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

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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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Piussi, R., Magnusson, C., Andersson, S., Mannerkorpi, K., Thomeé, R., Samuelsson, K., & Senorski, E. H. (2022) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-022-07271-1 · Cited by 19
Psychological Patient-reported Outcomes Cannot Predict a Second Anterior Cruciate Ligament Injury in Patients who Return to Sports after an Anterior Cruciate Ligament Reconstruction
Piussi, R., Simonson, R., Högberg, J., Thomeé, R., Samuelsson, K., & Senorski, E. H. (2022) · International Journal of Sports Physical Therapy · doi:10.26603/001c.55544 · Cited by 19
Nutritional assessment in acute stroke patients: A systematic review of guidelines and systematic reviews
Mancin, S., Sguanci, M. E., Andreoli, D., Piredda, M., & Marinis, M. G. D. (2024) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2024.104859 · Cited by 22
Functional results of allograft vs. autograft tendons in anterior cruciate ligament (ACL) reconstruction at 10-year follow-up
Bistolfi, A., Capella, M., Guidotti, C., Sabatini, L., Artiaco, S., Massè, A., & Ferracini, R. (2020) · European Journal of Orthopaedic Surgery & Traumatology · doi:10.1007/s00590-020-02823-y · Cited by 18
“Recent studies underlined the importance of rehabilitation, as immediate knee mobilization and strength/neuromuscular training [17]; in this series, patients who dropped out of rehabilitation programs referred a greater amount of fear of new injury; meanwhile, patients that continued rehabilitation for up to 2–4 month…”
BackgroundInfluential
Healing potential of the anterior cruciate ligament in terms of fiber continuity after a complete rupture: A systematic review
Pitsillides, A., Stasinopoulos, D., & Giannakou, K. (2021) · Journal of Bodywork and Movement Therapies · doi:10.1016/j.jbmt.2021.06.003 · Cited by 18
Self‐Rehabilitation Guided by a Mobile Application After Anterior Cruciate Ligament Reconstruction Leads to Improved Early Motion and Less Pain
Foissey, C., Thaunat, M., Bondoux, L., Sonnery‐Cottet, B., & Fayard, J.-M. (2021) · Arthroscopy Sports Medicine and Rehabilitation · doi:10.1016/j.asmr.2021.07.007 · Cited by 18
Early postoperative practices following anterior cruciate ligament reconstruction in France
Sezer, H. B., Noailles, T., Toanen, C., Lefèvre, N., Bohu, Y., Fayard, J., & Hardy, A. (2021) · Orthopaedics & Traumatology Surgery & Research · doi:10.1016/j.otsr.2021.103065 · Cited by 18
Adolescents’ experience with sports-related pain and injury: A systematic review of qualitative research
Sheehan, N., Summersby, R., Bleakley, C., Caulfield, B. M., Matthews, M., Klempel, N., & Holden, S. (2024) · Physical Therapy in Sport · doi:10.1016/j.ptsp.2024.05.003 · Cited by 23
Critical appraisal of the quality of clinical practice guidelines for idiopathic pulmonary fibrosis
Li, X., Yu, X., Xie, Y., Feng, Z., Ma, Y., Chen, Y., & Li, J. (2020) · Annals of Translational Medicine · doi:10.21037/atm-20-3200 · Cited by 17
Return to sport after anterior cruciate ligament reconstruction - prognostic factors and prognostic models: A systematic review
van Haren, I. E. P. M., van der Worp, M. P., van Rijn, R. M., Stubbe, J. H., van Cingel, R. E. H., Verbeek, A. L. M., van der Wees, P. J., & Staal, J. B. (2025) · Annals of Physical and Rehabilitation Medicine · doi:10.1016/j.rehab.2024.101921 · Cited by 16
Self-citation
Predicting readiness for return to sport and performance after anterior cruciate ligament reconstruction rehabilitation
van Haren, I. E. P. M., van Cingel, R. E. H., Verbeek, A. L. M., van Melick, N., Stubbe, J. H., Bloo, H., Groenewoud, J. H. M. M., van der Wees, P. J., & Staal, J. B. (2022) · Annals of Physical and Rehabilitation Medicine · doi:10.1016/j.rehab.2022.101689 · Cited by 20
Self-citation
Revision Anterior Cruciate Ligament Reconstruction (ACLR): Causes and How to Minimize Primary ACLR Failure.
Roethke, L. C., Braaten, J. A., Rodriguez, A. N., & LaPrade, R. F. (2023) · PubMed Central · doi:10.22038/abjs.2022.60187.2970 · Cited by 15
Current Standards of Early Rehabilitation after Anterior Cruciate Ligament Reconstruction in German Speaking Countries—Differentiation Based on Tendon Graft and Concomitant Injuries
Memmel, C., Krutsch, W., Szymski, D., Pfeifer, C., Henssler, L., Frankewycz, B., Angele, P., Alt, V., & Koch, M. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19074060 · Cited by 15
Quality appraisal of clinical nutrition practice guidelines for critically ill adult patients: a systematic review using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX)
Cattani, A., Teixeira, P. P., Eckert, I. D. C., Busnello, F. M., Gabriel, F. C., Stein, A. T., & Silva, F. M. (2022) · British Journal Of Nutrition · doi:10.1017/s0007114522000654 · Cited by 14
“Similar to other studies conducted for quality evaluation of the pharmacological management of chronic diseases in primary care(38), diabetes mellitus guidelines created by Chinese researchers(39), asthma guidelines(40), rehabilitation after anterior cruciate ligament reconstruction(41) and physical activity and safe…”
Result
Changes in Quadriceps Rate of Torque Development After Anterior Cruciate Ligament Reconstruction and Association to Single-Leg Hop Distance
Tayfur, B., Johnson, A. K., & Palmieri‐Smith, R. M. (2023) · Sports Health A Multidisciplinary Approach · doi:10.1177/19417381231205295 · Cited by 13
“2,4,39 Maximum quadriceps strength is the most often quantified measure of neuromuscular function after ACLR, 37 but strength alone does not allow for a complete understanding of neuromuscular recovery as it does not provide information about the timing and control of force production.”
Is muscular strength a predictor for primary or secondary ACL injury? A scoping review of prospective studies
Straub, R. K., & Powers, C. M. (2023) · Physical Therapy in Sport · doi:10.1016/j.ptsp.2023.03.004 · Cited by 12
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
Romandini, I., Cance, N., Dan, M. J., Pineda, T., de Fontenay, B. P., Demey, G., & Dejour, D. H. (2023) · Journal of Experimental Orthopaedics · doi:10.1186/s40634-023-00694-w · Cited by 12
No sign of weakness: a systematic review and meta-analysis of hip and calf muscle strength after anterior cruciate ligament injury
Girdwood, M., Culvenor, A. G., Patterson, B., Haberfield, M. J., Rio, E., Hedger, M., & Crossley, K. M. (2024) · British Journal of Sports Medicine · doi:10.1136/bjsports-2023-107536 · Cited by 12
“Guidelines and consensus exercises recommend a key focus on regaining quadriceps strength after injury, 70 74 and this should remain a top priority.”
Background
A reduced concentration femoral nerve block is effective for perioperative pain control following ACL reconstruction: a retrospective review
Muench, L. N., Wolf, M. R., Kia, C., Berthold, D. P., Cote, M. P., Fischler, A. H., Arciero, R. A., & Edgar, C. M. (2021) · Archives of Orthopaedic and Trauma Surgery · doi:10.1007/s00402-021-04221-3 · Cited by 12
Feasibility of the SOAR (Stop OsteoARthritis) program
Whittaker, J. L., Truong, L. K., Silvester-Lee, T., Losciale, J. M., Miciak, M., Pajkic, A., Le, C. Y., Hoens, A. M., Mosewich, A. D., Hunt, M. A., et al. (2022) · Osteoarthritis and Cartilage Open · doi:10.1016/j.ocarto.2022.100239 · Cited by 12
A critical appraisal of clinical practice guidelines on insomnia using the RIGHT statement and AGREE II instrument
Zhu, H., Li, M., Pan, B., Yang, Q., Cao, X. Q., Wang, Q., Chen, Y., Ding, G., Tian, J., & Ge, L. (2022) · Sleep Medicine · doi:10.1016/j.sleep.2022.08.023 · Cited by 11
What Do Women (With Serious Knee Injury) Want to Know About Knee Health? Identifying Research Priorities With a Consumer Advisory Group
Haberfield, M. J., Crossley, K. M., Patterson, B., & Bruder, A. M. (2025) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2025.12869 · Cited by 11
Criteria-Based Decision Making for Introducing Open Kinetic Chain Exercise after-ACL Reconstruction: A Scoping Review
Forelli, F., Mazeas, J., Korakakis, V., Ramtoola, H., Vandebrouck, A., Duffiet, P., Ratte, L., Kakavas, G., Alaoui, I. B., Douryang, M., et al. (2025) · Sports Medicine - Open · doi:10.1186/s40798-025-00843-8 · Cited by 10
“Contemporary evidence and clinical practice guidelines on rehabilitation after ACLR conclude in favor of discarding temporal data dictating rehabilitation and assert that rehabilitation consists of several phases based on criteria and specific goals and objectives rather than time [12, 21, 24, 25].”
Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction
Simonsson, R., Piussi, R., Högberg, J., Sundberg, A., & Senorski, E. H. (2023) · Clinics in Sports Medicine · doi:10.1016/j.csm.2023.07.004 · Cited by 9
Effect of open kinetic chain exercises during the first weeks of anterior cruciate ligament reconstruction rehabilitation: A systematic review and meta-analysis
Fontanier, V., Vergonjeanne, M., Eon, P., Bruchard, A., & Laplaud, D. (2025) · Physical Therapy in Sport · doi:10.1016/j.ptsp.2025.02.005 · Cited by 10
Rehabilitation guidelines after autograft anterior cruciate ligament reconstruction need more graft‐specific exercise recommendations—A scoping review
Briem, K., Zebis, M. K., Haraldsson, B. T., Bencke, J., & Fernandes, L. (2025) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1002/ksa.12666 · Cited by 11
“No strong evidence supports the use of a knee brace [1, 70, 84], so it did not come as a surprise that only two papers recommended their use during the early post ‐ operative phase.”
Influential
Lived experiences of patients undergoing treatment for traumatic knee injury using integrated psychological training (MOTIFS) in the context of care-as-usual training: a phenomenological interview study
Cederström, N., Ageberg, E., & Granér, S. (2022) · BMJ Open Sport & Exercise Medicine · doi:10.1136/bmjsem-2022-001409 · Cited by 9
Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations
Solie, B. S., Tollefson, L. V., Doney, C. P., O'keefe, J., Thompson, W. C., & LaPrade, R. F. (2024) · International Journal of Sports Medicine · doi:10.1055/a-2270-3233 · Cited by 10
“While greater psychological readiness may improve the rate of return to the pre-injury level of sport, the relationship between psy - chological readiness and re-injury after ACLR appears more complex.”
BackgroundResultInfluential
What Determines the Quality of Rehabilitation Clinical Practice Guidelines?
Dijkers, M. P. J. M., Ward, I., Annaswamy, T. M., Dedrick, D., Hoffecker, L., & Millis, S. R. (2020) · American Journal of Physical Medicine & Rehabilitation · doi:10.1097/phm.0000000000001645 · Cited by 9
“Andrade et al.17 (2020) Rehabilitation after ACL reconstruction Anwer et al.18 (2018) Management of type 2 DM in adults Appenteng et al.19 (2018) Management of acute pediatric TBI Bhatt et al.20 (2018) Management of type 2 DM in children Boaden et al.21 (2020) Performing videofluoroscopic swallowing studies Bragge et…”
Background
Quality assessment of clinical guidelines on probiotics therapy in children with IBD using the AGREE II instrument
Cheng, H., Ma, Z., Yu, B., Liu, X., Tian, C., Zhong, X., & Zhao, L. (2021) · Journal of Clinical Pharmacy and Therapeutics · doi:10.1111/jcpt.13422 · Cited by 9
Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport
Pulver, M., Hilfiker, R., Bizzini, M., Mathieu, N., Meyer, S., & Allet, L. (2023) · Physical Therapy in Sport · doi:10.1016/j.ptsp.2023.10.007 · Cited by 8
‘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
Marmura, H., Bryant, D., Getgood, A. M. J., & Webster, F. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-076799 · Cited by 8
Association of suture augmentation with graft failure and clinical outcomes following anterior cruciate ligament reconstruction: A systematic review and meta‐analysis of comparative studies with a minimum 2‐year follow‐up
Gao, Y., Shi, W., Zhang, Z., Bai, W., Yang, Y., Ma, Y., Wang, C., Wang, J., Gong, X., & Wang, J. (2024) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1002/ksa.12537 · Cited by 8
Beginning With the End in Mind: Implementing Backward Design to Improve Sports Injury Rehabilitation Practices
Chia, L., Taylor, D., Pappas, E., Hegedus, E. J., & Michener, L. A. (2022) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2022.11440 · Cited by 8
Clinical Practice Guidelines for the Management of Patients With Cleft Lip and Palate: A Systematic Quality Appraisal Using the Appraisal of Guidelines for Research and Evaluation II Instrument
Yver, C. M., Chorath, K. T., Connolly, J., Shah, M., Majmudar, T., Moreira, A. G., & Rajasekaran, K. (2021) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000008155 · Cited by 8
“In fact, our ICC coefficient is equivalent to or exceeds the ICC reported in existing studies that apply the AGREE II to other sets of guidelines.(12,15,16) There are some limitations inherent to the AGREE II tool.”
Result
Anterior Cruciate Ligament Reconstruction Return to Sport Testing Passing Rates for Healthy People: A Systematic Review
Wood, A. S., Hargreaves, M. D., Manfredi, J. N., Harrell, M. L., Benson, E. M., Rahaman, C. A., Dayal, D., Brabston, E. W., Evely, T. B., Casp, A., et al. (2025) · The American Journal of Sports Medicine · doi:10.1177/03635465241313194 · Cited by 7
“1,50,47,53 Most commonly, the limb symmetry index (LSI) has been used as a measure to assess patients at various stages in postoperative rehabilitation because of its practical clinical utility.”
Youth With a Sport-Related Knee Injury Exhibit Significant and Persistent Knee-Related Quality-of-Life Deficits at 12-Month Follow-up Compared to Uninjured Peers
Le, C. Y., Galarneau, J.-M. F., Filbay, S. R., Emery, C. A., Manns, P. J., & Whittaker, J. L. (2023) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2023.11611 · Cited by 8
Current methods of rehabilitation after arthroscopic reconstruction of the anterior cruciate ligament of the knee joint (review of literature)
Akhtyamov, I. F., Айдаров, В. И., & Равилевич, Х. Э. (2021) · Genij Ortopedii · doi:10.18019/1028-4427-2021-27-1-121-127 · Cited by 7
Mechanics of cadaveric anterior cruciate ligament reconstructions during simulated jump landing tasks: Lessons learned from a pilot investigation
Schilaty, N. D., Martin, R. K., Ueno, R., Rigamonti, L., & Bates, N. A. (2021) · Clinical Biomechanics · doi:10.1016/j.clinbiomech.2021.105372 · Cited by 7
Anterior Cruciate Ligament Reconstruction Using a Fascia Lata Graft With FiberTape Augmentation
Weninger, P., Steffel, C., Rabel, S., Karimi, R., & Feichtinger, X. (2022) · Arthroscopy Techniques · doi:10.1016/j.eats.2022.09.002 · Cited by 7
“We recommend instant full weight-bearing exercises and free range of motion as tolerated.(15) In the early postoperative phase of rehabilitation compression and cryotherapy via the full leg boot (Game Ready, CoolSystems, Inc.”
Method
Biomechanical principles of exercise prescription in knee rehabilitation
Anwer, S., Li, H., Anwar, D., & Wong, A. Y. L. (2023) · Elsevier eBooks · doi:10.1016/b978-0-323-90597-8.00029-3 · Cited by 7
‘Going through the motions’; a rich account of the complexity of the anterior cruciate ligament reconstruction pathway, a UK qualitative study
Carter, H. M., Beard, D. J., Leighton, P. A., Moffatt, F., Smith, B. E., Webster, K. E., & Logan, P. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-079468 · Cited by 6
Surface Electromyography and Gait Features in Patients after Anterior Cruciate Ligament Reconstruction
Wu, X., Zhang, H., Cui, H., Pei, W., Zhao, Y., Wang, S., Cao, Z., & Li, W. (2024) · Orthopaedic Surgery · doi:10.1111/os.14256 · Cited by 6
Automatic Segmentation of Quadriceps Femoris Cross-Sectional Area in Ultrasound Images: Development and Validation of Convolutional Neural Networks in People With Anterior Cruciate Ligament Injury and Surgery
Tayfur, B., Ritsche, P., Sunderlik, O., Wheeler, M., Ramirez, E., Leuteneker, J. E., Faude, O., Franchi, M. V., Johnson, A. K., & Palmieri‐Smith, R. M. (2024) · Ultrasound in Medicine & Biology · doi:10.1016/j.ultrasmedbio.2024.11.004 · Cited by 6
Ensuring safety in cytotoxic drug preparation: A systematic review of guidelines addressing education for pharmacy professionals
Moreira, F., Jesus, A. M. C., Pinho, C., Santos, M., Serdoura, M., & Cruz, A. (2025) · Journal of the American Pharmacists Association · doi:10.1016/j.japh.2025.102352 · Cited by 6
Drop landing between subjects post anterior cruciate ligament reconstruction and uninjured controls: A biomechanical and neuromuscular analysis
Murphy, C. L., Landry, S. C., Urquhart, N., Coady, C. M., & Rutherford, D. J. (2025) · Clinical Biomechanics · doi:10.1016/j.clinbiomech.2025.106504 · Cited by 6
Postoperative regular use of a self‐rehabilitation mobile application for more than two weeks reduces extension deficit and cyclop syndrome after anterior cruciate ligament reconstruction
Foissey, C., Abid, H., Freychet, B., Sonnery‐Cottet, B., Thaunat, M., & Fayard, J. (2023) · Journal of Experimental Orthopaedics · doi:10.1186/s40634-023-00578-z · Cited by 6

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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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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