Anterior cruciate ligament (ACL) reconstruction is one of the most common orthopedic procedures in sports medicine. While surgical techniques have advanced significantly, the success of ACL reconstruction relies heavily on the quality of postoperative rehabilitation. Optimised rehabilitation aims not only to restore knee stability and function but also to reduce the risk of reinjury and support safe return to sport (van Melick et al., 2016).

1. Early Phase: Protect and Prepare

The initial 0–2 weeks after surgery are critical for laying the foundation of recovery. The focus should be on:

Pain and swelling control through cryotherapy, elevation, and compression (Adams et al., 2012).

Early range of motion (ROM) restoration, particularly achieving full knee extension to prevent arthrofibrosis (Wright et al., 2015).

Quadriceps activation, with exercises such as quadriceps setting and straight leg raises, to prevent muscle inhibition (Hart et al., 2010).

2. Progressive Loading and Strengthening

From 2–12 weeks post-surgery, progressive loading becomes the cornerstone of rehab:

Closed kinetic chain exercises (mini squats, step-ups, leg presses) reduce stress on the graft while building strength (Beynnon et al., 2005).

Neuromuscular training to restore balance, proprioception, and movement quality, reducing reinjury risk (Gokeler et al., 2013).

Gradual resistance progression, using body weight, bands, or weights, tailored to graft healing timelines (van Grinsven et al., 2010).

3. Functional Training and Movement Quality

Around 3–6 months post-surgery, emphasis shifts towards functional performance:

Sport-specific drills that mimic real movement patterns (Myer et al., 2006).

Plyometric training to improve power and landing mechanics (Sugimoto et al., 2016).

Agility and coordination training, with progressive complexity, to rebuild confidence and reactive movement ability (Arundale et al., 2018).

4. Psychological Readiness

Rehabilitation is not only physical—it is also psychological:

Fear of reinjury is a significant barrier to return to sport. Mental skills training, reassurance, and graded exposure to sport tasks can help (Ardern et al., 2013).

Goal setting and feedback maintain motivation through the long rehab journey (Ross et al., 2017).

5. Objective Criteria for Return to Sport

Instead of relying solely on timeframes, evidence suggests using objective performance measures:

Quadriceps and hamstring strength ≥ 90% of the contralateral leg.

Hop test performance ≥ 90% symmetry.

Satisfactory scores on patient-reported outcome measures (e.g., IKDC, KOOS).

Absence of pain, swelling, or instability during functional activities (Grindem et al., 2016).

6. Technology and Individualisation

Rehabilitation can be further optimised by:

Isokinetic dynamometry and force plates to objectively measure progress (Buckthorpe et al., 2019).

Wearable technology and motion analysis to assess biomechanics during dynamic tasks (Kotsifaki et al., 2022).

Individualised progression, acknowledging that recovery speed varies due to factors such as graft type, concomitant injuries, and patient age (van Melick et al., 2016).

7. Long-Term Injury Prevention

Even after return to sport, long-term strategies are essential:

Neuromuscular training programs (e.g., FIFA 11+, PEP program) reduce risk of secondary ACL injury (Sugimoto et al., 2012).

Load management to avoid overuse during reintroduction to competition (Clanton et al., 2012).

Ongoing strength maintenance, especially of quadriceps, hamstrings, and hip musculature (Palmieri-Smith & Lepley, 2015).

Conclusion

Optimised ACL rehabilitation is a holistic, criterion-based, and patient-centered process. It integrates physical, psychological, and technological approaches, aiming not only for recovery but also for reinjury prevention and long-term performance. The most successful outcomes arise when surgeons, physiotherapists, strength coaches, and athletes collaborate closely, ensuring safe progression at every stage of recovery.

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References

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