Table 6

Summary of conclusions and recommendations

Conclusions and recommendationsLevel of evidence
Preoperative rehabilitation
A preoperative extension deficit (lack of full extension) is a major risk factor for an extension deficit after ACLR2
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 ACLR2
Recommendation: measure quadriceps strength and also HS strength
Prehabilitation ensures better self-reported knee function up to 2 years after ACLR3
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 therapist2
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 strength2
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 pain2
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 ROM1
Recommendation: cryotherapy could eventually be applied in the first postoperative week to reduce pain
Isometric quadriceps exercises are safe from the first postoperative week2
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 weeks1
CKC and OKC training can be used for regaining quadriceps strength1
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 types2
Neuromuscular training should be added to strength training to optimise self-reported outcome measurements1
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 ACLR2
Recommendation: evaluate psychological changes during rehabilitation with an objective instrument
Criteria for return to play2
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 play2
It is not clear which cut-off point of the LSI should be used for strength and hop tests3
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.