The ultimate goal of rehabilitation after a football player gets an anterior cruciate ligament (ACL) reconstruction is to manage instability and to enable a successful return to the pitch at the pre-injury level of performance. Clinicians follow specific stepwise progression rehabilitation criteria and should rely on several clinical, subjective, objective and functional criteria to base their decisions before progress in rehabilitation and allowing the football player return to play. There is unfortunately substantial heterogeneity in the ACL rehabilitation protocols that are used, and it is possible that this may lead to difference in clinical outcomes.
This FastFact highlights a systematic review1 that appraised the quality of internationally available ACL post-operative rehabilitation clinical practice guidelines. The quality of the clinical practice guidelines was generally good, but showed poor applicability (external validity), meaning it may be difficult for clinicians to implement the guidelines into their clinical daily practice. Guidelines failed to identify and describe the potential facilitators, barriers and cost implications to implement their recommendations. It is also suggested that the wording used to recommend rehabilitation approaches is standardised to the strength of recommendations, in order to guide rehabilitation (what clinicians should do/not do).
The review has highlighted some common themes that should be considered when making a rehabilitation plan. Clinical practice guidelines recommended that immediate knee mobilisation and strength/neuromuscular training should be used. Cryotherapy and neuromuscular electrostimulation, early open and closed kinetic-chain exercises and early full weight-bearing exercises may be used according the individual circumstances. Continuous passive motion and functional bracing should be eschewed. The dosage of interventions, progression and return to sport criteria were often missing or overlooked. However, some criteria that clinicians may use as milestones to progress on the rehabilitation and to decide on the resumption to sport were highlighted. These included clinical (eg, KOOS, IKDC or Lysholm scores), functional (eg, battery of hop tests) and psychological (eg, ACL-RSI) criteria.
1Andrade R, Pereira R, van Cingel R, Staal JB and Espregueira-Mendes J (2019). How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II) BJSM Published Online First: 07 June 2019. doi: 10.1136/bjsports-2018-100310