Best Practice & Research Clinical Rheumatology: Stephanie R. Filbay, Hege Grindem

Best Practice & Research Clinical Rheumatology xxx (xxxx) xxx
Contents lists available at ScienceDirect
Best Practice & Research Clinical

Rheumatology
journal homepage: www.elsevierhealth.com/berh
Evidence-based recommendations for the

management of anterior cruciate ligament (ACL)
rupture
Stephanie R. Filbay a, *, Hege Grindem b
a
Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, Nuffield Department of Orthopaedics,
Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD,
UK
b
Oslo Sport Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences,
PB 4014 Ullevål Stadion, Oslo, 0806, Norway
a b s t r a c t
Keywords:
Anterior cruciate ligament reconstruction Anterior cruciate ligament (ACL) rupture occurs most commonly in
Clinical recommendations young and active individuals and can have negative long-term
Evidence-based practice physical and psychological impacts. The diagnosis is made with a
Knee osteoarthritis combination of patient's history, clinical examination, and, if
Patient-centered care appropriate, magnetic resonance imaging. The objectives of man-
Quality of life
agement are to restore knee function, address psychological bar-
Rehabilitation
Return to sport
riers to activity participation, prevent further injury and
osteoarthritis, and optimize long-term quality of life. The three
main treatment options for ACL rupture are (1) rehabilitation as
first-line treatment (followed by ACL reconstruction (ACLR) in
patients, who develop functional instability), (2) ACLR and post-
operative rehabilitation as the first-line treatment, and (3) pre-
operative rehabilitation followed by ACLR and post-operative
rehabilitation. We provide practical recommendations for
informing and discussing management options with patients, and
describe patient-related factors associated with a worse ACL-
rupture outcome. Finally, we define evidence-based rehabilita-
tion and present phase-specific rehabilitation recommendations
and criteria to inform return to sport decisions.
© 2019 The Authors. Published by Elsevier Ltd. This is an open
access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
* Corresponding author.
E-mail addresses: stephanie.fi[email protected] (S.R. Filbay), [email protected] (H. Grindem).
https://doi.org/10.1016/j.berh.2019.01.018
1521-6942/© 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Filbay SR, Grindem H, Evidence-based recommendations for the management
of anterior cruciate ligament (ACL) rupture, Best Practice & Research Clinical Rheumatology, https://
doi.org/10.1016/j.berh.2019.01.018
2 S.R. Filbay, H. Grindem / Best Practice & Research Clinical Rheumatology xxx (xxxx) xxx
Introduction
In the USA alone, 250,000 individuals suffer an anterior cruciate ligament (ACL) rupture per year [1].
.These injuries commonly incur during sports and exercise, and clinical practice patterns for ACL
rupture management differ across the globe. In North America, athletes with an ACL rupture most often
undergo surgical ACL reconstruction (ACLR). However, this is not the standard of management in all
countries. Regardless of surgical intervention or not, there has been an increased focus on the
importance of performing evidence-based rehabilitation. In this context, the term evidence-based
rehabilitation refers to exercise therapy, which may be augmented with other modalities that have
scientific evidence of benefit. Exercise therapy includes components, such as resistance training,
neuromuscular exercise, high-level dynamic functional tasks and sport-specific training. This chapter
presents the best-evidence recommendations for the clinician reader, who treats patients with ACL
rupture. We provide a guide to injury diagnosis and management, with a focus on rehabilitation and
return to sport decisions. This chapter also includes a best-evidence summary of the consequences of
ACL rupture, outcomes with different treatment strategies, and patient-related factors that are asso-
ciated with outcome. This information will provide clinicians with the necessary knowledge to inform
and make shared management decisions with their patients, with the overarching aim of optimizing
function and quality of life (QOL).
How do you diagnose an ACL rupture?
To accurately diagnose an ACL rupture, the clinician will combine information from a patient his-
tory, clinical examination and, if appropriate, imaging. ACL ruptures often occur with concomitant
injury to menisci, cartilage, or other knee ligaments. Special consideration should be taken to diagnose
substantial concomitant injuries accurately.
History
An ACL rupture should always be suspected if the patient reports (1) an injury mechanism that
involves deceleration/acceleration in combination with a knee valgus load, (2) hearing or feeling a
“pop” at the time of injury, or (3) hemarthrosis within 2 h of injury [2].
Clinical examination
Several clinical tests can be used to detect an ACL rupture. The Lachman test is the most accurate
clinical diagnostic test, with a pooled reported sensitivity of 85% and specificity of 94% [3]. The anterior
drawer test has high sensitivity and specificity for chronic ACL ruptures (92% sensitivity and 91%
specificity), but lower accuracy for acute cases [3]. When positive, the pivot shift test is a very clear
indication of an ACL rupture (98% specificity). A negative test is, however, not sufficient to rule the
injury out (24% sensitivity) [3].
Magnetic resonance imaging (MRI)

In experienced assessors, the combination of patient history and clinical examination will often be
sufficient to diagnose an ACL rupture. However, pain and effusion in an acute setting may make it
difficult to detect the injury during clinical examination. Misdiagnosis is common; half of patients with
an acute ACL rupture were misdiagnosed as an uncomplicated knee sprain in an orthopedic emergency
unit [4]. Repeated clinical examination or MRI in the subacute phase may therefore be necessary to rule
the injury out. The diagnostic accuracy of MRI is comparable to that of the Lachman test [5]. For pa-
tients with suspected ACL rupture, MRI holds value as (1) an adjunct when the clinical diagnosis is
uncertain; and (2) part of the assessment of concomitant knee injuries that may be harder to diagnose
clinically (e.g., meniscal and cartilage injuries).
Differential diagnosis and concomitant injuries

Following substantial acute knee trauma, the Ottawa Knee Rule should be used to rule out fracture
[6]. The rule is designed to accurately exclude knee fractures (sensitivity 98.5%), but is not sufficient to
rule a fracture in (specificity 48.6%) [6]. Patients who have at least one positive answer on any of five
doi.org/10.1016/j.berh.2019.01.018
S.R. Filbay, H. Grindem / Best Practice & Research Clinical Rheumatology xxx (xxxx) xxx 3
questions (Table 1) should be considered for x-ray imaging. Adolescents who present with acute
effusion after rotational knee trauma should also be carefully assessed to rule out patellar dislocation
[4,7].
ACL ruptures often occur with concomitant ligament sprains, meniscus tears, bone marrow lesions,
articular cartilage injuries, and intra-articular fractures [4]. The rates of concomitant lateral collateral
ligament (LCL) and posterior cruciate ligament (PCL) injuries are generally low, while concomitant
medial collateral ligament (MCL) injuries and meniscal tears are common (prevalence of 30% and 42%,
respectively) [4].
What are the consequences of an ACL rupture?
Once the diagnosis is clear, the clinician should inform the patient of the injury and known con-
sequences. For many individuals, their ACL-injured knee will never feel as it did before the injury. More
than five years after ACL rupture, knee pain, symptoms, recreational limitations, and impaired QOL are
common [9,10]. Additionally, an alarming number of individuals with ACL rupture will develop
symptomatic knee osteoarthritis during young- or middle-adulthood [11]. Many individuals do not
return to sport and adopt a physically inactive lifestyle, and fear of re-injury is likely to be a contrib-
uting factor in this decision [12e14]. Of further concern is the high rate of re-injury, which is associated
with worse long-term outcome [15e17]. Collectively, these factors can have a detrimental impact on
the QOL of individuals who were highly active before sustaining an ACL rupture and often rely on their
ability to be active for a fulfilling and satisfying QOL [18,19]. However, not all individuals have poor
outcomes after ACL rupture. This highlights the importance of identifying modifiable risk factors for
poor outcome in ACL-injured individuals, and implementing personalized management strategies to
optimize long-term outcome and QOL across the lifespan.
What are the objectives of ACL rupture management?
The objectives of management for an individual with ACL rupture are to (1) restore knee function,
(2) address psychological barriers to resuming activity participation, (3) prevent further knee injury
and reduce the risk of knee osteoarthritis, and (4) optimize long-term QOL.
Restore knee function

Treatments to achieve this objective are targeted toward the specific impairments of the patient.
Establishing realistic and specific goals, and accurate assessment of current impairments that need to
be addressed to reach these goals, are therefore key. Typical impairments after injury include varying
degrees of muscle strength deficits, altered movement patterns, decreased knee joint proprioception,
and increased passive knee laxity. Collectively, these impairments contribute to the varying degrees of
functional knee instability that patients with ACL rupture experience.
Address psychological barriers to resuming activity participation

Although the functional status of the knee is associated with whether the patient returns to sport
[20], problems with the injured knee is only the third most frequently cited reason for not returning to
sport [13]. More patients attribute not returning to sport to a fear of re-injury or a lack of trust in the
knee. Continued follow-up and support throughout the return to sport period may therefore be needed
to ease the transition back to sports.
Table 1
Questions in the Ottawa knee rule [8].
Is the patient 55 years or older?

Is there isolated tenderness of the patella?
Is there tenderness of the head of the fibula?
Is the patient unable to flex the knee to 90 ?
Is the patient unable to bear weight for four steps?
doi.org/10.1016/j.berh.2019.01.018
Prevent further knee injury and reduce the risk of knee osteoarthritis
The main threats to future knee health are knee re-injury and the development of posttraumatic
knee osteoarthritis. To date, no randomized trials exist to support interventions that can eliminate
these risks. The risk for knee re-injury is lower in those who (1) do not participate in sports with
frequent pivoting and cutting, (2) complete rehabilitation to the point where they pass functional
return to sport criteria before returning to pivoting sports, and (3) return to pivoting sports later than 9
months after an ACLR [21,22]. Additionally, neuromuscular training programs are highly effective in
reducing the risk of knee injury in a primary setting [23]. To reduce the risk for knee re-injury, the
clinician should provide patient-education that includes information on the probable benefit of activity
modification. In patients who make an informed decision to pursue participation in pivoting sports
following ACLR, the treatment strategy should include at least 9 months postoperative rehabilitation,
return to sport only after passing specific criteria, and continued performance of neuromuscular
training programs after return to sport.
The risk for knee osteoarthritis is higher in those with higher BMI, those who are physically inactive,
and those with quadriceps muscle weakness [24,25]. Although physical inactivity and obesity are not
common concerns in the young and active people who usually sustain ACL ruptures, sustaining a knee
injury in youth increases the risk of becoming physically inactive and gaining fat mass in the longer
term [26]. These modifiable risk factors should therefore be targeted after ACL rupture. Regaining
quadriceps muscle strength is an essential goal of rehabilitation after ACL rupture and can be achieved
with heavy resistance strength training [27]. Because many athletes do not return to their preinjury
level of sport, guidance on alternative modes of physical activity may be a key factor to prevent physical
inactivity. Finally, patients who already have a high BMI at the time of ACL rupture should receive
support to adopt healthy weight-loss strategies.
Optimize long-term quality of life

Maintaining participation in a satisfying form of physical activity is a key determinant of long-term
QOL following ACLR [19]. Negotiating fear of re-injury and decisions surrounding continuation or
cessation of sport participation are also closely related to long-term QOL after ACLR [19]. Individuals
who return to preinjury sport after ACL rupture report better health-related and knee-related QOL
5e20 years later, compared with those who do not return to sport [18]. Physical activity and sport
participation play an important role in the lives of individuals with ACL rupture, and the inability to be
physically active has a detrimental effect on the QOL of those who develop symptomatic post-
traumatic knee osteoarthritis [28]. A key objective is to reduce the negative impact the ACL-
ruptured knee has on a person's current and future QOL. This will require a personalized approach
in line with the individual's goals, values, and life priorities. The clinician should be aware that goals,
values, and life priorities are likely to change over time, and an individual with ACL rupture may benefit
from guidance and support to adapt to changing life circumstances and manage their knee throughout
various stages of their life [19].
What are the common management strategies for ACL rupture?
The treatment for patients with ACL rupture needs to be individualized and several options are
currently in use in clinical practice. In this chapter, we present three main options for the reader (Table 2).
Considering methods for rehabilitation and surgical techniques can vary, rehabilitation clinicians and
surgeons should both be a part of the discussion of best treatment for the individual patient. Most of the
scientific literature in his area is centered on the debate of whether patients who undergo ACLR have
Table 2
Main management options for treatment of ACL rupture.
(1) Rehabilitation as the first-line treatment (followed by ACLR and postoperative rehabilitation if the patient develops
functional instability).
(2) ACLR as the first-line treatment, followed by postoperative rehabilitation.
(3) Preoperative rehabilitation followed by ACLR and postoperative rehabilitation.
doi.org/10.1016/j.berh.2019.01.018
better outcomes than those who are treated without ACLR. In the following section, we present the
current evidence on this topic.
Do the outcomes of ACL rupture differ depending on management strategy?
There are a number of literature reviews comparing outcomes between individuals that are ACL-
deficient or have had an ACLR [9,29e32]. It is important to note that most studies included in these
reviews do not reflect best practice for nonoperative management of ACL rupture. For example, many
of the nonoperatively managed patients in these studies received a diagnostic knee arthroscopy, some
were advised to reduce activity levels, and rehabilitation was often not monitored, of a low intensity or
short duration, or included post-injury immobilization with a brace or cast [9,29e33]. Despite this,
these literature reviews report similar outcomes in ACL-deficient and ACL-reconstructed groups,
including similar patient-reported outcomes, knee function, activity levels, QOL [9,29,30,33] and either
no difference in radiographic osteoarthritis prevalence [29] or a slightly increased prevalence following
ACLR [30,32].
There is a notable shortage of high quality research comparing outcomes following the man-
agement of patients with an ACL rupture with high-quality rehabilitation compared to ACLR. A
recent review of all randomized controlled trials (RCTs) for ACL injury identified only 1 (The
KANON Trial) out of 412 trials that compared outcomes following ACL management with reha-
bilitation plus optional delayed ACLR vs. ACLR and postoperative rehabilitation [34]. The two
groups had similar two-year and five-year self-reported physical activity levels, rates of meniscus
surgery, symptoms, pain, QOL, and radiographic joint changes [35,36]. Notably, there was also no
difference in outcomes between patients, who had an early ACLR, patients managed with reha-
bilitation alone, and those initially managed with rehabilitation who underwent a delayed ACLR
(51% after five years) [35,36].
Several relevant recent studies did not feature in the previous reviews. A recent cohort study
compared outcomes between patients with an ACL rupture managed with strength and neuro-
muscular training or ACLR followed by postoperative rehabilitation. The treatment groups had
similar five-year functional and radiographic outcomes, but the ACLR group had more joint effusion,
better self-reported knee function, and lower self-reported fear [37]. Furthermore, Kovalak et al.
(2018) found no group difference in time to return to regular physical activity, eight-year knee
function, strength or QOL between athletes who were managed with neuromuscular training alone
or with ACLR [38]. Van Yperen et al. (2018) compared 20 year outcomes in 50 high-level athletes with
an ACL rupture managed with structured rehabilitation and lifestyle modifications or ACLR (due to
persistent instability after 3-months of nonoperative management). Despite the fact that the ACLR
group had less knee laxity, there were no between-group differences in meniscectomy rates,
radiographic osteoarthritis, and functional outcomes [39]. Combined, these recent studies support a
larger body of evidence demonstrating that on average, individuals experience similar functional,
radiographic, and patient-reported outcomes after ACL rupture, irrespective of management with
rehabilitation alone or with ACLR.
Knee laxity and functional instability

Knee laxity refers to the passive intra-articular translation available in the tibiofemoral joint (i.e.,
assessed manually or by a device) whereas functional instability refers to the patient's perception of an
“unstable” knee [40]. The magnitude of knee laxity is of questionable clinical relevance given that it
does not account for dynamic joint control afforded by the surrounding musculature. Studies that
report more knee laxity in ACL-deficient individuals (compared to ACL-reconstructed individuals), also
find similar self-reported knee instability, functional outcomes and physical activity levels between
groups [30,39]. Research suggests that despite greater laxity in ACL-deficient knees compared to ACLR
knees, functional stability can be achieved through neuromuscular training [31]. Despite common
misconceptions to the contrary, research suggests that it is possible for an individual who suffers an
ACL rupture to return to sport following management with rehabilitation alone [30,36,41]. Several
studies have found no difference in physical activity levels or return to sport rates between patients
managed with ACLR and those managed with rehabilitation [30,36,41].
doi.org/10.1016/j.berh.2019.01.018
Additional knee injury and surgery

Meniscus or cartilage damage at the time of ACLR is associated with worse outcomes and higher
rates of osteoarthritis [11,42e49]. Reducing the risk for subsequent meniscus and cartilage injury
should therefore be a key priority when managing individuals with an ACL rupture.
Subsequent knee injury is common following ACLR; one third of young individuals who undergo
ACLR experience a second ACL tear [15] and 27% experience a third within 2e9 years after revision
ACLR [50]. This is concerning, considering a second ACL injury is associated with meniscus and/or
cartilage damage in approximately 90% of individuals [51] and ACLR revision is associated with more
pain and symptoms, reduced function, inactivity, higher rates of osteoarthritis, and worse QOL
compared to primary ACLR [16,17,52].
A common belief is that early ACLR prevents additional meniscus and cartilage injury. However,
studies referenced to support this belief are typically retrospective reviews of surgical records, and
show more severe joint injury in patients presenting for ACLR months or years after ACL rupture,
following unknown/no rehabilitation [53]. On the other hand, evidence from prospective studies do
not suggest management with rehabilitation as the first-line treatment results in more joint injury
compared with management with early ACLR [53]. Grindem et al. (2014) reported that knee re-injury
was more common in patients who chose ACLR (24%) compared to those who chose rehabilitation
alone (9%). This difference was not significant after accounting for group differences, suggesting that
being young and active has a larger impact on re-injury risk than the patient's chosen treatment [54].
Additionally, the KANON Trial found a similar proportion of patients underwent meniscus surgery
between ACL treatment groups over a five-year follow-up period [36]. In summary, best available
evidence does not indicate that an individual is at greater risk of subsequent injury if they are managed
with rehabilitation as the first-line treatment as opposed to ACLR.
What patient-related factors are associated with ACL rupture outcome?
Understanding patient-related factors that are associated with outcomes after ACL rupture can
enable the clinician to better tailor the information and management strategy to the individual patient.
In those who are treated with ACLR, younger athletes, men, and elite athletes are more likely to return
to sport [13]. Athletes under the age of 25 also have higher rates of second ACL ruptures than older
athletes [55]. Compared to those who have concomitant meniscal or cartilage pathology, patients with
isolated ACL ruptures are likely to be more physically active, have better knee function, and less pain
2e6 years after ACLR [56e58].
Patients who are better prepared, both psychologically and functionally, prior to ACLR also have
better outcomes after an ACLR. Preoperative factors associated with better postoperative outcomes
include optimism, self-efficacy, greater quadriceps muscle strength, and passive knee extension range
of motion [59e61]. These findings highlight the importance of preoperative rehabilitation, which has
been associated with better postoperative patient-reported function and activity level compared to no
or limited rehabilitation prior to ACLR [62e64].
Fewer studies are available on factors that are associated with outcomes following rehabilitation
alone, and it is largely unknown how and if these factors interact with treatment choice. An exploratory
analysis of the KANON trial showed that undergoing repeat knee surgery was associated with worse
five-year pain, symptoms, function in sport, and QOL, and regardless of treatment [57]. However,
meniscal injury, chondral damage and worse pain, symptoms, function in sport and QOL at baseline
was only associated with worse five-year outcomes (symptoms, function in sport, and QOL) in the
group who had early ACLR and rehabilitation [57].
Recently, Grindem et al. [65] proposed predictive models for successful 2-year outcome in
nonprofessional pivoting sport athletes, who were treated for ACL rupture with rehabilitation as the
first-line treatment. An athlete was classified as having a successful outcome if he or she avoided
functional instability leading to late ACLR and had self-reported knee function within the normative
range of individuals with no history of knee injury. Athletes who were older, women, and individuals
with better knee function early after ACL rupture were more likely to have successful two-year out-
comes [65]. This information may be used to inform patients of the likelihood of a successful outcome if
deciding to pursue management of ACL rupture with rehabilitation alone.
doi.org/10.1016/j.berh.2019.01.018
How should you discuss management options and expectations with your patient?
ACL ruptures can have serious long-term consequences, optimal management requires substantial
investment from the patient, and the patient's short- and long-term priorities may be conflicting (i.e.,
short-term return to sport might be prioritized over long-term knee health). The treatment choice
should therefore be a shared decision between the individual patient and the treating health-care
professionals. To ensure that the patient makes an informed commitment to a treatment plan, the
first step of this process is to provide high-quality information about the injury, short- and long-term
consequences, what the different treatment options are, and the patient's likely prognosis with the
different treatment options.
Expectations
Patients tend to have very high expectations prior to ACLR, which do not match average outcomes. Of
181 patients who awaited ACLR, all patients expected to have almost normal or normal knee function
within 12 months of surgery, 91% expected to return to sport within one year of surgery and 98% ex-
pected no or only a slight increased risk of knee osteoarthritis after ACLR [66]. These expectations are not
realistic; long-term knee symptoms are common [67], only 42% of nonprofessional athletes return to
competitive sport following ACLR [13] and as many as 50% develop radiographic knee osteoarthritis
within 10 years of ACLR [11]. Although a rigorous informed consent process takes time in a busy clinical
schedule, clinicians have a fiduciary duty to inform the patient of the expected outcomes with a treat-
ment [68]. This information must be delivered in a way that is comprehensible to the patient.
Choosing a management strategy

Discussing the pros and cons of different management options will allow the patient to make an
informed decision and select the approach that is best suited to him or her. To give the patient the
greatest chance of success, it is critical that the initial advice is based on best-evidence recommen-
dations and not biased toward a particular treatment strategy. This requires the clinician to synthesize
the scientific evidence and their clinical experience to make specific recommendations for the indi-
vidual patient. The rationale behind these recommendations should be as transparent as possible.
As the only randomized trial on the topic did not support a superior outcome with early ACLR [35], it
is prudent to suggest a period of rehabilitation before surgical decision-making for most patients with
ACL rupture. This strategy is also supported by the findings that preoperative rehabilitation improves
postsurgical outcomes in those who go on to have an ACLR [62e64]. There is clinical agreement that
patients who have functional instability after rehabilitation are likely to benefit from ACLR [69]. The
rationale behind this is that frequent instability episodes can be prevented by an ACLR, thereby
reducing potential damage to the menisci and cartilage.
Clinical practice patterns also show that many nonprofessional athletes choose to have an ACLR to
enable return to pivoting sports [54,69]. This does not reflect the current evidence [36,41,54]. Health-care
professionals may favor one treatment over another, which could be reflected in the language used when
they present management options to the patient. For example, consider the impact of a health-care pro-
fessional using the following language: “you can have rehabilitation and change your lifestyle to avoid
cutting and pivoting activities, or you can have surgery to fix your ACL and return to sport”. This phrasing is
likely to leave the patient feeling as though ACLR is clearly the superior treatment. It would also obscure the
important information that less than half of nonelite athletes return to competitive sport following ACLR,
and that rehabilitation is usually more demanding following ACLR than with a nonsurgical approach.
Other factors such as concomitant injuries, access to treatment, patient preferences, and life plans
may also influence the final decision. For example, external pressure will often give a professional
athlete limited time for the decision-making process. It may therefore not be feasible to delay a surgical
decision to see if they can return to sport with rehabilitation alone. On the other hand, if the athlete
sustains an ACL rupture close to an important event and has no signs of functional instability, having an
early ACLR would mean they could not compete in this event. He or she might therefore choose to
participate in the event before considering whether surgery is likely to be of additional benefit to
rehabilitation. The key to the treatment decision is to agree on a realistic treatment plan that sets the
patient up with the best opportunity to achieve his or her goals.
doi.org/10.1016/j.berh.2019.01.018
What is evidence-based ACL rehabilitation?
Evidence-based ACL rupture rehabilitation recommendations are presented in Table 3. Rehabilita-

tion of patients with an ACL rupture should be led by a rehabilitation clinician who is experienced in
rehabilitation of patients with ACL rupture. The physician should therefore refer the patient to a
physical therapist or related health professional with this background. The number of visits needed will
depend on the treatment plan and progress for each individual patient. Although it is not necessary for
the rehabilitation clinician to monitor the execution of all exercises in a rehabilitation program, visits at
least every two weeks may be required to ensure adequate progress. This requires that the patient has
access to a location where he or she can perform the exercises in the rehabilitation plan, as the fre-
quency of performing the exercises may range from daily to 2e3 times per week. Communication
between the rehabilitation clinician and the physician is the key to optimal treatment, and the patient
should be referred back to the physician if he or she (1) experiences symptoms of a new knee injury or
repeated knee giving-way episodes, or (2) shows signs of complications that should be assessed. Ex-
amples of this include symptoms of a failed meniscal repair or failure to achieve full passive extension,
which may be indicative of a cyclops lesion.
Over the last decades, rehabilitation has moved from time-based protocols to individualized and
criterion-based content and progression. There are five distinct phases of rehabilitation after ACL
rupture (Table 3). Progress from one phase to the other only occurs when the patient meets specific
clinical milestones. This criterion-based approach ensures that progression in rehabilitation does not
surpass the functional and biological capacity of the knee. The move from time-based to criterion-
based protocols also means that progress is not delayed unnecessarily.
Factors that necessitate adjustments to the rehabilitation program
The principles of rehabilitation are similar for those who are treated with rehabilitation alone and
those who elect to undergo ACLR. However, a shorter time-frame should be expected for those who do
not have ACLR. After both ACL rupture and ACLR, concomitant injury and/or surgery may also require
adjustments to the rehabilitation program. There are multiple combinations of concomitant injury
presentations, and an injured structure may be nonoperatively managed or surgically treated using a
variety of methods. For example, meniscus injuries may be surgically treated with a small resection,
repair, or meniscus transplantation. These surgical methods require very different adaptations to the
rehabilitation program [75]. Postsurgical restrictions will often be specified by the treating orthopedic
surgeon, but clinicians who have less experience in managing these injuries postoperatively should
consult a specialist if needed.
In patients, who undergo ACLR, the graft choice should be considered in postoperative rehabilita-
tion. An ACLR can be performed with allograft (a donor graft) or autograft (usually from the patient's
own ipsilateral patellar tendon or medial hamstring tendons). Rehabilitation after ACLR should address
impairments from the ACL rupture and impairments from graft harvesting. ACLR with a patellar tendon
autograft is associated with donor-site pain and quadriceps weakness [76,77]. Rehabilitation clinicians
should therefore monitor donor-site pain when the patient performs quadriceps strengthening exer-
cises. After ACLR with hamstring grafts, the mechanical properties of the neo tendons may eventually
recover with time [78]. To allow for healing, heavy resistance hamstring strengthening exercises are
usually delayed for a period postoperatively [75], but there is no consensus on the optimal time frame
for initiation of heavy resistance hamstring exercises. Hamstring peak muscle strength may also fully
recover, but notable weakness in knee flexion strength at increased knee flexion angles is reported [79].
There is very little evidence to guide how rehabilitation should be tailored for patients who undergo
less common methods of ACL surgery (e.g., ACLR with quadriceps tendon autograft, or ACL repair with
internal bracing).
How do I know when an individual is ready to return to sport after ACL rupture?
As outlined in the previous section, a gradual return to activity/sport is an integrated part of the
rehabilitation progress. Different sports, and even different aspects within one sport, pose different
doi.org/10.1016/j.berh.2019.01.018
Table 3
Evidence-based ACL rupture rehabilitation recommendations.
Rehabilitation Main goals Description

phase
Preoperative No knee joint effusion, full active and For patients who plan to undergo ACLR, preoperative
phase (for those passive range-of-motion, 90% rehabilitation should be performed to improve postsurgical
who elect ACLR) quadriceps strength symmetry outcomes [63,64]. Rehabilitation should start as soon as
possible after diagnosis. Preoperative rehabilitation follows
the principles of acute and intermediate phase
rehabilitation (described below), but deficits in passive knee
extension range-of-motion and quadriceps strength should
be specifically targeted as these factors are associated with
poor postsurgical outcomes [70]. In patients with full range-
of-motion, no effusion, and the ability to hop on one leg,
preoperative rehabilitation with heavy resistance strength
training and plyometric exercises is safe (3.9% adverse
events) [71] and has benefits that extend at least two years
after ACLR [62,63].
Acute phase (after No knee joint effusion, full active and Treatments that target full passive extension and
ACL rupture and/ passive range of motion, straight leg quadriceps muscle function should start the first day after
or ACLR) raise without lag ACL rupture or reconstruction. Active and passive range-of-
motion exercises (e.g., quadriceps sets, active straight leg
raise, prone hang, and heel slides), and effusion
management by adjustment of loading are advocated in this
phase [70]. Cryotherapy can be used to manage pain, but is
not effective for the reduction of knee joint effusion [70]. As
an additive to active exercises, high-intensity
neuromuscular electrical stimulation (NMES) is effective in
improving quadriceps strength after ACLR [72].
Postoperatively, evidence-based guidelines recommend
both weight-bearing (closed kinetic chain) and nonweight-
bearing (open kinetic chain) exercises [70].
Intermediate Control of terminal knee extension in This phase will integrate both neuromuscular training and
phase (after ACL weight-bearing positions, 80% muscle strength training [70]. Neuromuscular training aims
rupture and/or quadriceps strength symmetry, 80% to improve dynamic knee stability by establishing more
ACLR) hop test symmetry with adequate beneficial proprioception and motor control strategies.
movement quality Neuromuscular training is an umbrella term that includes
perturbation training, balance training, agility drills, and
plyometrics. A multi-modal approach is typically used and
there is insufficient evidence to suggest that one type of
training is superior to another. Blanchard and Glasgow [73]
have described a theoretical model that can be used to
progress neuromuscular exercises. An exercise starts with
an internal focus. This means the focus is on achieving
sound movement patterns in the exercise. Exercise
characteristics, such as duration, speed, distance, or
repetitions are then manipulated to increase the difficulty of
the exercise. External factors, such as perturbations, hurdles
or unstable surfaces are also added to progress the exercise.
To enable skill transfer to sports, it is recommended to tailor
the type of exercises to the patient by gradually introducing
sport-specific skills [70].
The goal of a muscle strengthening program is to restore the
muscle strength and power needed for participation in the
patient's sport and desired recreational activities. Muscle
strength exercises will start with an adjustment period that
has lighter loads and a high number of repetitions and
gradually progress to heavy loads with a lower number of
repetitions. A strength training program that includes both
bilateral and unilateral exercises, and that gradually
progresses to principles for strength training for uninjured
people, leads to better outcomes than training programs
that consistently use a high number of repetitions [27]. The
(continued on next page)
doi.org/10.1016/j.berh.2019.01.018
Table 3 (continued )
Rehabilitation Main goals Description

phase
“þ2 principle” can be used for load progression: once the

patient can perform an extra two repetitions over the target
number of repetitions, the load is increased in the next
session [71].
Late phase (after 90% quadriceps strength symmetry, Late phase rehabilitation should be individualized based on
ACL rupture and/ 90% hop test symmetry with adequate the patient's specific goals and athletic demands. The type
or ACLR) movement quality, maintain/build of sport and physical activity that patients with an ACL
athletic confidence, progress sport- rupture wish to participate in can vary widely; assessment
specific skills from closed skills with of these athletic demands are therefore key to tailor a
internal focus to open skills with rehabilitation plan that leads to successful return to sport or
external focus activity. Typically, this phase includes impairment-specific
heavy strength training, power and agility drills, and sport-
specific exercises. After passing the criteria of a
performance-based return to sport test battery, the athlete
gradually resumes participation in unrestricted sports
practice. This is achieved with a staged progression from
modified training (e.g., noncontact only), to full training
(unrestricted), to restricted participation in competition (by
the number of minutes), to unrestricted participation in
competition.
Continued injury Maintain muscle strength and dynamic An injury prevention program should be performed at least
prevention knee stability, manage load twice per week as the patient gradually returns to sport and
phase (after ACL this should be maintained after a patient returns to full
rupture and/or sport participation. Effective injury prevention programs
ACLR) exist for a variety of pivoting sports [23], and include lower
limb strength exercises and training of low-risk movement
patterns. Sports injury risk increases with sudden spikes in
load (the combination of intensity and frequency of
participation). Appropriate load-management may also be
used to reduce the risk for knee re-injury and for injuries to
other body parts [74].
demands to physical and psychological readiness. As the patient improves with rehabilitation, a
gradual increase in sports participation is recommended to ensure the best transition back to full
participation [80].
There are no high-level interventional studies that compare different criteria for return to sport.
Current guidelines in this area are therefore informed by observational studies and expert opinion.
Regardless of which activity/sport the patient is aiming to return to, there are three key considerations
for the medical decision-making team: (1) is the athlete physically ready to participate in the activity/
sport? (2) is the athlete mentally ready to perform in the activity/sport? (3) have we allowed enough
time from injury/surgery for sufficient biological healing to occur?
Physical readiness
Assessment of the patient's knee function is a key aspect in the clinical decision of whether they
should return to activity/sports. Pivoting sport athletes who pass specific criteria prior to return to
sport have 4e6 times lower risk for re-injury [21,22]. Grindem et al. [21] classified athletes as having
passed or failed return to sport criteria with a return to sport test battery consisting of isokinetic
quadriceps strength testing (90% of opposite leg), four single-legged hop tests (90% of opposite leg)
and scores 90 on a scale from 0 (worst) to 100 (best) on a global rating scale of perceived function and
the Knee Outcome Survey e Activities of Daily Living Scale. Athletes who failed any of the return to
sport criteria were more likely to sustain a new knee injury (38%), compared to those who passed all
return to sport criteria (6%). The test battery used by Kyritsis et al. [22] consisted of isokinetic quad-
riceps strength testing (90% of opposite leg), three single-legged hop tests (90% of opposite leg), and
an agility test (11 s). Additionally, athletes had to complete on-field sport-specific rehabilitation.
Among those who failed return to sport criteria, 33% sustained a graft rupture. In comparison, 10% of
those who passed return to sport criteria ruptured their ACL graft.
doi.org/10.1016/j.berh.2019.01.018
Performance-based tests of muscle strength and single-legged hop ability have traditionally been
the cornerstone of functional return to sport criteria [81]. Recently, there has been an increased focus
on supplementing these tests with assessments of direction changes and reactive agility tests [80]. The
rationale for these tests is to assess knee function during tasks that closely mimic those performed
during sport participation. The choice of test will therefore depend on the sport to which the patient
aims to return. Gradual introduction of sport-specific exercise in late phase rehabilitation can also be
used to assess these aspects [80]. A gradual increase in training load is also a key component of the
transition back to activity/sports [74]. Knee joint effusion and knee soreness rules are commonly used
clinical markers to assess response to load [75], and can be used to guide progression throughout
rehabilitation and return to sport. Once the athlete has resumed restricted sports activity, load can be
monitored by multiplying session-rating of perceived exertion with session training minutes. A
consistent progression in load is recommended to avoid exacerbation of symptoms and/or injury to the
knee or other body parts [74].
Psychological readiness to return to sport

Psychological factors are highly associated with not returning to sport after ACLR. These factors can
be related to the patient's competence, autonomy, and relatedness (e.g., low intrinsic motivation, low
confidence, and high fear of re-injury) [82,83]. Although psychological responses generally improve
with rehabilitation, fear may increase, and remain a prominent emotion at the time of return to sport
[82]. To assess psychological factors related to returning to sport, clinicians can use patient-reported
tools, such as the anterior cruciate ligament return to sport after injury scale (ACL-RSI) [84]. Routine
use of this tool can help the clinician and patient identifies important barriers to return to sport, and
determine if additional treatment is required. This additional treatment may involve referral to a sports
psychologist, but several strategies can be employed by the patient and non-psychologist clinician.
There is currently very little research on interventions that effectively improve return to sport after ACL
rupture through improved psychological readiness. Suggested strategies that target psychological
factors include active goal-setting, having a role model the patient can relate to, relaxation techniques,
and mental practice [83].
Biological healing
Over the last decades, clinical practice patterns have shifted toward earlier return to activity. Recent
research has now highlighted that important biological healing processes are still ongoing at the time
when athletes traditionally resume sports activities. Free tendon autografts are commonly used for
ACLR. After systematically reviewing the literature, Claes et al. [85] observed that the time frame of the
ligamentization process of these grafts was not well-defined, but may last more than 12 months after
surgery. The process was prolonged in humans compared to animals, questioning previous knowledge
on healing properties that was largely based on animal studies. After an isolated ACLR, cartilage quality
and recovery in response to load is diminished [86]. Returning to sport before six months after surgery
has been associated with poorer cartilage recovery after running, possibly implicating early exposure to
high-impact activities in the development of post-traumatic knee osteoarthritis [86]. Early return to
pivoting sports has also been associated with a high rate of knee re-injuries [21,87]. It is unknown if the
reduced risk of knee re-injury with more time after ACLR is explained by better biological healing or
improved physical/psychological readiness. Up until 9 months after ACLR, a delay in return to sport by
one month was associated with a 51% reduction in knee re-injury rates [21]. It is therefore recom-
mended to delay return to pivoting sports until at least 9 months after ACLR.
Summary
Following an ACL rupture the clinician and patient should, together, devise a treatment plan that
addresses (1) rehabilitation, (2) appropriateness of ACLR, and (3) return to sport. Average long-term
outcomes are similar following management of ACL rupture with rehabilitation alone or with ACLR
and rehabilitation. Irrespective of treatment strategy, ACL rupture management should aim to restore
knee function, address psychological barriers to sport/activity participation, reduce the risk of further
injury and knee osteoarthritis, and optimize long-term QOL. Rehabilitation after an ACL rupture and/or
doi.org/10.1016/j.berh.2019.01.018
ACLR should be individualized and criterion-based, with gradual return to sport/activity as an inte-
grated part of rehabilitation progression. The three main factors in deciding readiness to participate in
sport are (1) physical readiness, (2) psychological readiness, and (3) biological healing. Athletes who
return to pivoting sport after ACLR can reduce their risk for re-injury by passing time-based and
functional criteria before returning to sport.
Practice points
* The objective of ACL-injury management is to restore knee function, address psychological

impacts, prevent further knee injury and osteoarthritis, and optimize long-term QOL;
* Current evidence suggests average long-term outcomes are similar following management
of ACL rupture with ACLR and rehabilitation or with rehabilitation alone;
* Rehabilitation should start as early as possible after injury, and progress in rehabilitation is
performed when the patient meets specific clinical or functional milestones;
* For some patients, not returning to sport can negatively impact long-term QOL, but returning
to pivoting sport increases the risk of subsequent knee injury;
* Subsequent knee injury after ACL-injury is associated with poor long-term outcome, and
reducing risk of subsequent knee injury should be a key priority when managing ACL-injured
individuals;
* To reduce the risk for subsequent injury, pivoting sport athletes with ACLR should pass
functional criteria for return to sport and delay full participation for at least nine months after
surgery
Research agenda
* Research to determine optimal strategies for preventing subsequent knee injury and oste-
oarthritis after ACL rupture is required;
* Research is needed to establish return to sport guidelines for ACL-injured people who are
treated with rehabilitation alone;
* Further research on late-phase rehabilitation and the efficacy of return to sport criteria is
required;
* There is a need for research on interventions to improve psychological readiness to return to
sport, and for research to evaluate the implications of such interventions on re-injury rates
and long-term QOL;
* There is a need for further research to identify which patients will benefit most from man-
agement with or without ACLR
Conflict of interest
None.
Acknowledgements
Funding: Dr Filbay is funded by Arthritis Research UK, Centre for Sport, Exercise and Osteoarthritis
(grant reference 21595).
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doi.org/10.1016/j.berh.2019.01.018

Best Practice & Research Clinical Rheumatology: Stephanie R. Filbay, Hege Grindem

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Contents lists available at ScienceDirect

Best Practice & Research Clinical

Evidence-based recommendations for the

How do you diagnose an ACL rupture?

Magnetic resonance imaging (MRI)

Differential diagnosis and concomitant injuries

What are the consequences of an ACL rupture?

What are the objectives of ACL rupture management?

Restore knee function

Address psychological barriers to resuming activity participation

Is the patient 55 years or older?

Optimize long-term quality of life

What are the common management strategies for ACL rupture?

Do the outcomes of ACL rupture differ depending on management strategy?

Knee laxity and functional instability

Additional knee injury and surgery

What patient-related factors are associated with ACL rupture outcome?

Choosing a management strategy

What is evidence-based ACL rehabilitation?

Evidence-based ACL rupture rehabilitation recommendations are presented in Table 3. Rehabilita-

Factors that necessitate adjustments to the rehabilitation program

Rehabilitation Main goals Description

Rehabilitation Main goals Description

“þ2 principle” can be used for load progression: once the

Psychological readiness to return to sport

* The objective of ACL-injury management is to restore knee function, address psychological

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