Should clinical practice guidelines for rehabilitation after anterior cruciate ligament injury be standardised?

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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.

To learn more about ACL injuries, including the treatment and rehabilitation of these injuries, complete the ACL module in the FIFA Diploma in Football Medicine.

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

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Zivota Nikolic
27 June 2019 12:37

First, we have to eliminate any injuries to connective and soft tissue by preventing swelling. Injured cells of the connective tissue (not ligaments) are not able in-process synthesis to produce the essential amino acid which is a mane element not to have swelling. Accumulation of urea in the injured area is producing swelling and pressure and damaging healthy cells. When we are dealing with ACL injuries we need to be sure that knee joint is not damaged and is locking properly (not open) and preventing any synovia liquid going true joints and creating swelling around the knee and inside joint… Read more »

30 June 2019 16:25

La reeducationpost reconstitution du LAC entraînent.des critères objectifs.subjectifs et rééducation doit être progressive spé existe une hétérogénéité.substenciels dans le protocole de rééducation du LAC entraînant des différences dans les résultats
La FIFA a travers des stages doit uniformiser le traitement servant de breviere pour tous le personnel médical en général et les KINÉSITHÉRAPEUTE en particulier

Dr Bertrand Tamalet
01 August 2019 12:41

I agree with most of CPG but there’s a lack of precision about OKC exercises. To our experience, restrictions concerns only Quad OKC exercises. About Hamstring harvested ACL reconstruction, this paper mentionned “open kinetic chain exercises (90–45°) can be added as early as 4 weeks (but without extra weight in the first 12 weeks for hamstrings graft)” that is absolutely not adapted to football (soccer) players. OKC hamstring exercices (focusing on eccentric) against progressive resistance should be initiated asap and painless (weights, rubber band, Isokinetic…) targeting full hamstring recover < 4 months.