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Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus
  1. Adam G Culvenor1,
  2. Michael A Girdwood1,
  3. Carsten B Juhl2,3,
  4. Brooke E Patterson1,
  5. Melissa J Haberfield1,
  6. Pætur M Holm2,4,
  7. Alessio Bricca2,4,
  8. Jackie L Whittaker5,6,
  9. Ewa M Roos2,
  10. Kay M Crossley1
  1. 1La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
  2. 2Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Funen, Denmark
  3. 3Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Copenhagen, Denmark
  4. 4The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
  5. 5Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  6. 6Arthritis Research Canada, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Adam G Culvenor; a.culvenor{at}


Objective Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes.

Design Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.

Data sources MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

Eligibility criteria Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults.

Results We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion.

Conclusion The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.

  • knee
  • anterior cruciate ligament
  • rehabilitation
  • exercise

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  • Twitter @agculvenor, @m_girdwood, @Knee_Howells, @melhabphysio, @jwhittak_physio, @ewa_roos

  • Contributors AGC, JLW, EMR and KMC designed the systematic review and were involved in priority theme setting. AGC, BP and MH completed all searches and study selection (including inclusion and exclusion of abstracts). AGC and MG completed all data extraction and risk of bias assessment. AGC and CBJ planned the analyses, and all authors interpreted the data. MG prepared all figures. AGC wrote the initial draft. All authors critically revised the manuscript for important intellectual content and approved the final version of the manuscript.

  • Funding This review is part of the OPTIKNEE consensus ( which has received funding from the Canadian Institutes of Health Research (OPTIKNEE principal investigator JLW #161821). Initial priority theme setting was supported by a La Trobe University Research Focus Area Collaboration Grant (OPTIKNEE principal investigator AGC). AGC is a recipient of a National Health and Medical Research Council (NHMRC) of Australia Investigator Grant (GNT2008523). MG is a recipient of a NHMRC of Australia PhD Scholarship (GNT1190882). The funders had no role in any part of the study or in any decision about publication

  • Competing interests AGC, BP and JLW are Associate Editors of BJSM. KMC is a senior advisor of BJSM. All other authors declare no competing interests.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.