How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)

Andrade, Renato; Pereira, Rogério; van Cingel, Robert; Staal, J Bart; Espregueira-Mendes, João

doi:10.1136/bjsports-2018-100310

Cited by 264Knee injuries and reconstruction techniquesClinical practice guidelines implementationHealth Sciences Research and Education

How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)

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Andrade, Renato, Pereira, Rogério, van Cingel, Robert, Staal, J Bart, Espregueira-Mendes, João·2020·British Journal of Sports Medicine

DOI 10.1136/bjsports-2018-100310

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Abstract

Objectives: To summarise recommendations and appraise the quality of international clinical practice guidelines (CPGs) for rehabilitation after ACL reconstruction. Design: Systematic review of CPGs (PROSPERO number: CRD42017020407). Data sources: Pubmed, EMBASE, Cochrane, SPORTDiscus, PEDro and grey literature databases were searched up to 30 September 2018. Eligibility criteria: English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations. Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. We summarised recommendations for rehabilitation after ACL reconstruction. Results: Six CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63% were included. One CPG had an overall score below the 50% (poor quality score) and two CPGs scored above 80% (higher quality score). The lowest domain score was ‘applicability’ (can clinicians implement this in practice?) (29%) and the highest ‘scope and purpose’ (78%) and ‘clarity of presentation’ (75%). CPGs recommended immediate knee mobilisation and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electrostimulation may be used according individual circumstances. The CPGs recommend against continuous passive motion and functional bracing. Conclusion: The quality of the CPGs in ACL postoperative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous passive motion and functional bracing should be eschewed.

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Patellofemoral joint stress steadily increases from partial to medium depth squatting (0° to 90°).
“Patellofemoral joint stress steadily increases from partial to medium depth squatting (0° to 90°).42”
From A Biomechanical Review of the Squat Exercise: Implications for Clinical Practice. (2024) · cites this paper as [42]
The ‘What does this study mean for clinicians?’ section discusses patellofemoral pain and exercise selection after ACL reconstruction, but not how joint stress changes with squat depth. Searches for patellofemoral joint stress and squatting from 0° to 90° found no passage addressing the claim; page numbers were unavailable. (LLM, conf=0.73)
Experimental — accuracy not yet measured
Quadriceps force contributes directly to patellofemoral joint reaction force and patellofemoral joint stress.
“This is important as quadriceps force contributes directly to patellofemoral joint reaction force and patellofemoral joint stress.42”
From A Biomechanical Review of the Squat Exercise: Implications for Clinical Practice. (2024) · cites this paper as [42]
The ‘What does this study mean for clinicians?’ section recommends quadriceps strengthening and prioritising closed kinetic-chain exercises to mitigate patellofemoral pain. It does not address whether quadriceps force directly contributes to patellofemoral joint reaction force or stress; searches for those terms and their biomechanical relationship found no supporting passage. Page numbers were not available in our copy. (LLM, conf=0.75)
Experimental — accuracy not yet measured
The increase in patellofemoral joint stress is the result of a steadily increasing patellofemoral joint reaction force that is more pronounced than the increase in contact area as the knee flexes.
“The increase in patellofemoral joint stress is the result of a steadily increasing patellofemoral joint reaction force that is more pronounced than the increase in contact area as the knee flexes.42”
From A Biomechanical Review of the Squat Exercise: Implications for Clinical Practice. (2024) · cites this paper as [42]
The section ‘What does this study mean for clinicians?’ discusses limiting patellofemoral pain during ACL rehabilitation, but does not explain how patellofemoral joint stress changes with knee flexion. Searches for joint reaction force, contact area, and stress found no passage in our copy addressing the claimed mechanism; page numbers were unavailable. (LLM, conf=0.76)
Experimental — accuracy not yet measured

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Recommendations for weight management in osteoarthritis: A systematic review of clinical practice guidelines
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From Control to Chaos: Visual-Cognitive Progression During Recovery From ACL Reconstruction
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Clinical Practice Guidelines for the Management of Behavioral and Psychological Symptoms of Dementia: A Systematic Review With AGREE II
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Emergency Department Visits Within 90 Days of Anterior Cruciate Ligament Reconstruction
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Ecological and Specific Evidence-Based Safe Return To Play After Anterior Cruciate Ligament Reconstruction In Soccer Players: A New International Paradigm
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Oral Health Care: A Systematic Review of Clinical Practice Guidelines
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Current perspectives of New Zealand physiotherapists on rehabilitation and return to sport following anterior cruciate ligament reconstruction: A survey
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The modifying factors that help improve anterior cruciate ligament reconstruction rehabilitation: A narrative review
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The Influence of Quadriceps Strength and Rate of Torque Development on the Recovery of Knee Biomechanics During Running After Anterior Cruciate Ligament Reconstruction
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The Efficacy of Blood Flow Restriction Training to Improve Quadriceps Muscle Function after Anterior Cruciate Ligament Reconstruction
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Environmental Risk Factors for Osteoarthritis: The Impact on Individuals with Knee Joint Injury
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The vancomycin soaking technique: no differences in autograft re-rupture rate. A comparative study
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Age-, Sex-, and Graft-Specific Reference Values From 783 Adolescent Patients at 5 to 7 Months After ACL Reconstruction: IKDC, Pedi-IKDC, KOOS, ACL-RSI, Single-Leg Hop, and Thigh Strength
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Intensive supervised rehabilitation versus less supervised rehabilitation following anterior cruciate ligament reconstruction? A systematic review and meta-analysis
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Functional Return‐to‐Sport Testing Demonstrates Inconsistency in Predicting Short‐Term Outcomes Following Anterior Cruciate Ligament Reconstruction: A Systematic Review
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Hop to It! A Systematic Review and Longitudinal Meta-analysis of Hop Performance After ACL Reconstruction
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Anterior Cruciate Ligament Reconstruction Return-to-Sport Decision-Making: A Scoping Review
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Quadriceps and Hamstring Strength Symmetry After Anterior Cruciate Ligament Reconstruction: A Prospective Study
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Effectiveness of a supervised rehabilitation compared with a home-based rehabilitation following anterior cruciate ligament reconstruction: A systematic review and meta-analysis
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Cross-sectional study on relationships between physical function and psychological readiness to return to sport after anterior cruciate ligament reconstruction
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Return To Sport Following ACL Reconstruction
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Innovative rehabilitative bracing with applied resistance improves walking pattern recovery in the early stages of rehabilitation after ACL reconstruction: a preliminary investigation
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Psychological Patient-reported Outcomes Cannot Predict a Second Anterior Cruciate Ligament Injury in Patients who Return to Sports after an Anterior Cruciate Ligament Reconstruction
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Nutritional assessment in acute stroke patients: A systematic review of guidelines and systematic reviews
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Functional results of allograft vs. autograft tendons in anterior cruciate ligament (ACL) reconstruction at 10-year follow-up
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Healing potential of the anterior cruciate ligament in terms of fiber continuity after a complete rupture: A systematic review
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Self‐Rehabilitation Guided by a Mobile Application After Anterior Cruciate Ligament Reconstruction Leads to Improved Early Motion and Less Pain
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Early postoperative practices following anterior cruciate ligament reconstruction in France
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Critical appraisal of the quality of clinical practice guidelines for idiopathic pulmonary fibrosis
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Predicting readiness for return to sport and performance after anterior cruciate ligament reconstruction rehabilitation
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Revision Anterior Cruciate Ligament Reconstruction (ACLR): Causes and How to Minimize Primary ACLR Failure.
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Current Standards of Early Rehabilitation after Anterior Cruciate Ligament Reconstruction in German Speaking Countries—Differentiation Based on Tendon Graft and Concomitant Injuries
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Changes in Quadriceps Rate of Torque Development After Anterior Cruciate Ligament Reconstruction and Association to Single-Leg Hop Distance
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A non‐weight bearing protocol after ACL reconstruction improves static anterior tibial translation in patients with elevated slope and increased weight bearing tibial anterior translation
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No sign of weakness: a systematic review and meta-analysis of hip and calf muscle strength after anterior cruciate ligament injury
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A reduced concentration femoral nerve block is effective for perioperative pain control following ACL reconstruction: a retrospective review
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Feasibility of the SOAR (Stop OsteoARthritis) program
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A critical appraisal of clinical practice guidelines on insomnia using the RIGHT statement and AGREE II instrument
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What Do Women (With Serious Knee Injury) Want to Know About Knee Health? Identifying Research Priorities With a Consumer Advisory Group
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Criteria-Based Decision Making for Introducing Open Kinetic Chain Exercise after-ACL Reconstruction: A Scoping Review
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Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction
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Effect of open kinetic chain exercises during the first weeks of anterior cruciate ligament reconstruction rehabilitation: A systematic review and meta-analysis
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Rehabilitation guidelines after autograft anterior cruciate ligament reconstruction need more graft‐specific exercise recommendations—A scoping review
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Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations
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What Determines the Quality of Rehabilitation Clinical Practice Guidelines?
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Quality assessment of clinical guidelines on probiotics therapy in children with IBD using the AGREE II instrument
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Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport
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‘It’s just my knee’: a qualitative study investigating the process of reframing and young athletes’ perceived quality of life between anterior cruciate ligament injury and surgery
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Authors: Andrade, R., Pereira, R., van Cingel, R., Staal, J. B., & Espregueira-Mendes, J.
Affiliations: Universidade do Porto (PT)
Fernando Pessoa University (PT)
HAN University of Applied Sciences (NL)
Corresponding author: Andrade, Renato
ORCID: Andrade, Renato
Pereira, Rogério
Staal, J Bart
Venue: British Journal of Sports Medicine
Publisher: BMJ
Published: 2019-06-07
Volume: 54
Issue: 9
Pages: 512-519
ISSN: 0306-3674 (ISSN-L)
1473-0480
DOI: 10.1136/bjsports-2018-100310
OpenAlex: W2948803383
Cited by: 264
References: 59
Citations by year: 2026: 32 · 2025: 64 · 2024: 43 · 2023: 45 · 2022: 36 · 2021: 30 · 2020: 12 · 2019: 2
FWCI: 4.12
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: British Journal of Sports Medicine (publishedVersion)
PubMed (publishedVersion)
HighWire Press Open Archive (submittedVersion)
Radboud Repository (Radboud University) (submittedVersion)
Topics: Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
Keywords: anterior cruciate ligament reconstruction, postoperative rehabilitation, guideline quality assessment, AGREE II, resistance training, neuromuscular training, closed kinetic chain exercises, open kinetic chain exercises, cryotherapy, neuromuscular electrical stimulation, continuous passive motion, functional bracing, weight-bearing exercise
MeSH terms: Anterior Cruciate Ligament Injuries, Early Ambulation, Electric Stimulation Therapy, Exercise Therapy, Humans, Range of Motion, Articular, Practice Guidelines as Topic, Cryotherapy, Resistance Training, Anterior Cruciate Ligament Reconstruction

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