Purpose of Review The goal of this paper is to review the current management and prevention of post-operative complications after anterior cruciate ligament (ACL) reconstruction. Trends in rehabilitation techniques will be presented, in addition to suggestions for interventions and expected milestones in ACL reconstruction recovery. Recent Findings ACL reconstruction protocols have evolved to more of a criterion-based progression rather than a tissuehealing time frame. Given the evolution of ACL surgical reconstruction techniques and rehabilitation protocols, the risk of post-operative complications can arise both early and late in the recovery process. This paper will discuss the role of preventative measures as it applies to the post-operative patient with ACL reconstruction. Summary Short-term complications following ACL reconstruction include infection and deficits to knee motion and strength, whereas long-term complications include secondary ACL injury to either the involved or contralateral knee and lack of ability to return to high-level sports following this procedure. Future research should continue to address the multifactorial causes of secondary ACL injury and limited ability of patients to return to high level activities.

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This case study illustrates the safe inclusion of low-stress aquatic exercises as an early adjunct to traditional land-based rotator cuff repair rehabilitation programs in small- to medium-size repairs. Further studies are needed to determine the long-term effectiveness of adding aquatic therapy to traditional postoperative programs.

Mechanical loading to the knee joint results in a differential response based on the local capacity of the tissues (ligament, tendon, meniscus, cartilage, and bone) and how those tissues subsequently adapt to that load at the molecular and cellular level. Participation in cutting, pivoting, and jumping sports predisposes the knee to the risk of injury. In this narrative review, we describe different mechanisms of loading that can result in excessive loads to the knee, leading to ligamentous, musculotendinous, meniscal, and chondral injuries or maladaptations. Following injury (or surgery) to structures around the knee, the primary goal of rehabilitation is to maximize the patient's response to exercise at the current level of function, while minimizing the risk of re-injury to the healing tissue. Clinicians should have a clear understanding of the specific injured tissue(s), and rehabilitation should be driven by knowledge of tissue-healing constraints, knee complex and lower extremity biomechanics, neuromuscular physiology, task-specific activities involving weight-bearing and non-weight-bearing conditions, and training principles. We provide a practical application for prescribing loading progressions of exercises, functional activities, and mobility tasks based on their mechanical load profile to knee-specific structures during the rehabilitation process. Various loading interventions can be used by clinicians to produce physical stress to address body function, physical impairments, activity limitations, and participation restrictions. By modifying the mechanical load elements, clinicians can alter the tissue adaptations, facilitate motor learning, and resolve corresponding physical impairments. Providing different loads that create variable tensile, compressive, and shear deformation on the tissue through mechanotransduction and specificity can promote the appropriate stress adaptations to increase tissue capacity and injury tolerance. Tools for monitoring rehabilitation training loads to the knee are proposed to assess the reactivity of the knee joint to mechanical loading to monitor excessive mechanical loads and facilitate optimal rehabilitation. Key PointsMechanical loads encountered during high-risk cutting, pivoting, and jumping sports predispose the structures of the knee to risk of injury.Individual tissues of the knee respond and adapt differently to various mechanical load stimuli.

Study Design Systematic literature review with meta-analysis. Background Management of patellofemoral pain (PFP) may include the utilization of manual therapy (MT) techniques to the patellofemoral joint, surrounding soft tissues, and/or lumbopelvic region. Objectives To determine the effectiveness of MT, used alone or as an adjunct intervention, compared to standard treatment or sham for reducing pain and improving self-reported function in individuals with PFP. Methods An electronic literature search was conducted in the PubMed, Ovid, Cochrane Central Register of Controlled Trials, and CINAHL databases for studies investigating MT for individuals with PFP. Studies published through August 2017 that compared MT (local or remote to the knee), used alone or in combination with other interventions, to control or sham interventions were included. Patient-reported pain and functional outcomes were collected and synthesized. Trials were assessed via the Cochrane risk-of-bias tool, and a meta-analysis of the evidence was performed. Results Nine studies were included in the review, 5 of which were rated as having a low risk of bias. The use of MT, applied to the local knee structure, was associated with favorable short-term changes in self-reported function and pain in individuals with PFP, when compared to a comparison (control or sham) intervention. However, the changes were clinically meaningful only for pain (defined as a 2-cm or 2-point improvement on a visual analog scale or numeric pain-rating scale). The evidence regarding lumbopelvic manipulation was inconclusive for pain improvement in individuals with PFP, based on 3 studies. Conclusion The data from this review cautiously suggest that MT may be helpful in the short term for decreasing pain in patients with PFP. Several studies integrated MT into a comprehensive treatment program. Changes in self-reported function with the inclusion of MT were shown to be significant, but not clinically meaningful. The limitations in the studies performed to date suggest that future research should determine the optimal techniques and dosage of MT and perform longer follow-up to monitor long-term effects. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(5):358-371. Epub 6 Jan 2018. doi:10.2519/jospt.2018.7243.

Arthroscopic debridement of knee joint arthrofibrosis after ACLR in conjunction with a postoperative physical therapy algorithmic approach to maximizing knee joint extension ROM can be beneficial in gaining symmetrical knee extension range of motion and improved function. Further studies may help to understand the optimal mode, frequency, and duration of stretching to achieve full symmetrical knee extension in this population.

A single session of eccentric exercise and NES can produce immediate and next-day reductions in pain sensitivity in asymptomatic adults. The immediacy of these effects points toward a neurophysiologic mechanism. Future research needs to be performed in clinical populations and to assess any cumulative effects to repetitive intervention.