POSTOPERATIVE REHABILITATION FOLLOWING ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION: STAGES, PROTOCOLS AND THEIR ROLE IN PREVENTING REINJURY
Abstract
Introduction and purpose: An anterior cruciate ligament (ACL) injury is one of the most common knee joint injuries, particularly among athletes. Its reconstruction is one of the most frequently performed orthopedic procedures, enabling a return to full physical function. However, a crucial component of recovery is a well-planned and consistently implemented postoperative rehabilitation program, which helps reduce the risk of reinjury. This review discusses the individual stages of rehabilitation, the methods used, and their role in minimizing the aforementioned risk.
Material and methods: A comprehensive review and analysis of the literature from 2000 to 2025 was conducted using the PubMed, Google Scholar, Scopus, and Web of Science databases (including randomized controlled trials, meta-analyses, and guidelines). The focus was on various rehabilitation methods following ACL reconstruction and their impact on reducing the risk of reinjury.
Brief description of the state of knowledge: Current guidelines and studies identify four phases of rehabilitation: early, intermediate, late, and return to sport. Modern rehabilitation protocols vary in terms of progression rate, techniques used, and tools for assessing therapy outcomes. The psychological aspect is also emphasized, as fear of reinjury can have a significant impact on recovery.
Conclusions: Rehabilitation programs based on functional criteria and individualization allow for precise adaptation of therapeutic interventions to the patient’s needs at different stages of the recovery process, thereby significantly reducing the risk of reinjury. Moreover, modern technologies such as biofeedback, virtual reality, and biomechanical analysis can enhance the effectiveness of therapy by improving exercise precision and enabling better monitoring of the patient’s progress.
References
Moses B, Orchard J, Orchard J. (2012) Systematic review: annual incidence of ACL injury and surgery in various populations. Res Sports Med. https://doi.org/10.1080/15438627.2012.680633
Ardern CL, Taylor NF, Feller JA, et al. (2014) Fifty-five percent return to competitive sport following anterior cruciate ligament surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. https://doi.org/10.1136/bjsports-2013-093398
Ardern CL, Webster KE, Taylor NF, et al. (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med https://doi.org/10.1136/bjsm.2010.076364
Shah VM, Andrews JR, Fleisig GS, et al. (2010) Return to play after anterior cruciate ligament reconstruction in National Football League athletes. Am J Sports Med. https://doi.org/10.1177/0363546510372798
Raynor MC, Pietrobon R, Guller U, et al. (2005) Cryotherapy after ACL reconstruction: a meta-analysis. J Knee Surg https://doi.org/10.1055/s-0030-1248169
Kruse et al., JBJS Am. (2012) Rehabilitation after anterior cruciate ligament reconstruction: A systematic review https://doi.org/10.2106/JBJS.K.01246
van Melick et al., (2016) Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus https://doi.org/10.1136/bjsports-2015-095898
Heijne et al., (2008) Rehabilitation and recovery after anterior cruciate ligament reconstruction: patients' experiences https://doi.org/10.1111/j.1600-0838.2007.00700.x
Cavanaugh, J.T., Powers, M. ACL (2017) Rehabilitation Progression: Where Are We Now?. Curr Rev Musculoskelet Med. https://doi.org/10.1007/s12178-017-9426-3
Trees AH, Howe TE, Dixon J, et al. (2005) Exercise for treating isolated anterior cruciate ligament injuries in adults. Cochrane Database Syst Rev https://doi.org/10.1002/14651858.CD005316.pub2
Perry MC, Morrissey MC, King JB, et al. (2005) Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc https://doi.org/10.1007/s001670000161
Gregory D. Myer, MS, CSCS, Mark V. Paterno, PT, MS, SCS, ATC, Kevin R. Ford, MS, Carmen E. Quatman, BS, Timothy E. Hewett, PhD (2006) Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase https://www.jospt.org/doi/10.2519/jospt.2006.2222
Christopher V Nagelli, Samuel C Wordeman, Stephanie Di Stasi, Joshua Hoffman, Tiffany Marulli, Timothy E Hewett (2021) Neuromuscular Training Improves Biomechanical Deficits at the Knee in Anterior Cruciate Ligament–Reconstructed Athletes https://doi.org/10.1097/JSM.0000000000000723
Wiktoria Regina Skala MD, Urszula E. Zdanowicz MD (2025) Effectiveness of the FIFA 11+ Program in Reducing ACL Injury Incidence in Female Soccer Players: A Biomechanical Analysis https://doi.org/10.1016/j.jisako.2025.100571
Clare L Ardern, Nicholas F Taylor, Julian A Feller, Timothy S Whitehead, Kate E Webster (2013) Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery https://doi.org/10.1177/0363546513489284
Sterett WI, Briggs KK, Farley T, et al. (2006) Effect of functional bracing on knee injury in skiers with anterior cruciate ligament reconstruction: a prospective cohort study. Am J Sports Med. https://doi.org/10.1177/0363546506289883
S van Grinsven, R. E. H. van Cingel, C. J. M. Holla, C. J. M. van Loon (2010) Evidence-based rehabilitation following anterior cruciate ligament reconstruction https://doi.org/10.1007/s00167-009-1027-2
Brian J Eckenrode, James L Carey, Brian J Sennett, Miltiadis H Zgonis (2017) Prevention and Management of Post-operative Complications Following ACL Reconstruction https://doi.org/10.1007/s12178-017-9427-2
Ali Shamsi Majelan, Omid Shahani, Mohammad Amin Safaei Ghaleh Zo & Mahla Arman Far (2025) A comparative analysis of the effects of proprioception and virtual reality exercises on postural balance in athletes with anterior cruciate ligament reconstruction: a systematic review and meta-analysis https://doi.org/10.1186/s12891-025-08823-5
Mohammad A Yabroudi, James J Irrgang (2013) Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction https://doi.org/10.1016/j.csm.2012.08.016
Sean J Meredith, Thomas Rauer, Terese L Chmielewski, Christian Fink, Theresa Diermeier, Benjamin B Rothrauff, Eleonor Svantesson, Eric Hamrin Senorski, Timothy E Hewett, Seth L Sherman, Bryson P Lesniak, Panther Symposium (2021) Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group https://doi.org/10.1136/jisakos-2020-000495
Adams, D., Logerstedt, D., Hunter-Giordano, A., Axe, M. J., & Snyder-Mackler, L. (2012) Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. Journal of Orthopaedic & Sports Physical Therapy. https://doi.org/10.2519/jospt.2012.3871
Shelbourne, K. D., & Gray, T. (2009) Minimum 10-year results after ACL reconstruction: How the loss of normal knee motion affects outcome. The American Journal of Sports Medicine. https://doi.org/10.1177/0363546508326709
Hewett, T. E., Myer, G. D., & Ford, K. R. (2013) ACL injuries in female athletes: Part 1, mechanisms and risk factors. The American Journal of Sports Medicine. https://doi.org/10.1177/0363546505284183
Beynnon BD, Uh BS, Johnson RJ, Abate JA, Nichols CE, Fleming BC, Poole AR, Roos H. (2005) Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med. https://doi.org/10.1177/0363546504268406
Birmingham TB, Bryant DM, Giffin JR, Litchfield RB, Kramer JF, Donner A, Fowler PJ. (2008) A randomized controlled trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. Am J Sports Med. https://doi.org/10.1177/0363546507311601
Maddison R, Prapavessis H, Clatworthy M. (2006) Modeling and rehabilitation following anterior cruciate ligament reconstruction. Ann Behav Med. https://doi.org/10.1207/s15324796abm3101_13
Gerber JP, Marcus RL, Dibble LE, et al. (2007) Safety, feasibility, and efficacy of negative work exercise via eccentric muscle activity following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther https://doi.org/10.2519/jospt.2007.2362
Wright RW, Preston E, Fleming BC, et al. (2008) A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg https://doi.org/10.1055/s-0030-1247823
Chmielewski TL, Jones D, Day T, et al. (2008) The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. J Orthop Sports Phys Ther https://doi.org/10.2519/jospt.2008.2887
Kvist J, Ek A, Sporrstedt K, et al. (2005) Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc https://doi.org/10.1007/s00167-004-0591-8
McCullough KA, Phelps KD, Spindler KP, et al. (2012) Return to high school- and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med. https://doi.org/10.1177/0363546512456836
Hewett TE, Myer GD, Ford KR, et al. (2005) Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury Risk in female athletes. A prospective study. Am J Sports Med. https://doi.org/10.1177/0363546504269591
Everhart JS, Best TM, Flanigan DC. (20215) Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc https://doi.org/10.1007/s00167-013-2699-1
Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. (2016) Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and metaanalysis. Am J Sports Med. https://doi.org/10.1177/0363546515621554
Risberg MA, Lewek M, Snyder-Mackler L. (2004) A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Phys Ther Sport. https://doi.org/10.1016/j.ptsp.2004.02.003
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