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The Recovery Process of ACL Tears

Kayla Scott
Ms. Leila Chawkat
Independent Research Program Period 3
10 April 2018

Advisor: Hali Anderson

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Abstract
An ACL tear is a partial or complete one of the most important ligaments in the knee that
requires surgery and extensive physical therapy. Suffering a tear like this is devastating,
especially to an athlete looking to further their career. This paper will discuss why there has been
such an increase in ACL tears over the last few year, and then explain key actions in the recovery
process, including what to do to prevent the injury in the first place. The researcher has found
through reviewing literature and data collection by interviews and meta analysis that patellar
tendon grafts followed by epidural pain relief to counter the highly painful surgery, and then
recovering by using an accelerated physical therapy path is the best option for patients, and is the
fastest way to get back to playing the sport the patient loves. By educating the medical world,
patients will receive the best care they can possibly get while going through the recovery process
of an ACL tear, and be able to return to athletics sooner than a traditional method of surgery and
recovery would allow.
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Introduction

For many athletes, an ACL tear in the knee is a devastating, career ending injury. ACL

tears have recently become a common occurrence in young athletes, with most resulting in

surgery and periods of long recovery. New developments in surgery and physical therapy have

made recovery times shorter, more successful, and less painful. The purpose of this paper is to

inform the reader what causes ACL tears and relay results gained through research which proves

that a combination of patellar tendon grafts, epidural pain relief, and an accelerated physical

therapy program produce the best results for any patient who experiences an ACL tear.

Literature Review

Increases in the Prevalence of the injury

Over the past few years, the number of ACL tears have increased dramatically. There are

many things that may have contributed to this rise in occurence. For example, Dr. J. Todd

Lawrence states that “the rise in knee injuries is attributed, in part, to the growing intensity of

youth sports and the year-round practice model that more youth-sports teams are adopting.”

(Toporek, 2011). Today's youth are pushed to perform at one hundred percent , in a specific

sport, all year round, mostly due to the desire to become a professional or collegiate level athlete,

and be the best of the best. Parents and coaches increasingly push their youth to the point where

their bodies are tired and cannot handle full-force contact. To prevent this, coaches and parents

need to intervene as suggested in the following: “Athletes need to cross train to avoid muscle

imbalances. Their off season training should incorporate core and hip girdle strengthening, sport

specific agility drills utilizing good lower extremity mechanics and balance/proprioceptive

training." (Anderson, 2017). Cross training, training in all fields of motion, leads to a well-
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rounded athlete whose body is prepared for the worst while playing a sport whose body and

muscles are conditioned for any type of activity, which creates a stronger body that is less

susceptible to tears and other injuries. Additionally, another attributing factor leading to the

increase in ACL tears is the growing number of female athletes. According to Renstrom, “the

incidence of non-contact ACL tears is much higher in female athletes participating in sports such

as basketball and team handball than in male athletes.” (Renstrom and Ljungqvist, 2008). This

susceptibility to ACL tears in women is due to the differences in their bodies, bone structure,

muscle size, joint stability and strength. To deter this increase in ACL tears in women, it is

suggested that proper injury prevention programs are set in place to teach females the proper way

to move and land based on their body to avoid a tear. (Renstrom and Ljungqvist, 2008). Overall,

female athletes can hinder this proneness to ACL tears by injury prevention applications, which

have improved in the past few years. Diagnosis of ACL tears have also gotten much better in the

past few years. For example, according to an article in British Medicine Bulletin, Diagnosis by

MRI prove to diagnose ACL injuries much better than an arthroscopy would. It also eliminates

the risk an arthroscopy could impose to a patient. (Crawford et al. 2007). By having better, more

accurate and less invasive diagnosis devices, ACL tears are much easier to identify and fix

before they worsen and become surgical in nature. Creating better systems, such as these,

accounts for the increase in ACL tear being diagnosed more quickly over the past few years and

helps surgeons to fix the tears in a timely manner. Furthermore, these systems allow the

recovery process to begin faster than before, thus allowing the healing process to begin early and

minimize long-term issues caused from the initial tear, while still allowing patients to get back

into their sport faster.

Perioperative techniques
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Due to this major increase in ACL tears previously discussed, many new surgeries have

been tested and created to allow for speedier recovery with less problems later in life. For

example, double bundle surgeries that allow for, “Anterior tibial translation for the anatomic

reconstruction [to be] significantly closer to that of the intact knee than was the single-bundle

reconstruction.” (Masayoshi et al, 2002). Another technique surgeons choose to use with most

repair surgeries is Arthroscopic surgery. This minimally invasive surgery has created an

immense increase in recovery success rates. New types of grafts being used in surgeries are

similar in success rates. patellar tendon grafts prove to be the most stabilizing grafts, although

pain can be increasingly higher. Other grafts from places such as the tibia show that, “Gracilis

tendon harvest causes weakness of internal tibial rotation,” (Violan and Sterett, 2004), thus

causing more problems and weakness in the long run. Very different results when examining

patients with patellar tendon grafts show, “Patellar tendon autografts had a significantly lower

rate of graft failure and resulted in better static knee stability and increased patient satisfaction

compared with hamstring tendon autografts. However, patellar tendon autograft reconstruction

resulted in an increased rate of anterior knee pain.” (Freedman and D’Amato, 2003). As stated,

patellar tendon grafts have increasingly higher rates of pain post-surgery, something that can

cause a multitude of problems for the patients including fear of starting physical therapy, which

can lead to stiff knees and other knee-related issues in the future. Such fear and lack of physical

therapy participation should prompt use of adequate pain relief post successful graft surgery, like

the use of epidurals.

Epidural Pain Relief

As previously discussed, patellar tendon grafts cause increasingly higher amounts of pain

than quadricep tendon grafts would do. For example, “Anterior cruciate ligament reconstruction
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using the central quadriceps tendon-patellar bone graft showed clinical outcomes comparable to

those of anterior cruciate ligament reconstruction using the patellar tendon graft, with anterior

knee pain being less frequent in the former.” (Soo Han and Cheol Seong, 2008). However, pain

can be controlled in many ways, allowing for the better patellar graft to be used while deterring

its side effects of pain.

Many methods of pain relief have been tested and proved helpful or unhelpful, but

overall epidural pain is the best relief for a multitude of reasons, one being that, “The early

postoperative knee mobilization levels in both continuous epidural infusion and continuous

femoral block groups were significantly closer to the target levels prescribed by the surgeon than

in the patient-controlled morphine group.”(Capdevila and Barthelet, 1999). By giving the patient

epidural pain relief after the patellar graft surgery, patients have the most stability and the

greatest possible knee equivalency compared to the healthy knee. Furthermore, “Fear of

movement/re-injury appears to decrease during ACL reconstruction rehabilitation and are

associated with function in the timeframe when patients return to sports.” (Chmielewski and

Jones, 2008). By reducing pain, patients can start the accelerated physical therapy track faster,

causing less fear of pain and re-injury, allowing for the highest rate of success and fastest path to

recovery.

The Positives of Accelerated physical therapy

After surgery, physical therapy is hoped to, “control swelling while regaining full knee

range of motion.” (Shelbourne and Klotz, 2006). By doing this, rupture in the knee can be

reduced by almost half. (Wright and Magnussen, 2011). Following the operation, “Physical

therapy always occurs post ACL surgery for all of these reasons, another being the prevention of
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osteoarthritis and other joint problems.” (Lohmander, 2007). Accelerated physical therapy

decreases these risks even more, while also allowing athletes to go back into their sports sooner.

Accelerated physical therapy, “...appears beneficial and may decrease patellofemoral

pain. Early motion is safe and may help avoid problems with later arthrofibrosis.” (Wright and

Preston, 2008). Studies have confirmed that non-accelerated physical therapy after patellar graft

ACL surgery produces almost the same outcome as accelerated physical therapy; however,

choosing the accelerated path allows for faster recovery and the ability to go back to sports

sooner (Beynnon and Uh, 2005), a better choice for young athletes. Another positive of this

accelerated track is the decreased risk of instability and degeneration of the knee, a result of low

motion after surgery. By getting the patient into physical therapy sooner, the knee is immobile

for a shorter amount of time, not allowing it to degenerate and cause major problems in the long

run (Thomee and Kaplan, 2011). This created much higher rates of success and a much lower

risk of osteoarthritis and other joint problems later in life.

Conclusion

Overall, the combination of treatment including the use of a patellar graft for ACL

reconstruction, epidural pain relief, and an accelerated physical therapy track is the best for

anyone who endures an ACL tear. Using a patellar graft allows for the least amount of observed

complications perioperative and postoperative, which can then be followed by epidural pain

relief. This pain relief option allows the fear of starting physical therapy to be lessened and eases

the fear of re-injury, thus allowing full participation in the rehabilitation process. Starting

physical therapy early and following the accelerated physical therapy path, achieved through

adequate pain relief, allows the patient to recover faster and get back to sports and their daily

lives. Minimal knee degeneration is thus, achieved and optimal ACL stability is restored. This
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creates less problems later in life, including a decreased risk of muscle loss and osteoarthritis.

The data collection following this review explores what is expected during the entire recovery

process and explains what is to be looked for in a broader context.

Data Collection

For the topic of physical therapy and the speed of ACL recovery time, a mixed method of

data collection was chosen. Information from meta-analysis and interviews provided the best

source of information to help further understand current issues in the specific field, and modeled

what people were thinking in two different ways. The researcher was able to understand how

conclusions and decisions regarding new surgeries were made and became the standard by

looking at two matching academic journals and professional phone interviews. This helped to

elaborate on current ideals. Talking to professionals first hand broadened the understanding of

information obtained in the academic journals and allowed the researcher to ask more specific

questions that cannot necessarily be answered by the information presented in academic journals.

Other data collection methods with a tool, like a poll or survey, wouldn't have worked as well for

this topic. This topic is most successfully researched by talking to professionals first hand and

researching specific academic journals with meta-analysis. These methods proved to provide

more information than a survey or poll. Also, considering the 6 questions asked in the phone

interviews and their responses, took approximately 5-8 minutes each, it was not feasible to get

answers from a survey or poll.

Data

Sources Conclusions

“Reconstruction of the anterior cruciate This study concluded that waiting longer than
ligament: Timing of Surgery and the 4 weeks to have an ACL reconstruction
Incidence of Meniscal Tears and surgery has the possibility to create certain
Degenerative Change” by S. Church and J. meniscal and knee deterioration problems
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F. Keating, in The Journal of Bone and later in the recovery process.

Joint Surgery

“Results of Anterior Cruciate Ligament This study concluded that patients who have
Reconstruction Based on Meniscus and meniscal and knee deterioration problems pre-
Articular Cartilage Status at the Time of op were due to waiting too long to have the
Surgery” by Donald K. Shelbourne and reconstruction surgery, causing them to have a
Tinker Gray, in The American Journal of much harder recovery.
Sports Medicine

Questions Megan Bish John Tis

What do you think has ● Increase in hard ● Yes increase but also
caused such a large increase hitting contact more knowledge
in ACL tears and other ● Training in one ○ Able to
knee and ankle injuries over dimension identify sooner
the past few years? ○ Training to be ● Intense sports
pro in one ○ Women being
sport more involved
● Youth sports ○ Youth
○ Pushing kids ○ Pushing kids
beyond limits past their point
all year long ■ injury
● Shoe type
○ Not tailored to
the kids needs

Many different studies show ● ACL tears from N/A

many different results about contact are pretty
injury prevention. Do you inevitable
● Non contact can be
think that injury prevention
prevented
truly does help to prevent ○ Train off
things like ACL tears? season
○ All planes of
motion

What are the main target ● Range of motion is as N/A

areas for physical therapy perfect
do you usually look at for ○ Post op
patients with ACL tears outcome better
before they go into surgery? ● Full extension
● Quad strength, glute
strength, hip/girdle
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strength
○ More muscle
tone

How soon after the initial ● Not too long or too ● Wait to get back to
ACL injury would you short full range of motion
recommend doing ACL ○ Decrease ○ 4 weeks
reconstruction? abnormalities ● Not too long
before surgery ○ Gets damaged
Meniscus

Over the past few years, ● Minimally invasive ● Less invasive

many new methods of surgeries speed up surgeries
treatment, like easier recovery time because ○ Less damage
surgery and new methods of the rehabilitation ○ Quicker to get
physical therapy, have been process in much easier back
created. Do you think that with less scar tissue. ● New technology
these new forms of ● New types of PT to ○ arthroscopic
treatment have sped up increase range of ○ Operate on
recovery time? motion kids with open
growth plates
● Accelerated Physical
therapy
○ Start 1-2 days
after surgery
○ weight bearing
○ Running
● Electrostimulation

What are the main target ● Patient education N/A

areas for physical therapy ○ Not pushing
do you usually look at for themselves
● Full ability in their
patients after an ACL
sport
surgery? ○ Push harder in
clinic to make
sure they can
take it
○ Full range of
motion and
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strength
● Getting muscle
strength back
● Knowledge of abilities
before surgery as well

Analysis

By speaking to professionals and consulting academic journals, research has shown that

many things go into the ACL recovery process. Before an injury happens, injury prevention is

proven to be helpful in not only stopping an injury from happening, but during the recovery

process as well because the subjects would already have a body sense, or an understanding of

what their body can take, that helped them understand how to get back faster. The type of shoes

worn are also a contributing factor, according to Megan Bish, physical therapist, who said clients

need to pick shoes that are tailored to their body type, which can help prevent an injury, allow for

a faster recovery, and provide support to lower extremities, ankles and feet. Dr. John Tis,

orthopedic surgeon, did not agree with this thinking, which was surprising because all other

consulted resources said otherwise. However, it is a theory that has not been 100% proven to be

correct, so some disagreement was expected. Information researched from both interviews and

academic journals seemed to be unanimous and suggest that youth sports are the underlying

cause for ACL tears. Pushing kids to do one sport all year long created fatigue and worn out

muscles, thus making athletic participants not well rounded athletes and potentiated more

injuries. After the injury, knee health must be assessed first and taken in to account by the

physical therapist and surgeon. Range of motion and meniscal health seemed to be the number

one thing that is assessed before a surgery. The academic journal, “Results of Anterior Cruciate

Ligament Reconstruction Based on Meniscus and Articular Cartilage Status at the Time of

Surgery,” by Donald K. Shelbourne and Tinker Gray, in The American Journal of Sports
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Medicine, showed that patients with healthy menisci and low knee deterioration before the ACL

reconstruction surgery was completed have a much higher success rate and recovery time.

Physical therapist Megan Bish said she always makes sure that patients have the best range of

motion they can have going into the operating room to ensure the best results. Also, Dr. John Tis

and the academic journal, “Reconstruction of the anterior cruciate ligament: Timing of Surgery

and the Incidence of Meniscal Tears and Degenerative Change,” by S. Church and J. F. Keating,

in The Journal of Bone and Joint Surgery, both said that it was very important to not only have

knee health before the surgery, but to not wait longer or shorter than a month. Doing the surgery

too early can cause arthritis and knee stiffness, while waiting too long can cause many problems

as well, such as deterioration of muscles in the knee. Both cause postoperative recovery to be

slower and success to be lower. During surgery, many things have changed to speed up recovery

time. The creation of arthroscopic and less invasive surgery has helped enormously, according to

Dr. John Tis and Megan Bish. Less invasive surgeries have decreased scar tissue which has

optimized recovery speed and success. These new arthroscopic surgeries have also enabled

surgeries to be performed on young kids with open growth plates, according to Dr. John Tis,

which allows the kids to have healthier knees overall. These results were not surprising, however

the theories behind the research and what the results showed was better understood and

explained by doing this research. This research provided a deeper understanding and furthered

the researcher’s knowledge; thus, aiding in a conclusion to the research question of how to speed

up recovery time with ACL tears.

Conclusions

If something were to be changed in the data collection, more interviews would be done

rather than meta-analysis. Interviews allowed the researcher to ask extremely specific questions
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tweaked specifically to answer the research question, how to speed up ACL tear recovery time.

Interviews also allowed for more detailed answers that proved more helpful than academic

journals. However, meta-analysis allowed the researcher to learn new things that provided

questions for the interviews, questions that may not have been asked before. The results and

answers from the interviews and academic journals allowed many new conclusions to be made.

The researcher learned that there are many parts to ACL recovery, and that many things go into

getting an athlete back into their sport. This complicated the research question even more

because pre-injury, post-injury preoperative, perioperative, and postoperative, all need to be

considered in the ACL recovery process. Pre-injury, athletes need to have good shoes, know

limitations, not over train, and have complete knowledge of successful injury prevention skills

and training to hopefully prevent an injury. Pre-injury and post-op, patients need to have the best

range of motion possible during the 4 weeks after the injury so that they can be ensured the best

results. During operations, surgeons should avoid creating meniscal problems and scar tissue by

using arthroscopic/minimally invasive surgery. Finally, post-op patients need to have a plan for

physical therapy and train in all planes of motion tailored to their sport. The researcher is

specifically focusing on the perioperative and postoperative part of recovery, and how different

forms of physical therapy and surgery can speed up time of the recovery process, which began to

be answered in these interviews and academic journals.

Overall Conclusion

In conclusion, the results contribute to the world of athletics and health in many ways.

Athletes can understand what needs to be expected during the whole recovery process, starting

pre-injury. Surgeons and physical therapists can learn what is expected of them in the recovery

process and how patients should behave. Overall, a new knowledge of the whole recovery
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process and the best way to do is provided to the general public and the professional doctoral

world. From these results, new knowledge about injury prevention and injury recovery can be

extrapolated, finding that patellar tendon grafts, epidural pain relief, and then an accelerated

physical therapy path is the best option for recovery. Putting all the results together from all the

research done provides a new understanding of the full ACL tear recovery process and what is

looked for throughout the process. Relaying the results together in one paper allows anyone to

understand the entire process, and eventually the best way to speed up recovery time in patients

with ACL tears, while still having the same success rate.
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References

Anderson, H. Personal interview. 17 January 2018.

Beynnon, Bruce D. & Uh, Benjamin S. (2005) “Rehabilitation After Anterior Cruciate
Ligament Reconstruction.” The American Journal of Sports Medicine, 33(3); 347-359.
Retrieved from:
http://www.institutocefisa.com.br/design/imagens/sistemas/apostilas/352c0cdbea7241b5f
19e1b3738e9c670/4586.pdf

Capdevila, Xavier & Barthelet ,Yves. (1999). Effects of Perioperative Analgesic

Technique on the Surgical Outcome and Duration of Rehabilitation after Major Knee
Surgery. Anesthesiology, 91, 8-15. Retrieved from:
anesthesiology.pubs.asahq.org/article.aspx?articleid=1946722

Chmielewski, Terese L. & Jones, Debi. (2008) “The Association of Pain and Fear of
Movement/Re Injury With Function During Anterior Cruciate Ligament Reconstruction
Rehabilitation.” Journal of Orthopaedic & Sports Physical Therapy, 38(12): 746-753.
Retrieved from:
https://www.researchgate.net/profile/Terese_Chmielewski/publication/23560697_
The_Association_of_Pain_and_Fear_of_MovementReinjury_With_Function_During_An
terior_Cruciate_Ligament_Reconstruction_Rehabilitation/links/5624f03a08aed8dd19495
072.pdf

Church, S., & Keating, J. F., (2005). Reconstruction of the anterior cruciate ligament:
Timing of Surgery and the Incidence of Meniscal Tears and Degenerative Change. The
Journal of Bone and Joint Surgery, (Br), 1639-1642. Retrieved from:
https://pdfs.semanticscholar.org/8951/6f2dbc66c680979b6f4dc09f7abec4cc87c6.pdf

Crawford, Ruth, Gayle Walley, Stephen Bridgman, Nicola Maffulli. (2007) “Magnetic
resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating
on meniscal lesions and ACL tears: a systematic review” British Medical Bulletin,
Volume 84(1), 5–23. Retrieved from:
https://academic.oup.com/bmb/article/84/1/5/379738

Freedman, Kevin B. & D’Amato, Michael J. (2003) “Arthroscopic Anterior Cruciate

Ligament Reconstruction: A Meta-analysis Comparing Patellar Tendon and Hamstring
Tendon Autografts” The American Journal of Sports Medicine, 31(1): 2-11. Retrieved
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from: http://www.kneeligamentdoc.com/Articles/ACL%20Recon%20-
%20Meta%20Analysis.pdf

Lohmander, L. Stefan. (2007). "The Long-term Consequence of Anterior Cruciate

Ligament and Meniscus Injuries" The American Journal Of Sports Medicine, 35(10).
Retrieved from
https://www.researchgate.net/profile/Martin_Englund/publication/6077961_The_Long-
term_Consequence_of_Anterior_Cruciate_Ligament_and_Meniscus_Injuries_Osteoarthri
tis/links/55eb4a0708ae21d099c5e798.pdf

Renstrom, P. & Ljungqvist, A. (2008). "Non-contact ACL injuries in female athletes: an

International Olympic Committee current concepts statement" Br J Sports Med, 42(6):
394–412.. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920910/?_escaped_fragment_=po=5.08
685

Shelbourne, Donald K., & Gray, Tinker., (2000). Results of Anterior Cruciate Ligament
Reconstruction Based on Meniscus and Articular Cartilage Status at the Time of Surgery.
The American Journal of Sports Medicine , 28(4), 446-452. Retrieved from:
citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.975.5027&rep=rep1&type=pdf

Shelbourne, Donald K. & Klotz, Christine. (2006) “What I have learned about the ACL:
utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior
cruciate ligament reconstruction” Journal of Orthopaedic Science, 11:318–325. Retrieved
from: https://link.springer.com/content/pdf/10.1007%2Fs00776-006-1007-z.pdf

Soo Han, Hyuk & Cheol Seong, Sang. (2008) “Anterior Cruciate Ligament
Reconstruction: Quadriceps Versus Patellar Autograft” Clinical Orthopaedics and
Related Research, 466(1): 198–204. Retreived from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505304/

Thomee, Roland & Kaplan, Yonatan. (2011) “Muscle strength and hop performance
criteria prior to return to sports after ACL reconstruction.” European Board of Sports
Rehabilitation, 11(19): 1798-1805. Retrieved from: http://www.diva-
portal.org/smash/get/diva2:466453/FULLTEXT01.pdf

Toporek, B. (2011). Sports Injuries; "Knee Injuries in Children and Adolescents: Has
There Been an Increase in ACL and Meniscus Tears in Recent Years?" Education Week,
Scott 17

31(09), 5. Retrieved from http://link.galegroup.com/apps/doc/A271817309/GPS?u=

glen20233&sid=GPS&xid=b2d9d40

Viola, Randall W. & Sterett, William I. (2004) “Internal and External Tibial Rotation
Strength After Anterior Cruciate Ligament Reconstruction Using Ipsilateral
Semitendinosus and Gracilis Tendon Autografts.” The American Journal of Sports
Medicine, 28(4): 552-555. Retrieved from:
https://www.researchgate.net/profile/Michael_Torry2/publication/12397625_Internal_an
d_external_tibial_rotation_strength_after_anterior_cruciate_ligament_reconstruction_usi
ng_ipsilateral_semitendinosus_and_gracilis_tendon_autografts/links/566adfc608ae430ab
4f92cc5.pdf

Wright, Rick W & Magnussen, Robert A. (2011) “Ipsilateral Graft and Contralateral
ACL Rupture at Five Years or More Following ACL Reconstruction” The Journal of
Bone and Joint Surgery, 93(12): 1159–1165. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110421/

Wright, Rick W & Preston, Emily. (2008) “ACL Reconstruction Rehabilitation: A

Systematic Review Part II.” Europe PMC, 21(3): 225–234. Retrieved from:
http://europepmc.org/articles/pmc3692368

Yagi, Masayoshi & Wong, Eric K. (2002) “Biomechanical Analysis of an Anatomic

Anterior Cruciate Ligament Reconstruction” The American Journal of Sports Medicine,
30(5): 660-666. Retrieved from:
https://www.researchgate.net/profile/Savio_Woo/publication/11151813_Biomechanical_
Analysis_of_an_Anatomic_Anterior_Cruciate_Ligament_Reconstruction/links/53e23f0c
0cf2235f352c2671.pdf