Practice guidelines for anterior cruciate ligament rehabilitation

Anterior cruciate ligament reconstruction (ACLR) is a common treatment for athletes after ACL injury. The incidence of non-contact ACL injuries appears to be the greatest in athletes who are between 15 and 40 years of age and participate in pivoting sports like soccer, handball, volleyball and alpine skiing.

British Journal of Sports Medicine, in Medscape January 6, 2016

Robert Griffin III is wearing the DonJoy Defiance knee brace, which differs from the brace he wore late last season. John McDonnell The Washington Post

Every year, about 3% of amateur athletes injure their ACL; for elite athletes, this percentage could be as high as 15%. Females are two to eight times more likely to sustain an ACL injury than their male counterparts, probably because male and female neuromuscular patterns diverge during and following puberty.

The Royal Dutch Society for Physical Therapy (KNGF) instructed a multidisciplinary group of Dutch anterior cruciate ligament (ACL) experts to develop an evidence statement for rehabilitation after ACL reconstruction.

Consensus Conclusion
Although there are many articles published about ACL rehabilitation, there is limited evidence for parameters that influence or predict the final result of ACLR rehabilitation and return to play. The aim of this study was to describe the process in which the KNGF evidence statement for ACL rehabilitation was developed and to present this practice guideline, (see appendix 2).

The goal of the evidence statement was to describe the rehabilitation after ACLR with BPTB or HS autograft and to encourage uniformity in physical therapy treatment and the use of measurements of functional performance. The evidence statement is aimed to fill a gap between evidence and clinical practice and describes a complete protocol to rehabilitate an athlete after ACLR. The multidisciplinary approval of this evidence statement underlines the importance of a close collaboration between different professions.

Despite the fact that our evidence statement is based on information from RCTs and systematic reviews from the two most important databases, the evidence is inconclusive. Owing to this lack of scientific evidence, available background literature and a steering group consisting of ACL experts were used to develop a multidisciplinary consensus statement for an ACLR rehabilitation protocol. This consensus statement was based on three formulated questions with the following conclusions.

What are the Findings?
  • Rehabilitation after anterior cruciate ligament reconstruction should consist of three phases, which are goal-based rather than time-based. The goals for progression to the next phase and description of interventions during each phase should be based on the International Classification of Functioning, Disability and Health.
  • An extensive test battery, including at least a strength test battery, a hop test battery and measurement of quality of movement, is needed to determine the moment of return to play.
How Might it Impact on Clinical Practice in the Future?
  • Closed and open kinetic chain quadriceps training can be used for regaining strength, but neuromuscular training should be added to strength training to optimise outcome measurements after ACLR.
  • Movement quality may affect the ACL (re)injury rate.

Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus, Nicky van Melick, Robert E H van Cingel, Frans Brooijmans, Camille Neeter, Tony van Tienen, Wim Hullegie, Maria W G Nijhuis-van der Sanden. Br J Sports Med 2016;50:1506-1515 doi:10.1136/bjsports-2015-095898

Source British Journal of Sports Medicine via Medscape

Also see
KNGF Guideline for Physical Therapy in patients with Osteoarthritis of the hip and knee in Royal Dutch Society for Physical Therapy

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