uniqueness of each MLKI. Both surgery and rehabilitation are customized to meet the particular need of each patient with a MLKI. Guidelines regarding mechanisms and classifications of injuries, surgical procedures, and limited evidence-based literature on rehabilitation combined with our empirically based experience with patients with MLKI have been presented.

REFERENCES

1. Cooper A. A Treatise on Dislocations and on Fractures of the Joints. Boston, MA: Lilly, Wait, Carter & Hendee; 1824 [PubMed]
2. Annandale T. On 3 cases of dislocation of the knee-joint. Lancet. 1881;ii:903
3. Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg. 1963;45:889–904 [PubMed]
4. Almekinders LC, Logan TC. Results following treatment of traumatic dislocations of the knee joint. Clin Orthop. 1992;284:203–207 [PubMed]
5. Meyers MH, Harvey JP., Jr Traumatic dislocation of theknee joint. A study of eighteen cases. J Bone Joint Surg. 1971;53:16–29 [PubMed]
6. Meyers MH, Moore TM, Harvey JP., Jr Traumatic dislocation of the knee joint. J Bone Joint Surg Am. 1975;57:430–433 [PubMed]
7. Myles JW. Seven cases of traumatic dislocation of the knee. Proc R Soc Med. 1967;60:279–281 [PMC free article] [PubMed]
8. Reckling FW, Peltier LF. Acute knee dislocations and their complications. J Trauma. 1969;9:181–191 [PubMed]
9. Shields L, Mital M, Cave EF. Complete dislocation of the knee: Experience at the Massachusetts General Hospital.J Trauma. 1969;9:192–215 [PubMed]
10. Taylor AR, Arden GP, Rainey HA. Traumatic dislocation of the knee: A report of forty-three cases with special reference to conservative treatment. J Bone Joint Surg Br.1972;54:96–102 [PubMed]
11. Thomsen PB, Rud B, Jensen UH. Stability and motion after traumatic dislocation of the knee. Acta Orthop Scand. 1984;55:278–283 [PubMed]
12. Cole BJ, Harner CD. The multiple ligament-injured knee. Clin Sports Med. 1999;18:241–262 [PubMed]
13. Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction. Arthroscopy. 1996;12:5–14 [PubMed]
14. Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament injured knee: Evaluation, treatment, and results.Arthroscopy. 2005;21:471–486 [PubMed]
15. Frassica FJ, Sim FH, Staeheli JW, et al. Dislocation of the knee. Clin Orthop. 1991;263:200–205 [PubMed]
16. Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations. J Bone Joint Surg. 2004;86:262–273 [PubMed]
17. Ibrahim SA, Ahmad FH, Salah M, et al. Surgical management of traumatic knee dislocation. Arthroscopy. 2008;24:178–187 [PubMed]
18. Owens BD, Neault M, Benson E, et al. Primary repair of knee dislocations: Results in 25 patients (28 knees) at a mean follow-up of four years. J Orthop Trauma. 2007;21:92–98 [PubMed]
19. Mlizos KN, Xenakis T, Xanthis A, et al. Knee dislocations and their management; A report of 16 cases. Acta Orthop Scand. 1997;68:80–83 [PubMed]
20. Montgomery JB. Dislocation of the knee. Orthop Clin North Am. 1987;18:149–156 [PubMed]
21. Montgomery IJ, Savoie FH, White JL, et al. Orthopedic management of knee dislocations: Comparison of surgical reconstruction and immobilization. Am J Knee Surg. 1995;8:97–103 [PubMed]
22. Noyes FR, Barber-Westin SD. Reconstruction of the anterior cruciate and posterior cruciate ligaments after knee dislocation; Use of early protected postoperative motion to decrease arthrofibrosis. Am J Sports Med. 1997;25:769– 778 [PubMed]
23. Prohaska DJ, Harner CD. Surgical treatment of acute and chronic anterior and posterior cruciate ligament medial side injuries of the knee. Sports Med Arthrosc Rev. 2001;9:193–198
24. Richards RS, II, Moorman CT., III Surgical techniques of open surgical reconstruction in the multiple-ligament-injured knee. Op Tech Sports Med. 2003;11:275–285
25. Rihn JA, Cha PS, Groff YJ, et al. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg. 2004;12:334–346 [PubMed]
26. Robertson A, Nutton RW, Keating JF. Dislocation of the knee. J Bone Joint Surg. 2006;88:706–711 [PubMed]
27. Roman PD, Hopson CN, Zenni EJ., Jr Traumatic dislocation of the knee: A report of 30 cases and literature review. Orthop Rev. 1987;16:917–924 [PubMed]
28. Schenck R, Mercer D. Surgical reconstruction of the dislocated knee. Tech Knee Surg. 2006;5:174–186
29. Shapiro MS, Freedman EL. Allograft reconstruction of the anterior and posterior cruciate ligaments after traumatic knee dislocation. Am J Sports Med. 1995;23:580–587 [PubMed]
30. Shelbourne KD, Porter DA, Clingman JA, et al. Low-velocity knee dislocation. Orthop Rev. 1991;20:995–1004 [PubMed]
31. Shelbourne KD, Carr DR. Combined anterior and posterior cruciate and medial collateral ligament injury: Nonsurgical and delayed surgical treatment. AAOS Instructional Course Lectures. 2003;52:413–418 [PubMed]
32. Sisto DJ, Warren RF. Complete knee dislocation. A follow-up study of operative treatment. Clin Orthop. 1985;198:94–101 [PubMed]
33. Stannard JP, Riley RS, Sheils TM, et al. Anatomic reconstruction of the posterior cruciate ligament after multiligamentous knee injuries: A combination of the tibial-inlay and two-femoral-tunnel techniques. Am J Sports Med. 2003;31:196–202 [PubMed]
34. Strobel MJ, Schulz MS, Petersen WJ, et al. Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities. Arthroscopy. 2006;22;182–192 [PubMed]
35. Walker DN, Hadison R, Schenck RC. A baker's dozen of knee dislocations. Am J Knee Surg. 1994;7:117–124
36. Wascher DC, Becker JR, Dexter JG, et al. Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation: Results using fresh-frozen nonirradiated allografts. Am J Sports Med. 1999;27:189–196 [PubMed]
37. Wascher DC, Schenck RC. Surgical treatment of acute and chronic anterior cruciate ligament/posterior cruciate ligament/lateral sided injuries of the knee. Sports Med Arthrosc Rev. 2001;9:199–207
38. Fanelli GC, Harris JD. Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee. Sports Med Arthrosc Rev. 2006;14:78–83 [PubMed]
39. Fanelli GC, Harris JD. Late medial collateral ligament reconstruction. Tech Knee Surg. 2007;6:99–105
40. Azar FM. Surgical treatment of ACL/PCL/medial-side knee injuries. Op Tech Sports Med. 2003;11:249–256
41. Wright DG, Covey DC, Born CI, et al. Open dislocation of the knee. J Orthop Trauma. 1995;9:135–140 [PubMed]
42. Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg. 1977;59:236–239 [PubMed]
43. O'Donnel JF, Jr, Brewster DC, Darling RC, et al. Arterial injuries associated with fractures and/or dislocations of the knee. J Trauma. 1997;17:775–784 [PubMed]
44. Welling RE, Kakkasseril J, Cranley JJ. Complete dislocations of the knee with popliteal vascular injury. J Trauma. 1981;21:450–453 [PubMed]
45. Moore TM. Fracture-dislocation of the knee. Clin Orthop. 1981;156:128–140 [PubMed]
46. Schenck RC, McGanit PI, Hedman JD. Femoral-sided fracture-dislocation of the knee. J Orthop Trauma. 1997;6:416–421 [PubMed]
47. Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: Initial assessment and implications for treatment. J Orthop Trauma. 1997;11:525–529 [PubMed]
48. Hill JA, Rana NA. Complications of posterolateral dislocation of the knee: Case report and literature review. Clin Orthop. 1981;154:212–215 [PubMed]
49. Quinlan AG, Sharrard WJ. Posterolateral dislocation of the knee with capsular interposition. J Bone Joint Surg Br. 1958;40:660–663 [PubMed]
50. Said H, Learmonth DJ. Chronic irreducible posterolateral knee dislocation: Two-stage surgical approach. Arthroscopy. 2007;23:564e1–564e4 [PubMed]
51. Silverberg DA, Acus R. Irreducible posterolateral knee dislocation associated with interposition of the vastus medialis. Am J Sports Med. 2004;32:1313–1316 [PubMed]
52. Krakow KA, Thomas SC, Jones LC. A new stitch for ligament-tendon fixation: Brief note. J Bone Joint Surg Am. 1986;68:764–768 [PubMed]
53. Fitzpatrick DC, Sommers MB, Kam BC, et al. Knee stability after articulated external fixation. Am J Sports Med. 2005;33:1735–1741 [PubMed]
54. Fanelli GC, Tomaszewski DJ. Allograft use in the treatment of the multiple ligament injured knee. Sports Med Arthrosc Rev. 2007;15:139–148 [PubMed]
55. Harner CD, Olson E, Irrgang JJ, et al. Allograft versus autograft anterior cruciate ligament reconstruction: 3-5 year outcome. Clin Orthop. 1996;324:134–144 [PubMed]
56. Noyes FR, Barber-Westin SD. Reconstruction of the anterior cruciate ligament with human allograft: Comparison of early and later results. J Bone Joint Surg. 1996;78:524–537 [PubMed]
57. Tom JA, Rodeo SA. Soft tissue allografts for knee reconstruction in sports medicine. Clin Orthop. 2002;402:135–156 [PubMed]
58. Buck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus: An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop. 1989;240:129–136 [PubMed]
59. Centers for Disease Control and Prevention Update: Allograft-associated bacterial infections: United States, 2002. JAMA. 2002; 287: 1642– 1644 [PubMed]
60. Vangsness CT, Garcia IA, Mills CR, et al. Allograft transplantation in the knee: Tissue regulation, procurement, processing, and sterilization. Am J Sports Med. 2003;31:474–481 [PubMed]
61. LaPrade RF, Gilbert TJ, Bollom TS, et al. The magnetic resonance imaging appearance of individual structures of the posterolateral knee: A prospective study of normal knees and knees with surgically verified grade III injuries. Am J Sports Med. 2000;28:191–199 [PubMed]
62. LaPrade RF, Wentorf FA, Fritts H, et al. A pospective magnetic resonance imaging study of the incidence of posterolateral and multiple ligament injuries in acute knee injuries presenting with a hemarthrosis. Arthroscopy. 2007;23:1341–1347 [PubMed]
63. Sanders TG, Miller MD. A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med. 2005;33:131–148 [PubMed]
64. Yu JS, Goodwin D, Salonen D, et al. Complete dislocation of the knee: Spectrum of associated soft-tissue injuries depicted by MR imaging. Am J Rad. 1995;164:135–139 [PubMed]
65. Jordan SS, Campbell RB, Sekiya JK. Posterior cruciate ligament reconstruction using a new arthroscopic tibial inlay double-bundle technique. Sports Med Arthrosc Rev. 2007;15:176–183 [PubMed]
66. Jung YB, Jung HJ, Tae SK, et al. Reconstruction of the posterior cruciate ligament with a mid-third patellar tendon graft with use of a modified tibial inlay method: Surgical technique. J Bone Joint Surg. 2005;87:247–263 [PubMed]
67. Noyes FR, Barber-Westin S. Posterior cruciate ligament replacement with a two-strand quadriceps tendon-patellar bone autograft and a Tibial inlay technique. J Bone Joint Surg. 2005;87:1241–1252 [PubMed]
68. Weimann A, Wolfert A, Zantop T. Reducing the “killer turn” in posterior cruciate ligament reconstruction by fixation level and smoothing the tibial aperture. Arthroscopy. 2007;23:1104–1111 [PubMed]
69. Wind WM, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: Revisited. Am J Sports Med. 2004;32:1765–1775 [PubMed]
70. Chhabra A, Kline AJ, Harner CD. Single-bundle versus double-bundle posterior cruciate ligament reconstruction: Scientific rationale and surgical technique. AAOS Instructional Course Lectures. 2006;55:497–507 [PubMed]
71. Elkousy HA, Harner CD. ACL/PCL Reconstruction: The role of double-bundle PCL reconstruction. Op Tech Sports Med. 2003;11:286–293
72. Ma CB, Warren RF, MacGillivray JD, et al. Double-bundle posterior cruciate ligament reconstruction. Tech Knee Surg. 2003;2:229–238
73. Noyes FR, Barber-Westin SD. Posterior cruciate ligament revision reconstruction, Part 1: Causes of surgical failure in 52 consecutive operations. Am J Sports Med. 2005;33:646–654 [PubMed]
74. Noyes FR, Barber-Westin SD. Posterior cruciate ligament revision reconstruction, Part 2: Results of revision using a 2-strand quadriceps tendon-patellar bone autograft. Am J Sports Med. 2005;33:655–665 [PubMed]
75. Beynnon BD, Johnson RJ, Abate JA, et al. Treatment of anterior cruciate ligament injuries, Part 1. Am J Sports Med. 2005;33:1579–1602 [PubMed]
76. Beynnon BD, Johnson RJ, Abate JA, et al. Treatment of anterior cruciate ligament injuries, Part 2. Am J Sports Med. 2005;33:1751–1767 [PubMed]
77. Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy. 2008;24:113–115 [PubMed]
78. Jepsen CF, Lundberg-Jensen AK, Faunoe P. Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? A clinical, prospective, randomized double-blind study. Arthroscopy. 2007;23:1326–1333 [PubMed]
79. Lee MC, Seong SC, Lee S, et al. Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy. 2007;23:771–778 [PubMed]
80. Pinczewski LA, Salmon LJ, Jackson WF, et al. Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament. J Bone Joint Surg. 2008;90-B:172–179 [PubMed]
81. Siebold R, Ellert T, Metz S, et al. Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy. 2008;24:154–161 [PubMed]
82. Zabtop T, Kubo S, Petersen W, et al. Current techniques in anterior cruciate ligament reconstruction. Arthroscopy. 2007;23:938–947 [PubMed]
83. Asagumo H, Kimura M, Kobayashi Y, et al. Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: Surgical techniques, clinical outcomes, and complications. Arthroscopy. 2007;23:602–609 [PubMed]
84. Buoncristiani AM, Tjoumakaris FP, Starman JS, et al. Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2006;22:1000–1006 [PubMed]
85. Nyland J, Landes S, Crawford C, et al. Anatomical double-bundle anterior cruciate ligament reconstruction: Maximizing benefits while minimizing complexity: A balanced potential approach. Tech Knee Surg. 2007;6:191–203
86. Siebold R, Dehler C, Ellert T. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2008;24:137–145 [PubMed]
87. Markoff KL, O'Neill G, Jackson SR, et al. Reconstruction of knees with combined cruciate deficiencies: A biomechanical study. J Bone Joint Surg Am. 2003;85:1768–1774 [PubMed]
88. Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc Rev. 2006;14:84–90 [PubMed]
89. Jackson JB, Ferguson CM, Martin DF. Surgical treatment of chronic posteromedial instability using capsular procedures. Sports Med Arthrosc Rev. 2006;14:91–95 [PubMed]
90. Jacobson KE, Chi FS. Treatment of chronic injuries to the medial side of the knee. Tech Knee Surg. 2007;6:106–111
91. Petersen W, Loerch S, Schanz S, et al. The role of the posterior oblique ligament in controlling posterior tibial translation in the posterior cruciate ligament-deficient knee. Am J Sports Med. 2008;36:493–501 [PubMed]
92. Sims WF, Jacobson KE. The posteromedial corner of the knee: Medial-sided injury patterns revisited. Am J Sports Med. 2004;32:337–345 [PubMed]
93. Yoshiya S, Kuroda R, Mizuno K, et al. Medial collateral ligament reconstruction using autogenous hamstring tendons: Technique and results in initial cases. Am J Sports Med. 2005;33:1380–1385 [PubMed]
94. Apsingi S, Nguyen T, Bull AM, et al. Control of laxity in knees with combined posterior cruciate ligament and posterolateral corner deficiency: Comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction combined with modified Larson posterolateral corner reconstruction. Am J Sports Med. 2008;36:487–494 [PubMed]
95. Bicos J, Arciero RA. Novel approach for reconstruction of the posterolateral corner using a free tendon graft technique. Sports Med Arthrosc Rev. 2006;14:28–36 [PubMed]
96. Chang CB, Seong SC, Lee S. Novel methods for diagnosis and treatment of posterolateral rotatory instability of the knee. J Bone Joint Surg. 2007;89suppl 3:2– 14 [PubMed]
97. Cooper JM, McAndrews PT, LaPrade RF. Posterolateral corner injuries of the knee: Anatomy, diagnosis, and treatment. Sports Med Arthrosc Rev. 2006;14: 213–220 [PubMed]
98. Fanelli GC, Edson CJ, Reinheimer KN. Posterior cruciate ligament and posterolateral corner reconstruction. Sports Med Arthrosc Rev. 2007;15:168–175 [PubMed]
99. Flandry F, Sinco SM. Surgical treatment of chronic posterolateral rotatory instability of the knee using capsular procedures. Sports Med Arthrosc Rev. 2006;14:44–50 [PubMed]
100. Guettler JH, Moorman CT. Reconstruction of the posterolateral corner of the knee. Tech Knee Surg. 2003;2:53–62
101. Kocabey Y, Nawab A, Caborn DN, et al. Posterolateral corner reconstruction using a hamstring allograft and a bioabsorbable tenodesis screw: Description of a new technique. Arthroscopy. 2004;20suppl 1:159–163 [PubMed]
102. LaPrade RF, Johansen S, Wentorf FA, et al. An analysis of an anatomical posterolateral knee reconstruction: An in vitro biomechanical study and development of a surgical technique. Am J Sports Med. 2004;32:1405–1414 [PubMed]
103. Markoff KL, Graves BR, Sigward SM. How well do anatomical reconstructions of the posterolateral corner restore varus stability to the posterior cruciate ligament-reconstructed knee? Am J Sports Med. 2007;35:1117–1122 [PubMed]
104. Noyes FR, Barber-Westin SD. Posterolateral knee reconstruction with a anatomical bone-patellar tendonbone reconstruction of the fibular collateral ligament. Am J Sports Med. 2007;35:259–273 [PubMed]
105. Noyes FR, Barber-Westin SD. Anatomical posterolateral knee reconstruction: Surgical options and clinical results. Tech Knee Surg. 2008;7:34–47
106. Shelbourne KD, Haro MS, Gray T. Knee dislocation with lateral side injury; Results of an en masse surgical repair technique of the lateral side. Am J Sports Med. 2007;35:1105–1116 [PubMed]
107. Stannard JP, Brown SL, Farris RC, et al. The posterolateral corner of the knee: Repair versus reconstruction. Am J Sports Med. 2005;33:881–888 [PubMed]
108. Stannard JP, Brown SL, Robinson JT, et al. Reconstruction of the posterolateral corner of the knee. Arthroscopy. 2005;21:1051–1059 [PubMed]
109. Stuart MJ. Surgical treatment of ACL/PCL/lateral-side knee injuries. Op Tech Sport Med. 2003;11:257–262
110. Sugalski MT, Sanchez AR, LaPrade RF. Posterolateral reconstruction techniques. Tech Knee Surg. 2006;5:53–63
111. Wiley WB, Askew MJ, Melby A, et al. Kinematics of the posterior cruciate ligament/posterolateral corner-injured knee after reconstruction by single- and double intraarticular grafts. Am J Sports Med. 2006;34:741–748 [PubMed]
112. Zhao J, He Y, Wang J, et al. Anatomical reconstruction of knee posterolateral complex with the tendon of the long head of biceps femoris. Am J Sports Med. 2006;34:1615–1622 [PubMed]
113. Irrgang JJ, Fitzgerald GK. Rehabilitation of the multiple-ligament-injured knee. Clin Sports Med. 2000;19:545–571 [PubMed]
114. Romeyn R, Davies GJ, Jennings J. Examination, surgery and rehabilitation of patients with multiple knee ligament injuries. In Manske, editor. , R. Rehabilitation for Post-Surgical Knee and Post-Surgical Shoulder Conditions. Philadelphia, PA: Elsevier Saunders;2006:279–317
115. Medvecky MJ, Zazulak BT, Hewett TE. A multidisciplinary approach to the evaluation, reconstruction, and rehabilitation of the multi-ligament injured athlete. Sports Med. 2007;372:169– 187 [PubMed]
116. Beynnon BD, Johnson RJ, Fleming BC, et al. The measurement of elongation of anterior cruciate ligament grafts in vivo. J Bone Joint Surg. 1994;76-A:520–531 [PubMed]
117. Lutz GE, Palmitier RA, An KN, et al. Comparison of tibiofemoral joint forces during open and closed kinetic chain exercises. J Bone Joint Surg. 1993;75:732–739 [PubMed]
118. Fleming BC, Beynnon BD, Renstrom PA, et al. The strain behavior of the anterior cruciate ligament during stair climbing: An in-vivo study. Arthroscopy. 1999;15:185–191 [PubMed]
119. Henning CE, Lynch MA, Glick KR. An in-vivo strain gauge study of elongation of the anterior cruciate ligament. Am J Sports Med. 1985;13:22–26 [PubMed]
120. Lutz GS, Palmitier RA, An KN, et al. Comparison of tibiofemoral joint forces during open and closed kinetic chain exercises. J Bone Joint Surg. 1993;75-A:732–739 [PubMed]
121. Yack HJ, Collins CE, Whieldon K. Comparisons of closed and open kinetic chain exercises in the anterior cruciate ligament-deficient knee. Am J Sports Med. 1993;21:49–54 [PubMed]
122. Renstrom PS, Arms Stanwych TS, et al. Strain within the anterior cruciate ligament during hamstring and quadriceps activity. Am J Sports Med. 1986;14:83–87 [PubMed]
123. Beynnon BD, Fleming BC, Johnson RJ, et al. Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med. 1995;23:24–34 [PubMed]
124. Beynnon BD, Johnson RJ, Fleming BC, et al. The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension: A comparison of open and closed kinetic chain exercise. Am J Sports Med. 1997;25:823–829 [PubMed]
125. Draganich LF, Jaeger RJ, Knalj AR. Co-activation of the hamstrings and quadriceps during extension of the knee. J Bone Joint Surg. 1989;71-A:1075–1081 [PubMed]
126. Isear JA, Erickson JC, Worrell TW. EMG analysis of lower extremity muscle recruitment patterns during an unloaded squat. Med Sci Sports Exerc. 1997;29:532–539 [PubMed]
127. More RC, Karras BT, Neiman R, et al. Hamstrings – An anterior cruciate ligament protagonist: An in vitro study. Am J Sports Med. 1993;21:231–237 [PubMed]
128. Aune AK, Cawley PW, Ekeland A. Quadriceps muscle contraction protects the anterior cruciate ligament during anterior tibial translation. Am J Sports Med. 1997;25:187–195 [PubMed]
129. Grood ES, Stowers SF, Noyes FR. Limits of movement in the human knee: Effect of sectioning the posterior cruciate ligament and posterolateral structures. J Bone Joint Surg. 1988;88–97:70 [PubMed]
130. Hsieh HH, Walker PS. Stabilizing mechanisms of the loaded and unloaded knee joint. J Bone Joint Surg. 1976; 58-A: 87– 93 [PubMed]
131. Ellenbecker TS, Davies GJ. Closed Kinetic Chain Exercise. A Comprehensive Guide to Multiple Joint Exercises. Champaign, IL: Human Kinetics; 2001
132. Bynum EB, Barrack RL, Alexander AH. Open versus closed kinetic chain exercises after anterior cruciate ligament reconstruction: A prospective randomized study. Am J Sports Med. 1995;23:401–406 [PubMed]
133. Snyder-Mackler L, Delitto A, Bailey SL, et al. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. J Bone Joint Surg. 1995;77-A:1166–1173 [PubMed]
134. Dahlkuits NJ, Mago P, Seedholm BB. Forces during squatting and rising from a deep squat. Engineering Med. 1982;11:69–76 [PubMed]
135. Arms SW, Pope MH, Johnson RJ, et al. The biomechanics of the anterior cruciate ligament rehabilitation and reconstruction. Am J Sports Med. 1984;12:8. [PubMed]
136. Spencer JD, Hayes KC, Alexander JJ. Knee joint effusion and quadriceps inhibition in man. Arch Phys Med Rehabil. 1984; 65: 171– 177 [PubMed]
137. Sachs RA, Daniel DM, Stone ML, et al. Patellofemoral problems after anterior ligament reconstruction. Am J Sports Med. 1989;17:760–765 [PubMed]
138. Schlegel TF, Boublik M, Hawkins RJ, et al. Reliability of heel-height measurement for documenting knee extension deficits. Am J Sports Med. 2002;30:479–482 [PubMed]
139. Bandy WD, Irion JM. The effect of time on static stretching on the flexibility of the hamstring muscles. Phys Ther. 1994;74:845–850 [PubMed]
140. Bandy WD, Irion JM, Briggler M. The effect of time and frequency of static stretch on flexibility of the hamstring muscles. Phys Ther. 1997;77:1090–1096 [PubMed]
141. Bandy WD, Irion JM, Briggler M. The effect of static stretch and dynamic range of motion on the flexibility of the hamstring muscles. J Orthop Sports Phys Ther. 1998;27:295–300 [PubMed]
142. McClure PW, Blackburn LG, Dusold C. The use of splints in the treatment of joint stiffness: Biological rational and algorithm for making clinical decisions. Phys Ther. 1994;74:1101–1107 [PubMed]
143. Davies GJ, Ellenbecker TS.: Focused exercise aids shoulder hypomobility. Biomechanics. 1999; 77– 81
144. Feland JB, Myrer JW, Schulthies SS, et al. The effect of duration of stretching on the hamstring muscle group for increased range of motion in people aged 65 years and older. Phys Ther. 2001;81:1110–1117 [PubMed]
145. Nicholas JA, Strizak AM, Veras G. A study of thigh muscle weakness in different pathological states of the lower extremity. Am J Sports Med. 1976;4:241–248 [PubMed]
146. Gleim GW, Nicholas JA, Webb JN. Isokinetic evaluation following leg injuries. Phys Sports Med. 1978;6:74–82
147. Sapega AA, Quedenfeld TC. Biophysical factors in range of motion exercises. Phys Sports Med. 1981;9:57–65
148. Snyder-Mackler L, Ladin Z, et al. Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament: Effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles. J Bone Joint Surg. 1991;73:1025–1036 [PubMed]
149. Davies GJ. A Compendium of Isokinetics in Clinical Usage. 4th ed.Onalaska, WI: S&S Publishers; 1992
150. Rowinski MJ. Afferent neurobiology of the joint. In Gould JA, Davies GJ, editors. Orthopaedic and Sports Physical Therapy. St. Louis: Mosby;1985:50–64
151. Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in non-operative anterior cruciate ligament rehabilitation programs for physical active individuals. Phys Ther. 2000;80:128–140 [PubMed]
152. Ohkoshi Y, Yasuda K, Kaneda K, et al. Biomechanical analysis of rehabilitation in the standing position. Am J Sports Med. 1991;19:605–611 [PubMed]
153. Palmitier RA, An KN, Scott SG, et al. Kinetic chain exercises in knee rehabilitation. Sports Med. 1991;11:402–413 [PubMed]
154. Davies GJ, Heiderscheidt BC, Schulte R, et al. The scientific and clinical rationale for the integrated approach to open and closed kinetic chain rehabilitation. Orthop Phys Ther Clinic North Am. 2000;9:247–267
155. Neitzel JA, Kernozek TW, Davies GJ. Loading response following anterior cruciate ligament reconstruction during parallel squat exercise. Clin Biomech. 2002;17:551–554 [PubMed]
156. Rivera JE. Open versus closed kinetic chain rehabilitation of the lower extremity: A functional and biomechanical analysis. J Sports Rehab. 1994;3:154–167
157. Escamilla RF, Flesig GS, Zheng N, et al. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med Sci Sports Exerc. 1998;30:556–569 [PubMed]
158. Wilk KE, Escamilla RF, Flesig GS, et al. A comparison of tibio-femoral joint forces and EMG activity during open and closed kinetic chain exercises. Am J Sports Med. 1996;24:518–527 [PubMed]
159. Ciccotti MG, Kerlan RK, Perry J, et al. An EMG analysis of the knee during functional activities: Part II. Am J Sports Med. 1994;22:651–658 [PubMed]
160. Gauffin H, Tropp H. Altered movement and muscularactivation patterns during the one-legged jump in patients with an old anterior cruciate ligament rupture. Am J Sports Med. 1992;20:182. [PubMed]
161. Kauland S, Sinkjaer R, Arendt-Nielson L, et al. Altered timing of hamstring muscle action in anterior cruciate deficient patients. Am J Sports Med. 1990;18:245. [PubMed]
162. Solomonow M, Baratta R, Zhou BH, et al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med. 1987;15:207. [PubMed]
163. Davies GJ, Zillmer DA. Functional progression of exercise during rehabilitation. In: Ellenbecker TS, editor. Knee Ligament Rehabilitation. 2nd Ed.Philadelphia, PA: Churchill Livingstone; 2000:345–360

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