Recommendations on ACL rehabilitation and postoperative follow-up assessment.
| Recommendation item | NZGG38 | DOA36 | MOON34 | AAOS33 | KNGF37 | APTA35 |
| Supervised rehabilitation vs home-based exercises | Intensive supervised physical therapy may be used in some cases. | – | Home-based rehabilitation may be used in motivated patients. | – | Uncertain recommendation on supervised rehabilitation versus home-based exercises. | Exercise ambulatory programmes supplemented by a prescribed home-based programme supervised by a physical therapist should be used. |
| A minimally supervised rehabilitation may be used in specific groups of patients that are highly motivated and live far from a physical therapist. | ||||||
| Accelerated rehabilitation | Uncertain recommendation on ‘accelerated rehabilitation programmes’. | – | Uncertain recommendation on ‘accelerated rehabilitation programmes’. | Uncertain recommendation on ‘accelerated rehabilitation programmes’. | Prehabilitation and progressive goal-based rehabilitation rather than time base should be used. | Accelerated rehabilitation characterised as ‘immediate knee mobilisation’ should be used. |
| Continuous passive motion | – | – | Continuous passive motion is not recommended. | – | – | Continuous passive motion may be used in the immediate postoperative period. |
| ROM restrictions | – | – | Immediate knee mobilisation should be used following ACL reconstruction. | – | – | Immediate knee mobilisation (within 1 week) should be used following ACL reconstruction. |
| Weight bearing restrictions | – | – | Immediate full WB should be used following ACL reconstruction. | – | Immediate WB should be used after specific criteria is fulfilled. | Early WB (within 1 week) may be used as tolerated. |
| Postoperative functional bracing | Postoperative knee brace should not be used. | Postoperative knee brace should not be used. | Postoperative knee brace should not be used. | The routine use of postoperative functional knee brace should not be used. | – | Immediate postoperative knee brace according to patient’s preferences or associated ligament injuries. |
| OKC and CKC | OKC exercises (90–45°) may be used as early as 4 weeks. | Both OCK and CKC exercises may be used during strength training but CKC should be prioritised over OKC exercises at the early phase of rehabilitation. | Uncertain recommendation for OKC exercises in earlier stages of the rehabilitation. | – | Both OKC and CKC exercises may be used. OKC exercises (90–45°) may be used as early as 4 weeks. | – |
| OKC exercises may be used after 6 postoperative weeks | ||||||
| Strength and neuromuscular training | – | The combination of strength and neuromuscular training should be used in the postoperative rehabilitation. | Neuromuscular training should be used in most phases of ACL postoperative rehabilitation. | – | Isometric quadriceps exercises should be used from the first postoperative week. Eccentric (in CKC) and concentric quadriceps training should be used from the third postoperative week. Neuromuscular exercises should be used in addition to strength training. | WB and non–WB concentric and eccentric exercises should be used from 4 to 6 postoperative weeks (2–3×/week during 6–10 months). Neuromuscular re-education training should be used in addition to muscle strengthening exercises. |
| Neuromuscular electrostimulation | – | – | NMES may be used according to the clinician’s preference. | – | NMES may be used in addition to isometric strength training at the first postoperative weeks | NMES should be used for the initial 6–8 postoperative weeks. |
| Cryotherapy | – | – | – | – | Cryotherapy may be used in the first postoperative week. | Immediate cryotherapy should be used. |
| Outcomes and/or functional testing | – | The combination of clinical (Lachman, pivot shift and anterior drawer tests) and patient-reported Outcomes measures (IKDC subjective and KOOS) should be used. Tegner score may be used for measurement of activity. | – | Measures of knee pain, activities of daily living, quality of life, functional status, activity tolerance and self-reported physical function assessment should be used. | Psychological changes during rehabilitation with objective instruments should be used. | A combination of validated patient-reported outcome measures (IKDC 2000 or KOOS), activity level tool (Tegner or Marx) and a psychological questionnaire (ACL-RSI) should be used. Functional performance assessment (appropriated clinical or field testing) should be used. |
| RTS criteria | – | A minimum 3 month cut-off to resume heavy physical activity in labour or sports should be used. | – | Uncertain recommendation on waiting for a specific time or achieving a specific functional goal prior to return to sport. | An extensive test battery for assessing quantity and quality of movement should be used. LSI of >90% for cut-off point may be used may be used for strength and hop tests. For pivoting/contact sports, an LSI of ≥100% should be used. | Functional testing to determine a patient’s readiness to return to activities should be used. |
Colour coding: Green, 'should be used'; Yellow, 'may be used'; Dark red, 'should not be used'; Light red, 'uncertain recommendation'.
AAOS, American Academy of Orthopaedic Surgeons; ACL, anterior cruciate ligament; ACL-RSI, anterior cruciate ligament – return to sport after injury; APTA, American Physical Therapy Association; CKC, closed kinetic chain; CPG, clinical practice guideline; DOA, Dutch Orthopaedic Association; IKDC, International Knee Documentation Committee; KNGF, Royal Dutch Society for Physical Therapy; KOOS, Knee injury and Osteoarthritis Outcome Score; LSI, Limb Symmetry Index; MOON, Multicenter Orthopaedic Outcomes Network; NMES, neuromuscular electrical stimulation; NR, non-reported; NZGG, New Zealand Guidelines Group; OKC, open kinetic chain; ROM, range of movement; RTS, return to sport; WB, weight bearing.