Physical Therapy in Sport 5 (2004) 175178

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Case Study
The rehabilitation of two patients with functionally
unstable ACL deficient knees: a case report
L. Herrington*
School of Healthcare Professionals, University of Salford, Salford, Greater Manchester M6 6PU, UK
Received 23 January 2004; revised 8 July 2004; accepted 17 August 2004

Abstract
The general consensus is that ACL reconstruction should be undertaken if the patient has functional instability. Functional instability
occurring is not just related to the mechanical insufficiency, but also to the neurophysiological role the ACL has in motion control. It may be,
possible to enhance control of the abnormal joint motion through neuromuscular training. This case presentation outlines the rehabilitation of
two patients with ACL deficient knees, who both presented with functional instability and discusses the role of conservative treatment in the
management of this type of patient.
The cases reported on indicate that with appropriate rehabilitation, some patients with functional symptomatic instability and a wish to
return to high stress sports can be successfully rehabilitated to achieve these goals. The patients achieved these outcomes despite not having a
change in joint laxity on passive testing. The significance of joint laxity tests on short term outcome would appear therefore to be not that
great, with functional outcome after a period of rehabilitation proving a more sensitive indicator of the need for surgery in the ACL deficient
patient.
q 2004 Elsevier Ltd. All rights reserved.

Keywords: ACL rupture; Conservative rehabilitation; Outcome measures

1. Introduction Injury of the ACL is now the most common ligamentous

The anterior cruciate ligament (ACL) is regarded as
being crucial for the normal function of the knee. The
indications for when ACL reconstruction is required are far
from clear, but the general consensus is that reconstruction
should be undertaken if the patient presents with functional
instability. Functional instability is not just related to the
mechanical insufficiency, but also to the neurophysiological
role the ACL has in motion control. It maybe possible to
enhance control of the abnormal joint motion through
neuromuscular training. The purpose of this case study is to
outline the rehabilitation of two patients with ACL deficient
knees, who both presented with functional instability and
discuss the role of conservative treatment in the manage-
ment of this type of patient.
* Tel.: C1 61 295 2326; fax: C1 61 295 2395.
E-mail address: l.c.herrington@salford.ac.uk.
1466-853X/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2004.08.003
injury of the knee and accounts for about 30 injuries per
100,000 of the population (Irrgang, Safran, & Fu, 1996). A
definitive management strategy for patients with this injury
is still far from clear and is particularly evident when
deciding whether to reconstruct the ligament or carry out
conservative rehabilitation, to date, no appropriately con-
structed randomised controlled trials exist comparing ACL
reconstruction (ACLR) with conservative rehabilitation
(Risberg, Mork, Krogstad-Jenssen, & Holm, 2001).
Noyes, Matthews, Mooar, and Grood (1983) found
considerable variation in the outcomes from rehabilitation
of ACL deficient (ACLD) patients. They found one third
improved and compensated well for the injury, one third
partially compensated needing to modify activity and one
third became worse and failed the programme. Therefore,
only one third of ACLD patients may require surgery.
Daniel et al. (1994) believed that reconstruction of the ACL
was indicated if the patient wished to participate in sports
involving cutting or pivoting, or work which involved heavy
176 L. Herrington / Physical Therapy in Sport 5 (2004) 175178
manual labour. Bollen (1998) disagreed with Daniel et al.
(1994) believing that participation in any activity was
possible and that symptomatic instability should be the
major criterion to carry out surgery, if functional instability
was not present, acceptable results would occur with
conservative treatment.
Functional instability is often mentioned in the literature
but rarely defined. Beard, Dodd, Trundle, Hamish, and
Simpson (1994) reported that it was a common manifes-
tation of ACLD patients and the patient presented with the
symptom of giving way on activity, which resulted from a
loss of mechanical and/or neurophysiological function of
the ACL. Clinically, these patients present with giving way
(or apprehension of giving way) during activities involving
limb rotation and have little confidence in their affected
limb when weight bearing. Orthopaedic opinion would
indicate that these patients should have a surgical
reconstruction of the ligament, but within the literature
there is evidence that these patients can be rehabilitated and
regain functional stability of the limb using a neuromuscular
(proprioceptive) training programme (Beard et al., 1994;
Maitland, Ajemian, & Suter, 1999). Despite the fact that the
biomechanics of the knee are significantly altered after
injury to the ACL, Risberg, Mork, Krogstad-Jenssen, and
Holm (2001) believed that neuromuscular training had the
potential to enhance control of the abnormal joint
translation during functional activity. It could achieve this
by inducing compensatory alterations in muscle activity
patterns.
The available literature would indicate that functionally
unstable ACLD patients should undergo reconstructive
surgery. But within the literature, there is little unequivocal
evidence to back the premise that the ACLR alone can
improve functional performance without appropriate reha-
bilitation. There may even be an argument to support a case
for appropriate conservative rehabilitation alone to provide
satisfactory functional outcomes. Appropriate randomised
controlled trials are currently not available to examine and
resolve this question (Jones, Appleyard, Mahajan, &
Murrell, 2003).
This case study presents the cases of two ACLD patients,
with reported functional instability who returned to full
unlimited functional activity following a rehabilitation
programme in attempt to show conservative rehabilitation
could bring about favourable functional outcomes in
functionally unstable ACLD patients.
2. Patients
2.1. Patient 1
A 52-year-old male, whilst skiing the right ski became
fixed and he pivoted around the right knee causing an
external rotation and valgus stress to be applied to the knee
whilst in a flexed position, there was immediate swelling of
the knee joint. Four weeks later, he had an MRI scan of the
knee, which revealed a full mid substance ACL tear. He was
then referred to physiotherapy his treatment starting 6 weeks
after the original injury.
2.2. Patient 2
A 45 year old male, whilst playing football attempted to
cut back inside pushing of his right leg, the knee was
abducted and externally rotated and the patient heard a pop
was unable to weight bear and had immediate swelling of
the knee. Six weeks later, he had an MRI scan of the knee,
which revealed a full mid substance ACL tear. He was then
referred to physiotherapy his treatment starting seven and a
half weeks after the original injury.
3. Outcome measures
Patient outcome from treatment was measured using a
variety of indices. A functional rating score (Lysholm &
Gillquist, 1982) was taken. Joint laxity testing was carried
out by means of the pivot shift, lachmans and anterior
draw tests. Isokinetic strength testing of the Hamstrings
and Quadriceps (concentric peak torque and time to peak
torque) was carried out at 60 and 1808 per second on a
Cybex Norm isokinetic dynamometer. Wojtys and Huston
(2000) identified quadriceps and hamstring reaction time
as the best indicator of subjective functional outcome;
these findings may correlate with the improvements in
time to peak torque of the respective muscles. Functional
testing involved single leg crossover hop for distance and
single leg hop for distance with performance being
measured against a limb symmetry index (Clark, 2001),
Fitzgerald, Axe, and Snyder-Mackler, (2000) regarded
these hop tests as promising indicators of dynamic knee
stability.
4. Examination findings
Both patients reported the knee feeling unstable and not
trusting it during functional activities, neither patient could
run because of the feeling of instability. Both patients
presented with mild effusion in the knee, this effusion
limited both squat and knee flexion at the end of range. They
had inhibited and slightly atrophied quadriceps but normal
patella gliding. Ligament testing revealed a positive pivot
shift test for both patients and excessive joint laxity on
Lachmans test (greater than 5 mm difference bilaterally)
and anterior draw test (greater than 10 mm difference
bilaterally). Other ligament tests proved negative. Both
patients completed a functional rating scale, based on
Lysholm and Gilquist (1982), patient 1 scored 59 and
patient 2 scoring 62.
 L. Herrington / Physical Therapy in Sport 5 (2004) 175178
5. Rehabilitation programme
The aim of the rehabilitation programme was to improve
and optimise sensorimotor control in order to obtain the
largest possible envelope of homeostatic (non-pathological
loading) of the knee (Friden et al., 2001). This was to be
achieved by using closed kinetic chain exercises to
encourage hamstring co-activation, strengthening of the
quadriceps and correct lower limb alignment against load.
Proprioception exercises were incorporated into the pro-
gramme to improve joint sensorimotor awareness. The
details of the programme used have been described
elsewhere (Risberg et al., 2001).
6. Results
Tables 1A and B show the outcome measures for patient
1 and 2, respectively. Table 2 shows the results of the
isokinetic testing for both patients, here the results are
expressed as a percentage of the performance of the
uninvolved leg.
Lysholm scores of 6587 are regarded as fair, 8894 as
good, 95100 excellent (Lysholm & Gillquist, 1982). Both
patients achieved good scores after 16 weeks. On
functional testing normal function is said to exist when
limb symmetry index (LSI) is greater than 85% of the
unaffected limbs performance (Clark, 2001). At the end of
the rehabilitation period, both patients achieved LSI greater
than 85% of the unaffected limb. Ligamentous laxity tests
remain the same throughout the rehabilitation period.
Isokinetic testing is regarded as normal if bilateral
differences are less than 10% (Wilk, Andrews, Clancy,
Crockett, & OMara, 1999). Both patients had symptomatic
side strength deficits of less than 10% on final isokinetic
testing.
On review and final testing, 16 weeks post injury, patient
1 had returned skiing one week previously without problems
and was able to ski at the advanced level they had achieved
prior to injury. Patient 2 had returned to 5-a-side football
two weeks previously and had completed three full 1 h
games without incident.
Table 1A
Outcome measure scores for patient 1
Date post injury 8 weeks 12 weeks
Lysholm score 66 78
Anterior draw O10 mm O10 mm
Lachmans O5 mm O5 mm
Pivot shift Positive Positive
Cross over hop for 35 58
distance (LSI)
Hop for distance (LSI) 50 69
Distance achieved by affected limb
LSIZ limb symmetry indexZ Distance achieved by unaffected limb !100.
177
Table 1B
Outcome measure scores for patient 2
Date post injury 8 weeks 12 weeks 16 weeks
Lysholm score 69 78 89
Anterior draw O10 mm O10 mm O10 mm
Lachmans O5 mm O5 mm O5 mm
Pivot shift Positive Positive Positive
Cross over hop for 43 60 90
distance (LSI)
Hop for distance (LSI) 58 71 90
Distance achieved by affected limb
LSIZ limb symmetry indexZ Distance achieved by unaffected limb !100.
7. Discussion
Opinion is divided as to whether an ACLD knee should
be reconstructed or be conservatively rehabilitated. This
decision should be based upon whether or not the patient
presents with symptomatic instability (Bollen, 1998), as
research has shown there to be no correlation between joint
laxity and either subjective outcome or functional testing in
ACLD patients (Friden et al., 2001).
Presented in this case study where two patients who
exhibited both joint laxity on testing and symptomatic
instability, both wished to return to high level activity
(namely skiing and football) and would appear to be under
the criteria presented (Daniel et al., 1994), prime candidates
for ACL reconstruction. The two patients rather than having
surgery, undertook a conservative rehabilitation programme
aimed at reducing functional instability by improving
neuromuscular function in terms of not only muscular
strength but also endurance, postural control and co-
ordination. After 16 weeks, both patients had returned to
their chosen sport without any problems and no longer had
symptomatic instability on sports performance. Outcome
measures in terms of functional tests and isokinetic strength
testing improved to become bilaterally equal, subjective
reporting (Lysholm score) was greater than 85%, which has
been regarded as sufficient for the knee to withstand regular
participation in strenuous sports involving jumping, cutting
and pivoting manoeuvres. The only measure, which
remained unchanged, was joint laxity on standard testing.
These findings are consistent with those of Beard et al.
(1994) and Friden et al. (1991) with improved functional
performance following conservative rehabilitation of
ACLD patients.
None of the above studies have reported on long-term
review of these patients, it may prove that these patients
suffer from excessive deterioration and arthrosis because
16 weeks
90
they have not been surgically stabilised. But, no evidence
O10 mm exists to show that these patients are any more likely to
O5 mm suffer from these complaints than those who under went
Positive surgery. Jones, Appleyard, Mahajan, and Murrell (2003) in
87
their review of the literature concluded that the role of
89 ACLR in the prevention of joint degeneration is far from
clear. After an average follow up of 4 years, Hawkins,
Misamore, and Merritt (1986) reported that knee pain
178 L. Herrington / Physical Therapy in Sport 5 (2004) 175178

Table 2
Isokinetic testing results for patients one and two (% deficits)

Patient Date post injury Quadriceps Hamstrings

(weeks)
608 per second 1808 per second 608 per second 1808 per second
PT TPT PT TPT PT TPT PT TPT
1 8 56 40 37 43 49 52 57 56
12 28 19 12 15 18 23 21 20
16 0.9 3 0.2 5 3 5 6 6
2 8 43 36 42 43 38 41 40 37
12 15 10 19 18 18 23 19 16
16 1 2 4 4 3 6 5 4

PT, peak torque; TPT, time to peak torque.

and swelling were not a major complaint in their ACLD
patient cohort, with 46% of patients having no pain during
any activities and 68% any swelling. Shelbourne and Gray
(2000) reported the status of the articular surface and
menisci at the time of ACLR had a significant bearing on the
level of joint degeneration at 515 year follow up. This
would appear to indicate that the reconstruction alone is not
capable of preventing joint degeneration, whereas ACLD
would not appear to necessarily generate those clinical
markers of joint degeneration, namely, swelling and pain.
This point is significant in the older ACLD patient, where
degenerative joint changes may already be present and
surgery may increase the risk of further degenerative
changes not lessen them (Shelbourne & Gray, 2000), whilst
an appropriate exercise programme could lessen the risk of
degenerative disease progression (Buckwalter, 2003).
The cases reported indicate that with appropriate
rehabilitation, patients with functional symptomatic
instability and a wish to return to high stress sports can be
successfully rehabilitated to achieve these goals, whilst not
necessarily exposing themselves to a greater risk of joint
degeneration. The patients achieved these outcomes despite
not having a change in joint laxity on passive testing. The
significance of joint laxity tests on outcome would appear
therefore to be not that great, with these cases indicating
that functional outcome after a period of rehabilitation
proving a more sensitive indicator of the need for surgery in
the ACLD patient.
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