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Alarming underutilisation of rehabilitation in athletes with anterior cruciate ligament reconstruction: four ways to change the game
  1. Hege Grindem1,
  2. Amelia JH Arundale2,
  3. Clare L Ardern2,3
  1. 1 Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
  2. 2 Division of Physiotherapy, Linköping University, Linköping, Sweden
  3. 3 Faculty of Health Sciences, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
  1. Correspondence to Dr Hege Grindem, Norwegian School of Sport Sciences, Pb 4014,Ullevål Stadion, 0806 Oslo, Norway; hege.grindem{at}

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Alarming underutilisation of rehabilitation after ACL reconstruction (ACLR) was highlighted in a recent study.1 These Australian trends are not unique, but support the emerging realisation that athletes may be overtreated with ACLR surgery, but undertreated when it comes to rehabilitation. We use the term undertreated to describe insufficient rehabilitation—either because athletes are discharged too soon or because the rehabilitation content is inadequate.

Among non-elite athletes with ACLR, only 5% received rehabilitation1 that followed evidence-based guidelines2: ≥6 months’ rehabilitation, including agility and landing exercises, and a structured return to sport (RTS). Most athletes were undertreated: 45% (50 of 111) never saw a clinician after the third postoperative month and 70% (78 of 111) never did agility or landing exercises.1 When clinical practice does not follow evidence-based guidelines, we are not offering the best to our athletes.

Evidence-based rehabilitation restores function

Outcomes following ACLR are mainly dictated by the athlete, the rehabilitation clinician and the orthopaedic surgeon. And the rehabilitation clinician might be the central player in this trifecta.1 Almost a year after ACLR, the key criteria3 of >90% quadriceps strength and single hop performance were met by 31% and 53% of undertreated athletes, respectively.1 In comparison, 79% and 89% met these criteria after evidence-based rehabilitation in the USA.4 Similarly, in Norway, 9 out of 10 athletes who received evidence-based rehabilitation had self-reported symptoms within normative ranges compared with only half of undertreated athletes.5

Function matters

The chasm in function and symptoms between athletes who received evidence-based rehabilitation and undertreated athletes is important because knee function after rehabilitation is strongly related to the likelihood for reinjury,3 long-term knee function,6 and knee osteoarthritis.7

Athletes typically expect to return to sport 6–12 months after surgery. This broadly corresponds with the average time (8–11 months) to pass RTS criteria following evidence-based rehabilitation.8 But if athletes have been undertreated, muscle strength and neuromuscular function are often not restored by this time.1 For coaches and athletes, efficient utilisation of evidence-based rehabilitation is the champion of timely RTS and the first defender against reinjury and return to treatment.

What is evidence-based rehabilitation?

BJSM offers a free, updated, detailed guide to evidence-based ACLR rehabilitation.2 This gold standard should be used by all clinicians, including generalists in small, solo-practitioner clinics. Evidence-based rehabilitation for ACLR includes prehabilitation and three criterion-based postoperative phases, with gradual RTS after passing functional RTS criteria.2 The framework is complemented by tools to strengthen the athlete’s active role in the rehabilitation process: patient education, shared goal-setting and repeated functional testing to provide feedback.9

Evidence-based rehabilitation addresses pain, effusion, range of motion, muscle function (neuromuscular control, endurance, strength and power), movement patterns (in walking, running, jumping and specific sports), sports performance (eg, acceleration, agility, coordination, balance, endurance and sport-specific skills) and psychological readiness to RTS.2 The rehabilitation clinician will effectively tailor a programme to meet the athlete’s current goals. Therefore, a systematic approach with short-term and long-term goal-setting, repeated assessments and individual adjustments is paramount—sending the athlete home from hospital with a sheet of exercises is simply not enough!

Maximise the rehabilitation potential

There are at least three main contributors to undertreatment:

  1. The athlete’s adherence to rehabilitation. Adherence to rehabilitation programmes affects outcomes. Important tools to improve adherence include goal-setting, consistently measuring progress for benchmarking, identification of barriers to rehabilitation adherence and adjustments to the treatment plan on the basis of these factors.

  2. Economic constraints of the healthcare delivery system. Waiting lists and inadequate insurance coverage are common challenges that can prevent clinicians from providing high-quality treatment. Evidence-based practice and economic incentives are not always perfectly aligned, and this may influence the quality of treatment. On the other hand, there are few incentives to change healthcare delivery systems unless clinicians stay up-to-date with best evidence and continue to demonstrate superior outcomes for the money spent.

  3. Geographic barriers to accessing rehabilitation. Location and distance can hinder access to high-quality rehabilitation. Telerehabilitation (rehabilitation delivery via phone or internet) has the potential to broaden access by transcending geographical barriers and providing a low-cost complement to rehabilitation.


To help clinicians improve outcomes through better utilisation of rehabilitation after ACLR, we offer four suggestions:

  1. The importance of regaining function after ACLR must be recognised by all stakeholders: policymakers (third-party payers), orthopaedic surgeons, rehabilitation clinicians, coaches and athletes (and their parents/guardians when under age).

  2. Orthopaedic surgeons and rehabilitation clinicians must join forces to promote evidence-based practice, including the use of objective measures for progression and RTS.

  3. Evidence-based patient education should occur before all surgical or rehabilitation decision-making, and continue as rehabilitation progresses. This will ensure that the athlete can make an informed commitment to a treatment plan.

  4. Orthopaedic surgeons and rehabilitation clinicians must acknowledge their roles in building and maintaining athlete motivation for rehabilitation.



  • Contributors HG proposed the initial idea and wrote the first draft. All authors contributed equally to subsequent versions of the editorial and approved the submission of the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.