Summary of conclusions and recommendations
| Conclusions and recommendations | Level of evidence |
|---|---|
| Preoperative rehabilitation | |
| A preoperative extension deficit (lack of full extension) is a major risk factor for an extension deficit after ACLR | 2 |
| Recommendation: measure the preoperative ROM | |
| A preoperative deficit in quadriceps strength of >20% has a significant negative consequence for the self-reported outcome 2 years after ACLR | 2 |
| Recommendation: measure quadriceps strength and also HS strength | |
| Prehabilitation ensures better self-reported knee function up to 2 years after ACLR | 3 |
| Recommendation: refer the patient to a physical therapist when necessary | |
| Postoperative rehabilitation | |
| It is unclear whether there is a benefit of supervised rehabilitation compared to home-based rehabilitation or no rehabilitation at all. A minimally supervised rehabilitation programme may result in successful rehabilitation in specific groups of patients that are highly motivated and live far from a physical therapist | 2 |
| When comparing a 19-week with a 32-week rehabilitation programme, there are no differences in terms of laxity, ROM, self-reported knee function, single-leg hop test for distance or isokinetic concentric quadriceps and HS strength | 2 |
| Recommendation: continue rehabilitation for 9–12 months, depending on the final return-to-work or play goals of the patient | |
| Immediate weight bearing does not affect knee laxity and results in decreased incidence of anterior knee pain | 2 |
| Recommendation: immediate weight bearing should only be tolerated if there is a correct gait pattern (if necessary with crutches) and no pain, effusion or increase in temperature when walking or shortly after walking | |
| Cryotherapy is effective in decreasing pain immediately after application up to 1 week postsurgery after ACLR, but has no effect on postoperative drainage or ROM | 1 |
| Recommendation: cryotherapy could eventually be applied in the first postoperative week to reduce pain | |
| Isometric quadriceps exercises are safe from the first postoperative week | 2 |
| Recommendation: start isometric quadriceps exercises in this first week for reactivating the quadriceps muscles when they provoke no pain | |
| Electrostimulation, in combination with conventional rehabilitation, might be more effective for improving muscle strength for up to 2 months after ACLR than conventional rehabilitation alone. However, its effect on long-term functional performance and self-reported knee function is inconclusive. | |
| Recommendation: electrostimulation can be useful as an addition to isometric strength training for re-educating voluntary contraction of the quadriceps muscles during the first postoperative weeks | 1 |
| CKC and OKC training can be used for regaining quadriceps strength | 1 |
| After ACLR, OKC exercises can be performed from week 4 postoperative in a restricted ROM of 90–45° | |
| Recommendation: When the quadriceps is reactivated, concentric and eccentric exercises should be used to replace the isometric exercises, provided that the knee does not react with effusion or (an increase in) pain. CKC exercises can be performed from week 2 postoperative. For BPTB, OKC exercises can be started from 4 weeks postoperative in a restricted ROM of 90–45° and extra resistance is allowed, for example, at a leg extension machine. For HS, OKC exercises also can be started from 4 weeks postoperative in a restricted ROM of 90–45°, but no extra weight should be added in the first 12 weeks to prevent graft elongation. ROM can be increased to 90–30° in week 5, to 90–20° in week 6, to 90–10° in week 7 and to full ROM in week 8 for both graft types | 2 |
| Neuromuscular training should be added to strength training to optimise self-reported outcome measurements | 1 |
| Altered neuromuscular function and biomechanics after ACLR could be a risk factor for second ACL injury (graft rerupture or contralateral rupture) | 2 |
| Recommendation: neuromuscular training should be added to strength training. Pay attention to a correct quality of movement for prevention of reinjuries | |
| Psychological factors as self-efficacy, locus of control and fear of reinjury have influence on the rehabilitation process and return to play after ACLR | 2 |
| Recommendation: evaluate psychological changes during rehabilitation with an objective instrument | |
| Criteria for return to play | 2 |
| An extensive test battery should be used to determine the return-to-play moment, but there are no tests or test batteries that have been tested for construct or predictive validity for return to play | 2 |
| It is not clear which cut-off point of the LSI should be used for strength and hop tests | 3 |
| Recommendation: perform an extensive test battery for quantity and quality of movement. This test battery should include at least a strength test battery and a hop test battery and measurement of quality of movement. An LSI of >90% could be used as a cut-off point. For pivoting/contact sports, an LSI of ≥100% is recommended | |
ACLR, anterior cruciate ligament reconstruction; BPTB, bone-patellar tendon-bone; CKC, closed kinetic chain; HS, hamstring; LSI, Limb Symmetry Index; OKC, open kinetic chain; ROM, range of motion.