Rehabilitation of the knee following ACL repair and reconstruction: A review of clinical best practices
Abstract
Background and Study Aim. ACL reconstruction is the surgical replacement of the anterior cruciate ligament with a tissue graft to restore knee function. To avoid problems including edema, loss of range of motion, muscle weakness, poor balance, and recovery of knee function, rehabilitation treatment should be performed after surgery. Immediate implementation of open kinetic chain exercises, use of criterion-based progressions for various activities such as running, sprinting, and plyometrics, and implementation of a secondary prevention program. This clinical practice review is to discuss the parameters associated with the rate of phase repair for ACL repair and to guide therapists according to the parameters of postoperative healing.
Material and Methods. The patient presented with a knee brace still in place, swelling and incision marks above the patella, and atrophy of the dextra quadrisep muscle, the patient still had difficulty bending and straightening his right knee, and used crutches to help him walk. The modalities given are massage, electrotherapy (TENS), various exercises (exercise therapy), stretching, and cryotherapy.
Results. There are five phases of rehabilitation: maximal protection, moderate protection, minimum protection (initial strengthening), Neuromuscular Control and Functional Training (strengthening-cardiovascular conditioning), and maintenance and Return to Activity (controlled agility-advanced conditioning). These stages are to help reduce swelling, increase joint range of motion, increase muscle strength, and reduce pain.
Conclusion. Periodization theory should be fundamentally understood by sports rehabilitation professionals, especially physical therapists and sports medicine physicians. So that a safe and organized postoperative procedure can be established.
Keywords
References
Abulhasan, J., & Grey, M. (2017). Anatomy and Physiology of Knee Stability. J. Funct. Morphol. Kinesiol, 2(4), 34. https://doi.org/10.3390/jfmk2040034
Ahsan, M. (2023). Anterior Cruciate Ligament Reconstruction and Return to Sports: A Comprehensive Guide. Ann Sports Med Res, 10(5), 1219. https://doi.org/10.47739/2379-0571.sportsmedicine.1219
Andersen, L., Tufekovic, G., & Zebis, M. (2005). The effect of resistance training combined with timed ingestion of protein on muscle fi ber size and muscle strength. Metabol Clin Exp, 54, 151–156. https://doi.org/10.1016/j.metabol.2004.07.012
Ardern, C., Taylor, N., & Feller, J. (2014). Fifty-fi ve per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med, 01–11. https://doi.org/10.1136/bjsports-2013-093398
Baechile, T., & Earle, R. (2008). Essentials of strength training and conditioning. 3rd ed. Champaign, IL: Human Kinetics.
Bousquet, B. A., O’Brien, L., Singleton, S., & Beggs, M. (2018). Post-Operative Criterion Based Rehabilitation Of ACL Repairs: A Clinical Commentary. The International Journal of Sports Physical Therapy, 13(2), 293. https://doi.org/10.26603/ijspt20180293
Brinlee, A., Dickenson, S., Hunter-Giordano, A., & Snyder-Mackler, L. (2022). ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline. Sports Health, 14, 770–779. https://doi.org/10.1177/19417381211056873
Claiborne, T., Armstrong, C., & Gandhi, V. (2006). Relationship between hip and knee strength and knee valgus during a single leg squat. J App Biomech, 22, 41–50. https://doi.org/10.1123/jab.22.1.41
Culvenor, A., Girdwood, M., Juhl, C., Patterson, B., Haberfield, M., & Holm, P. (2022). Rehabilitation after anterior cruciate ligament and Reviews, meniscal injuries: a best-evidence synthesis of systematic Med, for the OPTIKNEE consensus. Br J Sports, 56, 1445–1453. https://doi.org/10.1136/bjsports-2022-105495
Di Stasi, S., Myer, G., & Hewett, T. (2013). Neuromuscular training to target deficits associated with second anterior cruciate ligament injury. J Ortho Sports Phys Ther, 43, 777–792. https://doi.org/10.2519/jospt.2013.4693
Domnick, C., Raschke, M., & Herbort, M. (2016). Biomechanics of the anterior cruciate ligament: Physiology, rupture and reconstruction techniques. World J Orthop, 7(2), 82–93. https://doi.org/10.5312/wjo.v7.i2.82
Ericson, M., NisellM, R., & Nemeth, G. (1998). Joint motions of the lower limb during ergometer cycling. J Orthop Sports Phys Ther, 9(8), 273–278.
Faltus, J., Criss, C., & Grooms, D. (2020). Shifting Focus: A Clinician’s Guide to Understanding Neuroplasticity for Anterior Cruciate Ligament Rehabilitation. Curr Sports Med Rep, 19, 76–83. https://doi.org/10.1249/JSR.0000000000000688
Fitzgerald, G., Piva, S., & Irrgang, J. (2003). A modifi ed neuromuscular electrical stimulation protocol for quadriceps strength training following anterior cruciate ligament reconstruction. J Ortho Sports Phys Ther, 33(9), 492–501. https://doi.org/10.2519/jospt.2003.33.9.492
Franck, F., Saithna, A., Vieira, T., Pioger, C., Vigne, G., & Le Guen, M. (2021). Return to Sport Composite Test After Anterior Cruciate Ligament Reconstruction (K-STARTS): Factors Affecting Return to Sport Test Score in a Retrospective Analysis of 676 Patients. Sports Health, 13, 364–372. https://doi.org/10.1177/1941738120978240
Garber, C., Blissmer, B., & Deschenes, M. (2011). Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fi tness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc, 43(7), 1334–1359. https://doi.org/10.1249/MSS.0b013e318213fefb
Gardinier, E., Di Stasi, S., & Manal, K. (2014). Knee contact force asymmetries in patients who failed return-to_sport readiness criteria 6 months after anterior cruciate ligament reconstruction. Am J of Sports Med, 42(12). https://doi.org/10.1177/0363546514552184
Gerami, M. H., Haghi, F., & Pelarak, F. (2021). Universal health coverage ‑ There is more to it than meets the eye. Newest Reconstr. Tech, 6(2), 169–170. https://doi.org/10.4103/jfmpc.jfmpc_13_17
Giesche, F., Niederer, D., Banzer, W., & Vogt, L. (2020). Evidence for the effects of prehabilitation before ACL-reconstruction on return to sport-related and self-reported knee function: A systematic review. PLoS One., 15. https://doi.org/10.1371/journal.pone.0240192
Grinsven, V., Gingel, V., & Holla, C. (2010). Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 18, 1128–1144. https://doi.org/10.1007/s00167-009-1027-2
Heijne, A., & Werner, S. (2007). Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc, 4, 204–214. https://doi.org/10.1007/s00167-006-0246-z
Hu, W., Charry, E., & Umer, M. (2014). An inertial sensor system for measurements of tibia angle with applications to knee valgus/varus detection. IEEE ISSNIP 2014 - 2014 IEEE 9th International Conference on Intelligent Sensors, Sensor Networks and Information Processing, Conference Proceedings. https://doi.org/10.1109/ISSNIP.2014.6827603
Kaya, D., Guney Deniz, H., Sayaca, C., Calik, M., & Doral, M. (2019). Effects on Lower Proprioception, Extremity Neuromuscular Control Exercises on Knee Muscle Strength, and Functional Level in Patients with ACL Reconstruction. Biomed Res. https://doi.org/10.1155/2019/1694695
Kiapour, A., & Murry, M. (2014). Basic science of anterior cruciate ligament injury and repair. Bone and Joint Research, 3, 20–31. https://doi.org/10.1302/2046-3758.32.2000241
LaPrade, C., Smith, S., & Rasmussen, M. (2015). Consequences of tibial reaming on the meniscal roots during cruciate ligament reconstruction in a cadaveric model, Part 1: The anterior cruciate ligament. Am J Sports Med, 43(1), 200–206. https://doi.org/10.1177/0363546514554769
Lepley, L. K. (2015). Defi cits in quadriceps strength and patient-oriented outcomes at return to activity after ACL reconstruction: A review of the current literature. Sports Health, 3, 231–238. https://doi.org/10.1177/1941738115578112
Lewek, M., Rudolph, K., & Axe, M. (2002). The effect of insuffi cient quadriceps strength on gait after anterior cruciate ligament reconstruction. Clin Biomech, 17, 56–63. https://doi.org/10.1016/s0268-0033(01)00097-3
Lorenz, D., & Morrison, S. (2015). Current concepts in periodization of strength and conditioning for the sports physical therapist. Int J Sports Phys Ther, 10(6), 734–747. https://pubmed.ncbi.nlm.nih.gov/26618056/
Moses, B., & Orchard, J. (2012). Systematic review: Annual incidence of ACL injury and surgery in various populations. Res Sports Med, 20(3–4), 157–179. https://doi.org/10.1080/15438627.2012.680633
Murray, M. (2013). Chapter 2: History of ACL treatment and current gold standard of care (In: The AC). NY. Springer.
Nguyen, D., Ramwadhdoebe, T., & van der Hart, C. (2014). Intrinsic healing response of the human anterior cruciate ligament: An histological study of reattached ACL remnants. J Orthop Research, 32, 296–301. https://doi.org/10.1002/jor.22511
Noyes, F., Mangine, R., & Barber, S. (1992). The early treatment of motion complications after reconstruction of the anterior cruciate ligament. Clin Ortho Relat Res, 217–228.
Palmieri-Smith, R., Thomas, A., & Wojtys, E. (2008). Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med, 27, 405–424. https://doi.org/10.1016/j.csm.2008.02.001
Piedade, S., Leite Arruda, B., de Vasconcelos, R., Parker, D., & Maffulli, N. (2023). Rehabilitation following surgical reconstruction for anterior cruciate ligament insufficiency: What has changed since the 1960s?- State of the art. J ISAKOS, 8, 153–162. https://doi.org/10.1016/j.jisako.2022.10.001
Rivera Brown, A., Frontera, W., Fontánez, R., & Micheo, W. (2022). Evidence for isokinetic and functional testing in return to sport decisions following ACL surgery. PM R, 14. https://doi.org/10.1002/pmrj.12815
Sanders, T., Kremers, H., & Bryan, A. (2016). Incidence of anterior cruciate ligament tears and reconstruction: A 21-year population-based study. Am J Sports Med, 44(6), 1502–1507. https://doi.org/10.1177/0363546516629944
Scott, W., Stevens, J., & Binder-Macleod, S. (2001). Human skeletal muscle fiber type classifi cations. J Am Phys Ther, 81(11), 1810–1816.
Sherman, M., Lieber, L., & Bonamo, J. (1991). The long-term followup of primary anterior cruciate ligament repair. Defi ning a rationale for augmentation. Am J Sports Med, 19, 243–255. https://doi.org/10.1177/036354659101900307
Stand, A. C. of S. M. position. (2009). Progression models in resistance training for healthy adults. Med Sci Sports Exerc, 41(3), 687–708. https://doi.org/10.1249/MSS.0b013e3181915670
Steadman, J., Cameron-Donaldson, M., & Briggs, K. (2006). A minimally invasive technique (“healing response”) to treat proximal ACL injuries in skeletally immature athletes. J Knee Surg, 19(1), 8–13. https://doi.org/10.1055/s-0030-1248070
Steadman, R., Matheny, L., & Briggs, K. (2012). Outcomes following healing response in older, active patients: A primary anterior cruciate ligament repair technique. J Knee Surg, 25, 255–260. https://doi.org/10.1055/s-0032-1313742
Taylor, S., Khair, M., & Roberts, T. (2015). Primary repair of the anterior cruciate ligament: A systematic review. Arthrosc: J Arthrosc Rel Surg, 31(11), 2233–2247. https://doi.org/10.1016/j.arthro.2015.05.007
Thomee, R., Kaplan, Y., & Kvist, J. (2011). Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surg Sports Trauma Arthrosc, 19(11), 1798–1805. https://doi.org/10.1007/s00167-011-1669-8
Vascellari, A., Gokeler, A., Grassi, A., Canata, G., Zaffagnini, S., & Jones, H. (2020). Functional progression milestones following anterior cruciate ligament reconstruction are more appropriate than time-based criteria: a survey among the ESSKA. Knee Surg Sports Traumatol Arthrosc., 28. https://doi.org/10.1007/s00167-020-05960-3
Wright, R., Preston, E., & Flemming, B. (2008). ACL reconstruction rehabilitation: A systematic review Part 1. J Knee Surg, 21(3), 217–224. https://doi.org/10.1055/s-0030-1247822
Yabroudi, M., & Irrgang, J. (2013). Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction. Clin Sports Med, 32, 165–175. https://doi.org/10.1016/j.csm.2012.08.016
DOI: https://doi.org/10.26418/tajor.v3i1.88592
Refbacks
- There are currently no refbacks.
Copyright (c) 2025 Muhammad Daffa Haidar, Rizki Mulyawan, Julian Dewantara, Joanna Michalina Jurek

This work is licensed under a Creative Commons Attribution 4.0 International License.
Tanjungpura Journal of Coaching Research published by
Sport Coaching Education Study Program
Faculty of Teacher Training and Education
Tanjungpura University
Pontianak, West Kalimantan, Indonesia.
Jalan Prof. Dr. Hadari Mawawi, Pontianak KalBar
Tanjungpura Journal of Coaching Research by https://jurnal.untan.ac.id/index.php/TAJOR/index is licensed under a Creative Commons Attribution 4.0 International License